Academy on Violence and Abuse Incorporating Economic Evaluation in the PH Model for Preventing Violence Phaedra S. Corso, PhD, MPA Academy on Violence and Abuse April 24, 2009 All presentations must start with an approved slide that includes both the HHS and CDC logos.

Why Care About Economics within the Context of Preventing Violence? Maximizing outcomes is important. Minimizing costs is important too. Resources are limited, so hard (resource allocation) decisions must be made. Demonstrates the value provided from the resources expended.

Public Health Model for Prevention Problem Identification Risk and Protective Factor Identification Program and Policy Development Economic Impact - COI Program and Policy Evaluation Implementation and Dissemination Problem identification - SURVEILLANCE: what is the burden of disease or injury: incidence, prevalence, mortality rate. Economic burden: medical costs and losses in productivity associated with the disease or injury. Risk and protective factors – WHAT IS THE ETIOLOGY of disease or injury Information about risk and protective factors helps us redefine our surveillance systems to perhaps find target high risk populations, etc. From there, Program and policy development Evaluation: From efficacy to evaluation research Theoretically, one would only proceed with wide-spread implementation and dissemination interventions that are known to be efficacious and effective. Empirically, however, our funding sometimes comes programmatically (block grants for rape prevention, for example), without funding coming for evaluation research. This is typically how CDC Divisions are operationalized. For example, within our Division of Violence Prevention, we have an etiology and surveillance branch, a prevention development and evaluation branch (which I lead), and a program implementation and dissemination branch. Now, I would argue that there is a component missing. After or in conjunction with determining a program’s effectiveness, it is essential to assess cost-effectiveness as well. What is economic evaluation? Applied analytic methods used to: identify, measure, value, and compare the costs and consequences of prevention and treatment strategies.

COI Analysis Estimates total costs incurred because of a disease or condition medical costs non-medical costs productivity losses Generally reported as annual total cost average patient lifetime cost Non-medical costs can include: childcare and travel expenses

Costs of Violence in the United States Corso, Mercy, Simon, Finkelstein, Miller American J Preventive Medicine, 2007

Total Lifetime Costs= ~$70 Billion for Violence-Related Injuries Requiring Medical Attention in 2000 Assaults Total Costs Self-inflicted 2.2M $37.1 B 324,053 $33.3 B Male 1.2M $30 B 145,375 $27.8 B Female 1.0M (45.4%) $7.1 B (19.1%) 178,678 (55.1%) $5.5 B (16.5%)

So What? Economic burden estimates Provide the needed data to lobby for more prevention resources. Illustrate the potential savings (or costs avoided) if effective interventions are implemented Represent the potential returns on investment for prevention. Despite these limitations, these are the best and most complete national economic burden of injury estimates to date in the US. These results show that the burden is substantial in the US. These results can be used by researchers, practitioners, and advocates to leverage scarce resources for injury prevention. As a next step, more research is needed on the development, evaluation, and dissemination of effective and cost-effective interventions to reduce this economic burden. Such that, the costs to implement effective interventions less the economic burden prevented – can represent the potential returns on investment for injury prevention.

Public Health Model for Prevention Problem Identification Risk and Protective Factor Identification Cost Analysis Program and Policy Development Economic Impact - COI Program and Policy Evaluation Implementation and Dissemination Problem identification - SURVEILLANCE: what is the burden of disease or injury: incidence, prevalence, mortality rate. Economic burden: medical costs and losses in productivity associated with the disease or injury. Risk and protective factors – WHAT IS THE ETIOLOGY of disease or injury Information about risk and protective factors helps us redefine our surveillance systems to perhaps find target high risk populations, etc. From there, Program and policy development Evaluation: From efficacy to evaluation research Theoretically, one would only proceed with wide-spread implementation and dissemination interventions that are known to be efficacious and effective. Empirically, however, our funding sometimes comes programmatically (block grants for rape prevention, for example), without funding coming for evaluation research. This is typically how CDC Divisions are operationalized. For example, within our Division of Violence Prevention, we have an etiology and surveillance branch, a prevention development and evaluation branch (which I lead), and a program implementation and dissemination branch. Now, I would argue that there is a component missing. After or in conjunction with determining a program’s effectiveness, it is essential to assess cost-effectiveness as well. What is economic evaluation? Applied analytic methods used to: identify, measure, value, and compare the costs and consequences of prevention and treatment strategies.

