Moving beyond a limited follow-up in cost-effectiveness analyses of behavioral interventions

Promoting Intersectoral Collaboration Through the Evaluations of Public Health Interventions: Insights From Key Informants in 6 European Countries

BACKGROUND

Intersectoral collaboration is critical to the successful implementation of many public health interventions (PHIs). Little attention has been paid to whether and how processes at the stage of evaluation can promote intersectoral collaboration. The objective of this study was to examine European experiences and views on whether and how the evaluation of PHIs promote intersectoral collaboration.

METHODS

A qualitative study design was used. We conducted semi-structured interviews with 15 individuals centrally involved in the evaluation of PHIs in 6 European countries (Austria, Denmark, England, Germany, Norway, and Switzerland). Questions pertained to current processes for evaluating PHIs in the country and current and potential strategies for promoting intersectoral collaboration. Transcripts were analyzed using thematic analysis to identify key themes responding to our primary objective.

RESULTS

Experiences with promoting intersectoral collaboration through the evaluation of PHIs could be summarized in 4 themes: (1) Early involvement of non-health sectors in the evaluative process and inclusion of non-health benefits can promote intersectoral collaboration, but should be combined with greater influence of these sectors in shaping PHIs; (2) Harmonization of methodological approaches may enable comparison of results and facilitate intersectoral collaboration, but should not be an overriding goal; (3) Involvement in health impact assessments (HIAs) can promote intersectoral collaboration, but needs to be incentivized and be conducted without putting overwhelming demands on non-health sectors; (4) A designated body for evaluating PHIs may promote intersectoral collaboration, but its design needs to take account of realities of policy-making.

CONCLUSION

The full potential for promoting intersectoral collaboration through the evaluation of PHIs appears currently unrealized in the settings we studied. To further promote intersectoral collaboration, evaluators and decision-makers may consider the full range of strategies characterized in this study. This may be most effective if the strategies are deployed so that they reinforce each other, value outcomes beyond health, and are tailored to maximize political priority for PHIs across sectors.

Cost-effectiveness of enhancing a Quit-and-Win smoking cessation program for college students

OBJECTIVES

We conducted a cost-effectiveness analysis and model-based cost-utility and cost-benefit analysis of increased dosage (3 vs. 1 consecutive contests) and enhanced content (supplemental smoking-cessation counseling) of the Quit-and-Win contest using data from a randomized control trial enrolling college students in the US.

METHODS

For the cost-utility and cost-benefit analyses, we used a microsimulation model of the life course of current and former smokers to translate the distribution of the duration of continuous abstinence among each treatment arm's participants observed at the end of the trial (N = 1217) into expected quality-adjusted life-years (QALYs) and costs and an incremental net monetary benefit (INMB). Missing observations in the trial were classified as smoking. For our reference case, we took a societal perspective and used a 3% discount rate for costs and benefits. A probabilistic sensitivity analysis (PSA) was performed to account for model and trial-estimated parameter uncertainty. We also conducted a cost-effectiveness analysis (cost per additional intermediate cessation) using direct costs of the intervention and two trial-based estimates of intermediate cessation: (a) biochemically verified (BV) 6-month continuous abstinence and (b) BV 30-day point prevalence abstinence at 6 months.

RESULTS

Multiple contests resulted in a significantly higher BV 6-month continuous abstinence rate (RD 0.04), at a cost of $1275 per additional quit, and increased the duration of continuous abstinence among quitters. In the long run, multiple contests lead to an average gain of 0.03 QALYs and were cost saving. Incorporating parameter uncertainty into the analyses, the expected INMB was greater than $1000 for any realistic willingness to pay (WTP) for a QALY.

CONCLUSIONS

Assuming missing values were smoking, multiple contests appear to dominate a single contest from a societal perspective. Funding agencies seeking to promote population health by funding a Quit-and-Win contest in a university setting should strongly consider offering multiple consecutive contests. Further research is needed to evaluate multiple contests compared to no contest.

Improving data collection processes for routine evaluation of treatment cost-effectiveness

The healthcare system in Finland has begun routine collection of health-related quality of life (HRQoL) information for patients in hospitals to support more systematic cost-effectiveness analysis (CEA). This article describes the systematic collection of HRQoL survey data, and addresses challenges in the implementation of patient surveys and acquisition of cost data in the case hospital. Challenges include problems with incomplete data and undefined management processes. In order to support CEA of hospital treatments, improvements are sought from the process management literature and in the observation of healthcare professionals. The article has been written from an information system and process management perspective, concluding that process ownership, automation of data collection and better staff training are keys to generating more reliable data.

