Economic evaluations of alcohol prevention interventions: Is the evidence sufficient? A review of methodological challenges

Exploring the Broader Benefits of Obesity Prevention Community-based Interventions From the Perspective of Multiple Stakeholders

Community-based interventions (CBIs) show promise as effective and cost-effective obesity prevention initiatives. CBIs are typically complex interventions, including multiple settings, strategies and stakeholders. Cost-effectiveness evidence, however, generally only considers a narrow range of costs and benefits associated with anthropometric outcomes. While it is recognised that the complexity of CBIs may result in broader non-health societal and community benefits, the identification, measurement, and quantification of these outcomes is limited. This study aimed to understand the perspectives of stakeholders on the broader benefits of CBIs and their measurement, as well as perceptions of CBI cost-effectiveness. Purposive sampling was used to recruit participants from three stakeholder groups (lead researchers, funders, and community stakeholders of CBIs). Online semi-structured interviews were conducted, taking a constructivist approach. Coding, theme development and analysis were based on published guidance for thematic analysis. Twenty-six stakeholders participated in the interviews (12 lead researchers; 7 funders; 6 community stakeholders). Six key themes emerged; (1) Impacts of CBIs (health impacts and broader impacts); (2) Broader benefits were important to stakeholders; (3) Measurement of benefits are challenging; (4) CBIs were considered cost-effective; (5) Framing CBIs for community engagement (6) Making equitable impacts and sustaining changes-successes and challenges. Across all stakeholders, broader benefits, particularly the establishment of networks and partnerships within communities, were seen as important outcomes of CBIs. Participants viewed the CBI approach to obesity prevention as cost-effective, however, there were challenges in measuring, quantifying and valuing broader benefits. Development of tools to measure and quantify broader benefits would allow for more comprehensive evaluation of the cost-effectiveness of CBIs for obesity prevention.

Labour productivity losses from premature death due to alcohol in Spain (2002-2018): Estimation and comparative analysis with tobacco-related estimates

AIM

To estimate premature deaths, years of potential labour productivity lost, and productivity losses attributable to alcohol consumption in Spain (2002-2018) and, compare these losses with those from tobacco consumption.

METHODS

Using the human capital approach, data on employment, wages and mortality were analysed from national sources. Alcohol-related mortality risks were drawn from the Spanish Ministry of Health. Labour productivity losses were calculated based on working-age mortality (35-64 years), with adjustments for productivity growth and discount rates. Sensitivity analyses were conducted to validate the findings.

RESULTS

Between 2002 and 2018, premature deaths and productivity losses related to alcohol consumption decreased significantly, with losses declining from 1959 million euros in 2002-936 million euros in 2018, representing a 52.2 % reduction. Although there was also a favourable trend in this area, productivity losses due to tobacco-related deaths amounted to 68.6 %.

CONCLUSION

This study reveals a marked decline in alcohol-related labour productivity losses in Spain over the analysed period. Nevertheless, tobacco and alcohol continue to pose a greater economic burden, highlighting the need for sustained public health efforts targeting both alcohol and tobacco consumption to mitigate productivity losses.

Economic Evaluations of Obesity-Targeted Sugar-Sweetened Beverage (SSB) Taxes-A Review to Identify Methodological Issues

INTRODUCTION

Economic evaluations of public health interventions like sugar-sweetened beverage (SSB) taxes face difficulties similar to those previously identified in other public health areas. This stems from challenges in accurately attributing effects, capturing outcomes and costs beyond health, and integrating equity effects. This review examines how these challenges were addressed in economic evaluations of SSB taxes.

METHODS

A systematic review was conducted to identify economic evaluations of SSB taxes focused on addressing obesity in adults, published up to February 2021. The methodological challenges examined include measuring effects, valuing outcomes, assessing costs, and incorporating equity.

