ECP4530 Final Review I Cost Effective Analysis A Describe how to perform a cost effective analysis o Puts value on cost only o No value on benefit o Benefits denoted in life years or quality life years Often used when the benefits of a policy are clearly defined and deemed desirable Do not have to put a dollar value on life or quality of life Measuring cost o Included Direct costs Health care costs costs incurred by medical care providers such as hospitals physicians and nursing homes Non health care costs monetary costs imposed on any nonmedical personnel including patients Indirect costs implementation of the treatment mortality of morbidity o Costs are discounted when multiple time periods are involved o Usually omitted pain and suffering the time cost associated with Quality Adjusted Life Years adjusts a life year for quality taking into account that not all life years are created equal o Health Utility Index value from 0 1 0 is death 1 is perfect o Valuation approaches rating scales standard gamble time health trade off Rating Scales Category scale present rater with scenario rate on ladder from 0 to death to 10 completely well 5 half way in between etc Visual analogue method rater shown line 100 centimeters in lengthy with end points well defined rater marks line to indicate where his or her preference is Answers are rescaled to give health utility index values between 0 and 1 Ask question Suppose you were in the state of less than perfect health as described by the scenario Further suppose that there was an operation that would completely cure you or you would die instantly and painlessly on the operating table What probability of Standard Gamble death would make you indifferent between having or not having the operation o U d 1 U h U d o Critiques understand probability assumes people can calculate and Time Tradeoff dog walking example o Subject given choice of living for a defined amount of time in perfect health or a variable amount of time in another health state that is less desirable o Reduce time in well state leaving time in sub optimal Key differences state fixed to establish point of indifference psychological versus economic approaches o Method used makes a difference o Economists complain that utilities must be derived from explicit tradeoff questions which rating scale approaches do not do o Psychologists say that approaches such as standard gamble are too complex for respondents tradeoffs too artificial cite some evidence validating their approaches Health Utility Index HUI measure of quality of life normally measured on a scale from 0 to 1 where 1 equals one year of full health and 0 represents death Criticisms of health ratings o Hypothetical situations o Individual desires vary o Puts lower value on adding life years to the disabled DALY Disability adjusted life year one DALY is one year of healthy life lost 0 means no life lost Cost Effectiveness Ratio CER a ratio of the net costs to the net health outcomes benefits of alternative intervention strategies CER C 1 C2 O1 O2 o Costs measured in dollars In U S common threshold of 50 000 per LY or QALY B Distinguish between health improving and cost effective o Health improving treatment to increase quality or quantity of life Proton beam therapy for prostate cancer very expensive but does improve QALY o Cost effective treatment costs 50 000 per life year added Antiretroviral in Africa very cheap per QALY C Discuss the cost effectiveness and health effectiveness of various cancer behavior modifications screenings and treatments 1 Behavioral changes prevention o Smoking low cost most quit without aid Rational decision quit if the benefits costs Moderate for public health messages Mostly mental psychic costs that are difficult to quantify o Did not contribute to decline in mortality Colorectal obesity is a risk factor aspirin and folate decrease risk no overall change in mortality due to behavior 2 Screening o Smoking tobacco related Chest X ray did not decrease mortality Sputum cytology did not decrease mortality False positives CT scan 2010 earlier detection not better 5 year survival rates Mammogram very cost effective 70 gives 37 000 QALY 3 Treatment o Smoking no increase in life expectancy since 1990 Not cost effective Lungs no change in life expectancy Colon 0 3 increase in LE LY cost 137 464 D Compare cost effectiveness of HIV treatment and prevention methods Burdens of HIV AIDS in Africa o 7 2 prevalence rate overall 20 prevalence in some countries o Biggest health problem in Africa deaths concentrated among young adult women and middle aged men Probability transmission v time is U shaped as viral load increases Upon onset of AIDS opportunistic infections TB STDs death usually much more cost effective than treatment the CD4 cell count falls Prevention measures within two years lower the DALY the better o Prevent mother to child Without intervention transmission rates 15 30 at birth 10 20 via breast milk Prevention at birth Nevirapine to mother upon labor nevirapine to child upon birth medicine to treat HIV 1 and AIDS 50 DALY Prevention via formula instead of breast milk o Promote changes in sexual activity 1 21 DALY In sex workers peer education condom distribution In general population voluntary testing and counseling condom distribution childhood education Mass media campaigns ABC difficult to gauge effectiveness results short lived o Treat other STDs promote male circumcision estimated at 300 DALY but really around 100 Transmission rates higher with other STDs present Open sores simple effective cheap treatment o Treat HIV AIDS itself with antiretroviral therapy Medical resource intensive Requires follow dosing perfectly First line benefits 14 1 months 175 per year Second and third line o Treat opportunistic infections pneumonia treat or prevent TB in HIV 300 DALY for TB treatment 1 cause of death in those with AIDS Prevent TB Rx drug multivitamin treatment for TB Rx drug Treatment of HIV AIDS II Cost Benefit Analysis A Discuss the distinctions among cost effective analysis cost benefit analysis and comparative effectiveness research 1 cost benefit analysis requires putting monetary value on all costs and benefits associated with a health policy decision o Measure and find the difference of costs and benefits Costs direct medical costs direct nonmedical costs indirect costs of time Benefits medical costs avoided indirect costs avoided because death postponed and or health restored o Costs and