Estudio de costo-efectividad de intervenciones para prevenir el abuso de alcohol en México / Cost-effectiveness study of interventions to prevent alcohol abuse in Mexico

Introduction In Mexico, alcohol abuse involves overhead costs in terms of premature mortality caused by their related health problems. It is estimated that by itself it implies 9% of the total burden of disease in the country. Although effective interventions exist to treat this problem, national public policies are not integrated and in many occasions its real application is questioned. Cost-effectiveness studies are tools that permit to develop and to implement health public policies because they imply a rigorous economic evaluation and comparison of those in order to determine which obtains better balance between effectiveness and financial viability. Thus, the aim of the present study was to determine the cost-effectiveness of interventions to prevent and to control alcohol abuse in Mexico, based on the proposed methodology by the World Health Organization. It will permit to generate national public policies with local evidence and to carry out evaluations of their impact, as well as international comparisons. Method The World Health Organization methodology named WHO-CHOICE (CHOosing the Interventions that are Cost-Effective) was developed to evaluate and to select the most cost-effective interventions for the prevention or treatment of health problems. It is considered a generalized cost-effective analysis; therefore direct or tangible costs are particularly analyzed (vs. indirect or intangible costs). Procedure First, WHO-CHOICE analysis requires information from different sources about both the illness or problem and the preventive or therapeutic interventions to evaluate. Then, information is processed by special software. As annual standard discount of 3% is done to obtain and to compare the present supplies values; and age of individuals is praised, giving more weight to the young phases. Finally, the results are presented in terms of intervention cost-effectiveness to reduce the burden of disease, defined in terms of disability adjusted life years or DALYs. Interventions The following interventions were evaluated: 1. Current Setting: Taxes and random tests for the detection of alcoholic breath (breathalyzer); 2. Increment of 25% to taxes of products with harmful degree of alcohol; 3. Increment of 50% to taxes of products with harmful degree of alcohol; 4. Reduction of availability of products with harmful degree of alcohol; 5. Regulation of the associated publicity; 6. Brief preventive-persuasiveness intervention in the first level of attention; and 7. Random Tests for detection of alcoholic breath (breathalyzer). Results The independent measure with greater cost-effectiveness to avoid DALYs due to alcohol abuse was the increment of taxes, which is better when it reaches 50%. All increment of taxes avoids (with or without discount and adjustment by age) more than 1 50 000 DALYs per year. The increment of 50% surpasses even 300 000 DALYs per year (without adjustment neither discount). In contrast, none of the other interventions (with adjustment and discount) reaches 50 000 DALYs per year. Besides, the increments of taxes are always more economic than the interventions remainder. The extreme comparison of DALY avoided per year costs is among 50% taxes increment, which requires an investment of 567 Mexican pesos, and the brief intervention in the first level of attention, that implies an expense of 14,342 Mexican pesos. After taxes increment, effective independent interventions to reduce DALYs in Mexico include, in this order: reduction of the offering, integral prohibition of alcohol consumption publicity, brief intervention in the first level of attention, and the random test of alcoholic breath. Finally, the best integral strategy was a combination of the following measures: increment of taxes, greater proportion of people attended with brief interventions, control of publicity, and reduction of availability. Discussion In Mexico, as in many countries of the world, the increase of taxes was the most cost-effective intervention to reduce burden caused from abuse alcohol. This kind of interventions should consider the possible differential impacts according to the socioeconomical status of individuals or groups. Another related problem could be an increment of informal market. Therefore, it is necessary to complement the intervention with strategies directed at reducing the volume of alcoholic beverages that do not pay taxes. All other interventions (not taxes increment) were less cost-effective probably because they have considerably higher costs and smaller impact due their dispensation is eventual. Results of this exercise can have a positive impact among Mexican public policies on the field if the relevance of integral strategies is recognized, with political support, and having achieved a consensus of the population on the advantages of its orchestration.

