Lack of Cost-Effectiveness Analyses to Address Healthy People 2020 Priority Areas

Abstract

Objectives. To examine the extent to which recently published cost-utility analyses (cost-effectiveness analyses using quality-adjusted life-years to measure health benefits) have covered the leading health concerns in the US Department of Health and Human Services Healthy People 2020 report.

Methods. We examined data in the Tufts Medical Center Cost-Effectiveness Analysis Registry, a database containing 5000 published cost-utility analyses published in the MEDLINE literature through 2014. We focused on US-based cost-utility analyses published from 2011 through 2014 (n = 687). Two reviewers scanned abstracts and met for a consensus on categorization of cost-utility analyses that addressed the specific priorities listed in the 12 Healthy People 2020 areas (n = 120).

Results. Although 7.3% of recently published cost-utility analyses addressed key clinical preventive services, only about 2% of recently published cost-utility analyses covered each of the following Healthy People 2020 topics: reproductive and sexual health, nutrition/physical activity/obesity, maternal and infant health, and tobacco. Fewer than 1% addressed priorities such as injuries and violence, mental health or substance abuse, environmental quality, and oral health.

Conclusions. Few cost-utility analyses have addressed Healthy People 2020 priority areas.

Cost-effectiveness analysis provides a useful and time-tested approach for assessing the value of health and medical interventions. The number of cost-effectiveness analyses published in the medical literature has grown substantially, and health decision-makers in a variety of settings use the technique directly or indirectly to inform health care prioritization decisions.¹ Researchers have noted, however, that the cost-effectiveness analysis literature focuses disproportionately on certain areas, such as cardiovascular disease and cancer, and less on other health concerns, such as mental health and injuries, despite the high burden of these latter conditions.²

One way to assess whether cost-effectiveness analyses are adequately informing crucial decisions in health and health care is to consider the literature devoted to the government’s own health priorities. This question is important because published cost-effectiveness analyses help inform policymakers about society’s best opportunities to improve health. However, if analyses are not addressing key priority areas, decision-makers will lack information and thus risk misprioritizing resources.

The nation’s health priorities are perhaps best illustrated by the Healthy People initiative, which provides evidence-based, 10-year national objectives for improving the health of Americans.³ Healthy People identifies nationwide health improvement priorities in specific areas to “help people achieve high-quality, longer lives free of preventable disease, disability, injury, and premature death.”⁴ We previously highlighted the relatively small number of published cost-utility analyses (cost-effectiveness analyses that present results in terms of incremental costs per quality-adjusted life-years) in the United States that addressed the Department of Health and Human Services (DHHS) Healthy People 2010: Understanding and Improving Health⁵ priorities.² In this brief, we update those analyses by examining the extent to which recently published cost-utility analyses have covered the leading health concerns in the Healthy People 2020⁶ report.

METHODS

We examined data in the Tufts Medical Center Cost-Effectiveness Analysis Registry (http://www.cearegistry.org), a database containing 5000 cost-utility analyses published in the MEDLINE literature through 2014 (updates are ongoing). For this analysis, we focused on US-based cost-utility analyses published from 2011 (the year after the Healthy People 2020 report was published) through 2014 (n = 687).

Two reviewers scanned abstracts and used a data collection form to independently categorize the cost-utility analyses according to the specific priorities listed in the 12 Healthy People 2020 areas (Table 1). After independent review, any discrepant categorizations were discussed and assigned to agreed-on categories. The Cohen κ coefficient for interrater agreement before reviewer consensus was 0.502, suggesting moderate agreement. We categorized the resulting 120 cost-utility analyses into the DHHS Healthy People 2020 priority areas.

TABLE 1—

Published US-Based Cost-Utility Analyses, 2011–2014, Devoted to Categories of Healthy People 2020 Leading Health Indicators

