Eupha 4.obesityhealthandeconomicassessment by_michelececchini

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Improving Lifestyles, Tackling Obesity: Assessing the Health and Economic Impact of Prevention Strategies Michele Cecchini MD, MSc Health Policy Analyst, OECD

Transcript of Eupha 4.obesityhealthandeconomicassessment by_michelececchini

Page 1: Eupha 4.obesityhealthandeconomicassessment by_michelececchini

Improving Lifestyles, Tackling

Obesity: Assessing the Health

and Economic Impact of

Prevention Strategies

Michele Cecchini MD, MSc

Health Policy Analyst, OECD

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Chronic Diseases and Prevention

• Increasing prevalence of chronic diseases in the OECD area

– Incidence is increasing (ageing, lifestyles)

– Mortality is decreasing (better healthcare)

• Some risk factors are declining (e.g. smoking)…

• … but others are rising (e.g. unhealthy diet and physical inactivity)

• Prevention or treatment?

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Are Prevention Interventions Justified?

It is better to be healthy than ill or dead.

That is the beginning and the end of the only real argument for preventive medicine.

It is sufficient.

Geoffrey Rose

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The Goals of Prevention

Prevention may offer opportunities to:

• Increase social welfare

• Enhance health equity

Relative to a situation in which chronic diseases are treated when they emerge

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“Maintaining good health is an important goal for most individuals, but health is by no means the only outcome that individuals value when they choose how to lead their own lives. Individuals wish to engage in activities from which they expect to derive pleasure, satisfaction, or fulfilment, some of which may be conducive to good health, others less or not at all. […] An assessment of the role of prevention must not ignore those competing goals” (Sassi and Hurst, 2008)

Are Prevention Interventions Justified?

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• Market and rationality failure: – Externalities

– Information failures

– Supply-side market failures

– Failures of rationality

• Existing policies have undesired effects

• Health inequalities

Are Prevention Interventions Justified?

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Education and Smoking

From D. Kenkel’s presentation at OECD Expert Group meeting, 27 April 2007.

Smoking risk knowledge and degree Smoking prevalence and degree

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Concerns About Rising Obesity

• Evidence consistently shows rising overweight and obesity rates in OECD area

• No sign of decline or slowdown

• BMI distributions are shifting following similar patterns across countries and over time

• Countries with the lowest overweight prevalence today will have caught up with high prevalence rates within 10 years

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Obesity: a Growing Problem

20%

30%

40%

50%

60%

70%

80%

1970 1980 1990 2000 2010 2020

Pro

po

rtio

n o

verw

eigh

t (a

du

lt p

op

ula

tio

n)

Year

USA England

Spain

Austria

France

Australia

Canada

Korea

Italy

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What Policy Options?

Interventions assessed on the basis of interference with individual choice:

1. Actions that widen the choice set or decrease the price (opportunity cost) of selected choice options;

2. Actions that influence choices through means other than prices, such as persuasion, provision of information, or other suitable means;

3. Actions that increase the price (opportunity cost) of selected choice options;

4. Actions that restrict the choice set by banning selected choice options

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What Policy-Makers Want to Know

• Does prevention improve health?

• Does it reduce health expenditure?

• Does it improve health inequalities?

• Is it cost-effective?

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Expectations Must Be Realistic

0%

4%

8%

12%

16%

20%

24%

28%

32%

36%

Cost-saving < 10,000 10,000 to 50,000

50,000 to 100,000

100,000 to 250,000

250,000 to 1,000,000

≥ 1,000,000

increases cost and worsen health

Pro

po

rtio

n o

f p

ub

lish

ed

co

st-e

ffec

tiv

enes

s ra

tio

s

Cost-effectiveness ratio ($ per QALY)

Preventive measures Treatments for existing conditions

Adapted from Cohen JT, et al. NEJM 2008;358(7):661-3

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Physical activity P0 adequate physical act

P1 insuff .physical act

Body mass

index N normal weight

U pre-obesity

V obesity

Blood pressure Z0 normal

Z1 hypertension

Cholesterol

A0 normal

A1 hypercholesterolemia

Glycaemia B0 normal

B1 diabetes

Cancers

Stroke

Ischemic heart

disease

Distal risk factors Intermediate risk

factor Proximal risk factors Diseases

Fat F0 low fat intake

F1 medium fat intake

F2 high fat intake

Fibre Y0 adequate fibre intake

Y1 low fibre intake

Socio-economic status I0 upper

I1 lower

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Interventions

Health education and health promotion

Regulation and fiscal measures

Primary-care based interventions

Mass media campaigns Fiscal measures

(fruit and vegetables and foods high in fat)

Physician counselling of individuals at risk

School-based interventions

Government regulation or industry self-regulation of

food advertising to children

Intensive physician and dietician counselling of

individuals at risk

Worksite interventions Compulsory food

labelling

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Scope of Modelling Work

Regional analysis Country analyses

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Does Prevention Improve

Population Health?

