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Intervention strategies to reduce the burden of non-communicable diseases in Mexico: cost effectiveness analysis |
Salomon JA, Carvalho N, Gutierrez-Delgado C, Orozco R, Mancuso A, Hogan DR, Lee D, Murakami Y, Sridharan L, Medina-Mora ME, Gonzalez-Pier E |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of 101 strategies, for nine clusters of non-communicable diseases, in Mexico. The authors concluded that there were wide variations in the costs and benefits, within and across intervention categories, but for every disease area, at least some of the strategies were highly cost-effective, including both population-based and personal interventions. The methods were those recommended by the World Health Organization, and the authors’ conclusions appear to be robust. Type of economic evaluation Study objective This study examined the cost-effectiveness of 101 strategies, for nine clusters of non-communicable diseases, in Mexico. The nine clusters were depression, heavy alcohol use, tobacco use, cataracts, breast cancer, cervical cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), and diabetes. Interventions A wide range of interventions was considered for each disease cluster. For depression, interventions included tricyclic antidepressants, selective serotonin re-uptake inhibitors, and psychotherapy. For heavy alcohol use and tobacco use, interventions included taxes, and advertising bans. For cataracts, they included extracapsular cataract extraction and phacoemulsification. For cancers, they included radiotherapy, chemotherapy, surgery, and screening. For COPD, they included smoking cessation, and influenza vaccination. For CVD, they included education by mass media, and drug treatments. For diabetes, they included treatment for hypertension, lipid control, and glycaemic control. The comparator was no intervention. Location/setting Mexico/primary care, secondary care, tertiary care, and community. Methods Analytical approach:The analysis used different simulation and decision-analytic models for each disease cluster. A lifetime horizon was adopted. The authors stated that the analysis was undertaken from a societal perspective. Effectiveness data:Wherever possible, Mexican sources were selected. These included administrative registries, population estimates, and household surveys. Following the World Health Organization (WHO) Choosing Interventions that are Cost-Effective (CHOICE) approach, the key data on the efficacy of the interventions, which was the primary input for each model, was from published meta-analyses and systematic reviews. Different key inputs were used for each disease cluster, but the treatment effect and coverage were, generally, the most important items. Monetary benefit and utility valuations:The utility values were Mexican estimates that were consistent with WHO global burden of disease estimation methods. Their calculation was age weighted. Measure of benefit:Disability-adjusted life-years (DALYs) were the summary benefit measure and they were discounted at an annual rate of 3%. Cost data:Three main cost categories were considered: patient costs (hospital bed-days, hospital visits, health centre visits, ancillary care, laboratory and diagnostic tests, drugs, and other costs specific to each intervention), programme costs (planning and overheads), and training costs (depending on the length of training required). The quantities of resources were based on a review of the published literature and practice guidelines. The drug costs were based on public prices. The assessment of all other costs followed the WHO-CHOICE approach, using Mexican estimates from an econometric analysis of multinational cost data. All costs were in International dollars (INT$) and referred to 2005 prices. A 3% annual discount rate was applied. Analysis of uncertainty:An alternative method of calculating the DALYs was considered in a sensitivity analysis; this did not include age weighting. Results The cost-effectiveness threshold was the gross domestic product (GDP) per capita in Mexico in 2005, which was INT$ 10,770. Below this threshold, interventions were considered to be highly cost-effective; below three times the threshold, interventions were considered cost-effective. Across the 101 strategies, the health and economic burden varied substantially. At a population level, the average yearly costs ranged from less than INT$ 1 million (for cataract surgery or some elements of cervical cancer treatment) to more than INT$ 1 billion (for high coverage of treatment for hypercholesterolaemia or aggressive management of absolute cardiovascular risk). The DALYs averted ranged from less than 1,000 (for some components of cancer treatment or aspirin therapy) to more than 300,000 (for an aggressive combination of interventions to deal with alcohol use and cardiovascular risk). The cost per DALY averted ranged from less than INT$ 100 with taxation for alcohol, to more than INT$ 100,000 with high-intensity treatment for COPD or aspirin for acute ischaemic stroke. The dominated interventions, which were less effective and more expensive than another option, were excluded. For depression, newer antidepressant drugs in primary care, at target coverage, or newer antidepressant drugs plus psychotherapy, at target coverage, were cost-effective.For heavy alcohol use, increased taxation, increased taxation plus advertising bans, or increased taxation plus brief advice plus bans plus reduced access, were cost-effective. For tobacco use, increased taxation or increased taxation plus advertising bans, were cost-effective. For cataracts, both interventions were cost-effective. For breast cancer, treatment of all stages, and for cervical cancer, treatment at all stages plus screening, were cost-effective. For COPD, influenza vaccination or smoking cessation, were cost-effective. For CVD, population salt reduction, a combination of strategies, cardiac rehabilitation, diuretic, all heart failure interventions, and all secondary prevention, were cost-effective. For diabetes, blood pressure control was cost-effective. When interventions were grouped into community and public health interventions, low- and medium-complexity clinical interventions, or high complexity clinical interventions, the analysis showed that the first category provided the lowest cost-effectiveness ratios. The exclusion of age weighting in the calculation of DALYs did not substantially alter the findings. Authors' conclusions The authors concluded that there were wide variations in the costs and benefits, within and across intervention categories, but for every disease area, at least some of the strategies were highly cost-effective, including both population-based and personal interventions. CRD commentary Interventions:A wide range of health care programmes was considered. The authors stated that the interventions were selected in consultation with the Ministry of Health in Mexico, based on policy priorities and ongoing debate over the content of services from the System of Social Protection in Health (SSPH). Both population-based and personal interventions were considered. Effectiveness/benefits:The epidemiology and demographic data were appropriately from Mexican sources wherever available, while the treatment effects were often from meta-analyses or systematic reviews. These were valid sources and were accurately described in the online appendix for each disease. Only a few parameters were varied in the sensitivity analysis. DALYs were an appropriate measure, given the impact of each disease on quality of life and the lifespan of patients. This benefit measure also allowed comparisons between the various diseases considered. Costs:The economic analysis adopted a broad perspective, and a wide range of cost categories was analysed. The data sources were clearly reported and appear to have been appropriate, as the methods recommended by the WHO were applied. The unit costs were generally from local sources. Given the number of strategies assessed, the costs were not broken down to individual items, and the unit costs and quantities of resources were not reported. The price year was given, allowing reflation exercises. Analysis and results:The results were extensively reported in an appendix. The average cost-utility ratios were calculated to compare each intervention with no intervention, and incremental analyses were performed to compare all competing strategies. The uncertainty was not extensively investigated as only the DALYs were varied. A detailed description of the data sources and model parameters was provided in a technical appendix. The results were specific to Mexico, but might be similar for other middle-income countries. Concluding remarks:The methods were those recommended by the WHO, and the authors’ conclusions appear to be robust. Funding Funding received from the Ministry of Health, Mexico. Bibliographic details Salomon JA, Carvalho N, Gutierrez-Delgado C, Orozco R, Mancuso A, Hogan DR, Lee D, Murakami Y, Sridharan L, Medina-Mora ME, Gonzalez-Pier E. Intervention strategies to reduce the burden of non-communicable diseases in Mexico: cost effectiveness analysis. BMJ 2012; 344: e355 Indexing Status Subject indexing assigned by NLM MeSH Cost-Benefit Analysis; Female; Humans; Male; Mexico; Primary Prevention /economics AccessionNumber 22012008003 Date bibliographic record published 17/04/2012 Date abstract record published 19/02/2013 |
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