1. What does the ACE Prevention study tell us about the cost- effectiveness of prevention? Neil Craig Faisal Bhatti, Matt Lowther, Gerry McCartney

2. Outline  Aims  Overview of ACE: Assessing Cost-Effectiveness in Prevention  Approach  Results  Conclusions

3. ACE Prevention review Scottish Government asked NHSHS to:  Critically review ACE Prevention  Identify the elements of the ACE Prevention report that can be used in priority setting in Scotland  Identify small no. of priorities where evidence and professional consensus is strong Focused on 4 risk factors: alcohol, tobacco, physical activity and body mass

4. What is ACE Prevention?  Extensive priority setting exercise in Australia:  Quantitative - epidemiological data - effect sizes - cost/DALY avoided

5. What is ACE Prevention?  Qualitative  League table - dominant interventions - very cost-effective (A$0-10,000 per DALY) - cost-effective (A$10,000-50,000 per DALY) - non-cost effective (>A$50,000 per DALY)

6. Example results InterventionCost- effectiveness Strength of evidence Second filter Volumetric alcohol tax DominantLikelyPolitical will ABI GPVery $3800/DALY SufficientEquity; GP capacity Drink drive mass media Cost-effective $14k/DALY LimitedNone Weight watchers Not C-E $84k/DALY Sufficient PSA screening Dominated

7. ACE Conclusions  Many interventions for prevention have very strong cost-effectiveness credentials  For the four risk factors we considered, the most cost-effective were policy and regulation-based  Many interventions for prevention have poor cost-effectiveness credentials  For the four risk factors we considered, very few were not cost-effective or better

8. Approach to our review The review assessed:  the epidemiological information and methods used to inform the cost-effectiveness analyses  the effectiveness evidence and the associated estimated effect sizes  the methods and assumptions used to inform the economic analysis

9. Epidemiological evidence  Risky to transfer to Scotland  Need further clarification of the comparative burden of disease  Differences in risk factor-related mortality => greater cost-effectiveness in Scotland for alcohol?

10. Effectiveness evidence  Not always clear how identified and synthesised  Effect sizes used in ACE : - supported where reported - identified where unclear  Large number of interventions that were not included supported by effectiveness evidence

11. Economic analysis Appropriate methods applied consistently across wide range of interventions Issues in generalisation:  QALYs versus DALYs  Strength of evidence  Perspective  Comparators

12. QALYs vs DALYs Effect of converting from DALYs to QALYs depends on:  the age of disease onset  disease duration with and without treatment => relative ranking of interventions may change according to these differences in the diseases they seek to prevent

13. Strength of evidence Of 39 interventions:  Only 15 were deemed to have ‘sufficient’ evidence  15 had ‘limited’ or ‘inconclusive’ evidence  8 were ‘likely’ to be or were ‘maybe’ effective  1 had ‘no evidence’ of effectiveness

14. Perspective  Costs - only included costs to the health system and to patients and families  Benefits - patient perspective => Broader perspective ideal

15. Comparators  Current practice  Do nothing  Optimal pathways Relevant to practice in Scotland?

16. Conclusions  Broad conclusions valid - plausible - logical - consistent  Specific conclusions need to be reviewed in light of: - local comparators - best evidence on those comparators - decision-makers’ values and priorities  Using results should involve dialogue