Public Health Interventions with Harms and Benefits: A Graphical Framework for Evaluating Tradeoffs.

BACKGROUND: Evaluations of public health interventions typically report benefits and harms aggregated over the population. However, benefits and harms are not always evenly distributed. Examining disaggregated outcomes enables decision makers to consider health benefits and harms accruing to both intended intervention recipients and others in the population. METHODS: We provide a graphical framework for categorizing and comparing public health interventions that examines the distribution of benefit and harm between and within population subgroups for a single intervention and compares distributions of harm and benefit for multiple interventions. We demonstrate the framework through a case study of a hypothetical increase in the price of meat (5%, 10%, 25%, or 50%) that, via elasticity of demand, reduces consumption and consequently reduces body mass index. We examine how inequalities in benefits and harms (measured by quality-adjusted life-years) are distributed across a population of white and black males and females. RESULTS: A 50% meat price increase would yield the greatest net benefit to the population. However, because of reduced consumption among low-weight individuals, black males would bear disproportionate harm relative to the benefit they receive. With increasing meat price, the distribution of harm relative to benefit becomes less "internal" to those receiving benefit and more "distributed" to those not receiving commensurate benefit. When we segment the population by sex only, this result does not hold. CONCLUSIONS: Disaggregating harms and benefits to understand their differential impact on subgroups can strongly affect which decision alternative is deemed optimal, as can the approach to segmenting the population. Our framework provides a useful tool for illuminating key tradeoffs relevant to harm-averse decision makers and those concerned with both equity and efficiency.

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic.

OBJECTIVES: To estimate health outcomes of policies to mitigate the opioid epidemic. METHODS: We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic. RESULTS: Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. CONCLUSIONS: Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.

Cost-effectiveness of radiation and chemotherapy for high-risk low-grade glioma.

BACKGROUND: The addition of procarbazine, lomustine, vincristine (PCV) chemotherapy to radiotherapy (RT) for patients with high-risk (≥40 y old or subtotally resected) low-grade glioma (LGG) results in an absolute median survival benefit of over 5 years. We evaluated the cost-effectiveness of this treatment strategy. METHODS: A decision tree with an integrated 3-state Markov model was created to follow patients with high-risk LGG after surgery treated with RT versus RT+PCV. Patients existed in one of 3 health states: stable, progressive, or dead. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Analysis was conducted from the health care perspective. Deterministic and probabilistic sensitivity analysis explored uncertainty in model parameters. RESULTS: Modeled outcomes demonstrated agreement with clinical data in expected benefit of addition of PCV to RT. The addition of PCV to RT yielded an incremental benefit of 4.77 quality-adjusted life-years (QALYs) (9.94 for RT+PCV vs 5.17 for RT alone) at an incremental cost of $48635 ($188234 for RT+PCV vs $139598 for RT alone), resulting in an incremental cost-effectiveness ratio of $10186 per QALY gained. Probabilistic sensitivity analysis demonstrates that within modeled distributions of parameters, RT+PCV has 99.96% probability of being cost-effectiveness at a willingness-to-pay threshold of $100000 per QALY. CONCLUSION: The addition of PCV to RT is a cost-effective treatment strategy for patients with high-risk LGG.

Effect of Meat Price on Race and Gender Disparities in Obesity, Mortality and Quality of Life in the US: A Model-Based Analysis.

INTRODUCTION: There are large differences in the burden and health implications of obesity by race and gender in the US. It is unclear to what extent policies modifying caloric consumption change the distribution of the burden of obesity and related health outcomes. Meat is a large component of the American diet. We investigate how changing meat prices (that may result from policies or from exogenous factors that reduce supply) might impact the burden of obesity by race and gender. METHODS: We construct a microsimulation model that evaluates the 15-year body-mass index (BMI) and mortality impact of changes in meat price (5, 10, 25, and 50% increase) in the US adult population stratified by age, gender, race, and BMI. RESULTS: Under each price change evaluated, relative to the status quo, white males, black males, and black females are expected to realize more dramatic reduction in 2030 obesity prevalence than white females. Life expectancy gains are also projected to differ by subpopulation, with black males far less likely to benefit from an increase in meat prices than other groups. CONCLUSIONS: Changing meat prices has considerable potential to affect population health differently by race and gender. In designing interventions that alter the price of foods to consumers, it is not sufficient to assess health effects based solely on the population as a whole, since differential effects across subpopulations may be substantial.

Cost-Effectiveness of Adding Cardiac Resynchronization Therapy to an Implantable Cardioverter-Defibrillator Among Patients With Mild Heart Failure.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces mortality and heart failure hospitalizations in patients with mild heart failure. OBJECTIVE: To estimate the cost-effectiveness of adding CRT to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure. DESIGN: Markov decision model. DATA SOURCES: Clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, and Centers for Disease Control and Prevention life tables. TARGET POPULATION: Patients aged 65 years or older with a left ventricular ejection fraction (LVEF) of 30% or less, QRS duration of 120 milliseconds or more, and New York Heart Association (NYHA) class I or II symptoms. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: CRT-D or ICD alone. OUTCOME MEASURES: Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS: Use of CRT-D increased life expectancy (9.8 years versus 8.8 years), QALYs (8.6 years versus 7.6 years), and costs ($286 500 versus $228 600), yielding a cost per QALY gained of $61 700. RESULTS OF SENSITIVITY ANALYSES: The cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119 600 per QALY. More expensive CRT-D devices, shorter CRT-D battery life, and older age also made the cost-effectiveness of CRT-D less favorable. LIMITATIONS: The estimated mortality reduction for CRT-D was largely based on a single trial. Data on patients with NYHA class I symptoms were limited. The cost-effectiveness of CRT-D in patients with NYHA class I symptoms remains uncertain. CONCLUSION: In patients with an LVEF of 30% or less, QRS duration of 120 milliseconds or more, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected. PRIMARY FUNDING SOURCE: National Institutes of Health, University of Copenhagen, U.S. Department of Veterans Affairs.