Estimated Reductions in Influenza-related Mortality among the Elderly through
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Estimated Reductions in Influenza-related Estimated Reductions in Influenza-related Mortality among the Elderly through Mortality among the Elderly through
Direct-to-Consumer Advertising Direct-to-Consumer Advertising
of Influenza Vaccineof Influenza Vaccine
Mitesh S Patel*Mitesh S Patel*
Matthew M. DavisMatthew M. Davis##
*University of Michigan Medical School, and *University of Michigan Medical School, and ##Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,
Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, University of MichiganUniversity of Michigan
Influenza MortalityInfluenza Mortality
Predominately and disproportionately impacts elderlyPredominately and disproportionately impacts elderly
Rates of annual influenza vaccination among the elderly Rates of annual influenza vaccination among the elderly are approximately 65%are approximately 65%
Vaccination rates fall short of the Vaccination rates fall short of the Healthy People 2010Healthy People 2010 target of 90% and may be a concern on the national leveltarget of 90% and may be a concern on the national level
Direct-to Consumer (DTC) AdvertisingDirect-to Consumer (DTC) Advertising
Spending on DTC advertising rose from $266 million in Spending on DTC advertising rose from $266 million in 1994 to $3.2 billion in 20031994 to $3.2 billion in 2003
Effective method of increasing sales of prescription Effective method of increasing sales of prescription pharmaceuticalspharmaceuticals
Could it be an effective method of increasing influenza Could it be an effective method of increasing influenza vaccination rates and achieving mortality benefits?vaccination rates and achieving mortality benefits?
Research ObjectiveResearch Objective
To examine the potential cost-effectiveness of a federal To examine the potential cost-effectiveness of a federal program of DTC advertising for influenza vaccination of eldersprogram of DTC advertising for influenza vaccination of elders
Methods: Number Needed to VaccinateMethods: Number Needed to Vaccinate
Number Needed to Vaccinate (NNV)Number Needed to Vaccinate (NNV)
Quantifies the number of people that must be vaccinated to Quantifies the number of people that must be vaccinated to prevent one all-cause deathprevent one all-cause death
Analogous to the Number Needed to Treat (NNT)Analogous to the Number Needed to Treat (NNT)
NNV = 1NNV = 1 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(population mortality rate) x (vaccine efficacy against mortality)(population mortality rate) x (vaccine efficacy against mortality)
Methods: DTC Advertising and Methods: DTC Advertising and Pharmaceutical SalesPharmaceutical Sales
DTC advertising in DTC advertising in 19991999
SpendingSpending Change in SalesChange in Sales
24 Most heavily 24 Most heavily advertised drugsadvertised drugs $1.338 billion$1.338 billion 41.7%41.7%
Rest of the Rest of the MarketMarket $481 million$481 million 14.4%14.4%
Net DifferenceNet Difference $857 million$857 million 27.3%27.3%
Findlay. Pharmacoeconomics. 2001.
Methods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase
60
65
70
75
80
85
90
95
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Influ
enza
Eld
erly
Vac
cina
tion
Rat
e
.
.
Methods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase
60
65
70
75
80
85
90
95
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Influ
enza
Eld
erly
Vac
cina
tion
Rat
e
?