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Health Outcomes of Prevention

0 100,000 200,000 300,000 400,000 500,000

physician-dietician counselling

fiscal measures

physician counselling

food labelling

worksite interventions

food advertising regulation

school-based interventions

food adverting self-regulation

mass media campaigns

Disability-adjusted life years Life years

1 LY/DALY every 115/121 people

1 LY/DALY every 12/10 people

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Health Outcomes over Time England

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

0 10 20 30 40 50 60 70 80 90 100

DA

LYs

(pe

r m

illio

n p

op

ula

tio

n)

Time (years)

school-based interventions

worksite interventions

mass media campaigns

fiscal measures

physician counselling

physician-dietician counselling food advertising regulation food adverting self-regulation

food labelling

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Intervention Effectiveness (coverage)

Working for large employer [63%]

Employed [64%]

Population aged 18-65 [64%]

Participating

employers [50%]

Participating

employees

[45%]

Coverage = 5.8% of the population

Worksite interventions

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Intervention Effectiveness (Time to Steady State)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 98 99 100

1

2

3

90

91

age

pe

rio

d

0 10 20 30 40 50 60 70 80 90 100

school-based int

food advert reg

food advert self-reg

worksite interv

physician couns

phys/diet couns

mass media camp

food labelling

fiscal measures

years to steady state

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Does Prevention Reduce

Expenditure on Health Care?

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Financial Impacts

-50

50

150

250

350

450

550

Co

st

(bil

lio

n $

PP

P)

intervention costs health expenditure

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Health Outcomes and Expenditure Physician-Dietician Counselling

-15000-10000-10000

Health outcomes Impact on health expenditure

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

life years (thousands) DALYs (thousands)

-15,000

-10,000

-5,000

0

5,000

10,000

costs (million $PPP)

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Interventions vs. Age

0.95

1.00

1.05

1.10

1.15

Intervention (50 yrs old) Age (51 vs 50)

Change in risk of IHD

Note: risk equals to 1 for 50 year olds and no intervention

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Does Prevention Improve

Health Inequalities?

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Impact on Inequalities

Different social groups have:

• Different risk profiles:

– Larger benefits in those most at risk (~)

• Different responses to interventions:

– Larger benefits with a greater response

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Impact on Inequalities

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

high SES low SES

Worksite interventions Fiscal measures

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

high SES low SES

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Is Prevention Cost-Effective?

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Cost-Effectiveness of Prevention

0

50,000

100,000

150,000

200,000

250,000

300,000

10 20 30 40 50 60 70 80 90 100

Co

st-e

ffe

ctiv

en

ess

rati

o (

$P

PP

pe

r D

ALY

)

Years after initial implementation

school-based interventions worksite interventions mass media campaigns

fiscal measures physician counselling physician-dietician counselling

food advertising regulation food adverting self-regulation food labelling

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Cost-effectiveness of Prevention after 20 years

-30

0

30

60

90

120

150

0 1 2 3 4 5 6 7 8 9 10

Co

st

(an

nu

al

av

er

ag

e,

bil

lio

n $

PP

P)

Effect (average annual DALY gain, millions)

phys-diet couns

phys couns

fiscal measures

food labelling

worksite interv

food adv self-reg

‡ food adv reg

mass media camp

* school-based int

*

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-50

0

50

100

150

200

250

0 2.5 5 7.5 10 12.5 15 17.5 20

Co

st

(an

nu

al

av

er

ag

e,

bil

lio

n $

PP

P)

Effect (average annual DALY gain, millions)

phys-diet couns phys couns

worksite interv

food labelling

fiscal measures food adv self-reg

food adv reg

school-based int

mass media camp

Cost-effectiveness of Prevention after 100 years

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The role of prevention packages

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Multiple interventions Health outcomes Impact on health expenditure

(selected diseases)

Multiple int. 1 school-based intervention + mass media camp + physician-dietician counselling

Multiple int. 2 food labelling + food advert self-regulation + school-based interventions + mass media campaigns + physician-dietician counselling

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Life years (thousands)

Disability-adjusted life years (thousands)

-70,000

-60,000

-50,000

-40,000

-30,000

-20,000

-10,000

0

Impact on health expenditure (million $PPP)

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Multiple Interventions

0 50 100 150 200 250 300 350 400

Cost-effectiveness ratio (thousand $PPP per DALY)

50

,00

0 $

PP

P/D

AL

Y

mo

re t

ha

n 1

,00

0,0

00

$P

PP

/DA

LY

0 25 50 75 100

Cost-effectiveness ratio (thousand $PPP per DALY)

50

,00

0 $

PP

P/D

AL

Y

Fiscal measures

Mass media camp

Phys-diet couns.

Food labelling

Multiple int. 2

Multiple int. 1

Physician couns.

Worksite interv.

Food adv self-reg.

Food advert.

School-based int.

Cost-effectiveness of interventions after 10 years Cost-effectiveness of interventions after 100 years

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Policy Implications

• Prevention is an effective and cost-effective way to improve population health

• Prevention can decrease health expenditure and improve inequalities, but not to a major degree

• Comprehensive strategies combining population and individual approaches provide best results

• Involvement of relevant stakeholders is key to the success of prevention

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OECD work on prevention

• Obesity and the economics of prevention: fit not fat

• OECD health working papers HWP 32, 45, 46, 48

• Paper in Lancet series on chronic diseases (forthcoming)

www.oecd.org/health/prevention www.oecd.org/health/fitnotfat [email protected]