EXAMPLES OF COST-EFFECTIVENESS ANALYSES OF
COMMUNITY PREVENTION STRATEGIES IN THE LITERATURE
- Chirikos TN, Herzog TA, Meade CD, Webb MS, Brandon TH. Costeffectiveness
analysis of a complementary health intervention: the case of
smoking relapse prevention. International Journal of Technology
Assessment in Health Care. 2004; 20(4):475-480.
Objectives: We assessed the cost-effectiveness of smoking relapse prevention
interventions designed to keep quitters from resuming the use of cigarettes. Because
relapse prevention is complementary to smoking cessation efforts, the appropriate test of
its cost-effectiveness is whether it reduces the incremental cost-effectiveness ratio (ICER) of
smoking cessation. The major goal of the study is to carry out such a test.
Methods: Data from a randomized trial that ascertained the effectiveness of alternative
modes of smoking relapse prevention were combined with ICER estimates of smoking
cessation to assess whether relapse prevention is cost-effective.
Results: The trial produced convincing evidence that relapse prevention yields statistically
significant reductions in the proportion of quitters who are smoking at 24 months post-quit.
The intervention effects are substantial enough to raise the denominator terms of the
smoking cessation ICER and, thereby, offset the amount relapse prevention adds to cost
numerator terms. In this sense, smoking relapse prevention tends to pay for itself.
Conclusions: Smoking relapse prevention is a highly cost-effective addition to current
efforts to curb cigarette consumption. Complementary health interventions of this type
should be assessed by different methods than those commonly found in the costeffectiveness
literature. - Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost-effectiveness of
smoking-cessation services under four insurance plans in a health
maintenance organization. NEJM. 1998; 339(10):673-679.
Background: Lack of information about the effect of insurance coverage on the demand for
and use of smoking-cessation services has prevented wide-scale adoption of coverage for
such services.
Methods: In a longitudinal, natural experiment, we compared the use and costeffectiveness
of three forms of coverage with those of a standard form of coverage for
smoking-cessation services that included a behavioral program and nicotine replacement
therapy (NRT). The study involved seven employers and a total of 90,005 adult enrollees.
The standard plan offered 50% coverage of the behavioral program and full coverage of
NRT. The other plans offered 50% coverage of both the behavioral program and NRT
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(reduced coverage), full coverage of the behavioral program and 50% coverage of NRT
(flipped coverage), or full coverage of both the behavioral program and NRT.
Results: Estimated annual rates of use of smoking cessation services ranged from 2.4%
(among smokers with reduced coverage) to 10% (among those with full coverage).
Smoking cessation rates ranged from 28% (among users with full coverage) to 38%
(among those with standard coverage). The estimated percentage of all smokers who would
quit smoking per year as a result of using the services ranged from 0.7% (with reduced
coverage) to 2.8% (with full coverage). The average cost to the health plan per user who
quit smoking ranged from $797 (with standard coverage) to $1,171 (with full coverage).
The annual cost per smoker ranged from $6 (with reduced coverage) to $33 (with full
coverage). The annual cost per enrollee ranged from $0.89 (with reduced coverage) to
$4.92 (with full coverage).
Conclusions: Use of smoking cessation services varies according to the extent of coverage,
with the highest rates of use among smokers with full coverage. Although the rate of
smoking cessation among the benefit users with full coverage was lower than the rates
among users with plans requiring co-payments, the effect on the overall prevalence of
smoking was greater with full coverage than with the cost sharing plans. - The Diabetes Prevention Program Research Group Within-trial costeffectiveness
of lifestyle intervention or metformin for the primary
prevention of type 2 diabetes. Diabetes Care. 2003; 26(9):2518-2523.
Objective: The Diabetes Prevention Program (DPP) demonstrated that intensive lifestyle
and metformin interventions reduced the incidence of type 2 diabetes compared with a
placebo intervention. The aim of this study was to assess the cost-effectiveness of the
lifestyle and metformin interventions relative to the placebo intervention.
Research Design and Methods: Analyses were performed from a health system
perspective that considered direct medical costs only and a societal perspective that
considered direct medical costs, direct nonmedical costs, and indirect costs. Analyses were
performed with the interventions as implemented in the DPP and as they might be
implemented in clinical practice.
Results: The lifestyle and metformin interventions required more resources than the
placebo intervention from a health system perspective, and over 3 years they cost
approximately $2,250 more per participant. As implemented in the DPP and from a societal
perspective, the lifestyle and metformin interventions cost $24,400 and $34,500,
respectively, per case of diabetes delayed or prevented and $51,600 and $99,200 per
quality-adjusted life year (QALY) gained. As the interventions might be implemented in
routine clinical practice and from a societal perspective, the lifestyle and metformin
interventions cost $13,200 and $14,300, respectively, per case of diabetes delayed or
prevented and $27,100 and $35,000 per QALY gained. From a health system perspective,
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
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costs per case of diabetes delayed or prevented and costs per QALY gained tended to be
lower.
