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Session: Cost-Effectiveness of Programmes
Room: Helsinki Hall
Time: Fri 16:00-17:15

Presenter: Pia Johansson (Karolinska Institutet. Karolinska Institutet School of Public Health)

Abstract

Background: Methodology recommendations and standards for economic evaluations within health and medicine have mainly been developed for and applied to pharmaceuticals. As many prevention and health promotion activities share important features with pharmaceuticals, and the technologies might be substitutes from a decision-making view, there are advantages in using similar methods for economic evaluation. Recently, however, cost-effectiveness analyses of public health interventions have been criticised and methodological challenges identified.
Aims: To critically discuss the methodological challenges and public health relevance of a published (by the author) cost-effectiveness analysis of a community-based lifestyle programme.
Methods: The programme sought to prevent future diabetes and cardiovascular disease by promoting healthy lifestyles, in particular physical activity and food habits, in the general population in three communities in Stockholm, Sweden. The economic evaluation was based on an effect evaluation with a quasi-experimental design, i.e. with control areas, among middle-aged community inhabitants with 8-10 year follow-up. The economic evaluation followed Swedish methodology recommendations, i.e. incremental cost-utility analysis with future disease-related societal costs and health effects estimated by a Markov model. The methods employed are discussed according to the four previously identified methodological challenges: Attribution of effects, Measuring and valuing outcomes, Intersectoral costs and consequences and Equity considerations.
Results: The major constraint of the performed cost-effectiveness analysis is found in the challenge Measuring and valuing outcomes, as only disease-related individual-level welfare effects were included, measured as QALYs. This might considerably underestimate the social value of the programme, as lifestyle programmes often convey significant non-health effects, such as individual wellbeing derived from process utility (or disutility) or societal welfare effects from externalities such as diffusion of lifestyles. The societal perspective sought to consider Intersectoral costs and consequences, but lack of cost estimates resulted in further underestimates. Equity considerations were not explicitly addressed. The challenge Attribution of effects was negatively affected by the design of the effect evaluation, which included a relatively short follow-up period and a narrow population group.
Conclusion: The performed cost-effectiveness analysis overcame few of the methodological challenges. This restricts the public health relevance of the study and might imply a serious underestimate of the social value of the programme. Alternative economic evaluation methods should thus be tried, to investigate which methods are most appropriate for public health programmes.

Key Terms

cost-effectiveness analysis, lifestyles, health promotion, economic evaluation methodology

Authors:

Pia Johansson (Karolinska Institutet. Karolinska Institutet School of Public Health)

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