Welcome to the Bang for the Buck series!
In this series, we will look at the most recent cost and cost-effectiveness research on public health methods and technology and discuss their potential for policy and implementation within the current health care system. As the costs of treating diseases continue to rise faster than inflation, prevention and public health interventions may be one of the most cost-effective ways to maintain a reasonable quality of health care for everyone.
While some countries have already invested in public health interventions, many others still prioritize investments in personal care and are facing the effects of these decisions. The United States, for example, spent $3.3 trillion on health care in 2016, yet still has a shorter life expectancy and poorer health quality indicators than other comparable countries that spend far less.
Looking at health expenditure in the U.S., we note that the majority of expenses in health care are associated with personal health care costs of diseases with modifiable risk factors, while only 2.8% goes to public health spending. However, even with these numbers, it is not simple to make a case for investing in preventive measures. One reason is that the effects of public health investments do not ordinarily manifest within the term of a political administration. Public health interventions take time to prove worthwhile, and this makes those investments speculative for policy-makers.
One way to overcome this hurdle is to provide strong evidence of the return on investment of preventive and public health interventions. Through the substantiation provided by cost and cost-effectiveness studies, the case for prevention and public health expenses can be made. In Bang for the Buck, we will look at studies that can help set priorities to maximize funding value. Our first entry makes such a case as it tackles an approach to the most significant single preventable cause of disability and death: smoking.
Tobacco use costs the United States over $300 billion a year. However, the country will only use less than 3% of funds from tobacco settlements to fund prevention and smoking cessation programs. This is alarming considering the amount of evidence that underlies the effectiveness and cost-effectiveness of smoking cessation programs of different types.
In one campaign, wittily named Stoptober, researchers found that by using traditional and new media to support a mass quit movement in England on the first of October with the goal of being smoke-free for the rest of the month; an estimated 8,816.57 people permanently quit their smoking habit (95% CI [1991.74, 15,641.40]). Over 350,000 smokers tried to quit during the program that year.
In another study, this time on counseling, researchers who conducted a microsimulation analysis on a US birth cohort of 4 million found that counseling youth would prevent 42,686 smoking-attributable fatalities while adult counseling would prevent 69,901 smoking-attributable fatalities. Together with the increase in quality-adjusted life years attributed to the counseling, the authors estimated that counseling may equate to a net saving of $225 in youth counseling and $580 in adult counseling per person. These are just two of the many studies that have looked into the outcomes of different types of smoking cessation programs, most with similarly favorable outcomes.
Cessation programs targeting hospitalized individuals are another way to potentially curb smoking. Smoking cessation programs for hospitalized patients are simultaneously strategic and formidable. These programs hold potential to ease accessibility and provide a continuous stream of clients. Patients’ reasons for hospitalization may serve as a motivator for smoking cessation. Furthermore, being immersed in a hospital stresses the notion of urgency, while providing the opportunity to throw queries to experts.
An earlier study tested these concepts by giving hospitalized individuals who were current smokers cessation counseling, self-help materials, referrals to the New York State Smokers’ Fax-to-Quit program, and recommendations for nicotine replacement therapy or bupropion. That study found that those enrolled in the program had improved smoking cessation outcomes, increased use of nicotine replacement therapy, and lower mortality six months post-discharge.
In recent years, The Joint Commission (JC) has recommended that all current smokers are identified upon hospitalization, receive smoking cessation services while in the hospital, and are followed up after discharge. Outcomes of implementation have been promising; showing a two-fold higher quit rate one month after discharge, as well as lower readmission rates following discharge. Despite promising results, some of the members of the 2009 JC committee that made recommendations about tobacco cessation programs have pointed out a strategic flaw in the program’s adaptation that could cause poor utilization among hospitals. According to these members, because the accreditation of JC hospitals requires reporting of only four (4) out of fourteen (14) performance measures, such as acute myocardial infarction and heart failure, hospitals will most likely forego the tobacco-use measure set because it requires more resources than the others.
A study recently published in Medical Care examined the resources required to run a hospital-based tobacco cessation program and its effects on future health care charges. The authors examined the impact of the Medical University of South Carolina’s JC-patterned tobacco dependence treatment service (TDTS) on health care charges one-year post-hospital discharge.
Patients’ tobacco use status was gathered from electronic medical records, their utilization of services from a TDTS registry, and hospitalization charges from a statewide dataset. After matching these parameters, the authors were then able to compare charges incurred by those exposed to TDTS and those who were not exposed. Exposure to TDTS was defined as having received bedside consults and/or responded to at least one follow-up call through an interactive voice response technology. Those opting out of the service by not receiving the bedside consult or by not responding to the follow-up calls were considered as unexposed.
Interestingly, healthcare charges were found to be $7,299 lower in those exposed to TDTS services compared to those who were not. Considering the sample of 1,640 patients, that is a cost saving of up to $4.8 million. And the cost to achieve this was less than $35 per patient, modest if you consider the returns.
Because these results were compared not with a true control group, but rather a comparison group of patients who opted out of the service, differences in demographics, baseline health status, or other unobservable characteristics could have been the reason for the rates of utilization. To ease this limitation of selection, the authors used propensity weighting to balance baseline characteristics, as well as covariate adjustments in their statistical model. They found similar results after conducting this modification. Hence, the robustness of their findings further strengthens the connection between cost-saving potential and TDTS.
Noteworthy, however, is that the study showed through its comparison group that many participants opted out of the service by failing to respond to an interactive voice response technology developed to make follow-up phone calls and link the patients to phone-based counselors after discharge. Future studies could, therefore, look into modifications in the interactive voice response technology and the promotion of the TDTS to hospitalized patients.
Nonetheless, the study provides evidence that TDTS consistent with JC smoking cessation standards may help reduce health care charges and consequently be a cost-saving technology. Hopefully, with this and with future prospective studies, more hospitals will come to realize the value of TDTS and implement the program in their system.
Watch out for the next Bang for the Buck as we look at how diagnosing and treating sleep apnea with positive airway pressure affects health care utilization.
Red Thaddeus Miguel