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

Overview • Introduction to economic evaluation • Overview of ACE Prevention • Introduction to 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 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 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 Cost. A Consequences. A Program B Cost. B Consequences. B Choice

Types of economic evaluation Types of economic evaluation

Assessing Cost-Effectiveness. Prevention Rob Carter, Theo Vos, Chris Doran, Alan Lopez, Andrew Wilson, Ian 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) Assessing Cost-Effectiveness (ACE) studies in Australia • • Pilot project in cancer prevention (2000) ACE–Heart Disease (2000 -2003) • • ACE–Mental Health (2001 -2004) • • Focus on childhood interventions ACE-Alcohol (2006 -2008) • • • 20 + interventions for depression, schizophrenia, anxiety and ADHD ACE-Obesity (2004 -2005) • • 20 + interventions for prevention of coronary heart disease 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 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, 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 ‘ 2 nd 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 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 Slope = CER = costs -----------health effects • The flatter the slope, the more cost-effective

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

Intervention pathways: ‘Ideal mix’ Intervention pathways: ‘Ideal mix’

Alcohol intervention pathway Alcohol intervention pathway

Combining everything in one model Combining everything in one model

Combined impact 43 very cost-effective prevention measures Intervention costs - <$10, 000/DALY package Cost Combined impact 43 very cost-effective prevention measures Intervention costs - <$10, 000/DALY package Cost offsets - <$10, 000/DALY package Health gain - <$10, 000/DALY package $3 1 million healthy life years Immediate cost savings in blood pressure & cholesterol $2 Costs $4 billion upfront investment 80 $1 $0 60 40 20 0 Treatment cost saved -$1 2003 2010 2017 2024 2031 2038 2045 2052 2059 2066 2073 2080 Years -20 DALYs averted Billions $4 Thousands Intervention costs - Current practice

ACE Prevention - main findings Areas amenable to preventive interventions to reduce size of 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 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. Ph. Ds) Cons • Very technical – policy makers found it hard to understand, eg. What is a DALY? • Focus on health outcomes – for certain risk factors (alcohol) nonhealth 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 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 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 … this need is central to the Wills and Mc. Keon reviews 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

The imperative for measuring research impact… • Socially responsible and good for patients • 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 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) COST Demand for the research Program aims Translational research pathway (From an economic perspective) COST 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 BENEFIT Impact or benefit (i. e. how does the community benefit from the research outcomes )

Example: Family well-being (FWB) • FWB program focuses on the empowerment and personal development 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

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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 BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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 BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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 BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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 BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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? BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

Translational research pathway (An example from Family Wellbeing - FWB) COST Demand for the Translational research pathway (An example from Family Wellbeing - FWB) COST 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 lifeskills 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. COST 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? BENEFIT Impact or benefit: Reduced risks for disease & injury, better health (cost avoided), reduced violence (cost avoided), higher wellbeing (GEM), increased capacity

DEMAND COST AIMS & ACTIVITIES IMPACT OUTCOMES Better lifestyle choices: self manageme nt of DEMAND COST AIMS & ACTIVITIES IMPACT OUTCOMES Better lifestyle choices: self manageme nt of health, diet, exercise, smoking Better able to cope with conflict 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 lifeskill training Reduced risk factors for disease & injury Reduction of stress; reduction in domestic violence; better quality of life (wellbeing) Better engagemen t 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 Better health outcomes; improved life expectancy better quality of life / wellbeing 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 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) 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

COST ACTIVITY OUTPUT / OUTCOME IMPACT / BENEFIT Provision of appropriate care to manage COST ACTIVITY OUTPUT / OUTCOME IMPACT / BENEFIT Provision of appropriate care to manage chronic conditions Service delivery IUIH budget 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, ehealth) Better educated towards chronic diseases Reduced risk factors for disease & injury Reduced complications / fewer hospitalisations / saving to health care system Better health outcomes; improved life expectancy better quality of life / wellbeing Better lifestyle choices: diet, exercise, smoking Building cultually aware workforce Building sustainable partnerships Building the evidence base More effective / productive workforce Greenfield and brownfield clinics; improved governance Data management services Contribution to Indigenous health and social policy

Example: Institute of Urban Indigenous Health • The IUIH activities are diverse, multifaceted and 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 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 Thank you Chris. [email protected] com. au