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Cost-effectiveness analyses of health promotion programs: a case study of smoking prevention and cessation among Dutch students |
Vijgen S M, van Baal P H, Hoogenveen R T, de Wit G A, Feenstra T L |
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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 assessed the cost-effectiveness of a health education programme in schools to prevent or stop smoking in adolescents. The authors concluded that the programme was a cost-effective strategy in the Dutch setting, but the findings should be interpreted with caution, due to a lack of evidence for the estimates used in the model. The study was not extensively reported and the authors' conclusion is appropriate. Type of economic evaluation Cost-effectiveness analysis, cost-utility analysis Study objective This study assessed the cost-effectiveness of a health education programme, in schools, to prevent or stop smoking in adolescents. Interventions The intervention was a one-year health education programme, for smoking prevention or cessation, which was implemented, using a social influence (SI) approach, in the form of special magazines and weekly peer-led lessons to eighth grade students. This SI programme was compared with no intervention. Location/setting Netherlands/community (school). Methods Analytical approach:This economic evaluation was based on a chronic disease model, published by the National Institute for Public Health and the Environment (RIVM), which simulated the long-term clinical and economic impact of the differences in smoking prevalence for 14 smoking-related diseases. The time horizon was lifetime (100 years). The authors stated that the analysis was carried out from the perspective of the health care system.
Effectiveness data:Most of the clinical data were already incorporated in the published decision model. The efficacy of the intervention was derived from a published study, with 51 classes from 32 schools, in the intervention arm, and 67 classes from 20 schools, in the control arm. Further details of this study, such as its design and the characteristics of the students, were not provided. Some assumptions regarding the number of daily and non-regular smokers were also made. The efficacy rate, which was the number of smokers after 12 or 18 months with or without the intervention, was the key clinical endpoint.
Monetary benefit and utility valuations:Not reported.
Measure of benefit:The rate of averted smokers, life-years (LYs), and quality-adjusted life-years (QALYs) were the summary benefit measures, and were discounted at an annual rate of 4%.
Cost data:The economic analysis considered two main categories of costs: the costs associated with the implementation of the intervention, and the health care costs due to the 14 smoking-related diseases. The former costs were calculated using data from the Dutch intervention study and official Dutch data, while the latter costs were already in the RIVM decision model. All costs were in Euros (EUR) and were discounted at a 4% annual rate and the price year was 2004.
Analysis of uncertainty:A deterministic sensitivity analysis was undertaken on the model inputs and assumptions for the intervention costs, discount rate, and time horizon. The assumption that the programme was equally effective in daily and experimental smokers was also tested. Results In a cohort of 1,000 adolescents, the cumulative intervention costs were EUR 75,000, the reduction in the number of smokers, at one year, due to the programme was 32, and the incremental cost per averted smoker was EUR 2,300.
When considering both the intervention and health care costs, the cumulative LYs gained with the intervention were 58 and the incremental cost per LY gained was EUR 18,200. The cumulative QALYs gained were 41 and the incremental cost per QALY gained was EUR 19,900. When considering only the intervention costs, the incremental cost per LY gained was EUR 14,100 and the incremental cost per QALY gained was EUR 15,400.
The sensitivity analysis suggested that the incremental cost per QALY remained below the threshold of EUR 20,000 as long as the number of averted smokers was greater than 30. These findings were sensitive to variations in the time horizon; when the time horizon was shorter, the cost-utility ratios were less favourable. Authors' conclusions The authors concluded that the health education programme, in schools, to prevent or stop smoking in adolescents, was a cost-effective strategy, in the Dutch setting. However, they pointed out that their findings should be interpreted with caution, due to a lack of evidence for the estimates used in the model. CRD commentary Interventions:The rationale for the selection of the comparators was clear in that the proposed intervention was compared with the conventional approach in the authors’ setting, which was no intervention. A brief description of the health promotion programme was provided.
Effectiveness/benefits:The approach used to derive the clinical inputs was not described in detail. As the bulk of the evidence was already incorporated in the decision model, no information on these clinical inputs was reported. Similarly, only limited information on the primary Dutch study on the implementation of the programme was given. This limits the possibility of judging the validity of the clinical analysis. The use of different benefit measures makes the findings interesting from different standpoints and the use of QALYs and LYs allows cross-disease comparisons.
Costs:The analysis of costs also relied mostly on data already incorporated in the model, which was supplemented by new inputs from official Dutch sources. The resources and costs associated with the health programme were extensively reported, but those for the 14 diseases were not described. Other details such as the price year and use of discounting were reported.
Analysis and results:The costs and benefits were combined using an incremental approach and only the incremental findings were reported. The issue of uncertainty was addressed by means of a deterministic sensitivity analysis, which focused on individual model inputs and alternative scenarios. The results of these key analyses were presented and discussed. The authors noted that the estimation of the efficacy of the programme was difficult due to the differences between daily and non-regular smokers, which were not fully captured in the Dutch intervention study. Also, the treatment effect observed in this study was not confirmed by published meta-analyses.
Concluding remarks:On the whole, the study was not extensively reported and caution is required when interpreting the findings. Bibliographic details Vijgen S M, van Baal P H, Hoogenveen R T, de Wit G A, Feenstra T L. Cost-effectiveness analyses of health promotion programs: a case study of smoking prevention and cessation among Dutch students. Health Education Research 2008; 23(2): 310-318 Other publications of related interest Tengs TO, Osgood ND, Chen LL. The cost-effectiveness of intensive national school-based anti-tobacco education: results from the Tobacco Policy Model. Prev Med 2001;33:558-70.
Wang LY, Crossett LS, Lowry R, et al. Cost-effectiveness of a school-based tobacco-use prevention program. Arch Pediatr Adolesc Med 2001;155:1043-50.
Dijkstra M, Mesters I, De Vries H, et al. Effectiveness of a social influence approach and boosters to smoking prevention. Health Educ Res 1999;14:791-802. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Cost-Benefit Analysis; Female; Health Promotion /economics /organization & Health Services /economics /utilization; Humans; Life Expectancy; Male; Models, Econometric; Netherlands; Quality-Adjusted Life Years; Schools /organization & Smoking /economics /prevention & Smoking Cessation /economics; administration; administration; control AccessionNumber 22008100419 Date bibliographic record published 22/04/2009 Date abstract record published 05/08/2009 |
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