Cost Analysis (CA) Estimates total costs of running a program Costs are the value of the resources (people, building, equipment and supplies) used to produce a good or a service Important for realizing costs from varying perspectives e.g., incurred by program, incurred by participant Includes not just financial, but also economic costs. Important for budget justification, decision making, and forecasting. Provides the first step of a full economic evaluation IDENTIFY: The first step is to explicitly delineate ALL possible intervention alternatives being considered by the decision maker. MEASURE: EE involves the use of quantitative techniques (descriptive epidemiology, decision analysis, economic evaluation, meta-analysis) VALUE: EE necessarily provides estimates of probabilities, costs, and outcomes for each alternative. COMPARE: Final step in an EE is to answer the question: how do the intervention outcomes compares with the costs. By combining basic components of applied research on epidemiology, (ie efficacy and effectiveness), with the economic component (ie costs), Economic evaluations allow one to develop a summary statement of the implications of choosing one particular course of action or decision over another.

Aggregating Costs Across Sites

Public Health Model for Prevention Problem Identification Risk and Protective Factor Identification Cost Analysis Program and Policy Development Economic Impact - COI Program and Policy Evaluation Implementation and Dissemination Problem identification - SURVEILLANCE: what is the burden of disease or injury: incidence, prevalence, mortality rate. Economic burden: medical costs and losses in productivity associated with the disease or injury. Risk and protective factors – WHAT IS THE ETIOLOGY of disease or injury Information about risk and protective factors helps us redefine our surveillance systems to perhaps find target high risk populations, etc. From there, Program and policy development Evaluation: From efficacy to evaluation research Theoretically, one would only proceed with wide-spread implementation and dissemination interventions that are known to be efficacious and effective. Empirically, however, our funding sometimes comes programmatically (block grants for rape prevention, for example), without funding coming for evaluation research. This is typically how CDC Divisions are operationalized. For example, within our Division of Violence Prevention, we have an etiology and surveillance branch, a prevention development and evaluation branch (which I lead), and a program implementation and dissemination branch. Now, I would argue that there is a component missing. After or in conjunction with determining a program’s effectiveness, it is essential to assess cost-effectiveness as well. What is economic evaluation? Applied analytic methods used to: identify, measure, value, and compare the costs and consequences of prevention and treatment strategies. Economic Evaluation

Economic Evaluation Methods What is Economic Evaluation? Applied analytic methods used to identify, measure, value and compare the costs and consequences of treatment and prevention programs, interventions, and policies. What are the Methods? BCA – benefit-cost analysis CEA – cost-effectiveness analysis CUA – Cost-utility analysis IDENTIFY: The first step is to explicitly delineate ALL possible intervention alternatives being considered by the decision maker. MEASURE: EE involves the use of quantitative techniques (descriptive epidemiology, decision analysis, economic evaluation, meta-analysis) VALUE: EE necessarily provides estimates of probabilities, costs, and outcomes for each alternative. COMPARE: Final step in an EE is to answer the question: how do the intervention outcomes compares with the costs. By combining basic components of applied research on epidemiology, (ie efficacy and effectiveness), with the economic component (ie costs), Economic evaluations allow one to develop a summary statement of the implications of choosing one particular course of action or decision over another.