RESULTS

Fourteen economic evaluations of SSB taxes were identified. Across these evaluations, estimating SSB tax effects was uncertain due to a reliance on indirect evidence that was less robust than evidence from randomised controlled trials. Health outcomes, like quality-adjusted life years, along with a healthcare system perspective for costs, dominated the evaluations of SSB taxes, with a limited focus on broader non-health consequences. Equity analyses were common but employed significantly different approaches and exhibited varying degrees of quality.

CONCLUSION

Addressing the methodological challenges remains an issue for economic evaluations of public health interventions like SSB taxes, suggesting the need for increased attention on those issues in future studies. Dedicated methodological guidelines, in particular addressing the measurement of effect and incorporation of equity impacts, are warranted.

Modeling the impact of a long-term horizon and multiple treatment episodes on estimates of the cost-effectiveness of alcohol treatment in the United States

BACKGROUND

Most clinical studies of alcohol use disorder (AUD) treatment have short follow-up periods, underestimating the full benefits of alcohol treatment. Furthermore, clinical studies only consider one treatment cycle and do not account for the need for multiple episodes to treat a chronic recurrent condition.

METHODS

A validated microsimulation model of the long-term drinking patterns of people with AUD in the United States simulated 10,000 individuals resembling those from a large clinical trial. The model was used to assess the impact of (1) 1-year, 5-year, and lifetime horizon on alcohol treatment cost-effectiveness estimates and (2) no, one, two, four, and unlimited additional treatment episodes on alcohol treatment cost-effectiveness estimates. Model outcomes included healthcare costs, crime costs, labor market productivity, life expectancy, quality-adjusted life years (QALYs), alcohol-related hospitalizations, and deaths. Cost-effectiveness analyses were conducted for two perspectives: a healthcare perspective that included costs from hospitalization and AUD treatment, and a broader societal perspective that also included crime costs and productivity.

RESULTS

The incremental cost per additional QALY gained for alcohol treatment compared with no treatment decreased from $55,590 after 1 year to $78 when healthcare costs and QALYs were tracked over the lifetime, that is, treatment became more cost effective. Treatment was cost saving for any time frame when the impacts on crime and labor productivity were also accounted for in a societal perspective. Access to multiple treatment episodes dominated (i.e., it was more effective and less costly) than no-treatment and one-episode scenarios. From a healthcare perspective, incremental costs per additional QALY for increasing from a maximum of two to four treatment episodes was $499 and from four to unlimited episodes was $5049. The unlimited treatment scenario dominated all others from a societal perspective. Results were robust in sensitivity analyses.

CONCLUSIONS

A long-term perspective and multiple episodes of alcohol treatment improve cost-effectiveness estimates. When societal impacts are included, alcohol treatment is cost saving. Results support the value of alcohol treatment.

Interventions to prevent alcohol use: systematic review of economic evaluations

BACKGROUND

Alcohol use is a leading risk factor for death and disability worldwide.

AIMS

We conducted a systematic review on the cost-effectiveness evidence for interventions to prevent alcohol use across the lifespan.

METHOD

Electronic databases (EMBASE, Medline, PsycINFO, CINAHL and EconLit) were searched for full economic evaluations and return-on-investment studies of alcohol prevention interventions published up to May 2021. The methods and results of included studies were evaluated with narrative synthesis, and study quality was assessed by the Drummond ten-point checklist.

RESULTS

A total of 69 studies met the inclusion criteria for a full economic evaluation or return-on-investment study. Most studies targeted adults or a combination of age groups, seven studies comprised children/adolescents and one involved older adults. Half of the studies found that alcohol prevention interventions are cost-saving (i.e. more effective and less costly than the comparator). This was especially true for universal prevention interventions designed to restrict exposure to alcohol through taxation or advertising bans; and selective/indicated prevention interventions, which involve screening with or without brief intervention for at-risk adults. School-based interventions combined with parent/carer interventions were cost-effective in preventing alcohol use among those aged under 18 years. No interventions were cost-effective for preventing alcohol use in older adults.

CONCLUSIONS

Alcohol prevention interventions show promising evidence of cost-effectiveness. Further economic analyses are needed to facilitate policy-making in low- and middle-income countries, and among child, adolescent and older adult populations.

