Cairns 16th October 2014 Professor Christopher Doran Insights from ACE Prevention: what worked and what needs to be done in economic evaluation Cairns 16th October 2014 Professor Christopher Doran

Overview Introduction to economic evaluation Overview of ACE Prevention Introduction to impact assessment 2 Indigenous examples of impact assessment

Context of economic evaluation Resources are scarce in relation to needs / demand Scarcity forces choices to be made and choices imply a sacrifice or foregone opportunity

Economic evaluation is … The comparative analysis of alternative courses of action in terms of both their costs and consequences in order to assist policy decisions”. Program A CostA ConsequencesA Choice Program B CostB ConsequencesB

Types of economic evaluation

Assessing Cost-Effectiveness-Prevention Rob Carter, Theo Vos, Chris Doran, Alan Lopez, Andrew Wilson, Ian Anderson, Jan Barendregt, Wayne Hall

Assessing Cost-Effectiveness (ACE) studies in Australia Pilot project in cancer prevention (2000) ACE–Heart Disease (2000-2003) 20 + interventions for prevention of coronary heart disease ACE–Mental Health (2001-2004) 20 + interventions for depression, schizophrenia, anxiety and ADHD ACE-Obesity (2004-2005) Focus on childhood interventions ACE-Alcohol (2006-2008) Around 10 interventions to reduce harm from alcohol misuse ACE-Prevention (2005-2009) ACE-Alcohol Indigenous (2010-2014)

ACE Prevention: methods Understand natural history of disease (from burden of disease study) Analyse current practice: % receiving intervention(s); adherence Efficacy/effectiveness from literature Impact in routine Australian health services? Model change in health outcomes (often over a lifetime) in DALYs Difference in costs of intervention & cost offsets Cost-effectiveness ratios in $$/DALY Mix of most cost-effective interventions

From policy to measurement of benefit Two-stage approach adopted in ACE First, a measure of health gain in relation to resources consumed ($ cost per DALY) Picks up element of cost, efficacy/effectiveness and efficiency objectives Second, explicitly provide for broader considerations not in this C/E ratio Which we call our ‘2nd stage filters’ (equity; acceptability; feasibility; size of the problem) Plus confidence in evidence base

Presenting cost-effectiveness Can put all costs (y-axis) and health effects (x-axis) on a graph Slope of the line represents the economic attractiveness of an intervention costs Slope = CER = ---------------------- health effects The flatter the slope, the more cost-effective

Topic areas and interventions Total population Indigenous  Topic Prevention Treatment Alcohol 9 2 Tobacco 8 Physical activity 6 Nutrition 26 Body mass Blood pressure/cholesterol 12 5 Bone mineral density 3 Illicit drugs 1 Cancer Diabetes 7 Renal disease 4 Mental disorders 11 10 Cardiovascular disease Other 18 Total 123 27 19

Intervention pathways: ‘Ideal mix’

Alcohol intervention pathway

Combining everything in one model

Combined impact 43 very cost-effective prevention measures 1 million healthy life years $4 billion upfront investment Immediate cost savings in blood pressure & cholesterol Treatment cost saved

ACE Prevention - main findings Areas amenable to preventive interventions to reduce size of burden : Substantial CVD, diabetes, kidney disease, tobacco, alcohol, physical inactivity, salt Moderate Mental disorders, drug use, osteoporosis Modest to small Obesity (unless regs/tax work), F&V, cancer screening

ACE Prevention - summary Pros Good engagement with policy makers / Indigenous leaders Platform of recent epidemiological data Used sophisticated methods Attempted to consider equity, acceptability, feasibility Very good dissemination and capacity building (eg. PhDs) Cons Very technical – policy makers found it hard to understand, eg. What is a DALY? Focus on health outcomes – for certain risk factors (alcohol) non-health very important Relied on secondary data of mixed quality Modelling considered a black box – not very researcher friendly

ACE Prevention – what next? Funding stopped limited interest / funding to extend methods in Australia Centre for Burden of Disease and Cost-Effectiveness ceased to exist Majority of staff left UQ Prof Lopez moved to Uni Melbourne Prof Theo Vos and A/Prof Lim moved to Uni Washington to work on the Global Burden of Disease study funded by Bill Gates Others now working at World Health Organisation, Oxford University + other Australian Unis I relocated to Hunter Medical Research Institute to focus on translation research and impact assessment

