Economics of prevention in Australia - Sante Publique...

Economics of

prevention in Australia Prof Theo Vos

for the ACE-Prevention Research Team

Journées de la Prévention, INPES June 7th 2013

Assessing Cost Effectiveness—Prevention

ACE-Prevention Research Team

n  Principal investigators Theo Vos Rob Carter

n  Researchers Jonathan Anderson Isaac Asamoah Jan Barendregt Melanie Bertram Josh Byrnes Dominique Cadilhac Daphni Chao Linda Cobiac Siobhan Dickinson Chris Doran

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Jun Fen Megan Forster Michael Gascoigne Shahram Ghaffari Hideki Higashi Linda Kemp Yong Yi Lee Anne Magnus Cathy Mihalopoulos Vittal Mogasale

Marj Moodie Farid Najavi Shamesh Naidoo Katherine Ong Michael Otim Sophy Shih Utsana Tonmukayakul Kiu Tay Teo Lennert Veerman Angela Wallace


Overview of the Session

1.  Introduction to ACE-Prevention 2.  ACE-Prevention results

a)  Intervention pathways b)  Costs/health gain/cost savings from

recommended packages 3.  Interpretation of results

3

Assessing Cost Effectiveness—Prevention 4

Brief History

n  ACE-Prevention was a 5 year NHMRC Health Services Research Grant (2005-2009) ¨ Across 2 sites (University of Queensland and Deakin)

n  Followed on from earlier ACE studies funded by both government & competitive grants

n  Focus in ACE studies is priority setting ¨  What to do? (‘allocative efficiency’) ¨  How to do it? (‘technical efficiency’)


Why are governments now more interested in explicit priority setting?

n Three reasons given prominence in health economic literature ¨ Controlling health expenditure ¨ Increasing evidence of inefficiency ¨ Reluctance to rely too heavily on the free

market as mechanism of choice n  can’t opt out n  asymmetry in information

5


Projected total health expenditure (2002–03 dollars) by cause, Australia, 2002–03 to 2032–33

6

Expenditure by year ($billion) Change 2003-2033 Cause 2002–03 2032–33 Per cent Cardiovascular 9.3 22.6 + 143 Respiratory 7.2 22.0 + 206 Injuries 6.7 14.4 + 115 Dental 5.9 14.9 + 153 Mental 5.2 12.1 + 133 Digestive 4.9 16.5 + 237 Neurological 4.7 21.5 + 357 Musculoskeletal 4.4 14.2 + 223 Genitourinary 3.7 10.9 + 195 Cancer 3.5 10.1 + 189 Diabetes 1.6 8.6 + 438 Other 28.0 78.3 + 180 Total health expenditure 85.1 246.1 + 189 Goss J. Projection of Australian health care expenditure by disease, 2003 to 2033. Health and Welfare Expenditure Series No. 36. Canberra: Australian Institute of Health and Welfare, 2008.


Opportunities for change?

q  Projections reflect ‘business as usual’ scenario

q  Are there opportunities to improve? q  Requires detailed information on the costs

and outcomes of current practice and alternative intervention approaches

q  ACE-Prevention does this for prevention of non-communicable disease


Origins of ACE approach n  There is a theoretical underpinning to ACE n  What is “ideal” approach to priority setting? n  We developed checklist based on 4 rationales

¨ Economic theory ¨ Ethics & social justice ¨ Empirical evidence ¨ Needs of decision-makers

n  Essence of ACE is trying to achieve balance between technical rigour and due process

Carter R, Vos T, Moodie M, Haby M, Magnus A, Mihalopoulos C (2008). Priority Setting in Health: Origins, Description and Application of the Assessing Cost Effectiveness (ACE) Initiative. Expert Review of Pharmacoeconomics and Outcomes Research, 8:593--617.