Introducción Los análisis de costo-efectividad se sugieren como una herramienta esencial para gestionar e implementar políticas públicas en salud, pues permiten compararlas a fin de conocer cuál es la que obtiene mejor balance entre efectividad y viabilidad financiera. El objetivo del presente trabajo fue determinar el costo-efectividad de las intervenciones para prevenir y controlar el abuso de alcohol en México. Método Se utilizó la metodología WHO-CHOICE de la Organización Mundial de la Salud: un análisis de costo-efectividad generalizado (vs. particular) que toma en cuenta prácticamente los costos directos o tangibles (vs. los intangibles). El procedimiento implica la obtención de información de diversas fuentes, tanto de la enfermedad o problema en cuestión como de las intervenciones preventivas o terapéuticas a evaluar. Esta información se carga entonces para su análisis en un software o programa ad hoc. Se hace un descuento estándar de 3% anual para obtener y comparar el valor presente de los insumos, y se pondera la edad de los individuos, dando más peso a las etapas jóvenes. Finalmente, los resultados se plantean en términos de costo-efectividad de las intervenciones para reducir la carga de la enfermedad, definida en años vividos con discapacidad o disfunción (DALYs, por sus siglas en inglés: disability adjusted life-years). Las intervenciones que se evaluaron son: 1. Escenario actual: Impuestos al consumo de productos con grado nocivo de alcohol y pruebas aleatorias a automovilistas para detección de aliento alcohólico (alcoholímetro); 2. Incremento de 25% en los impuestos al consumo de productos con grado nocivo de alcohol; 3. Incremento de 50% en los impuestos al consumo de productos con grado nocivo de alcohol; 4. Reducción de la disponibilidad de productos con grado nocivo de alcohol (incrementar edad permitida del cliente, horario de venta, densidad de puntos de venta y corresponsabilidad del expendedor); 5. Regulación de la publicidad asociada al consumo de productos con grado nocivo de alcohol; 6. Intervención preventi-va-persuasiva breve en el primer nivel de atención; 7. Pruebas aleatorias a automovilistas para detección de aliento alcohólico. Resultados La medida independiente con mayor costo-efectividad para evitar DALYs debidos al abuso de alcohol fue el incremento de impuestos, más aún cuando llega a 50%. Todos los incrementos de impuestos evitan por sí solos (con o sin descuento y ajuste por edad) más de 150 000 DALYs por año. El incremento de 50% supera incluso los 300 000 (sin ajuste ni descuento). En cambio, ninguna de las otras intervenciones (con ajuste y descuento) llega a los 50 000. Además, los incrementos de impuestos son siempre más económicos que el resto de las intervenciones. La comparación extrema del costo por DALY evitado al año es entre el incremento de impuestos a 50%, que requiere una inversión de 567 pesos, y el consejo breve en el primer nivel de atención, que implica un gasto de hasta 14,342 pesos. Finalmente, la mejor estrategia integral fue la combinación de las siguientes medidas: incremento de impuestos, mayor proporción de personas atendidas con intervenciones breves, control de la publicidad y reducción de la disponibilidad de alcohol. Discusión Aunque el aumento de impuestos resultó, como en muchos países del mundo, la intervención aislada más costo-efectiva para reducir la carga que ocasiona el alcohol, deben tomarse en cuenta sus posibles impactos diferenciales en tanto el poder adquisitivo de los individuos o grupos y sobre el crecimiento del mercado de alcohol informal. Esto último sugiere la necesidad de acompañarle con estrategias dirigidas a reducir el volumen de bebidas alcohólicas que no pagan impuestos. El resto de las intervenciones fueron menos efectivas en tanto que tienen un impacto considerablemente menor cuando se dispensan de forma aislada, debido principalmente a sus altos costos.

Estudio de costo-efectividad del tratamiento de la depresión en México / Cost-effectiveness study of depression management in Mexico

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the <

Introducción La depresión es un problema de salud pública que conlleva costos importantes para el individuo y la sociedad. Con la finalidad de establecer prioridades basadas en evidencias para la asignación de recursos en el cuidado de la salud mental, es necesario integrar los costos y la efectividad de las intervenciones y especificar los paquetes esenciales para su tratamiento. En esta dirección, la Organización Mundial de la Salud convocó al Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, como centro colaborador, a participar en el proyecto <

Estudio de costo-efectividad del tratamiento de la esquizofrenia en México / Cost effectiveness study of schizophrenia a management in Mexico