The imperative for measuring research impact… … there is a need to maximise the translation of effective research outcomes into health policy, programs and services The generation and use of high-quality, relevant research evidence will improve health policy and program effectiveness, achieve better health and help build efficient services. Wills Review, 2012 In Australia the debate on improving health outcomes has relied too much on arguments about increasing resources, and not enough on improving productivity and effectiveness through microeconomic reform and translation of innovations from research. Mckeon Review, 2013 … this need is central to the Wills and McKeon reviews

The imperative for measuring research impact… Socially responsible and good for patients Policy makers and the community are looking for research that is likely to provide a positive social return on investment (SROI) Policy is already changing Reward research that demonstrates its potential (and actual) ‘research translation’ Onus on researchers to demonstrate ‘value for money’ Further evidence of this shift in policy NHMRC (NHMRC Advanced Health Research and Translation Centres) ARC (principles of research translation).

Existing work in this field Measuring research impact Payback method: Buxton& colleagues UK in 1996 Core domains of benefit, each with metrics: knowledge, research, political and administrative, health sector and economic. Scores to represent success in each domain Other versions: Canadian Institutes of Health (2005), Research Impact Framework (2006), Canadian Academy of Health Sciences Framework (2009) Becker list (Washington University School of Medicine) (Last update 2014) All include a dimension of economic impact. AU Government NSW Government Evaluation Framework (2013) Cooperative Research Centre (Impact Tool)

Translational research pathway (From an economic perspective) Demand for the research Program aims Activity (i.e. what will the research do?) Outcomes (i.e. what will the research ‘produce’) Use of the outcomes in the community Impact or benefit (i.e. how does the community benefit from the research outcomes ) COST COST BENEFIT

Example: Family well-being (FWB) FWB program focuses on the empowerment and personal development of Indigenous people through people sharing their stories, discussing relationships, and identifying goals for the future. Workshops are held with both adults and children to highlight the various health and social issues experienced by Indigenous communities and the steps that can be implemented to deal with these issues. HMRI are working with James Cook University to identify the economic impact of the program of the program

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Deliver course content, refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, the Yaba Bimbie Men’s Group, Yarrabah, Gindaja Treatment and Healing Service, Yarrabah, Ma’Ddaimba-Balas Mens’s Group, Innisfail and Queensland Department of Com Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Deliver course content, refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, the Yaba Bimbie Men’s Group, Yarrabah, Gindaja Treatment and Healing Service, Yarrabah, Ma’Ddaimba-Balas Mens’s Group, Innisfail and Queensland Department of Com Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, the Yaba Bimbie Men’s Group, Yarrabah, Gindaja Treatment and Healing Service, Yarrabah, Ma’Ddaimba-Balas Mens’s Group, Innisfail and Queensland Department of Com Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, the Yaba Bimbie Men’s Group, Yarrabah, Gindaja Treatment and Healing Service, Yarrabah, Ma’Ddaimba-Balas Mens’s Group, Innisfail and Queensland Department of Com Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, Gindaja Treatment and Healing Service, Yarrabah etc. Is there a cost to deliver this program? Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

Demand for the research Use of the outcomes in the community Translational research pathway (An example from Family Wellbeing - FWB) Demand for the research Demand for the FWB program is mostly generated by Indigenous groups and organisations. The program targets participants who have experienced, or are experiencing, distress and/or trauma in their lives. Program aims to provide life-skills for performing leadership roles and dealing with difficulties of life. skills include : Leadership; Basic human needs; Relationships; Life journey; Conflict resolution; Emotions; Crises; Beliefs and attitudes; and, Sensitivity as a leader. Activity (i.e. what will the research do?) Refine content to specific groups as needed, provide post-course support. Outcomes (i.e. what will the research ‘produce’) empowerment; better lifestyle choices; ability to cope with conflict; better engagement with family Use of the outcomes in the community RFDS, Gindaja Treatment and Healing Service, Yarrabah etc. Is there a cost to deliver this program? Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity COST COST BENEFIT

