insights from ace prevention: what worked and what needs to be done in economic evaluation

Cairns 16th October 2014

Professor Christopher Doran

Insights from ACE Prevention: what worked

and what needs to be done in economic evaluation

• Introduction to economic evaluation

• Overview of ACE Prevention

• Introduction to impact assessment

• 2 Indigenous examples of impact assessment

Overview

• Resources are scarce in relation to needs / demand

• Scarcity forces choices to be made and choices imply a sacrifice or foregone opportunity

Context of economic evaluation

Economic evaluation is …

Program A

Program B

Choice

CostB

ConsequencesB

CostA

ConsequencesA

The comparative analysis of alternative courses of action in terms of both their costs and consequences in order to assist policy decisions”.

Types of economic evaluation

TYPE OF ANALYSIS

COSTS

CONSEQUENCES

RESULT

Cost Minimisation Analysis (CMA)

Dollars Identical in all respects Least cost alternative

Cost Effectiveness Analysis (CEA)

Dollars Different magnitude of a common measure, eg Life years (LY) gained, blood pressure reduction

Cost per unit of consequence, eg cost per LY gained

Cost Utility Analysis (CUA)

Dollars Single or multiple effects not necessarily common. Valued as “utility”, eg QALY

Cost per unit of consequence, eg per QALY/DALY

Cost Benefit Analysis (CBA)

Dollars As for CUA but valued in money

Net $ (P.V.) Cost/Benefit ratio

Assessing Cost-Effectiveness-Prevention

Rob Carter, Theo Vos, Chris Doran,

Alan Lopez, Andrew Wilson, Ian Anderson, Jan Barendregt, Wayne Hall

Assessing Cost-Effectiveness (ACE) studies in Australia

• Pilot project in cancer prevention (2000)• ACE–Heart Disease (2000-2003)

• 20 + interventions for prevention of coronary heart disease

• ACE–Mental Health (2001-2004)• 20 + interventions for depression, schizophrenia, anxiety and

ADHD

• ACE-Obesity (2004-2005)• Focus on childhood interventions

• ACE-Alcohol (2006-2008)• Around 10 interventions to reduce harm from alcohol misuse

• ACE-Prevention (2005-2009)• ACE-Alcohol Indigenous (2010-2014)

ACE Prevention: methods

• Understand natural history of disease (from burden of disease study)

• Analyse current practice: % receiving intervention(s); adherence

• Efficacy/effectiveness from literature• Impact in routine Australian health services?• Model change in health outcomes (often over a lifetime)

in DALYs• Difference in costs of intervention & cost offsets• Cost-effectiveness ratios in $$/DALY• Mix of most cost-effective interventions

From policy to measurement of benefit

• Two-stage approach adopted in ACE

• First, a measure of health gain in relation to resources consumed ($ cost per DALY) Picks up element of cost, efficacy/effectiveness and efficiency

objectives

• Second, explicitly provide for broader considerations not in this C/E ratio Which we call our ‘2nd stage filters’ (equity; acceptability;

feasibility; size of the problem) Plus confidence in evidence base

Presenting cost-effectiveness • Can put all costs (y-axis) and health effects (x-axis) on a graph • Slope of the line represents the economic attractiveness of an

intervention

costsSlope = CER = ----------------------

health effects

• The flatter the slope, the more cost-effective

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

Topic areas and interventions

Intervention pathways: ‘Ideal mix’

Alcohol intervention pathway

-$600

-$500

-$400

-$300

-$200

-$100

$0

$100

- 20 40 60 80 100 120 140

Ne

t lif

eti

me

co

sts

(m

illio

ns

AU

S$

20

03

) 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

Combining everything in one model

Combined impact 43 very cost-effective prevention measures

$4 billionupfrontinvestment

Immediate cost savings in blood pressure & cholesterol

Treatment cost saved

1 million healthy life years

ACE Prevention - main findings

Areas amenable to preventive interventions to reduce size of burden :

Substantial CVD, diabetes, kidney disease, tobacco, alcohol, physical inactivity, salt

Moderate Mental disorders, drug use, osteoporosis

Modest to small Obesity (unless regs/tax work), F&V, cancer screening

Pros•Good engagement with policy makers / Indigenous leaders

•Platform of recent epidemiological data

•Used sophisticated methods

•Attempted to consider equity, acceptability, feasibility

•Very good dissemination and capacity building (eg. PhDs)

Cons•Very technical – policy makers found it hard to understand, eg. What is a DALY?

•Focus on health outcomes – for certain risk factors (alcohol) non-health very important

•Relied on secondary data of mixed quality

•Modelling considered a black box – not very researcher friendly

ACE Prevention - summary

• Funding stopped– limited interest / funding to extend methods in Australia– Centre for Burden of Disease and Cost-Effectiveness ceased to exist

• Majority of staff left UQ– Prof Lopez moved to Uni Melbourne– Prof Theo Vos and A/Prof Lim moved to Uni Washington to work on the

Global Burden of Disease study funded by Bill Gates– Others now working at World Health Organisation, Oxford University +

other Australian Unis

• I relocated to Hunter Medical Research Institute to focus on translation research and impact assessment

ACE Prevention – what next?