Overview of economic methods

n  Clear criteria for selection of interventions n  Standardised evaluation methods to minimise

methodological confounding n  Evaluation conducted as integral part of

exercise (not collation from literature) n  ‘Evidence’-based approach with extensive

uncertainty & sensitivity testing


C/E analysis protocol

Perspective Health Sector (focus on government; key societal effects flagged)

Comparator Current practice + no interventions (‘null’) for analyses of intervention mix

Target pop Cohort of patients with conditions/risk factor of interest, Aust. population 2003

Time horizon Track costs & benefits 100 yrs or death

Discounting 3% Costs Best available unit costs (documented); Real costs $AUD 2003


C/E analysis protocol Outcomes

Cost per DALY saved

Uncertainty analysis 95% uncertainty intervals using probabilistic analysis

Sensitivity analysis Test scenarios around key design features

Reporting cost-effectiveness ranges cost-effectiveness planes expansion path


Total population Indigenous Topic Prevention Treatment Prevention Treatment Alcohol 9 2 Tobacco 8 Physical activity 6 Nutrition 26 Body mass 9 Blood pressure/cholesterol 12 5 Bone mineral density 3 Illicit drugs 2 1 Cancer 9 1 Diabetes 7 7 Renal disease 2 2 4 2 Mental disorders 11 10 Cardiovascular disease 1 5 Other 18 6 3 Total 123 27 19 2

Topic areas and interventions




a)  Intervention pathways: “ideal mix” b)  Costs/health gain/cost savings from


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Results: DALYs, costs, cost-effectiveness ratios alcohol interventions

DALYs Intervention

cost Cost

offsets Net cost Cost-effectiveness

ratio averted $Million $Million $Million $$/DALY Taxation increase 30% 100,000 0.6 -530 -530 Dominant Volumetric taxation 11,000 0.6 -57 -56 Dominant Advertising bans 7,800 20 -31 -12 Dominant Minimum drinking age 21 150 0.6 -0.8 -0.2 Dominant Licensing controls 2,700 20 -11 9 3,300 Brief intervention 160 2.3 -1.2 1.1 6,800 Brief intervention + telemarketing 340 6.1 -2.6 3.5 10,000 Drink drive mass media 1,500 39 -11 28 14,000 Random breath testing 2,300 71 -17 54 24,000 Residential treatment & naltrexone 480 59 4.4 55 120,000 Residential treatment 190 37 -1.7 35 150,000

Cobiac L, Vos T, Doran C, Wallace A (2009).Cost-effectiveness of interventions to prevent alcohol-related disease and injury in Australia. Addiction, 104:1646-55


Alcohol intervention pathway

-$600

-$500

-$400

-$300

-$200

-$100

$0

$100

- 20 40 60 80 100 120 140

Net lifetime costs (millions AUS$ 2003) Lifetime DALYs averted (thousands)

Ad bans

RBT

Drink drive mass media

Res. treat. + naltrexone

Licensing controls

Min. legal drinking age to 21 yrs Brief intervention

30% tax

Current practice

Volumetric tax


Physical inactivity

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-$1,000

-$800

-$600

-$400

-$200

$00 10 20 30 40 50 60 70

Net lifetime cost (millionsAUS$2003)

Lifetime DALYs averted (thousands)

Pedometers

GP referralMass media

Internet

GP prescription

TravelSmart


-4

0

4

8

12

16

0 200 400 600 Net

life

time

cost

s (2

008

A$

in b

illio

ns)

Lifetime DALYs averted

Salt Diuretic

H M L

Ca-channel blocker

H M

L

ACE-inhibitor H M

L ACE-inhibitor

H

M

L

Community heart health

Dietary counselling & sitostanols

Current practice

Blood pressure & cholesterol lowering


Blood pressure & cholesterol lowering

Cost per year for 40 mg generic simvastatin: Australia: $400 New Zealand: <$20

Diuretic H Diuretic M CCB H

CCB M - ACEi H

ACEi M

Statin H

Statin M

ACEi M

ACEi H CCB M

CCB H Diuretic M Diuretic H StatinNZ M StatinNZ H

- $0.5

$0.0

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

0 20 40 60 80 100 120 140

Net

life

time

cost

s (2

008A

$)

Billions

Lifetime DALYs averted or QALYs gained Thousands

$50,000/DALY or QALY


-4,000

-3,000

-2,000

-1,000

00 50 100 150 200 250 300

Net lifetime costs (million AUS $)

Lifetime DALYs averted (thousands)

Tax

Lapband

Diet & exercise

Weight loss


Dialysis & transplant (current practice)

DM ( 50-79)

Dialysis only

- 200

0

200

400

600

800

5,000 10,000 15,000 20,000 Net

LIfe

time

Cos

t (m

illio

n A

U$

2003

)


Screening and early treatment

DM ( 40-49)

DM ( 25-39)

Non-DM ( 50-79)

