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http://www.publichealthontario.ca/

Health Promotion Capacity Building webinar:

Making Cents of Economic Evaluations—Part 2

February 25, 2016


We provide training and support services to Ontario’s public health and health care intermediaries to assist them to plan, conduct and evaluate interventions which improve health and prevent chronic disease and injury at a community and population level.

2

About HPCB



Presenters:

Allison Meserve

Health Promotion Consultant

[email protected]

Man Wah Yeung

Epidemiologist

[email protected]

Assisted by: Laura Bellissimo Health Promotion Coordinator [email protected]

3

Introductions


mailto:[email protected]



PublicHealthOntario.ca 5



Context for MobileMums

• Physical inactivity leads to negative health consequences

• 24% of cardiovascular disease and diabetes explained by physical inactivity in Australia

• Women less likely to be physically active

• Women with young children even more unlikely

• Evidence on interventions for this population weak

7

Burn E, Marshall AL, Miller YD, Barnett AG, Fjeldsoe BS, Graves N. The cost-effectiveness of the MobileMums intervention to increase physical activity among mothers with young children: a Markov model informed by a randomised controlled trial. BMJ Open. 2015;5(4)

Fjeldsoe BS, Miller YD, Graves N, Barnett AG, Marshall AL. Randomized Controlled Trial of an Improved Version of MobileMums, an intervention for increasing physical activity in women with young children. Ann. Behav. Med. 2015;49(487-499).



MobileMums

• 12-week intervention delivered via SMS:

• Initial face to face meeting to develop physical activity goals

• Five personalized SMS in weeks 1-4

• Four personalized SMS in weeks 5-12

• Personalized SMS sent to identified support person

• Online supports

• Additional resources

• Developed using the Social Cognitive Theory (SCT)

8

Burn E, Marshall AL, Miller YD, Barnett AG, Fjeldsoe BS, Graves N. The cost-effectiveness of the MobileMums intervention to increase physical activity among mothers with young children: a Markov model informed by a randomised controlled trial. BMJ Open. 2015;5(4)



Data collection: Randomized controlled trial

• Healthcare use

• Estimated costs using the Medicare Benefits Schedule and Australian hospital statistics

• Quality of life

• SF-12 questionnaire

9

T1 Prior to program, 0 months

T2 Immediately after program completion, 3 months

T3 Further six months of no contact, 9 months



Critical appraisal tool

10



• Weighs costs and outcomes

• Compares ONE alternative (i.e. new program) with ANOTHER alternative

Is this a true economic evaluation?

Why is this study necessary when an RCT was conducted already?



Types of economic evaluations

13

ICER = ∆ Cost

∆ Effect

Cost-Effectiveness Natural units

i.e., life-years gained,

cases averted, heart attacks avoided, deaths averted

Cost-Utility Utility

i.e., quality-adjusted life-

years (QALY)

A. CEA

B. CUA

C. Neither



Measuring costs

• Direct costs

• Productivity costs (indirect costs)

14

∆ Cost

∆ Effect

Perspective

• Third-party payer (i.e., Ontario)

• Societal (includes opportunity cost)

Which perspective was taken in the analysis?

A. Patients in Queensland

B. Third-party payer (Queensland hospital)

C. Third-party payer (Queensland health system)

D. Societal (Queensland)



Types of costs

15

What costs were included? Check all that apply.

A. Out-of-pocket purchases for exercise, i.e., purchasing a treadmill

B. Salaries of behavioural counsellors and program coordinators

C. Charges from receiving text messages

D. Time used for physical activity, i.e. instead of minding the home/ kids, working, etc

E. Program materials, i.e., handbook, refrigerator magnet

F. Universal healthcare services, i.e., Medicare, hospital

∆ Cost

∆ Effect



∆ Cost

∆ Effect



• Health-related quality of life measured as utilities

• Value from 0 (dead) to 1 (perfect health)

• Standardized approaches and questionnaires (i.e., EQ-5D)

∆ Cost

∆ Effect

Measuring effects in CUA:

Quality adjusted life year



Health-related quality of life

19

Direct methods

• Given disease vignettes

• Asked to trade-off lifetime and quality of life; to gamble for better quality of life

