What does the ACE Prevention study tell us

about the cost-effectiveness of prevention?

Neil CraigFaisal Bhatti, Matt Lowther, Gerry McCartney

Outline

Aims Overview of ACE: Assessing Cost-Effectiveness

in Prevention Approach Results Conclusions

ACE Prevention review

Scottish Government asked NHSHS to: Critically review ACE Prevention Identify the elements of the ACE Prevention

report that can be used in priority setting in Scotland

Identify small no. of priorities where evidence and professional consensus is strong

Focused on 4 risk factors: alcohol, tobacco, physical activity and body mass

What is ACE Prevention?

Extensive priority setting exercise in Australia:

Quantitative- epidemiological data - effect sizes- cost/DALY avoided

What is ACE Prevention?

Qualitative

League table - dominant interventions - very cost-effective (A$0-10,000 per DALY) - cost-effective (A$10,000-50,000 per DALY) - non-cost effective (>A$50,000 per DALY)

Example results

Intervention Cost-effectiveness

Strength of evidence

Second filter

Volumetric alcohol tax

Dominant Likely Political will

ABI GP Very $3800/DALY

Sufficient Equity; GP capacity

Drink drive mass media

Cost-effective $14k/DALY

Limited None

Weight watchers

Not C-E $84k/DALY

Sufficient

PSA screening

Dominated

ACE Conclusions

Many interventions for prevention have very strong cost-effectiveness credentials

For the four risk factors we considered, the most cost-effective were policy and regulation-based

Many interventions for prevention have poor cost-effectiveness credentials

For the four risk factors we considered, very few were not cost-effective or better

Approach to our review

The review assessed: the epidemiological information and methods

used to inform the cost-effectiveness analyses the effectiveness evidence and the associated

estimated effect sizes the methods and assumptions used to inform the

economic analysis

Epidemiological evidence

Risky to transfer to Scotland

Need further clarification of the comparative burden of disease

Differences in risk factor-related mortality=> greater cost-effectiveness in Scotland for alcohol?

Effectiveness evidence

Not always clear how identified and synthesised

Effect sizes used in ACE :- supported where reported - identified where unclear

Large number of interventions that were not

included supported by effectiveness evidence

Economic analysis

Appropriate methods applied consistently across wide range of interventions

Issues in generalisation: QALYs versus DALYs Strength of evidence Perspective Comparators

QALYs vs DALYs

Effect of converting from DALYs to QALYs depends on:

the age of disease onset disease duration with and without treatment

=> relative ranking of interventions may change according to these differences in the diseases they seek to prevent

Strength of evidence

Of 39 interventions: Only 15 were deemed to have ‘sufficient’

evidence 15 had ‘limited’ or ‘inconclusive’ evidence 8 were ‘likely’ to be or were ‘maybe’ effective 1 had ‘no evidence’ of effectiveness

Perspective

Costs- only included costs to the health system and to patients and families

Benefits- patient perspective

=> Broader perspective ideal

Comparators

Current practice

Do nothing

Optimal pathways

Relevant to practice in Scotland?

Conclusions

Broad conclusions valid- plausible - logical- consistent

Specific conclusions need to be reviewed in light of:- local comparators- best evidence on those comparators- decision-makers’ values and priorities

Using results should involve dialogue