Non-DM ( 40-49)

Non-DM ( 25-39)

Chronic Kidney disease


Expansion pathway general vs Indigenous population

General population Indigenous population

DM ( 50-79)

DM (40-49)

DM (25-39)

Non-DM (50-79 )

Non-DM (40-49)

Non-DM (25-39)

-400

-200

0

200

400

600

800

0 5 000 10 000 15 000 20 000 25 000 30 000

Net

LIfe

time

Cos

t (m

illio

n A

U$

2003

)


DM

( 50-79)

Non-DM (50-79)

DM (40-49)

DM (25-39 )

Non-DM (40-49)

Non-DM (25-39)

DM

(50-79) Non-DM (50-79)

DM (40-49)

DM (25-39)

Non-DM (40-49)

Non-DM (25-39)

-40

-20

0

20

40

60

0 500 1 000 1 500 2 000

Net

LIfe

time

Cos

t (m

illio

n A

U$

2003

)


Chronic kidney disease intervention pathway (CKD screening, Indigenous population)

Remote






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23 dominant (cost-saving) preventive interventions


23 dominant preventive interventions vs. current practice

-30

-10

10

30

50

70

-$600

-$200

$200

$600

$1,000

$1,400

2003 2010 2017 2024 2031 2038 2045 2052 2059 2066 2073 2080

DALYs averted

Thousands

Costs

Millions

Years

Cost offsets - Dominant package Intervention costs - Current practice

Intervention costs - Dominant package Cost offsets - Current practice

Health gain - Dominant package Health gain - Current practice


-20

0

20

40

60

80

-$1

$0

$1

$2

$3

$4

2003 2010 2017 2024 2031 2038 2045 2052 2059 2066 2073 2080

DA

LYs

aver

ted

Mill

iers

Cos

ts

Mill

iard

s

Years

Intervention costs - Current practice Intervention costs - <$10,000/DALY package

Cost offsets - <$10,000/DALY package Health gain - <$10,000/DALY package

Combined impact 43 very cost-effective prevention measures

$4 billion upfront investment

Immediate cost savings in blood pressure & cholesterol

Treatment cost saved

1 million healthy life years






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Very cost-effective and large health impact: §  Tax alcohol, tobacco and ‘unhealthy food’ §  Regulation of salt content in bread, cereals and

margarine §  Treating blood pressure and cholesterol …. but doing

this more efficiently than we currently do •  using cheaper drugs •  better targeting who needs to be treated

§  Gastric banding for the very obese (but expensive!)

Key findings


Very cost-effective and moderate health impact:

§  Pedometers & mass media for physical activity

§  Smoking cessation drugs

§  Screen elderly women for osteoporosis & alendronate

§  Screen diabetics for chronic kidney disease


Very cost-effective and more modest health impact:

§  Fluoride drinking water

§  Hepatitis B vaccination

§  A range of 7 measures to prevent mental disorders or

suicide

Key findings


Other cost-effective measures:

§  Increased Sunsmart effort

§  HPV vaccination and Pap smear testing cervix cancer

§  Screen for pre-diabetes + drug or lifestyle intervention

§  Screen for chronic kidney disease + drug

§  Diet and exercise for overweight people (but limited

impact on weight loss)

Key findings


Not recommended:

§  PSA testing for prostate cancer (more harm than good)

§  Weight watchers

§  Drugs for losing weight

§  Most fruit and veg interventions

§  Aspirin to prevent cardiovascular disease

§  School based drug interventions

§  Vaccination for shingles

Key findings


Insufficient evidence of effectiveness:

§  Screening for vision loss

§  Dental check-ups

Key findings


Summary of results

1.  Taxation/regulation interventions tend to be very cost-effective (from health sector perspective) and have large health impact

2.  Great potential to improve efficiency in CVD prevention thru blood pressure and cholesterol lowering and accelerate CVD decline

3.  Untapped potential to address pre-diabetes, chronic kidney disease


Summary of results

4.  Emerging evidence for a substantial role in prevention of mental disorders

5.  Targeted interventions with drug treatments in CVD prevention, pre-diabetes, chronic kidney disease, osteoporosis good credentials

6.  Targeted interventions aiming to change behaviour tend not to be cost-effective and if so, have modest impact on population health outcomes


http://www.sph.uq.edu.au/bodce-ace-prevention

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