COMMUNITY PREVENTION STRATEGIES IN THE LITERATURE
EXAMPLES OF COST-EFFECTIVENESS ANALYSES OF
COMMUNITY PREVENTION STRATEGIES IN THE LITERATURE
- Chirikos TN, Herzog TA, Meade CD, Webb MS, Brandon TH. Costeffectiveness
analysis of a complementary health intervention: the case of
smoking relapse prevention. International Journal of Technology
Assessment in Health Care. 2004; 20(4):475-480.
Objectives: We assessed the cost-effectiveness of smoking relapse prevention
interventions designed to keep quitters from resuming the use of cigarettes. Because
relapse prevention is complementary to smoking cessation efforts, the appropriate test of
its cost-effectiveness is whether it reduces the incremental cost-effectiveness ratio (ICER) of
smoking cessation. The major goal of the study is to carry out such a test.
Methods: Data from a randomized trial that ascertained the effectiveness of alternative
modes of smoking relapse prevention were combined with ICER estimates of smoking
cessation to assess whether relapse prevention is cost-effective.
Results: The trial produced convincing evidence that relapse prevention yields statistically
significant reductions in the proportion of quitters who are smoking at 24 months post-quit.
The intervention effects are substantial enough to raise the denominator terms of the
smoking cessation ICER and, thereby, offset the amount relapse prevention adds to cost
numerator terms. In this sense, smoking relapse prevention tends to pay for itself.
Conclusions: Smoking relapse prevention is a highly cost-effective addition to current
efforts to curb cigarette consumption. Complementary health interventions of this type
should be assessed by different methods than those commonly found in the costeffectiveness
literature. - Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost-effectiveness of
smoking-cessation services under four insurance plans in a health
maintenance organization. NEJM. 1998; 339(10):673-679.
Background: Lack of information about the effect of insurance coverage on the demand for
and use of smoking-cessation services has prevented wide-scale adoption of coverage for
such services.
Methods: In a longitudinal, natural experiment, we compared the use and costeffectiveness
of three forms of coverage with those of a standard form of coverage for
smoking-cessation services that included a behavioral program and nicotine replacement
therapy (NRT). The study involved seven employers and a total of 90,005 adult enrollees.
The standard plan offered 50% coverage of the behavioral program and full coverage of
NRT. The other plans offered 50% coverage of both the behavioral program and NRT
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-2
(reduced coverage), full coverage of the behavioral program and 50% coverage of NRT
(flipped coverage), or full coverage of both the behavioral program and NRT.
Results: Estimated annual rates of use of smoking cessation services ranged from 2.4%
(among smokers with reduced coverage) to 10% (among those with full coverage).
Smoking cessation rates ranged from 28% (among users with full coverage) to 38%
(among those with standard coverage). The estimated percentage of all smokers who would
quit smoking per year as a result of using the services ranged from 0.7% (with reduced
coverage) to 2.8% (with full coverage). The average cost to the health plan per user who
quit smoking ranged from $797 (with standard coverage) to $1,171 (with full coverage).
The annual cost per smoker ranged from $6 (with reduced coverage) to $33 (with full
coverage). The annual cost per enrollee ranged from $0.89 (with reduced coverage) to
$4.92 (with full coverage).
Conclusions: Use of smoking cessation services varies according to the extent of coverage,
with the highest rates of use among smokers with full coverage. Although the rate of
smoking cessation among the benefit users with full coverage was lower than the rates
among users with plans requiring co-payments, the effect on the overall prevalence of
smoking was greater with full coverage than with the cost sharing plans. - The Diabetes Prevention Program Research Group Within-trial costeffectiveness
of lifestyle intervention or metformin for the primary
prevention of type 2 diabetes. Diabetes Care. 2003; 26(9):2518-2523.
Objective: The Diabetes Prevention Program (DPP) demonstrated that intensive lifestyle
and metformin interventions reduced the incidence of type 2 diabetes compared with a
placebo intervention. The aim of this study was to assess the cost-effectiveness of the
lifestyle and metformin interventions relative to the placebo intervention.
