Economic evaluation of reproductive health

interventionsOverview of design options

Ulla Kou GriffithsLSHTM

Croydon consultation18th September 2013

Outline

1. What makes a good economic evaluationstudy?

2. What are the possible study designs?3. What do we know about cost‐effectiveness of

reproductive health interventions?

Definition

• “Economic evaluation is the comparativeanalysis of alternative courses of action in terms of both their costs and their consequences.” (Drummond et al. 2005)

3

A technique that can help us to make evidence‐based decisions on the most effective way of using scarce resources.

Components of a cost‐effectiveness study

Delivery costs

Health effects

Intervention A(i.e. community 

based distribution)

Intervention B(i.e. clinic based distribution)

Decision analytic modelling

Costs attached to each event

Demography

Parameters

What we want in the end is a cost‐effectiveness ratio

• Incremental costs per unintended pregnancy averted• Incremental costs permaternal death averted• Incremental costs per death• Incremental costs per life years gained• Incremental costs per Disability Adjusted Life Year (DALY) averted

• Incremental costs per Quality Adjusted Life Year (QALY)

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The most basic modeling: Decision Analysis Tree

live

live

die

die

Abortion care A

Abortion care B

No abortion care

Incremental costsper maternal death averted

Incremental costs per maternal death averted

die

live

Types of decision analytic models

Type Suitable for

Decision tree model •Short time horizon•Straight forward outcome estimation

State transition  (Markov) model

•Longer time frame•Probability varies over time•Chronic diseases: Blindness, Obesity, diabetes

Individual micro simulation model

•When increased level of detail are required for the variables that predict outcomes• Family planning, diabetes

Transmission dynamic model •Interactions between groups have an impact on the results•Infectious diseases

Com

plex

ity

Outline

1. What makes a good economic evaluationstudy?

2. What are the possible study designs?3. What do we know about cost‐effectiveness of

reproductive health interventions?

An economist can’t do it alone• Intervention effects are measured in epidemiological studies– Most optimal is the economic evaluation is done alongside these studies

• Facilitates cost data collection• Facilitates early identification of needed outcome data• Ensures that the economist is part of a team of disease specific experts

– Learning necessary for designing the decision‐analytic model

• Increases the policy relevance of study/trial findings

• Exception could be a pure modelling study using secondary data

Suitability of economic evaluation alongside epidemiological studies

Study design Suitable? Explanation

Experimental Yes •Patient specific data collected•Incidence data often collected as part of study•Intermediate outcome measures a drawback

Cohort Yes •Multiple long‐term outcomes are measured

Cross sectional No •Single point in time•Not intervention focused

Observational No •No data collection systems in place

Case‐control No •Only a percentage effect measure is generated – incidence rates are missing

Ecological No •No patient specific data being collected

Outline

1. What makes a good economic evaluationstudy?

2. What are the possible study designs?3. What do we know about cost‐effectiveness

of reproductive health interventions?

Review of cost‐effectiveness studies included in DFID report

DFID report overall finding on family planning CE evidence

• Investing in family planning is generally cost‐effective, but decision makers lack information on:– How to best use funds within a programme– How interventions are most efficiently delivered in various settings

– How best to combine related services

DFID report overall finding on safe abortion CE  evidence• Very little robust comparative evidence on the cost‐effectiveness of safe abortion delivery models

2010

Individual micro simulationmodel

Goldie et al. (2010) conclusions

• Interventions that reduce family planning and safe abortion needs in India could reduce maternal deaths by 30%

• The interventions are highly cost‐effective– < US$ 500 per DALY averted or cost saving

• Management of complications  due to unsafe pregnancies likely to exceed intervention costs

Conclusions

• Cost-effectiveness studies are suitable for being undertaken alongside epidemiological studies evaluating intervention impact• This is happening more and more

• Modelling of some sort is always needed• Our models have gradually become more and

more sophisticated• Robust cost-effectiveness studies on

reproductive health interventions are rare