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Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
Retooling cost-effectiveness analysis for global health relevance
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Retooling cost-effectiveness analysis for global health relevance

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GHME 2013 Conference …

GHME 2013 Conference
Session: New directions in cost-effectiveness analysis
Date: June 18 2013
Presenter: Josh Salomon
Institute:
Harvard School of Public Health

Published in: Health & Medicine
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  • 1. Salomon – Cost-effectiveness - 2 An observation • Hundreds of cost- effectiveness analyses are published each year • Relatively few examples of these analyses being used in formulation or modification of policies in global health Source: Tufts CEA Registry 0 50 100 150 200 250 300 350 400 1990 1995 2000 2005 2010 Numberofstudies Year
  • 2. Salomon – Cost-effectiveness - 3
  • 3. Salomon – Cost-effectiveness - 4 June 2011
  • 4. Salomon – Cost-effectiveness - 5 Secretary Clinton, November 8, 2011: “…our efforts have helped set the stage for a historic opportunity, one that the world has today: to change the course of this pandemic and usher in an AIDS-free generation.” President Obama, December 1, 2011: “…Today, we come together as a global community … to renew our commitment to ending the AIDS pandemic once and for all.” Global Fund for world health halts new programs By JOHN HEILPRIN, Associated Press – Nov 24, 2011 GENEVA (AP) — The world's biggest financier in the fight against three killer diseases says it has run out of money to pay for new grant programs for the next two years — a situation likely to hit poor AIDS patients around the world. November - December 2011
  • 5. Salomon – Cost-effectiveness - 6 HPTN 052: Preventing transmission with early ART Cohen et al. NEJM, July 2011
  • 6. Salomon – Cost-effectiveness - 7 Treatment as prevention: ‘breakthrough of the year’ Science, December 2011
  • 7. Salomon – Cost-effectiveness - 8 Fifteen years earlier… WHO Press Release, March 1997
  • 8. Salomon – Cost-effectiveness - 9 March 1997
  • 9. Salomon – Cost-effectiveness - 10 Boehme et al. NEJM, September 2010 Small & Pai NEJM, September 2010 Game change for TB diagnosis? (September 2010)
  • 10. Salomon – Cost-effectiveness - 11 Sputum smear microscopy Xpert MTB/RIF
  • 11. Salomon – Cost-effectiveness - 12 Xpert MTB/RIF • Automated, cartridge-based PCR • Simplified procedures, rapid turn- around (<2 hours) • Specificity: 98% • Sensitivity: 92% (sm+), 73% (sm–) • WHO, Dec 2010: “the foundation for a revolution in the diagnosis of TB and drug-resistant TB” • Vassall et al. 2011 (PLoS Med): Xpert appears highly cost- effective in South Africa Game changer?
  • 12. Salomon – Cost-effectiveness - 13 An observation • Hundreds of cost- effectiveness analyses are published each year • Relatively few examples of these analyses being used in formulation or modification of policies in global health Why? Source: Tufts CEA Registry 0 50 100 150 200 250 300 350 400 1990 1995 2000 2005 2010 Numberofstudies Year
  • 13. Salomon – Cost-effectiveness - 14 An agenda for cost-effectiveness analysis in global health Intervention $ / DALY averted Condoms + treatment of STI for sex workers 1 Blood safety 1 – 43 Peer education for sex workers 4 – 7 Voluntary counseling and testing 18 – 22 Prevention of mother-to- child transmission 1 – 730 Treatment of other STIs 12 Antiretroviral therapy 1,000 – 2,000 Source: Creese et al. Lancet 2002 Example: Estimated cost-effectiveness of HIV/AIDS interventions in Africa • Published evidence on cost-effectiveness often seems too good to be true • Agenda item #1: More ex-post analysis of cost- effectiveness • Not only impact but also efficiency should be submitted to rigorous evaluation in real-world programs
  • 14. Salomon – Cost-effectiveness - 15 • CEA often fails to focus on actionable decisions in real-world contexts • Need information on cost-effectiveness of strategies, which are more than just technologies. Strategy = technology + specific implementation plan An agenda for cost-effectiveness analysis in global health