The imperative for measuring research impact…

… there is a need to maximise the translation of effective

research outcomes into health policy, programs and

services

… this need is central to the Wills and McKeon reviews

The generation and use of high-quality, relevant research

evidence will improve health policy and program effectiveness,

achieve better health and help build efficient services.

Wills Review, 2012

In Australia the debate on improving health outcomes has relied

too much on arguments about increasing resources, and not

enough on improving productivity and effectiveness through

microeconomic reform and translation of innovations from

research.

Mckeon Review, 2013

• Socially responsible and good for patients• Policy makers and the community are looking for research

that is likely to provide a positive social return on investment (SROI)

• Policy is already changing • Reward research that demonstrates its potential (and

actual) ‘research translation’• Onus on researchers to demonstrate ‘value for money’• Further evidence of this shift in policy

• NHMRC (NHMRC Advanced Health Research and Translation Centres) • ARC (principles of research translation).

The imperative for measuring research impact…

Existing work in this field

• Measuring research impact• Payback method: Buxton& colleagues UK in 1996

• Core domains of benefit, each with metrics: knowledge, research, political and administrative, health sector and economic. Scores to represent success in each domain

• Other versions: Canadian Institutes of Health (2005), Research Impact Framework (2006), Canadian Academy of Health Sciences Framework (2009)

• Becker list (Washington University School of Medicine) (Last update 2014)

• All include a dimension of economic impact.

• AU Government• NSW Government Evaluation Framework (2013)• Cooperative Research Centre (Impact Tool)

Translational research pathway (From an economic perspective)

COST BENEFITCOST

Example: Family well-being (FWB)

• FWB program focuses on the empowerment and personal development of Indigenous people through people sharing their stories, discussing relationships, and identifying goals for the future. – Workshops are held with both adults and children to highlight the

various health and social issues experienced by Indigenous communities and the steps that can be implemented to deal with these issues.

• HMRI are working with James Cook University to identify the economic impact of the program of the program

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

Translational research pathway (An example from Family Wellbeing - FWB)

COST BENEFITCOST

DEMAND AIMS & ACTIVITIES OUTCOMES IMPACTCOST

Developing a framework to evaluate the impact of Family well-being?

• Our framework includes a specific FWB survey that enables us to collect information pertinent to assessing impact• If the evaluation is conducted as a prospective exercise (rather than

retrospective – as occurs in most cases) it can also provide ongoing feedback to researchers / service providers on performance.

• In this way it can act as a component/facilitator of continuous quality improvement

• We acknowledge some problems but we are working on this• The GEM is an appropriate measure of wellbeing

• Currently cannot convert changes in wellbeing scores to $ values• Some international work is suggesting that wellbeing be included

in all cost benefit analyses and the UK Treasury have published a paper on their attempt to convert wellbeing into $ values

• Our aim is to advance this research in Australia

Example: Institute of Urban Indigenous Health

• The Institute of Urban Indigenous Health (IUIH) was established in July 2009 as a strategic response to the growth and geographic dispersion of the Aboriginal and Torres Strait Islander population in South East Queensland (SEQ) which accounts for 38% of Queensland’s, and 10% of Australia’s total Aboriginal and Torres Strait Islander population.

• The role of the IUIH is to lead health service planning, develop and co-ordinate health service delivery, and to play a major role in the development of partnerships between health care providers

• The IUIH activities are diverse, multifaceted and lead to a range of outputs. The impacts of these activities are closely aligned with the strategic goals of the IUIH: to improve access to comprehensive primary health care; to develop an effective and culturally aware workforce; to build sustainable partnerships; and to contribute to building the evidence base. While some of these impacts may lead to quantifiable economic return, others are more difficult to quantify. In this analysis benefits were quantified for avoided hospitalisations, avoided time in hospital and the economy wide benefits from employment.

IMPACT / BENEFITOUTPUT / OUTCOMEACTIVITYCOST

Example: Institute of Urban Indigenous Health

• The IUIH activities are diverse, multifaceted and lead to a range of outputs.

• The impacts of these activities are closely aligned with the strategic goals of the IUIH: to improve access to comprehensive primary health care; to develop an effective and culturally aware workforce; to build sustainable partnerships; and to contribute to building the evidence base.

• While some of these impacts may lead to quantifiable economic return, others are more difficult to quantify.

• The next logical step for the Institute is to unpack the rich clinical data that it collects to demonstrate longitudinal improvements in patient and community outcomes from the range of Institute activities.

• A better understanding of this clinical data would facilitate a more comprehensive assessment of the economic benefit of the IUIH and a better understanding of the IUIH contribution to closing the gap

Summary

• In an environment of limited resources it is important to evaluate what we do

• Economics provide a framework to identify value for money ranging from cost-effectiveness to cost-benefit analysis

• Cost-effectiveness is appropriate when comparing health programs

• Cost benefit is appropriate when examining return on investment or conducting an impact assessment

• Policy makers are increasingly requiring evaluations that make sense – what is the return on the investment?

• Good evaluation requires good data, plausible assumptions and a robust methodology

Thank you

Chris.doran@hmri.com.au