What does the ACE Prevention study tell us about the cost-effectiveness of prevention?

1. What does the ACE Prevention study tell us about the cost-effectiveness of prevention? Neil Craig Faisal Bhatti, Matt Lowther, Gerry McCartney

2. Outline • Aims • Overview of ACE: Assessing Cost-Effectiveness in Prevention • Approach • Results • Conclusions

3. 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

4. What is ACE Prevention? • Extensive priority setting exercise in Australia: • Quantitative- epidemiological data - effect sizes- cost/DALY avoided

5. 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)

6. Example results

7. 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

8. 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

9. 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?

10. 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

11. Economic analysis Appropriate methods applied consistently across wide range of interventions Issues in generalisation: • QALYs versus DALYs • Strength of evidence • Perspective • Comparators

12. 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

13. 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

14. Perspective • Costs- only included costs to the health system and to patients and families • Benefits- patient perspective => Broader perspective ideal

15. Comparators • Current practice • Do nothing • Optimal pathways Relevant to practice in Scotland?

16. 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