Healthy People 2020 Category	No. (%) of Cost-Utility Analyses (n = 687)
Clinical preventive services	50 (7.3)
Adults who receive a colorectal cancer screening based on the most recent guidelines
Adults with hypertension whose blood pressure is under control
Persons with diagnosed diabetes whose A1c value is > 9%
Children aged 19–35 mo who receive the recommended doses of DTP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines
Reproductive and sexual health	17 (2.5)
Sexually active females aged 15–44 y who received reproductive health services in the past 12 mo
Knowledge of serostatus among HIV-positive persons
Maternal, infant, and child health	11 (1.6)
All infant deaths
Total preterm live births
Nutrition/physical activity/obesity	11 (1.6)
Adults who meet current federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity
Adults who are obese
Obesity among children and adolescents
Total vegetable intake for persons aged 2 y and older
Tobacco	11 (1.6)
Adults who are current cigarette smokers
Adolescents who smoked cigarettes in the past 30 d
Access to health services	6 (0.9)
Persons with medical Insurance
Persons with a usual primary care provider
Injury and violence	5 (0.7)
Fatal injuries
Homicides
Mental health	5 (0.7)
Suicides
Adolescents who experienced major depressive episodes
Substance abuse	4 (0.6)
Adolescents using alcohol or any illicit drugs during the past 30 d
Adults engaging in binge drinking during the past 30 d
Environmental quality	0 (0)
Air Quality Index exceeding 100
Children exposed to secondhand smoke
Social determinants	0 (0)
Students who graduate with a regular diploma 4 y after starting ninth grade
Oral health: children, adolescents, and adults who visited the dentist in the past year	0 (0)

Note. DTP = diphtheria and tetanus toxoids and pertussis; Hib = Haemophilus influenzae type b; MMR = measles, mumps, rubella; PCV = pneumococcal conjugate.

Source. Tufts Medical Center Cost Effectiveness Analysis Registry. Available at: http://www.cearegistry.org. Accessed July 22, 2016.

RESULTS

As of February 2016, few recently published cost-utility analyses have covered the Healthy People 2020 priorities (Table 1).⁴ About 7% addressed key clinical preventive services, such as colorectal cancer screening and childhood immunizations. Only 2.5% covered reproductive and sexual health, and 1.6% addressed each of the following: nutrition/physical activity/obesity; maternal, infant, and child health; and tobacco. Fewer than 1% addressed priority interventions for injuries and violence, mental health, or substance abuse. No recent cost-utility analyses addressed specific Healthy People 2020 priorities on oral health, environmental quality, or social determinants of health.

DISCUSSION

The need for the United States to increase investment in key health priorities is underscored by the Healthy People 2020 initiative. However, our study found that since those priorities were announced in 2010, few published cost-effectiveness studies have addressed specific interventions in these areas, particularly in certain key areas, such as injuries and violence, substance abuse, maternal and infant health, oral health, and the broader environmental determinants. In contrast, a separate study found that approximately 18% of published cost-utility analyses have focused on cardiovascular disease and 15% on cancer.¹ Our study also highlights the lack of progress in terms of cost-utility analyses addressing key health priorities. For example, in a previous study assessing whether cost-utility analyses focused on Healthy People 2010 priorities, we found that only 0.6% of the cost-utility analyses had addressed substance abuse, 0.4% covered overweight and obesity, and 0.6% focused on tobacco use.²

Our analysis had some limitations. Judgment is involved in assigning cost-utility analyses to health categories and to types of interventions, and other investigators may have classified them differently. Furthermore, the Healthy People 2020 priorities may not cover all interventions related to a particular topic area. For example, a cost-utility analysis measuring the cost-effectiveness of an intervention for adults using chewing tobacco would not be classified as related to the Healthy People 2020 topic tobacco, because it does not relate to the specific definition in the 2020 report: adults who are current cigarette smokers; adolescents who smoked cigarettes in the past 30 days (Table 1).⁴

PUBLIC HEALTH IMPLICATIONS

The scarcity of cost-utility analyses on the government’s own priorities, including interventions addressing areas with substantial burdens of morbidity and mortality, is troubling. Why so few cost-utility analyses have focused on Healthy People 2020 priorities is not entirely clear, but elsewhere we have shown that cost-effectiveness analyses tend to devote a great deal of attention to pharmaceuticals (which constituted 46% of the cost-utility analyses published from 2010 to 2012), perhaps driven by reimbursement debates and decisions surrounding prescription drugs. However, a growing knowledge base underscores the effect of broader determinants of health (i.e., environment and social factors).⁷ The lack of evaluation of interventions that mitigate risks in these areas keeps the United States on the path of solving health problems largely through medical care rather than through changes in the built and social environment. Growing evidence indicates that this is not a cost-effective strategy.^8,9