1. 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.

2. 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.

3. 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.

4. 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

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

6. 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%)

7. 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.

8. 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.

9. 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.

10. Aggregating Costs Across Sites

11. 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

12. 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.

13. 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

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

15. 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

16. 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

17. 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!!!!).

18. 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

19. 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

20. 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

21. 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.

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

23. Thank You!!