Introduction Schizophrenia is a disorder that causes significant disability. In addition, its treatment is expensive because the increased prescription of atypical antipsychotics with associated high costs. In a recent 14-country study on disability associated with physical and mental conditions, active psychosis was ranked the third most disabling condition in general population, more than paraplegia and blindness. In the global burden of disease study, schizophrenia accounted for 1.1% of the total Disability-adjusted life years (DALYs) and 2.8% of Years of lived with disability (YLDs). The economic cost of schizophrenia for society is also high. The study of the burden of schizophrenia for society, whether expressed in epidemiological or costs terms, is an insufficient basis for setting priorities for resources allocation. Thus, increasingly sophisticated economic models have been developed. Such is the case of cost-effectiveness studies, which show the relationship between resources used (costs) and benefit achieved (effectiveness) of an intervention compared with others. In Mexico, there is only one study that evaluated the cost-effectiveness of different antipsychotics to treat schizophrenia, but it was a specific approach (not generalized), and did not include psychological interventions. The present study is part of a World Health Organization's initiative labeled WHO-CHOICE: CHOosing Interventions that are Cost-Effective. WHO-CHOICE methodology involves the evaluation of interventions based on a generalized measure: DALYs, which allows carrying out several and important comparisons. The main objective was to determine the cost-effectiveness of different interventions for the treatment of schizophrenia in Mexican communitarian settings. Method Schizophrenia was modeled as a serious chronic disorder with a high level of disability, excess mortality from natural and unnatural causes, and a low rate of remission. The incidence, prevalence, and the fatality rate were estimated based on the study of the Global Burden of Disease and a review of the epidemiological literature. As the first episode of schizophrenia is currently not preventable, the occurrence represents how the epidemiological situation would be without intervention. In relation to the referral and the fatality, we did not found evidence that these rates change by a specific effect of the treatment; thus, they were kept as constants for the scenarios with or without treatment. Community-level interventions assessed were: 1. typical traditional antipsychotics (haloperidol), 2. new atypical antipsychotics (risperidone), 3. traditional antipsychotics + psychosocial treatment (family therapy, social skills training and cognitive behavioral therapy), 4. new antipsychotics + psychosocial treatment, 5. traditional antipsychotics + psychosocial treatment + case management, and 6. new antipsychotics + psychosocial treatment + case management. The effectiveness of the treatments referred to the control of positive and negative symptoms and associated levels of disability. To calculate the improvement in disability compared with natural history (when the disease is not treated), the effect sizes reported in controlled clinical trials were converted to a weight change of disability. Efficacy and extrapyramidal effects of typical and atypical antipsychotics compared to placebo were estimated from the meta-analysis of controlled clinical trials, with the score of the BPRS severity scale and the need anti-Parkinson drugs as efficacy measures. From another meta-analysis we obtained an estimate of the magnitude of the effect by adding psychosocial interventions. As an ad hoc Cochrane systematic review that found case management did not had a significant impact on clinical or psychosocial outcomes, only a minimal addition effect size when added to the combination of pharmacologic-psychosocial treatment was observed. Costs included those of the patient, the program and the training required to implement the intervention. The provision of community-based services, daily administration of antipsychotics and anticholinergics, and laboratory tests were taken into account. For psychological interventions were envisaged from 6 to 12 sessions: in primary care from 6 to 12 visits, in outpatients services a visit per month for 20-50% of cases, and in day care communitarian attention from 1-2 times a week for 20-50% of cases. A 3% discount by the process of converting future values to present ones and an age adjustment giving less weight to year lived by young were included. Finally, the cost of DALYs averted for each intervention was estimated to determine their cost-effectiveness. Results The main findings of the study are, in relation to the costs of interventions: 1. the largest share corresponds to those generated by medication, 2. the current intervention is the cheapest, and 3. the combination of new atypical antipsychotics, psychological treatment and proactive case management is the most expensive intervention. Concerning the effectiveness of interventions, the one available today, with a coverage of 50%, prevents 68 222 DALYs. Increasing coverage to 80%, the number of DALYs averted is almost doubled with the use of typical antipsychotics. The effect of psychological interventions makes the number of DALYs averted three to four times higher. Finally, in regard to cost effectiveness, the combination of typical antipsychotics, psychosocial intervention and proactive case management was the treatment with the best relation. The cost per DALY averted was $390,892 Mexican pesos, which corresponds to one third of the cost of DALY averted in the current scenario ($1,313,120 Mexican pesos). Conclusions The resources for the attention of a public health issue involve a social investment rather than an expense budget, but they are also finite and must be chosen properly to be allocated. Cost-effectiveness studies of available interventions are an essential tool for making such important decisions. Our Mexican study of cost-effectiveness of interventions to treat schizophrenia in communitarian settings suggests, in general terms: 1. That while the current situation is the one with the lowest cost, it is the least efficient, 2. all alternatives involve an additional cost to the current situation because they assume an expansion of coverage; however, the extra cost in not excessive, and 3) that within a model of community-based care, the least expensive option is treatment with typical antipsychotics combined with psychological intervention. Thus, for a modest extra cost it is possible to yield a major impact on disability. Recently, the Mexican Federal Government has included schizophrenia in the catalog of diseases covered by the program called <>, that provides a health insurance to general population, especially to the poorest and unemployed ones. The planned actions include four specialty consultations in an interval of two months and annual psychopharmacological treatment. Clearly the addition of haloperidol, trifluoperazine and risperidone to the list of available medications should be considered a success. However, schizophrenia also requires a proactive case monitoring of long-term for best control of symptoms and a successful rehabilitation. Moreover, consistent with our findings, case management has proven to be cost-effective when compared with routine care in the community. Among the limitations of the study it is important to note that it was based on modeled parameters obtained from the international literature. In this sense, the challenge is the data generation directly from studies in Mexico.