Use of EE Methods to Inform Prevention Policy Tier of Decision Making US Congress Allocation decision between health, defense, and education. Outcome comparator: $ Director of HHS Allocation decision between violence prevention and cancer screening. Outcome comparator: QALYs Local HD Allocation decision between two interventions designed to reduce child neglect. Outcome comparator: Cases of neglect prevented BCA CUA President: Decisions between defense and health Outcomes different CBA CDC Director Decisions between health programs: cancer screening versus injury prevention Outcomes are now health related, but different health outcomes: cancer vs disabilities CUA NCIPC Decisions with same health outcome: 2 interventions to decrease incidence of cervical cancer CEA CEA

CEA of Family Connections (DePanfilis et al CEA of Family Connections (DePanfilis et al., Child Abuse & Neglect 2008)

FC3 = $337/unit change in CBCL raw score CEA Results: FC3 = $337/unit change in CBCL raw score FC9 = $276/unit change in CBCL raw score ICER = $242/unit change in CBCL comparing FC9 to FC3

Cost-utility Analysis – CUA A CEA that includes Quality of Life A method used to compare costs and benefits of interventions where benefits are expressed as the number of life years saved adjusted to account for loss of quality. Combines Length of life (survival), and Quality of life (a weight from 0, death, to 1, perfect health) Compares disparate outcomes in terms of utility Quality-adjusted life years (QALYs) Derives a ratio of cost per health outcome $/QALY

When is CUA Used? When quality of life is the important outcome. When the program affects both morbidity and mortality. When the programs being compared have a wide range of different outcomes. When the program is being compared with a program that has already been evaluated using CUA (clinical interventions!!!!).

Predicted Utility Losses by Age Group and Type of Child Maltreatment Corso, Edwards, Fang, Mercy American J of Public Health, 2008 Age group ALL PA SA EA PN EN 19-39 .042* .023* .029* .003 .018 .039* 40-49 .038* .021* .019* .011 .033* 50-59 .017* .005 .007 .014 .015 60-69 .016* .018* .004 .028* 70+ .025* .013 .051* .027 .017 .015* .010 .026* Here are predicted utility losses by age group and type of child maltreatment. Noteworthy points on this slide are: EA, emotional abuse, only has a significant impact on persons 70 and older And conversely, persons 70 and older are only signfiicantly impacted by emotional abuse Across all age groups, emotional neglect has the highest significant contribution to the overall effect of CM on utility, compared to the other types of child maltreatment. * Significant at p < 0.05

Public Health Model for Prevention Problem Identification Risk and Protective Factor Identification Cost Analysis Program and Policy Development Economic Impact - COI Economic Evaluation Program and Policy Evaluation Implementation and Dissemination Problem identification - SURVEILLANCE: what is the burden of disease or injury: incidence, prevalence, mortality rate. Economic burden: medical costs and losses in productivity associated with the disease or injury. Risk and protective factors – WHAT IS THE ETIOLOGY of disease or injury Information about risk and protective factors helps us redefine our surveillance systems to perhaps find target high risk populations, etc. From there, Program and policy development Evaluation: From efficacy to evaluation research Theoretically, one would only proceed with wide-spread implementation and dissemination interventions that are known to be efficacious and effective. Empirically, however, our funding sometimes comes programmatically (block grants for rape prevention, for example), without funding coming for evaluation research. This is typically how CDC Divisions are operationalized. For example, within our Division of Violence Prevention, we have an etiology and surveillance branch, a prevention development and evaluation branch (which I lead), and a program implementation and dissemination branch. Now, I would argue that there is a component missing. After or in conjunction with determining a program’s effectiveness, it is essential to assess cost-effectiveness as well. What is economic evaluation? Applied analytic methods used to: identify, measure, value, and compare the costs and consequences of prevention and treatment strategies. Economic Evaluation

National Replication of Project SafeCare (Lutzker, PI) Research Type Population Strategies Intermed Outcomes Final Outcomes Evaluation Research Participants SafeCare Participation Attrition Decreased CM Implement-ation Providers Implemen-tation Plan Increased Fidelity

Final Comments Economic evaluation (EE) methods are valuable to decision making and for setting health policy. For practitioners and evaluators, these skills are necessary because the DEMAND for these analyses is growing. Bullet 1: Here at CDC and beyond. Bullet 2: Systematic reviews of economic evaluation are currently being conducted for firearms Bullet 3: It is likely that many economic gaps will be identified.

Resources Applying cost analysis to PH interventions (manual available at www.phf.org) Haddix, Teutsch, Corso – Prevention Effectiveness: A Guide to Economic Evaluation (Oxford University Press, 2003)

Thank You!! pcorso@uga.edu