Methodological issues in economic evaluations of disease prevention and health promotion: an overview of systematic and scoping reviews

BACKGROUND

We aimed to provide a comprehensive overview of methodological challenges in economic evaluations of disease prevention and health promotion (DPHP)-measures.

METHODS

We conducted an overview of reviews searching MEDLINE, EMBASE, NHS Economic Evaluation Database, Database of Promoting Health Effectiveness Reviews, Cochrane Database of Systematic Reviews (CDSR) and Database of Promoting Health Effectiveness Reviews (DOPHER) (from their inception to October 2021). We included both systematic and scoping reviews of economic evaluations in DPHP addressing following methodological aspects: (i) attribution of effects, (ii) outcomes, (iii) inter-sectoral (accruing to non-health sectors of society) costs and consequences and (iv) equity. Data were extracted according to the associated sub-criteria of the four methodological aspects including study design economic evaluation (e.g. model-based), type/scope of the outcomes (e.g. outcomes beyond health), perspective, cost categories related to non-health sectors of society, and consideration of equity (method of inclusion). Two reviewers independently screened all citations, full-text articles, and extracted data. A narrative synthesis without a meta-analysis or other statistical synthesis methods was conducted.

RESULTS

The reviewing process resulted in ten systematic and one scoping review summarizing 494 health economic evaluations. A lifelong time horizon was adopted in about 23% of DPHP evaluations, while 64% of trial-based evaluations had a time horizon up to 2 years. Preference-based outcomes (36%) and non-health outcomes (8%) were only applied in a minority of studies. Although the inclusion of inter-sectoral costs (i.e. costs accruing to non-health sectors of society) has increased in recent years, these were often neglected (between 6 and 23% depending on the cost category). Consideration to equity was barely given in economic evaluations, and only addressed in six of the eleven reviews.

CONCLUSIONS

Economic evaluations of DPHP measures give only little attention to the specific methodological challenges related to this area. For future economic DPHP evaluations a tool with structured guidance should be developed. This overview of reviews was not registered and a published protocol does not exist.

The art and science of priority-setting: assessing the value of Public Health England's Prioritization Framework

BACKGROUND

Findings are presented from the evaluation of Public Health England's (PHE) Prioritization Framework (PF) aimed to assist local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings.

METHODS

Semi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops.

RESULTS

Participants acknowledged that the PF provided a systematic means of guiding priority-setting and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in the local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success.

CONCLUSIONS

The study assessed the value and impact of PHE's PF tool in three early adopter local authorities. Further research could explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending.

Cost-effectiveness analysis of public health interventions with impacts on health and criminal justice: An applied cross-sectoral analysis of an alcohol misuse intervention

Cost-effectiveness analyses of health care programs often focus on maximizing health and ignore nonhealth impacts. Assessing the cost-effectiveness of public health interventions from a narrow health care perspective would likely underestimate their full impact, and potentially lead to inefficient decisions about funding. The aim of this study is to provide a practical application of a recently proposed framework for the economic evaluation of public health interventions, evaluating an intervention to reduce alcohol misuse in criminal offenders. This cross-sectoral analysis distinguishes benefits and opportunity costs for different sectors, makes explicit the value judgments required to consider alternative perspectives, and can inform heterogeneous decision makers with different objectives in a transparent manner. Three interventions of increasing intensity are compared: client information leaflet, brief advice, and brief lifestyle counseling. Health outcomes are measured in quality-adjusted life-years and criminal justice outcomes in reconvictions. Costs considered include intervention costs, costs to the NHS and costs to the criminal justice system. The results are presented for four different perspectives: "narrow" health care perspective; criminal justice system perspective; "full" health care perspective; and joint "full" health and criminal justice perspective. Conclusions and recommendations differ according to the normative judgment on the appropriate perspective for the evaluation.