Introducción La esquizofrenia es un trastorno que produce una importante discapacidad, y su costo para la sociedad es muy elevado. El estudio de la carga que impone la esquizofrenia sobre la sociedad, ya sea expresada en términos epidemiológicos o de costos, es una base insuficiente para establecer las prioridades para la asignación de recursos, por lo que se han desarrollado modelos económicos cada vez más elaborados. Tal es el caso de los estudios de costo-efectividad, que muestran la relación entre los recursos empleados (costos) y los beneficios logrados (efectividad) de una intervención comparada con otra(s). El presente trabajo forma parte de la iniciativa de la Organización Mundial de la Salud (OMS) para la elección basada en evidencia de intervenciones costo-efectivas denominada WHO-CHOICE, Choosing Interventions that are Cost-Effective, que implica la determinación de una medida general que posibilita comparaciones internacionales: los años de vida vividos con discapacidad (AVISAs o DALYs, de las siglas de Disability-adjusted life years). Objetivo Fue determinar la relación costo-efectividad en México de diferentes intervenciones que han demostrado ser efectivas para el tratamiento comunitario de la esquizofrenia. Método Se evaluaron las siguientes intervenciones: 1. Antipsicóticos tradicionales típicos (haloperidol), 2. Antipsicóticos nuevos atípicos (risperidona), 3. Antipsicóticos tradicionales + tratamiento psicosocial (terapia familiar, entrenamiento en habilidades sociales y terapia cognitivo conductual), 4. Antipsicóticos nuevos + tratamiento psicosocial, 5. Antipsicóticos tradicionales + tratamiento psicosocial + manejo de caso, y 6. Antipsicóticos nuevos + tratamiento psicosocial + manejo de caso. La efectividad relativa de los tratamientos se refirió al control tanto de los síntomas positivos y negativos así como de los niveles asociados de discapacidad. Se consideraron los costos del paciente, del programa y del entrenamiento, así como un descuento de 3% por el proceso de convertir valores futuros a presentes, y un ajuste de edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, se calculó el costo por AVISA evitado por cada intervención para determinar su costo-efectividad. Resultados Los principales hallazgos del estudio son, en relación con los costos de las intervenciones: 1. que la mayor proporción corresponde a los generados por los medicamentos; 2. que la intervención actual resulta la más barata; y 3. que la combinación de antipsicótico nuevo o atípico con intervención psicosocial y manejo proactivo de caso es la más cara. En cuanto a la efectividad de las intervenciones, la disponible en la actualidad, con cobertura de 50%, evita 68 222 AVISAs. Aumentando la cobertura a 80%, el número de AVISAs evitados casi se duplica con el empleo de antipsicóticos típicos. El efecto de las intervenciones psicosociales hace que el número de AVISAs evitados sea tres a cuatro veces mayor. Finalmente, en lo que respecta a costo-efectividad, la combinación de antipsicóticos típicos, intervención psicosocial y manejo proactivo de caso fue el tratamiento con la mejor relación. El costo por AVISA evitado fue de $390,892, que corresponde a un tercio del costo de AVISA evitado en el escenario actual ($1,313,120). Conclusiones Los hallazgos del estudio sugieren, en términos generales: 1. Que aunque la situación actual es la de menor costo, es la menos eficiente; 2. Que todas las alternativas implican un costo adicional a la situación actual porque asumen una ampliación de la cobertura, sin embargo, ese costo extra no es excesivo; y 3. Que dentro de un modelo de atención basado en la comunidad, la opción menos costosa es el tratamiento con antipsicóticos típicos combinados con intervención psicosocial. Por un costo extra modesto se obtendría un impacto importante en la discapacidad. Entre las limitaciones del estudio destaca que fue producto de un modelado con parámetros obtenidos de la bibliografía internacional. En este sentido, el reto es la generación de datos derivados directamente de estudios realizados en México.