Conclusions: Over 3 years, the lifestyle and metformin interventions were effective and
were cost-effective from the perspective of a health system and society. Both interventions
are likely to be affordable in routine clinical practice, especially if implemented in a group
format and with generic medication pricing. - Dueson RR, Brodovicz KG, Barker L, Zhou F, and Euler GL. Economic analysis
of a child vaccination project among Asian Americans in Philadelphia, Pa.
Arch Pediatr Adolesc Med. 2001 Aug; 155 (8):909-914.
Objective: To ascertain the cost-effectiveness and the benefit-cost ratios of a communitybased
hepatitis B vaccination catch-up project for Asian American children conducted in
Philadelphia, Pennsylvania, from October 1, 1994, to February 11, 1996.
Design: Program evaluation.
Setting: South and southwest districts of Philadelphia.
Participants: A total of 4384 Asian American children.
Interventions: Staff in the community-based organizations educated parents about the
hepatitis B vaccination, enrolled physicians in the Vaccines for Children program, and visited
homes of children due for a vaccine dose. Staff in the Philadelphia Department of Public
Health developed a computerized database; sent reminder letters for children due for a
vaccine dose; and offered vaccinations in public clinics, health fairs, and homes.
Main Outcome Measures: The numbers of children having received 1, 2, or 3 doses of
vaccine before and after the interventions; costs incurred by the Philadelphia Department of
Public Health and the community-based organizations for design, education, and outreach
activities; the cost of the vaccination; cost-effectiveness ratios for intermediated outcomes
(i.e., per child, per dose, per immunoequivalent patient, and per completed series);
discounted cost per discounted year of life saved; and the benefit-cost ratio of the project.
Results: For the completed series of three doses, coverage increased by 12 percentage
points at a total cost of $268,600 for design, education, outreach, and vaccination. Costs
per child, per dose, and per completed series were $64, $119, and $537, respectively. The
discounted cost per discounted year of life saved was $11,525, and 106 years of life were
saved through this intervention. The benefit-cost ratio was 4.44:1.
Conclusion: Although the increase in coverage was modest, the intervention proved costeffective
and cost-beneficial.
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-4 - Finkelstein EA, Troped PJ, Will JC, and Palombo R. Cost-Effectiveness of a
cardiovascular disease risk reduction program aimed at financially
vulnerable women: The Massachusetts WISEWOMAN project. Journal of
Women’s Health and Gender-Based Medicine. 2002; 11(6):519-526.
Objective: The Massachusetts WISEWOMAN Project is a cardiovascular disease (CVD) risk
reduction program targeting older uninsured and underinsured women. The costeffectiveness
of providing CVD screening and enhanced lifestyle interventions (EI),
compared with providing CVD screening and a minimum intervention (MI), was assessed at
five EI and six MI health care sites.
Methods: Cost calculations were based on data collected during screenings and
intervention activities conducted with 1,586 women in 1996. Risk factor data, including
cholesterol and blood pressure measures, were used to create a summary effectiveness
outcome, the 10-year probability of developing coronary heart disease (CHD). The costeffectiveness
ratio of the EI, compared with the MI, was calculated by dividing the
incremental cost of the EI by the incremental effectiveness of the EI.
Results: The incremental cost of the EI was $191. During the 1-year study period, the 10-
year probability of CHD decreased from 9.4% to 9.2% in the MI group and from 10.3% to
9.8% in the EI group. Based on these results, it would cost $637 to achieve a 1 percentage
point larger decrease in the 10-year probability of CHD for women enrolled in the EI.
However, because differences between groups were not statistically significant, we cannot
reject the hypothesis that the EI results in no greater reductions in CHD risk.
Conclusions: Although women enrolled in both the MI and EI showed decreases in CHD
risk during the study period, future research is needed to assess the impact of lifestyle
interventions targeting financially disadvantaged women. - Hatziandreu EJ, Sacks JJ, Brown R, Taylor WR, Rosenberg ML, and Graham
JD. The cost effectiveness of three programs to increase use of bicycle
helmets among children. Public Health Report. 1995 May-June;
110(3):251-259.
Each year in the United States, 280 children die from bicycle crashes and 144,000 are
treated for head injuries from bicycling. Although bicycle helmets reduce the risk of head
injury by 85%, few children wear them.