Dealing With Missing Behavioral Endpoints in Health Promotion Research by Modeling Cognitive Parameters in Cost-Effectiveness Analyses of Behavioral Interventions: A Validation Study

Cost-effectiveness analyses (CEAs) of behavioral interventions typically use physical outcome criteria. However, any progress in cognitive antecedents of behavior change may be seen as a beneficial outcome of an intervention. The aim of this study is to explore the feasibility and validity of incorporating cognitive parameters of behavior change in CEAs. The CEA from a randomized controlled trial on smoking cessation was reanalyzed. First, relevant cognitive antecedents of behavior change in this dataset were identified. Then, transition probabilities between combined states of smoking and cognitions at 6 weeks and corresponding 6 months smoking status were obtained from the dataset. These rates were extrapolated to the period from 6 to 12 months in a decision analytic model. Simulated results were compared with the 12 months' observed cost-effectiveness results. Self-efficacy was the strongest time-varying predictor of smoking cessation. Twelve months' observed CEA results for the multiple tailoring intervention versus usual care showed € 3188 had to be paid for each additional quitter versus € 10,600 in the simulated model. The simulated CEA showed largely similar but somewhat more conservative results. Using self-efficacy to enhance the estimation of the true behavioral outcome seems a feasible and valid way to estimate future cost-effectiveness.

Cost-effectiveness of a voucher-based intervention for smoking cessation

BACKGROUND

Contingency management (CM) has been shown to be effective in reducing smoking consumption, but has traditionally been criticized for its costs.

OBJECTIVES

This study assessed the cost-effectiveness of using a voucher-based CM protocol added to a cognitive behavioral treatment (CBT) for smoking cessation among treatment-seeking patients from the general population.

METHODS

A total of 92 patients were randomly assigned to CBT or CBT plus CM for abstinence. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the increase in costs by the increase in effects (continuous abstinence, longest duration of abstinence at 6-month follow-up and cotinine results during the treatment). An acceptability curve illustrated the statistical uncertainty surrounding the cost-effectiveness estimate. We also determined the optimum cost per participant for predicting the smoking status at 6-month follow-up.

RESULTS

The average cost per participant in the CBT condition was €138.73 (US$ 150.23) as opposed to €411.61 (US$ 445.73) in the CBT plus CM condition (p < 0.01). The incremental cost of using voucher-based CM to increase the number of participants that maintained abstinence at 6-month follow-up by one extra participant was €68.22 (US$ 73.88), and to lengthen the longest duration of abstinence by 1 week was €53.92 (US$ 58.39). The incremental cost to obtain an extra cotinine-negative result was €181.90 (US$ 196.98).

CONCLUSION

Compared with CBT alone, the voucher-based protocol required additional costs but achieved significantly better outcomes. These results will allow stakeholders to make policy decisions about CM implementation for smoking cessation in the broader community.

Exploring Outcomes to Consider in Economic Evaluations of Health Promotion Programs: What Broader Non-Health Outcomes Matter Most?

Background

Attention is increasing on the consideration of broader non-health outcomes in economic evaluations. It is unknown which non-health outcomes are valued as most relevant in the context of health promotion. The present study fills this gap by investigating the relative importance of non-health outcomes in a health promotion context.

Method

We investigated the relative importance of ten non-health outcomes of health promotion programs not commonly captured in QALYs. Preferences were elicited from a sample of the Dutch general public (N = 549) by means of a ranking task. These preferences were analyzed using Borda scores and rank-ordered logit models.

Results

The relative order of preference (from most to least important) was: self-confidence, insights into own (un)healthy behavior, perceived life control, knowledge about a certain health problem, social support, relaxation, better educational achievements, increased labor participation and work productivity, social participation, and a reduction in criminal behavior. The weight given to a particular non-health outcome was affected by the demographic variables age, gender, income, and education. Furthermore, in an open question, respondents mentioned a number of other relevant non-health outcomes, which we classified into outcomes relevant for the individual, the direct social environment, and for society as a whole.

Conclusion

The study provides valuable insights in the non-health outcomes that are considered as most important by the Dutch general population. Ideally, researchers should include the most important non-health outcomes in economic evaluations of health promotion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0908-y) contains supplementary material, which is available to authorized users.