Lesley Owen

Background: Modifiable risks—tobacco use, poor diet, alcohol consumption, physical inactivity and mental ill-health—drive substantial disease in UK. NICE evidence on preventive interventions targeting these risks and estimates of eligible populations and disease burden demonstrate the potential for prevention and reducing health inequalities. Methods: Deaths and DALYs from behavioural risks and mental health conditions were estimated using GBOD 2021 data. Prevalence by deprivation quintile came from national surveys. NICE guidelines were reviewed to identify cost effective preventive interventions. Results: In 2021, tobacco and dietary risks caused the highest mortality and disease burden: tobacco nearly 58 000 deaths and 1·4 million DALYs; diet 48 000 deaths and 1.05 million DALYs. Mental health had low mortality (5·7 deaths) but high DALYs (1·45 million), especially in younger people. Alcohol and inactivity had lower death counts and moderate DALY impacts. Most risks were more prevalent in deprived areas. NICE-recommended interventions such as smoking cessation, alcohol brief advice, obesity treatments, and psychological therapies, are relevant to millions, especially high-need groups. Conclusion: (Re-)investing in prevention and equitable strategies could substantially reduce disease burden and address inequalities, with the greatest gains likely to arise from sustained and targeted investment in populations and areas that have been left behind.

Background: People with respiratory conditions are susceptible to health problems caused by exposure to indoor air pollutants. An economic framework was developed to inform a guideline developed by National Institute for Health and Care Excellence (NICE) to estimate the required level of efficacy necessary for an intervention to be cost-saving in dwellings across England. Methods: An economic modelling framework was built to estimate the incremental costs pre- and post-implementation of interventions designed to reduce exposure to indoor air pollution within dwellings of varying building-related risk factors and profiles. The intervention cost was varied simultaneously with the relative reduction in symptomatic cases of each health condition to estimate the point at which an intervention may become cost-saving. Four health conditions were considered. Results: People living in dwellings with either an extreme risk profile or usable floor area 2 have the greatest capacity to benefit and save National Health Service (NHS) costs from interventions at any given level of effectiveness and upfront cost. Conclusions: At any effectiveness level, the threshold for the upfront intervention cost to remain cost-saving is equivalent across the different home characteristics. The flexible model can be used to guide decision-making under a range of scenarios.

Whilst people with intellectual disability grow older, evidence has emerged internationally about the largely unmet health needs of this specific ageing population. Health checks have been implemented in some countries to address those health inequalities. Evaluations have focused on measuring process outcomes due to challenges measuring quality of life outcomes. In addition, the cost-effectiveness is currently unknown. As part of a national guideline for this population we sought to explore the likely cost-effectiveness of annual health checks in England. Decision-analytical Markov modelling was used to estimate the cost-effectiveness of a strategy, in which health checks were provided for older people with intellectual disability, when compared with standard care. The approach we took was explorative. Individual models were developed for a selected range of health conditions, which had an expected high economic impact and for which sufficient evidence was available for the modelling. In each of the models, hypothetical cohorts were followed from 40 yrs. of age until death. The outcome measure was cost per quality-adjusted life-year (QALY) gained. Incremental cost-effectiveness ratios (ICER) were calculated. Costs were assessed from a health provider perspective and expressed in 2016 GBP. Costs and QALYs were discounted at 3.5%. We carried out probabilistic sensitivity analysis. Data from published studies as well as expert opinion informed parameters. Health checks led to a mean QALY gain of 0.074 (95% CI 0.072 to 0.119); and mean incremental costs of £4787 (CI 95% 4773 to 5017). For a threshold of £30,000 per QALY, health checks were not cost-effective (mean ICER £85,632; 95% CI 82,762 to 131,944). Costs of intervention needed to reduce from £258 to under £100 per year in order for health checks to be cost-effective. Whilst findings need to be considered with caution as the model was exploratory in that it was based on assumptions to overcome evidence gaps, they suggest that the way health systems deliver care for vulnerable populations might need to be re-examined. The work was carried out as part of a national guideline and informed recommendations about system changes to achieve more equal health care provisions.

The evidence on the extent to which stakeholders in different European countries agree with availability and importance of tobacco-control interventions is limited. This study assessed and compared stakeholders’ views from five European countries and compared the perceived ranking of interventions with evidence-based ranking using cost-effectiveness data. An interview survey (face-to-face, by phone or Skype) was conducted between April and July 2014 with five categories of stakeholders - decision makers, service purchasers, service providers, evidence generators and health promotion advocates - from Germany, Hungary, the Netherlands, Spain, and the United Kingdom. A list of potential stakeholders drawn from the research team’s contacts and snowballing served as the sampling frame. An email invitation was sent to all stakeholders in this list and recruitment was based on positive replies. Respondents were asked to rate availability and importance of 30 tobacco control interventions. Kappa coefficients assessed agreement of stakeholders’ views. A mean importance score for each intervention was used to rank the interventions. This ranking was compared with the ranking based on cost-effectiveness data from a published review. Ninety-three stakeholders (55.7% response rate) completed the survey: 18.3% were from Germany, 17.2% from Hungary, 30.1% from the Netherlands, 19.4% from Spain, and 15.1% from the UK. Of those, 31.2% were decision makers, 26.9% evidence generators, 19.4% service providers, 15.1% health-promotion advocates, and 7.5% purchasers of services/pharmaceutical products. Smoking restrictions in public areas were rated as the most important intervention (mean score = 1.89). The agreement on availability of interventions between the stakeholders was very low (kappa = 0.098; 95% CI = [0.085, 0.111] but the agreement on the importance of the interventions was fair (kappa = 0.239; 95% CI = [0.208, 0.253]). A correlation was found between availability and importance rankings for stage-based interventions. The importance ranking was not statistically concordant with the ranking based on published cost-effectiveness data (Kendall rank correlation coefficient = 0.40; p-value = 0.11; 95% CI = [− 0.09, 0.89]). The intrinsic differences in stakeholder views must be addressed while transferring economic evidence Europe-wide. Strong engagement with stakeholders, focussing on better communication, has a potential to mitigate this challenge.

A review of economic evaluations of public health interventions assessed by NICE between 2005 and 2010 found 85% were cost-effective. Owen et al. (The cost-effectiveness of public health interventions. J Public Health 2012;34(1):37–45). With significant pressure on budgets the role of economics in securing funding remains important. This study updates the earlier analysis. Economic evaluations carried out between 2011 and 2016 were categorized: cost-utility analysis (CUA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA) and cost-consequences analysis (CCA). Cost-effectiveness estimates were analysed and compared with Owen et al. (The cost-effectiveness of public health interventions. J Public Health 2012;34(1):37–45). Of 43 guidelines examined, 23 used CUA for specific interventions yielding 138 base-case incremental cost-effectiveness ratio (ICER) estimates, 11 used CUA for a threshold or ‘what if’ analysis, 1 used CEA, 3 used CCA, 1 used CBA and CUA and 1 used CEA and CUA, 5 did not require economic modelling. Compared with the earlier period, the median ICER for the 138 estimates was substantially higher (£7843 versus £1053) and there was greater variability (a higher proportion in the later period was cost-saving, but a higher proportion was also over £20 000 per quality adjusted life year). Nearly two-thirds (63%) of public health interventions assessed were cost-effective. However, increased variability in estimates highlights the importance of assessing cost-effectiveness to ensure good use of scarce resources.