estimated reductions in influenza-related mortality among the elderly through

Estimated Reductions in Influenza-related Estimated Reductions in Influenza-related Mortality among the Elderly through Mortality among the Elderly through

Direct-to-Consumer Advertising Direct-to-Consumer Advertising

of Influenza Vaccineof Influenza Vaccine

Mitesh S Patel*Mitesh S Patel*

Matthew M. DavisMatthew M. Davis##

*University of Michigan Medical School, and *University of Michigan Medical School, and ##Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,

Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, University of MichiganUniversity of Michigan

Influenza MortalityInfluenza Mortality

Predominately and disproportionately impacts elderlyPredominately and disproportionately impacts elderly

Rates of annual influenza vaccination among the elderly Rates of annual influenza vaccination among the elderly are approximately 65%are approximately 65%

Vaccination rates fall short of the Vaccination rates fall short of the Healthy People 2010Healthy People 2010 target of 90% and may be a concern on the national leveltarget of 90% and may be a concern on the national level

Direct-to Consumer (DTC) AdvertisingDirect-to Consumer (DTC) Advertising

Spending on DTC advertising rose from $266 million in Spending on DTC advertising rose from $266 million in 1994 to $3.2 billion in 20031994 to $3.2 billion in 2003

Effective method of increasing sales of prescription Effective method of increasing sales of prescription pharmaceuticalspharmaceuticals

Could it be an effective method of increasing influenza Could it be an effective method of increasing influenza vaccination rates and achieving mortality benefits?vaccination rates and achieving mortality benefits?

Research ObjectiveResearch Objective

To examine the potential cost-effectiveness of a federal To examine the potential cost-effectiveness of a federal program of DTC advertising for influenza vaccination of eldersprogram of DTC advertising for influenza vaccination of elders

Methods: Number Needed to VaccinateMethods: Number Needed to Vaccinate

Number Needed to Vaccinate (NNV)Number Needed to Vaccinate (NNV)

Quantifies the number of people that must be vaccinated to Quantifies the number of people that must be vaccinated to prevent one all-cause deathprevent one all-cause death

Analogous to the Number Needed to Treat (NNT)Analogous to the Number Needed to Treat (NNT)

NNV = 1NNV = 1 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(population mortality rate) x (vaccine efficacy against mortality)(population mortality rate) x (vaccine efficacy against mortality)

Methods: DTC Advertising and Methods: DTC Advertising and Pharmaceutical SalesPharmaceutical Sales

DTC advertising in DTC advertising in 19991999

SpendingSpending Change in SalesChange in Sales

24 Most heavily 24 Most heavily advertised drugsadvertised drugs $1.338 billion$1.338 billion 41.7%41.7%

Rest of the Rest of the MarketMarket $481 million$481 million 14.4%14.4%

Net DifferenceNet Difference $857 million$857 million 27.3%27.3%

Findlay. Pharmacoeconomics. 2001.

Methods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase

60

65

70

75

80

85

90

95

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Influ

enza

Eld

erly

Vac

cina

tion

Rat

e

.

.

Methods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase

60

65

70

75

80

85

90

95

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Influ

enza

Eld

erly

Vac

cina

tion

Rat

e

?

60

65

70

75

80

85

90

95

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Infl

uen

za E

lder

ly V

acci

nat

ion

Rat

eMethods: Vaccination Rate IncreaseMethods: Vaccination Rate Increase

Methods: Model ParametersMethods: Model Parameters

VariableBase Case Estimate

Range for SensitivityAnalysis

Costs

DTC Advertising, $

Increase per year, %

Vaccine Dose, $


Vaccine Admin Fee, $


194.1 million

3

12.20

10

18.90

3

+/- 10%

5 - 15

1.5 – 6

Population Mortality Rate 132.5/100,000

Methods: Model ParametersMethods: Model Parameters

VariableBase Case Estimate

Range for SensitivityAnalysis

Vaccine Efficacy, % Year 2006 67.61 56 – 76 (95% CI)

Elderly Population, millions(Revaccinated Persons, %) Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 Year 2011 Year 2012 Year 2013 Year 2014 Year 2015

37.2 (60.0)37.8 (69.9)38.7 (74.2)39.8 (77.5)40.2 (81.9)41.1 (83.1)42.6 (83.5)44.0 (85.0)45.3 (86.2)46.8 (86.6)

Methods: Primary Outcome MeasuresMethods: Primary Outcome Measures

For each year 2006-2015 we estimatedFor each year 2006-2015 we estimated

Reduction in mortalityReduction in mortality

Cost per life-year saved =Cost per life-year saved =

∑∑Year = xYear = x [cost (DTC + Vaccination)][cost (DTC + Vaccination)] - ∑ - ∑Year = (x-1)Year = (x-1) [cost (DTC + Vaccination)] [cost (DTC + Vaccination)]

Year=2006Year=2006 Year=2006Year=2006

____________________________________________________________________________________________________∑∑Year = xYear = x [life-years saved][life-years saved] - ∑ - ∑Year = (x-1)Year = (x-1) [life-years saved][life-years saved]

Year=2006 Year=2006 Year=2006Year=2006

Results: Base Case – Results: Base Case – First Year of ProgramFirst Year of Program

# 95% CI

NNV

Elderly lives saved

Life-years saved

Results: Base Case – Results: Base Case – First Year of ProgramFirst Year of Program