A systematic review of economic evaluations of public health interventions targeting alcohol, tobacco, illicit drug use and problematic gambling: Using a case study to assess transferability

AIMS

To identify and assess the cost-effectiveness of public health interventions targeting the use of alcohol, illicit drugs and tobacco, as well as problematic gambling behavior (ANDTS), and consider whether the results from these evaluations are transferable to the Swedish setting.

METHODS

A systematic review of economic evaluations within the area of ANDTS was conducted including studies published between January 2000 and November 2018, identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the possibilities of transferring results were assessed using criteria set out by the Swedish Agency for Health Technology Assessment.

RESULTS

Out of 54 relevant studies, 39 were of moderate to high quality and included in the review, however none for problematic gambling. Eighty-one out of a total of 91 interventions were cost-effective. The interventions largely focusing on taxed-based policies or screening and brief interventions. Thirteen of these studies were deemed to have high potential for transferability, with effect estimates considered relevant, and with good feasibility for implementation in Sweden.

CONCLUSIONS

Interventions targeting alcohol- and illicit-drug use and tobacco use are cost-effective approaches, and results may be transferred to the Swedish setting. Caution must be taken regarding cost estimates and the quality of the evidence which the studies are based upon.

Methods for public health economic evaluation: A Delphi survey of decision makers in English and Welsh local government

Standard reference case methods recommended for health technology appraisals do not translate well to a public health setting. This paper reports on a Delphi survey designed to elicit views of public health decision makers in England and Wales, about different methodological elements of economic evaluation. This is important as methods should align with the objective function of decision makers. The Delphi survey comprised two rounds, with round 1 allowing open-ended recommendations in addition to 5-point Likert scale responses. The final survey comprised 36 questions, and levels and strength of agreement were assessed using median values and mean absolute deviation of the median. The Delphi panel (n = 66) achieved high levels of agreement for costs, health, well-being, and productivity impact to be important elements within an economic evaluation. The panel agreed that evaluations should be relevant to the local context and include costs and consequences over a lifetime horizon. There was a call for the transparent reporting of costs and effects for different population subgroups, and for different sectors. Overall, the panel revealed a preference for a flexible approach, understanding that economic evidence fits within a dynamic process of decision making. These results provide empirical evidence to inform guidelines for public health economic evaluation.

Cost-effectiveness of a combined classroom curriculum and parental intervention: economic evaluation of data from the Steps Towards Alcohol Misuse Prevention Programme cluster randomised controlled trial

OBJECTIVES

This study aimed to assess the cost-effectiveness of the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) compared with education as normal (EAN) in reducing self-reported heavy episodic drinking (HED) in adolescents.

DESIGN

This is a cost-effectiveness analysis from a public sector perspective conducted as part of a cluster randomised trial.

SETTING

This study was conducted in 105 high schools in Northern Ireland and in Scotland.

PARTICIPANTS

Students in school year 8/S1 (aged 11-12) at baseline were included in the study.

INTERVENTIONS

This is a classroom-based alcohol education curricula, combined with a brief alcohol intervention for parents/carers.

OUTCOME MEASURES

The outcome of this study is the cost per young person experiencing HED avoided due to STAMPP at 33 months from baseline.

RESULTS

The total cost of STAMPP was £85 900, equivalent to £818 per school and £15 per pupil. Due to very low uptake of the parental component, we calculated costs of £692 per school and £13 per pupil without this element. Costs per pupil were reduced further to £426 per school and £8 per pupil when it was assumed there were no additional costs of classroom delivery if STAMPP was delivered as part of activities such as personal, social, health and economic education. STAMPP was associated with a significantly greater proportion of pupils experiencing a heavy drinking episode avoided (0.08/8%) and slightly lower public sector costs (mean difference -£17.19). At a notional willingness-to-pay threshold of £15 (reflecting the cost of STAMPP), the probability of STAMPP being cost-effective was 56%. This level of uncertainty reflected the substantial variability in the cost differences between groups.