Research Design and Methods: Analyses were performed from a health system
perspective that considered direct medical costs only and a societal perspective that
considered direct medical costs, direct nonmedical costs, and indirect costs. Analyses were
performed with the interventions as implemented in the DPP and as they might be
implemented in clinical practice.
Results: The lifestyle and metformin interventions required more resources than the
placebo intervention from a health system perspective, and over 3 years they cost
approximately $2,250 more per participant. As implemented in the DPP and from a societal
perspective, the lifestyle and metformin interventions cost $24,400 and $34,500,
respectively, per case of diabetes delayed or prevented and $51,600 and $99,200 per
quality-adjusted life year (QALY) gained. As the interventions might be implemented in
routine clinical practice and from a societal perspective, the lifestyle and metformin
interventions cost $13,200 and $14,300, respectively, per case of diabetes delayed or
prevented and $27,100 and $35,000 per QALY gained. From a health system perspective,
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-3
costs per case of diabetes delayed or prevented and costs per QALY gained tended to be
lower.
Conclusions: Over 3 years, the lifestyle and metformin interventions were effective and
were cost-effective from the perspective of a health system and society. Both interventions
are likely to be affordable in routine clinical practice, especially if implemented in a group
format and with generic medication pricing. - Dueson RR, Brodovicz KG, Barker L, Zhou F, and Euler GL. Economic analysis
of a child vaccination project among Asian Americans in Philadelphia, Pa.
Arch Pediatr Adolesc Med. 2001 Aug; 155 (8):909-914.
Objective: To ascertain the cost-effectiveness and the benefit-cost ratios of a communitybased
hepatitis B vaccination catch-up project for Asian American children conducted in
Philadelphia, Pennsylvania, from October 1, 1994, to February 11, 1996.
Design: Program evaluation.
Setting: South and southwest districts of Philadelphia.
Participants: A total of 4384 Asian American children.
Interventions: Staff in the community-based organizations educated parents about the
hepatitis B vaccination, enrolled physicians in the Vaccines for Children program, and visited
homes of children due for a vaccine dose. Staff in the Philadelphia Department of Public
Health developed a computerized database; sent reminder letters for children due for a
vaccine dose; and offered vaccinations in public clinics, health fairs, and homes.
Main Outcome Measures: The numbers of children having received 1, 2, or 3 doses of
vaccine before and after the interventions; costs incurred by the Philadelphia Department of
Public Health and the community-based organizations for design, education, and outreach
activities; the cost of the vaccination; cost-effectiveness ratios for intermediated outcomes
(i.e., per child, per dose, per immunoequivalent patient, and per completed series);
discounted cost per discounted year of life saved; and the benefit-cost ratio of the project.
Results: For the completed series of three doses, coverage increased by 12 percentage
points at a total cost of $268,600 for design, education, outreach, and vaccination. Costs
per child, per dose, and per completed series were $64, $119, and $537, respectively. The
discounted cost per discounted year of life saved was $11,525, and 106 years of life were
saved through this intervention. The benefit-cost ratio was 4.44:1.
Conclusion: Although the increase in coverage was modest, the intervention proved costeffective
and cost-beneficial.
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-4 - Finkelstein EA, Troped PJ, Will JC, and Palombo R. Cost-Effectiveness of a
cardiovascular disease risk reduction program aimed at financially
vulnerable women: The Massachusetts WISEWOMAN project. Journal of
Women’s Health and Gender-Based Medicine. 2002; 11(6):519-526.
Objective: The Massachusetts WISEWOMAN Project is a cardiovascular disease (CVD) risk
reduction program targeting older uninsured and underinsured women. The costeffectiveness
of providing CVD screening and enhanced lifestyle interventions (EI),
compared with providing CVD screening and a minimum intervention (MI), was assessed at
five EI and six MI health care sites.
Methods: Cost calculations were based on data collected during screenings and
intervention activities conducted with 1,586 women in 1996. Risk factor data, including
cholesterol and blood pressure measures, were used to create a summary effectiveness
outcome, the 10-year probability of developing coronary heart disease (CHD). The costeffectiveness
ratio of the EI, compared with the MI, was calculated by dividing the
incremental cost of the EI by the incremental effectiveness of the EI.