To help guide the choice of strategy to promote helmet use among children ages 5 to 16
years, the cost-effectiveness of legislative, communitywide, and school-based approaches
was assessed. A societal perspective was used, only direct costs were included, and a 4-
year period after program startup was examined. National age-specific injury rates and an
attributable risk model were used to estimate the expected number of bicycle-related head
injuries and deaths in localities with and without a program.
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
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The percentage of children who wore helmets increased from 4 to 47 in the legislative
program, from 5 to 33 in the community program, and from 2 to 8 in the school program.
Two programs had similar cost-effectiveness ratios per head injury avoided. The legislative
program had a cost of $36,643; the community-based program had a cost of $37,732; and
the school-based program had a cost of $144,498 per head injury avoided. The community
program obtained its 33% usage gradually over the 4 years, while the legislative program
resulted in an immediate increase in usage. Thus, considering program characteristics and
overall results, the legislative program appears to be the most cost-effective. The cost of
helmets was the most influential factor on the cost-effectiveness ratio.
The year 2000 health objectives call for use of helmets by 50% of bicyclists. Because
helmet use in all these programs is less than 50%, new or combinations of approaches may
be required to achieve the objective. - Holtgrave DR, Kelly JA. Preventing HIV/AIDS among high-risk urban
women: The cost-effectiveness of a behavioral group intervention. Am J
Public Health. 1996; 86:1442-1445.
Objectives: A human immunodeficiency virus (HIV) intervention trial for women at high
risk for acquired immunodeficiency syndrome and attending an urban clinic was reported
previously. The behavioral group intervention was shown to increase condom use behaviors
significantly. This study retrospectively assessed the intervention’s cost-effectiveness.
Methods: Standard methods of cost and cost-utility analysis were used.
Results: The intervention cost was just over $2,000 for each QALY saved; this is favorable
compared with other life-saving programs. However, the results are sensitive to changes in
some model assumptions.
Conclusions: Under most scenarios, the HIV prevention intervention was cost-effective. - Holtgrave DR, Kelly JA. Cost-effectiveness of an HIV/AIDS prevention
intervention for gay men. AIDS Behav. 1997; 1(3):173-180.
The present study sought to determine the cost per discounted QALY saved by a small
group workshop-format, cognitive-behavioral HIV-prevention intervention for gay men. The
methodology employed was a retrospective cost-utility analysis of the behavioral
intervention. The ability of the intervention to effect HIV-related behavior change was
previously assessed in a randomized controlled trial. In the original trial, clients were
recruited from gay bars, health department clinics, and other community settings in
metropolitan area of 400,000 residents; the intervention was delivered in a medical school
outreach setting. The participants were 104 gay men; 87% of the clients identified their
race/ethnicity as White and 13% as ethnic minority. The experimental intervention
comprised 12 sessions and provided HIV-related risk behavior education, self-management
and sexual assertion training, and development of reliable and positive social support
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networks. The comparison condition was a wait-list control group. The main outcome
measure in our retrospective cost-utility analysis was “cost per discounted QALY saved.”
Under base-case assumptions, the cost of the intervention was $24,000 (rounded to the
nearest thousand). The discounted medical costs averted by preventing HIV infection were
$42,000. Approximately 5.5 discounted QALYs were saved. Hence the intervention is costsaving
under base-case assumptions (i.e., the cost per discounted QALY saved ratio is less
than zero). The results are generally robust to changes in cost-utility analysis model
parameters and assumptions. Because the intervention is cost-saving under base-case
assumptions, it compares favorably with other health service interventions in which society
currently invests. Behavioral interventions such as the one examined here should receive
serious consideration for investment by public health decision makers allocating fiscal
resources for health services. - Johnson-Masotti AP, Pinkerton SD, Kelly JA, Stevenson LY. Costeffectiveness
of an HIV risk reduction intervention for adults with severe
mental illness. AIDS Care. 2000; 12(3):321-332.
Small-group HIV prevention interventions that focus on individual behavioral change have
been shown to be especially effective in reducing HIV risk among persons with severe
mental illness. Because economic resources to fund HIV prevention efforts are limited,
health departments, community planning groups and other key decision makers need
reliable information on the cost and cost-effectiveness (not solely on effectiveness) of
different HIV prevention interventions. This study used an economic evaluation technique
known as cost-utility analysis to assess the cost-effectiveness of three related cognitivebehavioral
HIV risk reduction interventions: a single-session, one-on-one intervention; a
multi-session small-group intervention; and a multi-session small-group intervention that
taught participants to act as safer sex advocates to their peers. For men, all three
interventions were cost-effective, but advocacy training was the most cost-effective of the
three. For women, only the single-session intervention was cost-effective. The gender
differences observed here highlight the importance of focusing on gender issues when
delivering HIV prevention interventions to men and women who are severely mentally ill. - Kahn JG, Kegeles SM, Hays R, Beltzer N. Cost-effectiveness of the
Mpowerment Project, a community-level intervention for young gay men. J
Acquir Immune Defic Syndr. 2001 Aug; 15; 27(5):482-491.