60
65
70
75
80
85
90
95
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Infl
uen
za E
lder
ly V
acci
nat
ion
Rat
eMethods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
194.1 million
3
12.20
10
18.90
3
+/- 10%
5 - 15
1.5 – 6
Population Mortality Rate 132.5/100,000
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
194.1 million
3
12.20
10
18.90
3
+/- 10%
5 - 15
1.5 – 6
Population Mortality Rate 132.5/100,000
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
194.1 million
3
12.20
10
18.90
3
+/- 10%
5 - 15
1.5 – 6
Population Mortality Rate 132.5/100,000
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
194.1 million
3
12.20
10
18.90
3
+/- 10%
5 - 15
1.5 – 6
Population Mortality Rate 132.5/100,000
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Vaccine Efficacy, % Year 2006 67.61 56 – 76 (95% CI)
Elderly Population, millions(Revaccinated Persons, %) Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015
37.2 (60.0)37.8 (69.9)38.7 (74.2)39.8 (77.5)40.2 (81.9)41.1 (83.1)42.6 (83.5)44.0 (85.0)45.3 (86.2)46.8 (86.6)
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Vaccine Efficacy, % Year 2006 67.61 56 – 76 (95% CI)
Elderly Population, millions(Revaccinated Persons, %) Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015
37.2 (60.0)37.8 (69.9)38.7 (74.2)39.8 (77.5)40.2 (81.9)41.1 (83.1)42.6 (83.5)44.0 (85.0)45.3 (86.2)46.8 (86.6)
Methods: Model ParametersMethods: Model Parameters
VariableBase Case Estimate
Range for SensitivityAnalysis
Vaccine Efficacy, % Year 2006 67.61 56 – 76 (95% CI)
Elderly Population, millions(Revaccinated Persons, %) Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015
37.2 (60.0)37.8 (69.9)38.7 (74.2)39.8 (77.5)40.2 (81.9)41.1 (83.1)42.6 (83.5)44.0 (85.0)45.3 (86.2)46.8 (86.6)
Methods: Primary Outcome MeasuresMethods: Primary Outcome Measures
For each year 2006-2015 we estimatedFor each year 2006-2015 we estimated
Reduction in mortalityReduction in mortality
Cost per life-year saved =Cost per life-year saved =
∑∑Year = xYear = x [cost (DTC + Vaccination)][cost (DTC + Vaccination)] - ∑ - ∑Year = (x-1)Year = (x-1) [cost (DTC + Vaccination)] [cost (DTC + Vaccination)]
Year=2006Year=2006 Year=2006Year=2006
____________________________________________________________________________________________________∑∑Year = xYear = x [life-years saved][life-years saved] - ∑ - ∑Year = (x-1)Year = (x-1) [life-years saved][life-years saved]
Year=2006 Year=2006 Year=2006Year=2006
Results: Base Case – Results: Base Case – First Year of ProgramFirst Year of Program
# 95% CI
NNV
Elderly lives saved
Life-years saved
Results: Base Case – Results: Base Case – First Year of ProgramFirst Year of Program
# 95% CI
NNV 1,116 993 – 1,348993 – 1,348
Elderly lives saved 1,999 1,656 – 2,2471,656 – 2,247
Life-years saved 22,768 18,861 - 25,59818,861 - 25,598
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
11000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Est
imat
ed N
um
ber
of
Eld
erly
Liv
es S
aved
Lower Bound Vaccine Efficacy Upper Bound Vaccine Efficacy Mean Vaccine Efficacy
Results: Elderly Lives SavedResults: Elderly Lives Saved
Year
OverallVaccination
Rate (%)
OverallVaccine
Efficacy (%)(95% CI)
Cost of DTCAdvertising
Program(millions
US$)
Cost ofIncrementalIncrease inVaccination
(millions US$)
IncrementalLife-Years
Saved
Cost PerLife-Year Saved
(US$)(95% CI)
2006 7167.61
(56 – 76)194.1 69.4 22,768
11,573(10,293 - 13,970)
2007 7668.68
(57.07 – 77.07)199.9 62.2 19,057
13,756(12,259 – 16,555)
2008 79.7569.15
(57.57 – 77.54)205.9 50.5 14,324
17,900(15,963 - 21,512)
2009 82.7569.51
(57.90 – 77.90)212.1 44.0 11,505
22,258(19,860 – 26,721)
2010 8569.99
(58.38 – 78.38)218.4 35.4 8,552
29,685(26,508 – 35,589)
Results: Cost-Effectiveness of a 10-year Results: Cost-Effectiveness of a 10-year DTC Program for Influenza VaccineDTC Program for Influenza Vaccine
Results: Cost-Effectiveness of a 10-year Results: Cost-Effectiveness of a 10-year DTC Program for Influenza VaccineDTC Program for Influenza Vaccine