Indirect questionnaires

• I.e., EQ-5D questionnaire

• Use scoring algorithm based on direct methods

Questionnaires that do not

generate utilities

• I.e., SF-12 questionnaire

• Map responses onto indirect questionnaires

Utilities ∆ Cost

∆ Effect



∆ Cost

∆ Effect



∆ Cost

∆ Effect

SF-12 questionnaire

• Missing data: multiple imputation

• Question omitted: scores randomly generated

• Too many responses: responses evenly split between next best/ worse choice



Discounting

• Preference to defer costs to the future and incur benefits now

• Attach lower weights to costs and effects which occur in the future

23

∆ Cost

∆ Effect

r = discount rate (3-5%)

t = time

Donaldson C, Shackley P. Economic studies. In: Oxford Textbook of Public Health. 3rd ed. Detels R et al. (eds.). Oxford. Oxford University Press. 1997.

Alternatives Year 1 Year 2 Year 3 Total

Surgery 3000 3000

Drug 1000 1000 1000 3000

Drug (discounted) 1000 952 907 2859



Discounting

• Yes; used 5% (recommended); discounted costs

• Yes; used 5% (recommended); discounted costs and effects

• No; used 5% (recommended); discounted costs and effects

• No; discounting should not have been used over such a short time frame of two years

• Can’t tell; poor reporting

24



Markov structure

26



Markov structure

Time (months) Inactive Active

T1 (0 m) 25,455 10,909

T2 (3 m) 25,055 11,309

T3 (9 m) 25,279 11,085

…

Cinactive = $75.40

36,364

Cactive = $53.30

Uinactive = 0.78 Uactive = 0.81

Usual care

∑ C usual ∑ U usual



Markov structure

Cinactive = $75.40 + 62.64

36,364

Cactive = $53.30 + 62.64 Uinactive = 0.78 Uactive = 0.81

MobileMums

∑ C Mobile ∑ U Mobile

Time (months) Inactive Active

T1 (0 m) 25,455 10,909

T2 (3 m) 18,509 17,855

T3 (9 m) 21,731 14,633

…



ICER = C Mobile - C usual

U Mobile - E usual

∆ Costs ($)

∆ Benefits

I II

III IV

↑Cost ↑Health

= 1 million AUD ÷ 130 QALYs

= $ 8,608 / QALY




U Mobile - E usual

∆ Costs ($)

∆ Benefits

I II

III IV


= $ 8,608 / QALY

↑Cost ↑Health

COST-SAVING




U Mobile - E usual


= $ 8,608 / QALY

“The threshold used is 64 000 AUD which is based on the estimate by Shiroiwa et al of the willingness-to-pay for an additional QALY in Australia”



Decision-making

• I.e., Ethics, equity, social welfare, feasibility, best evidence, values (Canada Health Act, Romanow Commission, Excellent Care for All Act)

41



42

Types of sensitivity analyses

One-way Two-way

Probabilistic Scenario

Threshold Extreme value

…etc



Assumptions

43

Is this assumption reasonable?



Scenarios

44



Scenarios

45



Size matters

How did the authors come up with this size?

What assumptions were made for this calculation?

Are the assumptions reasonable?

46

36,364



Scenarios

47



48

Types of sensitivity analyses

One-way Two-way

Probabilistic Scenario

Threshold Extreme value

…etc



Parameter uncertainty: Probabilistic sensitivity analysis

Monte Carlo simulation

• Vary all parameters simultaneously

• Use probability distributions

49



Cinactive Cactive

Uinactive Uactive

Beta Beta Uniform, Gamma

ICER= ∆ Cost

∆ Effect

x 100,000



PSA interpretation

• “MobileMums has a 98% probability of being cost-effective at a threshold of 64 000 AUD (98% of simulations are below the sloped threshold line). The intervention has around a 19% probability of being cost-saving and health-improving (19% of simulations are in the south-east quadrant).”

55



PSA interpretation

57



Thresholds are arbitrary!

• Cost-effectiveness acceptability curve

60 Iannazzo S, et al. Antivir Ther. 2013;18(4):623-33.

0%

85%



Is this study generalizable to your organization or to Ontario?

61



Disclaimer

This document may be freely used without permission for non-commercial purposes only and provided that appropriate credit is given to Public Health Ontario. No changes and/or modifications may be made to the content without explicit written permission from Public Health Ontario.


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