Session on Health Promotion Economics CPCRN Fall Meeting, Chapel Hill October 18-20, 2010

1. Economic Evaluation of Health Promotion ActivitiesOverview of the IssuesJoseph Lipscomb, PhDDepartment of Health Policy and Management and Emory Prevention Research Center Rollins School of Public Health andWinship Cancer InstituteEmory University Session on Health Promotion Economics CPCRN Fall Meeting, Chapel Hill October 18-20, 2010

2. Note at the outset….. • Aim is to set the stage and provide a general context for the presentations & discussion to follow • Frequent illustrative reference here to cancer screening interventions, but principles & problems & practices apply to full range of health promotion activities • Truly only an “Overview” – most every topic below merits an extended discussion

3. (1) Types of “Economic Evaluation” • Cost Analysis (often a Budget Impact Analysis) - If a mass advertising campaign to increase colorectal cancer screening is introduced in State X, what will be the impact on the state health department’s budget? • Cost-Consequence Analysis - For the CRC screen program introduced in state X, what will be the total number of cases detected per year and at what total cost? Or, what will be total life years gained for the cases detected per year and the total cost? • Cost-Minimization Analysis - Assuming state X decides to screen for CRC using intervention Y, what is the lowest cost way (per screen) to carry this out? The “cost-efficient” way?

4. (1) Types of “Economic Evaluation” • Cost-Effectiveness Analysis - Assume there are 2 or more ways to promote increased screening for CRC. Which way yields the greatest gain in “effectiveness” per dollar spent? - If effectiveness simply means “screening accomplished,” the best strategy may be the one with lowest cost per screen. - But if effectiveness means “cases of CRC detected” or “life years gained” or “quality-adjusted life years (QALYs) gained,” the most cost-effective strategy may or may not be evident simply by examining data on screening rates and screening costs – more on this later. • Cost-Benefit Analysis - Assume there are 2 or more ways to screen for CRC. Which way yields the greatest “net benefit,” defined as the difference between the monetized value of the output of the screening program, minus the dollar cost of the program. - Rarely applied to cancer prevention and screening studies → ongoing controversy re: placing a value on human life. But……

5. (2) Perspective of the Economic Evaluation Defines the Scope of the Cost Analyses Some alternative vantage points: • The public agency or private health care provider delivering the intervention • Third-party payers (public and private) • The individual at risk to cancer • Society at large

6. (3) Type of interventions being evaluated • The prevention strategies themselves - For CRC, the cost or cost-effectiveness of FOBT vs. flex sig vs. colonoscopy vs. some combination of screening approaches. • Interventions to promote uptake of evidence-based prevention strategies - For CRC, the cost or cost-effectiveness of: Client-Oriented Interventions: Client Reminders, Client Incentives, Small Media, Mass Media, Group Education, One-on-One Education, Reducing Structural Barriers, Reducing Out-of-Pocket Costs Provider-Oriented Interventions Provider Assessment and Feedback, Provider Incentives, Provider Reminders and Recall

7. (4) For Cost-Effectiveness Analysis (or, for that matter, for Comparative Effectiveness Analysis),How To Measure “Effectiveness”? • When the interventions are the prevention strategies: - Life-years gained (actually, the discounted-to-present value number of life years gained) - Quality-adjusted life-years (QALYs) gained (actually, the discounted number of QALYs gained) - Computing these is no simple matter: need longitudinal data and working assumptions on the individual’s life course progression of health states, conditional on prevention option received. Usually handled through sophisticated decision models – and for CRC screening analyses, we have lots of these (see next slide now). • When the focus is on client or provider interventions to promote use of evidence-based strategies: - Screenings per year, or screening per at-risk person per year - Measuring “effectiveness” relatively straightforward

8. Some Models for Assessing CRC Screening Effectiveness, Cost, and Cost-Effectiveness • NCI’s CRC Cancer Intervention and Surveillance Modeling Network (CISNET) teams: - Group Health Cooperative - University of Minnesota - Sloan-Kettering Institute for Cancer Research (see http://cisnet.cancer.gov) • Five models featured in the IOM report, “Economic Models of Colorectal Cancer Screening in Average-Risk Adults: Workshop Summary” (2005), including….. • The MISCAN model, whose later applications discussed here today by Iris Lansdorp-Vogelaar • And earlier: Pignone M, et al. Cost-effectiveness Analyses of Colorectal Cancer Screening: A Systematic Review for the U.S. Preventive Services Task Force. (AHRQ Report from the RTI-UNC Evidence-based Practice Center, Chapel Hill, NC., May 2002)

