BIOE 301Lecture SixteenReview of Lectures 13-15 What is the goal of cancer screening? Successful cancer screening examples? Can screening hurt more people than it helps? What are the challenges in cancer screening? Is cancer screening a good investment?Science of Understanding DiseaseEmerging Health TechnologiesPreclinical TestingClinical TrialsAdoption & DiffusionAbandoned due to:• poor performance• safety concerns• ethical concerns• legal issues• social issues• economic issuesBioengineeringEthics of researchCost-EffectivenessCreating Leaders;Meeting Global NeedsHealth$$$Worsens HealthSaves MoneyImproves HealthCosts MoneyImproves HealthSaves MoneyWorsens HealthCosts MoneyVaccines Most InterventionsDifficult DebateHealth Policy SpaceHealth Care Reform in Oregon Health services ranked according to cost-effectivenessBenefitDurationofdBenefitNetExpectetmentCostofTreatingpriorityra×=$$/DALY or $$/QALY What does a DALY measure? How much are we willing to spend to gain a year of life? Name two health interventions that result in cost SAVINGS.League TableIntervention Cost-Effectiveness RatioPneumococcal vaccine for adults over 65 years of age Cost savingTobacco cessation counselingCost saving to $2,000/QALY savedChlamydia screening for women 15-24 years old $2,500/QALY savedColorectal cancer screening for people >50 years old $13,000/QALY savedWhat is Society’s Threshold Ratio? No correct answer Common guesses: $20,000-$100,000 / QALY Median estimate = about $150,000/QALY [Hirth RA, et al. What should society be willing to pay for a QALY? Evidence from the value of life literature (abstract). Medical Decision Making 1999;18:459.]0%10%20%30%40%50%60%70%80%90%100%$0 $500 $1,000 $1,500 $2,000 $2,500 $3,000Lifetime Screening CostReduction in Cervical Cancer RiskSouth AfricaScreening 1X/LifeCost saving to <$50/YLSSouth AfricaScreening 2X/Life$50-$250/YLSSouth AfricaScreening 3X/Life$250-$500/YLSUnited StatesPap + HPV Every 3 yrs.$60,000/YLSUnited StatesPap + HPV Every 2 yrs.$174,000/YLSUnited StatesPap + HPV Every Year$795,000/YLS15 Weeks1,000 Years!How Much Life Can $50,000 Buy?What is Society’s Threshold Ratio? No correct answer Common guesses: $20,000-$100,000 / QALY Median estimate = about $150,000/QALY [Hirth RA, et al. What should society be willing to pay for a QALY? Evidence from the value of life literature (abstract). Medical Decision Making 1999;18:459.] What about in developing countries? Very cost-effective: amount to gain one QALY is < per person GDP Cost-effective: amount to gain one QALY is < 3 x per capita GDPHealth Expendituresper capitaActual ProjectedNational Health Expenditures$0$2,000$4,000$6,000$8,000$10,000$12,000$14,0007.2 %$3569.1 %$1,10212.3 %$2,81313.6 %$4,10413.8 %$4,79015.8 %$5,95216.0 %$7,09216.9 %$8,46817.9 %$10,11019.2 %$12,06219.2 %$12,7821970198019901993199719981999200020012007200620052004200320022008200920102015201420132012201120160%10%20%30%40%50%60%70%80%90%100%$0 $500 $1,000 $1,500 $2,000 $2,500 $3,000Lifetime Screening CostReduction in Cervical Cancer RiskHow Can New Technologies Help?• Requires globally minded:– Interdisciplinary researchers– Entrepreneurs – Policy-makersCost-Effectiveness Assessment Define the problem Identify the perspective Identify the alternatives Analyze the effectiveness Analyze the costs Perform discounting Perform sensitivity analysis Address ethical issues Interpret the resultsExample: Cervical Cancer Screening for Elderly Women 1988: Medicare did not cover cervical cancer screening Elderly accounted for 40% of cervical CA deaths Question: Should Medicare pay?Cost-Effectiveness Assessment Define the problem: Is cervical cancer screening for elderly women cost-effective? Identify the perspective Societal perspective Identify the alternatives No screening Analyze the costs & effectiveness Real clinical trial Projected costs and benefitsCost-Effectiveness Assessment Perform discounting 5% discount rate Perform sensitivity analysis Screening would be cost-saving in elderly women who had never been screened Address ethical issues Is it ethical for Medicare to pay for smears only for women who have never been screened? Interpret the resultsSummary of Study New Technology: Pap screening in low-income, elderly women Alternative: No screening Number of tests performed: 816 Costs of Technology: $59,733Markov ModelNormalHPVLGSIL HGSIL EICC DEATHLICCSummary of Study Benefits of Technology: 30.33 life years gained 36.77 QALYs gained Net Costs of Intervention: $59,733-$107,936 = -$48,203 Intervention SAVES money Cost-effectiveness: SAVE $1311/QALYImpact of Study 1990: Medicare extended to cover triennial screening with Pap smears for all women with no upper age limit Study was a one-time screen in population with limited prior access to screening! Should results be generalized? $2,254/QALY gained for triennial screening in elderly women in USCost-Effectiveness Study of Cervical Cancer Screening for Low-Income, Elderly Women:“I previously worked in the Harlem community and other New York City neighborhoods that were very poor in resources: housing, healthcare, and other resources. The issue I wanted to address was whether we should screen older women for cervical cancer. The reason I, as opposed to someone else, did this is that I was the only person in the primary care clinic who knew how to do gynecologic examinations, and I was the first person in 10 years to observe that the examination tables had stirrups! This was the beginning of my life’s work.In the first few years of our screening program, the nurse practitioner and I screened more than 800 women. They were on average 74 years old and had largely been unscreened previously. As a result, we found that screening these women actually saved lives as well as health care costs (3.72 lives and $5907 saved for every 100 Pap smears done)-an ideal program.But then serendipity came into play. We were doing this work at a time when there was an explosion in the growth of the older population and members of congress were receiving a lot of pressure from their older constituents to include preventive services. Along I came with my Pap smear analysis and showed that if we were to screen the average elderly population at
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