Year
OverallVaccination
Rate (%)
OverallVaccine
Efficacy (%)(95% CI)
Cost of DTC
AdvertisingProgram(millions
US$)
Cost ofIncrementalIncrease inVaccination
(millions US$)
IncrementalLife-Years
Saved
Cost PerLife-Year Saved
(US$)(95% CI)
2011 86.570.12
(58.51 – 78.51)225.0 25.6 5,676
44,159(39,440 – 52,921)
2012 87.7570.16
(58.55 – 78.55)231.7 23.5 4,790
53,291(47,599 – 63,858)
2013 88.7570.32
(58.71 – 78.71)238.7 20.7 3,874
66,945(59,809 – 80,183)
2014 89.570.45
(58.84 – 78.84)245.9 17.0 2,925
89,884(80,319 – 107,619)
2015 9070.50
(58.89 – 78.89)253.2 12.5 1,961
135,535(121,121 – 162,255)
Results: Cost-Effectiveness of a 10-year Results: Cost-Effectiveness of a 10-year DTC Program for Influenza VaccineDTC Program for Influenza Vaccine
Year
OverallVaccination
Rate (%)
OverallVaccine
Efficacy (%)(95% CI)
Cost of DTC
AdvertisingProgram(millions
US$)
Cost ofIncrementalIncrease inVaccination
(millions US$)
IncrementalLife-Years
Saved
Cost PerLife-Year Saved
(US$)(95% CI)
2011 86.570.12
(58.51 – 78.51)225.0 25.6 5,676
44,159(39,440 – 52,921)
2012 87.7570.16
(58.55 – 78.55)231.7 23.5 4,790
53,291(47,599 – 63,858)
2013 88.7570.32
(58.71 – 78.71)238.7 20.7 3,874
66,945(59,809 – 80,183)
2014 89.570.45
(58.84 – 78.84)245.9 17.0 2,925
89,884(80,319 – 107,619)
2015 9070.50
(58.89 – 78.89)253.2 12.5 1,961
135,535(121,121 – 162,255)
TOTAL 2,225 360.9 95,43427,096
(24,159 – 32,575)
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
Ov
era
ll C
os
t p
er
Lif
e Y
ea
r S
av
ed
Best Case Base Case Worst Case
Results: Overall Cost-EffectivenessResults: Overall Cost-Effectiveness
Study LimitationsStudy Limitations
Mortality benefits of influenza vaccinationMortality benefits of influenza vaccination
DTC advertising has only been studied for boosting DTC advertising has only been studied for boosting pharmaceutical salespharmaceutical sales
Medicare incurs greater program costsMedicare incurs greater program costs
Annual cost per average beneficiary is $5,400Annual cost per average beneficiary is $5,400
Average life expectancy of elders in hypothetical cohort is 11.7 Average life expectancy of elders in hypothetical cohort is 11.7 yearsyears
SummarySummary
Overall the cost per life-year saved is about $27,000 for Overall the cost per life-year saved is about $27,000 for the 10-year DTC promotion of influenza vaccine for the the 10-year DTC promotion of influenza vaccine for the elderlyelderly
Sensitivity analysisSensitivity analysis Worst caseWorst case
Cost per life-year saved < $40,000Cost per life-year saved < $40,000
Total lives saved > 7,000 livesTotal lives saved > 7,000 lives
Total cost of DTC advertising over 10 years = $2.2 billionTotal cost of DTC advertising over 10 years = $2.2 billion
ImplicationsImplications
First study to suggest potential benefits of DTC First study to suggest potential benefits of DTC advertising on public immunization effortsadvertising on public immunization efforts
DTC advertising directed towards elders mayDTC advertising directed towards elders may
Induce demand for influenza vaccineInduce demand for influenza vaccine
Raise vaccination rates towards the target of 90%Raise vaccination rates towards the target of 90%
Achieve mortality benefitsAchieve mortality benefits
Be cost-effective for the Federal Government to pursueBe cost-effective for the Federal Government to pursue
Estimated Reductions in Influenza-related Estimated Reductions in Influenza-related Mortality among the Elderly through Mortality among the Elderly through
Direct-to-Consumer Advertising Direct-to-Consumer Advertising
of Influenza Vaccineof Influenza Vaccine
Mitesh S Patel*Mitesh S Patel*
Matthew M. DavisMatthew M. Davis##
*University of Michigan Medical School, and *University of Michigan Medical School, and ##Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,
Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, University of MichiganUniversity of Michigan