9. (5) For Cost Analyses and CEA, How to Measure Cost? • When the interventions are the prevention strategies, cost components may include: - Start-up Costs * Program mgt, Public Educ & Outreach, Quality Assurance & Professional Development, Partnership Development, Data Collection & Tracking, Patient Support, Admin/Overhead, Other - Clinical and Programmatic Implementation Costs ** (Similar categories to Start-up Costs, but includes also Clinical Service Delivery and Service Delivery Contract Management) - Value of at-risk person’s time for participating in screening - Direct medical and direct non-medical costs over time for the individual with CRC who is screened-detected by the program - Direct medical and direct non-medical costs over time for that same individual with CRC if she had not been screened detected by the program → Which costs to include in a given instance depends on the purpose and perspective of the analysis. * Tangka FKL, et al. Cost of Start Colorectal Cancer Screening Programs: Results from Five Federally Funded Demonstration Program. Preventing Chronic Disease 2008; 5(2). http://cdc.gov/ped/issues/2008/apr /07_0202.htm. ** Subramanian S, et al. Clinical and Programmatic Costs of Implementing Colorectal Cancer Screening: Evaluation of Five Programs. Evaluation and Program Planning 2010. doi:10.1016/j.evalprogplan.2010.09.005

10. (5) For Cost Analyses and CEA, How to Measure Cost? • When the focus is on client or provider interventions to promote use of evidence-based strategies, cost components may include: - Start-up Costs (though may be comparatively small) - Programmatic Implementation Costs • And as the Task Force on Community Preventive Services has recommended *: - Document all cost and effectiveness data for future work to promote cross-study comparability - Clarify study perspective - Eliminate costs not related to the study intervention, and include all cost components relevant to the intervention * Baron RC, Rimer BK, Breslow RA, et al. Client-Directed Interventions to Increase Community Demand for Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review. American Journal of Preventive Medicine 2008;35 (1S). doi:10.1016/j.amepre.2008.002.

11. Getting to a Decision: Determining the Cost-Effectiveness of Strategies to Promote Evidence-based Interventions • Can we conclude from (4) and (5) that in CEAs to select optimal strategies to increase screening rates among at-risk individuals, it is generally sufficient to consider only the costs associated with client or provider interventions and the corresponding impact on screening rates? • Specifically, for CRC prevention, can we always select the “best” strategy for promoting use of evidence-based screening without bringing to bear the full CEA model? • Relatedly, is choosing the most “cost-efficient” strategy (lowest unit cost per person screened) tantamount to choosing the most cost-effective strategy?

12. Consider this hypothetical example…. Total at-risk population to disease: 100,000 Program’s total annual budget available for screening: $4.5M Only one of the following 4 options will be selected: ProgramTotal ScreensTotal CostAvg Cost/ScreenIncremental Cost/Screen [ ΔC/Δ S ] Status Quo 10,000 $0 $0 ---------- A 30,000 $1M $33/screen $50/screen B 25,000 $1.5M $60/screen Dominated by A C 50,000 $4M $80/screen $100/screen Observations: • Option with the lowest unit cost is the Status Quo. • Option with the lowest incremental cost relative to the Status Quo is A. • But the option that maximizes total effectiveness under the budget constraint is C.

13. Inquiry continues…… Suppose there no specified budget constraint (as often the case when such analyses are carried out by researchers sans a decision context): • If one assumes the decision maker’s willingness to pay (WTP) for a screen is less than $50/screen, the optimal choice is the Status Quo. • If WTP is at least $50/screen but less than $100/screen, adopt A. • If WTP is at least $100/screen, adopt C. But how can we “know” where the WTP cut-off is?? One viable response here: Integrate screening promotion options into a full-scale CRC screening model to see which option leads to the most cost-effective result overall, e.g., in terms of life-years gained per dollar spent.

14. As Baron et al. (Am J Prev Med) concluded: “Finally, questions remain about the value to program planners of cost effectiveness in achieving intermediate outcomes (e.g., additional completed screening) rather than the health outcomes ultimately desired (e.g., abnormal tests detected, life-years saved). “Further efforts, such as collection of data to estimate numbers of cases of cancer prevented or detected earlier, resulting from additional completed screening, and measuring subsequent improvement in both quality and quantity of life, are also needed to translate cost effectiveness of screening into cost effectiveness of achieving ultimate health goals.” (pS50)

15. Thank You !