COST AIMS & ACTIVITIES OUTCOMES IMPACT DEMAND DEMAND: E.G. A need to enhance wellbeing Funding to address the "need" Develop custom FWB program to address the specific "need" Deliver custom FWB program Empower individuals through life-skill training Better lifestyle choices: self management of health, diet, exercise, smoking Reduced risk factors for disease & injury Better health outcomes; improved life expectancy better quality of life / wellbeing Better able to cope with conflict Reduction of stress; reduction in domestic violence; better quality of life (wellbeing) Better engagement with family, community, and others Improved quality of life (wellbeing) Development of personal responsibility and improved leadership skills Better able to lead self / familiy / community Improved wellbeing for self and others Learning Increase capacity of self / community and organisation Employment Increased income; sense of control, wellbeing

Developing a framework to evaluate the impact of Family well-being? Our framework includes a specific FWB survey that enables us to collect information pertinent to assessing impact If the evaluation is conducted as a prospective exercise (rather than retrospective – as occurs in most cases) it can also provide ongoing feedback to researchers / service providers on performance. In this way it can act as a component/facilitator of continuous quality improvement We acknowledge some problems but we are working on this The GEM is an appropriate measure of wellbeing Currently cannot convert changes in wellbeing scores to $ values Some international work is suggesting that wellbeing be included in all cost benefit analyses and the UK Treasury have published a paper on their attempt to convert wellbeing into $ values Our aim is to advance this research in Australia

Example: Institute of Urban Indigenous Health The Institute of Urban Indigenous Health (IUIH) was established in July 2009 as a strategic response to the growth and geographic dispersion of the Aboriginal and Torres Strait Islander population in South East Queensland (SEQ) which accounts for 38% of Queensland’s, and 10% of Australia’s total Aboriginal and Torres Strait Islander population. The role of the IUIH is to lead health service planning, develop and co-ordinate health service delivery, and to play a major role in the development of partnerships between health care providers The IUIH activities are diverse, multifaceted and lead to a range of outputs. The impacts of these activities are closely aligned with the strategic goals of the IUIH: to improve access to comprehensive primary health care; to develop an effective and culturally aware workforce; to build sustainable partnerships; and to contribute to building the evidence base. While some of these impacts may lead to quantifiable economic return, others are more difficult to quantify. In this analysis benefits were quantified for avoided hospitalisations, avoided time in hospital and the economy wide benefits from employment.

IMPACT / BENEFIT OUTPUT / OUTCOME COST ACTIVITY IUIH budget Service delivery Preventative health Workforce development Service delivery (health assessment, chronic care plan and review) Preventative health (deadly choices, tobacco action, community events, educational programs) Workforce development (student placements, staff recruitment, work it out) Sustainable partnerships (new clinics, improved networking, better governance) Building evidence base (data management services, CQI, e-health) Better educated towards chronic diseases Better health outcomes; improved life expectancy better quality of life / wellbeing Better lifestyle choices: diet, exercise, smoking Provision of appropriate care to manage chronic conditions Reduced risk factors for disease & injury Reduced complications / fewer hospitalisations / saving to health care system Building cultually aware workforce More effective / productive workforce Building sustainable partnerships Greenfield and brownfield clinics; improved governance Building the evidence base Data management services Contribution to Indigenous health and social policy

Example: Institute of Urban Indigenous Health The IUIH activities are diverse, multifaceted and lead to a range of outputs. The impacts of these activities are closely aligned with the strategic goals of the IUIH: to improve access to comprehensive primary health care; to develop an effective and culturally aware workforce; to build sustainable partnerships; and to contribute to building the evidence base. While some of these impacts may lead to quantifiable economic return, others are more difficult to quantify. The next logical step for the Institute is to unpack the rich clinical data that it collects to demonstrate longitudinal improvements in patient and community outcomes from the range of Institute activities. A better understanding of this clinical data would facilitate a more comprehensive assessment of the economic benefit of the IUIH and a better understanding of the IUIH contribution to closing the gap

Summary In an environment of limited resources it is important to evaluate what we do Economics provide a framework to identify value for money ranging from cost-effectiveness to cost-benefit analysis Cost-effectiveness is appropriate when comparing health programs Cost benefit is appropriate when examining return on investment or conducting an impact assessment Policy makers are increasingly requiring evaluations that make sense – what is the return on the investment? Good evaluation requires good data, plausible assumptions and a robust methodology

Thank you Chris.doran@hmri.com.au