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