CONCLUSIONS

STAMPP was relatively low cost and reduced HED. STAMPP was not associated with any clear public sector cost savings, but neither did it increase them or lead to any cost-shifting within the public sector categories. Further research is required to establish if the cost-effectiveness of STAMPP is sustained in the long term.

TRIAL REGISTRATION NUMBER

ISRCTN47028486; Results.

Systematic review of the methods used in economic evaluations of targeted physical activity and sedentary behaviour interventions

The burden of noncommunicable diseases (NCD) on health systems worldwide is substantial. Physical inactivity and sedentary behaviour are major risk factors for NCD. Previous attempts to understand the value for money of preventative interventions targeting physically inactive individuals have proved to be challenging due to key methodological challenges associated with the conduct of economic evaluations in public health. A systematic review was carried out across six databases (Medline, SPORTSDiscus, EconLit, PsychINFO, NHS EED, HTA) along with supplementary searches. The review examines how economic evaluations published between 2009-March 2017 have addressed methodological challenges with the aim of bringing to light examples of good practice for future studies. Fifteen economic evaluations from four high-income countries were retrieved; there is a dearth of studies targeting sedentary behaviour as an independent risk factor from physical activity. Comparability of studies from the healthcare and societal perspectives were limited due to analysts' choice in cost categories, valuation technique and time horizon differing substantially. The scarcity of and inconsistencies across economic evaluations for these two behaviours have exposed a mismatch between calls for more preventative action to tackle NCD and the lack of information available on how resources may be optimally allocated in practice. Consequently, this paper offers a table of recommendations on how future studies can be improved.

Mobile phone applications to overcome malnutrition among preschoolers: a systematic review

Background

Malnutrition is one of the most important reasons for child mortality in developing countries, especially during the first 5 years of life. We set out to systematically review evaluations of interventions that use mobile phone applications to overcome malnutrition among preschoolers.

Methods

The review was conducted and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses: the PRISMA statement. To be eligible, the study had to have evaluated mobile phone interventions to increase nutrition knowledge or enhance behavior related to nutrition in order to cope with malnutrition (under nutrition or overweight) in preschoolers. Articles addressing other research topics, older children or adults, review papers, theoretical and conceptual articles, editorials, and letters were excluded. The PubMed, Web of Science and Scopus databases covering both medical and technical literature were searched for studies addressing preschoolers’ malnutrition using mobile technology.

Results

Seven articles were identified that fulfilled the review criteria. The studies reported in the main positive signals concerning the acceptance of mobile phone based nutritional interventions addressing preschoolers. Important infrastructural and technical limitations to implement mHealth in low and middle income countries (LMICs) were also communicated, ranging from low network capacity and low access to mobile phones to specific technical barriers. Only one study was identified evaluating primary anthropometric outcomes.

Conclusions

The review findings indicated a need for more controlled evaluations using anthropometric primary endpoints and put relevance to the suggestion that cooperation between government organizations, academia, and industry is necessary to provide sufficient infrastructure support for mHealth use against malnutrition in LMICs.

Health economics methods for public health resource allocation: a qualitative interview study of decision makers from an English local authority

Local authorities in England have responsibility for public health, however, in recent years, budgets have been drastically reduced placing decision makers under unprecedented financial pressure. Although health economics can offer support for decision making, there is limited evidence of it being used in practice. The aim of this study was to undertake in-depth qualitative research within one local authority to better understand the context for public health decision making; what, and how economics evidence is being used; and invite suggestions for how methods could be improved to better support local public health decision making. The study included both observational methods and in-depth interviews. Key meetings were observed and semi-structured interviews conducted with participants who had a decision-making role to explore views on economics, to understand the barriers to using evidence and to invite suggestions for improvements to methods. Despite all informants valuing the use of health economics, many barriers were cited: including a perception of a narrow focus on the health sector; lack of consideration of population impact; and problems with translating long timescales to short term impact. Methodological suggestions included the broadening of frameworks; increased use of natural experiments; and capturing wider non-health outcomes that resonate with the priorities of multiple stakeholders.