# 95% CI

NNV 1,116 993 – 1,348993 – 1,348

Elderly lives saved 1,999 1,656 – 2,2471,656 – 2,247

Life-years saved 22,768 18,861 - 25,59818,861 - 25,598

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Est

imat

ed N

um

ber

of

Eld

erly

Liv

es S

aved

Lower Bound Vaccine Efficacy Upper Bound Vaccine Efficacy Mean Vaccine Efficacy

Results: Elderly Lives SavedResults: Elderly Lives Saved

Year

OverallVaccination

Rate (%)

OverallVaccine

Efficacy (%)(95% CI)

Cost of DTCAdvertising

Program(millions

US$)

Cost ofIncrementalIncrease inVaccination

(millions US$)

IncrementalLife-Years

Saved

Cost PerLife-Year Saved

(US$)(95% CI)

2006 7167.61

(56 – 76)194.1 69.4 22,768

11,573(10,293 - 13,970)

2007 7668.68

(57.07 – 77.07)199.9 62.2 19,057

13,756(12,259 – 16,555)

2008 79.7569.15

(57.57 – 77.54)205.9 50.5 14,324

17,900(15,963 - 21,512)

2009 82.7569.51

(57.90 – 77.90)212.1 44.0 11,505

22,258(19,860 – 26,721)

2010 8569.99

(58.38 – 78.38)218.4 35.4 8,552

29,685(26,508 – 35,589)

Results: Cost-Effectiveness of a 10-year Results: Cost-Effectiveness of a 10-year DTC Program for Influenza VaccineDTC Program for Influenza Vaccine


Year

OverallVaccination

Rate (%)

OverallVaccine


Cost of DTC

AdvertisingProgram(millions

US$)


(millions US$)


Saved


(US$)(95% CI)

2011 86.570.12

(58.51 – 78.51)225.0 25.6 5,676

44,159(39,440 – 52,921)

2012 87.7570.16

(58.55 – 78.55)231.7 23.5 4,790

53,291(47,599 – 63,858)

2013 88.7570.32

(58.71 – 78.71)238.7 20.7 3,874

66,945(59,809 – 80,183)

2014 89.570.45

(58.84 – 78.84)245.9 17.0 2,925

89,884(80,319 – 107,619)

2015 9070.50

(58.89 – 78.89)253.2 12.5 1,961

135,535(121,121 – 162,255)


Year

OverallVaccination

Rate (%)

OverallVaccine


Cost of DTC

AdvertisingProgram(millions

US$)


(millions US$)


Saved


(US$)(95% CI)

2011 86.570.12

(58.51 – 78.51)225.0 25.6 5,676

44,159(39,440 – 52,921)

2012 87.7570.16

(58.55 – 78.55)231.7 23.5 4,790

53,291(47,599 – 63,858)

2013 88.7570.32

(58.71 – 78.71)238.7 20.7 3,874

66,945(59,809 – 80,183)

2014 89.570.45

(58.84 – 78.84)245.9 17.0 2,925

89,884(80,319 – 107,619)

2015 9070.50

(58.89 – 78.89)253.2 12.5 1,961

135,535(121,121 – 162,255)

TOTAL 2,225 360.9 95,43427,096

(24,159 – 32,575)

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Ov

era

ll C

os

t p

er

Lif

e Y

ea

r S

av

ed

Best Case Base Case Worst Case

Results: Overall Cost-EffectivenessResults: Overall Cost-Effectiveness

Study LimitationsStudy Limitations

Mortality benefits of influenza vaccinationMortality benefits of influenza vaccination

DTC advertising has only been studied for boosting DTC advertising has only been studied for boosting pharmaceutical salespharmaceutical sales

Medicare incurs greater program costsMedicare incurs greater program costs

Annual cost per average beneficiary is $5,400Annual cost per average beneficiary is $5,400

Average life expectancy of elders in hypothetical cohort is 11.7 Average life expectancy of elders in hypothetical cohort is 11.7 yearsyears

SummarySummary

Overall the cost per life-year saved is about $27,000 for Overall the cost per life-year saved is about $27,000 for the 10-year DTC promotion of influenza vaccine for the the 10-year DTC promotion of influenza vaccine for the elderlyelderly

Sensitivity analysisSensitivity analysis Worst caseWorst case

Cost per life-year saved < $40,000Cost per life-year saved < $40,000

Total lives saved > 7,000 livesTotal lives saved > 7,000 lives

Total cost of DTC advertising over 10 years = $2.2 billionTotal cost of DTC advertising over 10 years = $2.2 billion

ImplicationsImplications

First study to suggest potential benefits of DTC First study to suggest potential benefits of DTC advertising on public immunization effortsadvertising on public immunization efforts

DTC advertising directed towards elders mayDTC advertising directed towards elders may

Induce demand for influenza vaccineInduce demand for influenza vaccine

Raise vaccination rates towards the target of 90%Raise vaccination rates towards the target of 90%

Achieve mortality benefitsAchieve mortality benefits

Be cost-effective for the Federal Government to pursueBe cost-effective for the Federal Government to pursue

Estimated Reductions in Influenza-related Estimated Reductions in Influenza-related Mortality among the Elderly through Mortality among the Elderly through

Direct-to-Consumer Advertising Direct-to-Consumer Advertising

of Influenza Vaccineof Influenza Vaccine

Mitesh S Patel*Mitesh S Patel*

Matthew M. DavisMatthew M. Davis##

*University of Michigan Medical School, and *University of Michigan Medical School, and ##Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,

Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, Division of General Internal Medicine, and Gerald R. Ford School of Public Policy, University of MichiganUniversity of Michigan

estimated reductions in influenza-related mortality among the elderly through

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