  • 15. Salomon – Cost-effectiveness - 16 • CEA often fails to focus on actionable decisions in real-world contexts An agenda for cost-effectiveness analysis in global health 1980 2000 2020 2040 Year Granich et al. Lancet 2009Granich et al. PLoS ONE 2012 Costs for different ART eligibility scenarios, compared to status quo
  • 16. Salomon – Cost-effectiveness - 17 Source: Menzies et al. (in preparation) • CEA often fails to focus on actionable decisions in real-world contexts An agenda for cost-effectiveness analysis in global health 0 5 10 15 20 25 30 35 40 45 2012 2016 2020 2024 2028 TBmortality(per100,000) Projected TB mortality in Kenya Reductions in mortality if Xpert is implemented: • Where culture is available • Where only smear is available • Where neither smear and culture currently reach Example: Xpert test for TB being adopted rapidly based on strong evidence of effectiveness and preliminary analysis of CE
  • 17. Salomon – Cost-effectiveness - 18 Source: Menzies et al. 2012 • CEA often fails to focus on actionable decisions in real-world contexts • Agenda item #2: Emphasize analysis of adoptable strategies through a health systems lens, with explicit and credible accounting for all relevant costs, outcomes and constraints relevant to a specific implemen- tation approach An agenda for cost-effectiveness analysis in global health Example: Xpert test for TB being adopted rapidly based on strong evidence of effectiveness and preliminary analysis of CE …but most CE analyses to date have ignored the single biggest associated cost because it is not borne by the TB program
  • 18. Salomon – Cost-effectiveness - 19 Source: Salomon et al, PLoS Med 2006 Example: New, shorter TB drug regimens could avert millions of TB deaths  Decision analysis may be missing key opportunities to address problems most amenable to the approach e.g. investment choices on R&D toward new health technologies 0 0.2 0.4 0.6 0.8 1 1.2 2000 2005 2010 2015 2020 2025 2030 Time (years) An agenda for cost-effectiveness analysis in global health TBdeaths(millions)
  • 19. Salomon – Cost-effectiveness - 20 Source: Salomon et al, PLoS Med 2006 Example: New, shorter TB drug regimens could avert millions of TB deaths …but delay in investment has been costly  Decision analysis may be missing key opportunities to address problems most amenable to the approach e.g. investment choices on R&D toward new health technologies 0 0.2 0.4 0.6 0.8 1 1.2 2000 2005 2010 2015 2020 2025 2030 Time (years) An agenda for cost-effectiveness analysis in global health TBdeaths(millions)
  • 20. Salomon – Cost-effectiveness - 21 Source: Salomon et al, PLoS Med 2006 Example: New, shorter TB drug regimens could avert millions of TB deaths …but delay in investment has been costly …and further delay will continue to erode potential benefits  Decision analysis may be missing key opportunities to address problems most amenable to the approach e.g. investment choices on R&D toward new health technologies • Agenda item #3: Define a “global health technology portfolio” by assessing potential health returns on R&D investments 0 0.2 0.4 0.6 0.8 1 1.2 2000 2005 2010 2015 2020 2025 2030 Time (years) An agenda for cost-effectiveness analysis in global health TBdeaths(millions)
  • 21. Salomon – Cost-effectiveness - 22 Summary and final thoughts • In the US, resistance to cost-effectiveness analysis in healthcare is strong • In resource-poor countries, the need is greater, and resistance may be weaker • To be truly useful for global health policy, we need to re- evaluate the way we go about decision analysis:  Establish more credible evidence based on ex post evaluation  Move from identifying what can work under optimal circumstances to evaluating how we can maximize delivery of promising interventions within real-world systems  Take a long-term portfolio view on prioritizing investments in future health technologies

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