How can we maximise the bang from the bucks spent in preventive health?
This, to put it crudely, was one of the key questions asked by an important study released this morning in Melbourne, which is being billed as “the most comprehensive evaluation of health prevention measures ever conducted world-wide”.
The study looked at how to achieve a more efficient and a fairer health system, and had a particular focus on Indigenous health. As well as identifying what we should do more of, it suggests what we should do less of.
The Assessing Cost-Effectiveness of Prevention (or ACE-Prevention) study is a five-year investigation funded by the National Health and Medical Research Council and jointly led by Professor Theo Vos of the Centre for Burden of Disease and Cost-Effectiveness at the University of Queensland and Professor Rob Carter of the Deakin Health Economics Unit at Deakin University.
Thanks to Theo Vos and his UQ colleague Jan Barendregt for providing this report for Croakey readers:
The project’s aim was to make a comprehensive evaluation of the prevention of non-communicable disease and its main risk factors. Eventually, 123 preventive interventions were selected and analysed.
For comparison purposes, 27 treatment interventions were included. The measure of health benefit is the ‘disability-adjusted life year’ (DALY). Interventions with a cost-effectiveness ratio below a threshold value of $50,000 per DALY are deemed cost-effective.
ACE-Prevention is unique because of the large number of interventions evaluated in a comparable manner. It provides governments with a blueprint how to invest in cost-effective prevention and how to reduce wasteful spending.
An important conclusion is that much of current primary prevention in cardiovascular disease is very effective but highly inefficient. The 43 most cost-effective preventive interventions we advocate could be financed by more efficient prescribing for primary prevention of cardiovascular disease.
The cost savings could be even greater if the Department of Health and Aging would take their cue from New Zealand’s PHARMAC and negotiate better prices for drugs listed on the PBS.
- Many interventions for prevention have very strong cost-effectiveness credentials: 43 are either cost-saving or cost less than $10,000 per DALY prevented. Among these are taxation increases for alcohol, tobacco, and unhealthy food, blood pressure and cholesterol lowering drugs, but also infant hepatitis B vaccination and gastric banding for severe obesity. Such interventions should only be ignored if decision-makers have very serious reservations about the evidence base or are facing insurmountable problems in relation to stakeholder acceptability or feasibility of implementation.
- Another group of 31 preventive interventions are good value for money compared to the decision threshold of less than $50,000 per DALY prevented. These include screening for pre-diabetes and kidney disease, and some additional blood pressure and cholesterol lowering drugs.
- But there are also 38 interventions for prevention that have poor cost-effectiveness credentials. These include dietary interventions to combat obesity: they have poor effectiveness. Others are simply too expensive: Ranibizumab for age-related macular degeneration. Two are associated with more harm than benefit: prostate cancer screening and rosiglitazone after screening for diabetes. It is vital to recognise that prevention is not always value for money and is not always ‘better than cure’.
- A large impact on population health (i.e. >100,000 DALYs prevented over a lifetime per intervention) can be achieved by a limited number of cost-effective interventions: taxation of tobacco, alcohol and unhealthy foods; regulating the salt content of processed food; improving the efficiency of blood pressure- and cholesterol-lowering drugs; gastric banding for severe obesity; and an intensive SunSmart campaign.
- There are more cost-effective interventions with a moderate impact on population health (between 10,000 and 100,000 DALYs prevented per intervention). The main missed opportunities at the national level among these are screening programs for pre-diabetes, chronic kidney disease and low bone mineral density in elderly women. Smoking cessation aids, pedometers and mass media for physical activity are other approaches with moderate population health impact.
- Of the cost-effective interventions with a smaller population health impact (<10,000 DALYs per intervention), the growing list of potential preventive measures for mental disorders deserves special mention.
Addressing the inefficiency of current preventive drug treatment for cardiovascular disease (by choosing the most cost-effective drugs and targeting those at absolute risk rather than individual risk factor thresholds) could free up enough resources in the short term to fund most of the 43 most recommended interventions.
Implementation of the recommended package calls for political will, particularly for the taxation and regulation interventions. This study provides compelling evidence to make these changes.
A large number of the recommended interventions are delivered by primary care services and may require a combination of training and incentives to facilitate general practitioners to support them.
The recommended preventive drug interventions would require a large number of people to take medication for the rest of their lives. Introduction of a polypill for cardiovascular disease prevention could enhance the adherence to multiple preventive drug treatment.
The complete report and short pamphlets on specific topics are available from http://www.sph.uq.edu.au/bodce-ace-prevention