Objectives: Previous evaluation demonstrated that the Mpowerment Project communitylevel
intervention for young gay men reduces HIV risk behaviors. The current analysis was
undertaken to estimate the intervention’s health and economic outcomes.
Design/Methods: We conducted a retrospective cost-effectiveness analysis. We estimated
HIV infections averted, the gain in QALYs, cost per infection averted, and net cost. Using a
population-level model, we portrayed two epidemic scenarios: the first with stable HIV
prevalence and the other with rising HIV prevalence. Inputs included behavior change
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
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resulting from the intervention and program cost data. Cost was calculated from three
perspectives: societal, societal excluding volunteer time, and that of a community-based
organization (CBO). Outcomes were calculated for 1, 5 (baseline), and 20 years.
Results: The Mpowerment Project averted an estimated 2.0 to 2.3 HIV infections in the first
year (according to the epidemic scenario), 5.0 to 6.2 over 5 years, and 9.2 to 13.1 over 20
years. The societal cost per HIV infection averted was estimated at between $14,600 and
$18,300 over 5 years. Costs per infection averted were 28% lower when excluding
volunteer time and 35% lower from the CBO perspective. Net savings were $700,000 to
$900,000 over 5 years from the societal perspective.
Conclusions: The Mpowerment Project is cost-effective compared with many other HIV
prevention strategies. The cost per HIV infection prevented is far less than the lifetime
medical costs of HIV disease. - Meenan RT, Stevens VJ, Hornbrook MC, La Chance PA, Glasgow RE, Hollis JF,
Lichtenstein E, Vogt T. Cost-effectiveness of a hospital-based smoking
cessation intervention. Medical Care. 1998; 36(5):670-678.
Objectives: This study evaluated the cost-effectiveness of a smoking cessation and
relapse-prevention program for hospitalized adult smokers from the perspective of an
implementing hospital. It is an economic analysis of a two-group, controlled clinical trial in
two acute care hospitals owned by a large group-model health maintenance organization.
The intervention included a 20-minute bedside counseling session with an experienced
health counselor, a 12-minute video, self-help materials, and one or two follow-up calls.
Methods: Outcome measures were incremental cost (above usual care) per quit
attributable to the intervention and incremental cost per discounted life-year saved
attributable to the intervention.
Results: Cost of the research intervention was $159 per smoker, and incremental cost per
incremental quit was $3,697. Incremental cost per incremental discounted life-year saved
ranged between $1,691 and $7,444, much less than most other routine medical procedures.
Replication scenarios suggest that, with realistic implementation assumptions, total
intervention costs would decline significantly and incremental cost per incremental
discounted life-year saved would be reduced by more than 90%, to approximately $380.
Conclusions: Providing brief smoking cessation advice to hospitalized smokers is relatively
inexpensive, cost-effective, and should become a part of the standard of inpatient care. - Myers ML, Cole HP, Westneat SC. Cost-effectiveness of a ROPS retrofit
education campaign. J Agric Saf Health. 2004 May; 10(2):77-90.
A community educational campaign implemented in two Kentucky counties was effective in
influencing farmers to retrofit their tractors with rollover protective structures (ROPS) to
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-8
protect tractor operators from injury in the event of an overturn. This article reports on the
cost-effectiveness of this program in the two counties when compared with no program in a
control county. A decision analysis indicated that it would be effective at averting 0.27 fatal
and 1.53 nonfatal injuries over a 20-year period; extending this analysis statewide, 7.0 fatal
and 40 nonfatal injuries would be averted in Kentucky. Over the 20-year period, the cost
per injury averted was calculated to be $172,657 at a 4% annual discount rate. This cost
compared favorably with a national cost of $489,373 per injury averted despite the
additional program cost in Kentucky. The principle reason for the increased costeffectiveness
of the Kentucky program was the threefold higher propensity for tractors to
overturn in Kentucky. The cost per injury averted in one of the two counties was $112,535.
This lower cost was attributed principally to incentive awards financed locally for farmers to
retrofit their tractors with ROPS. - Pinkerton SD, Holtgrave DR, DiFranceisco WJ, Stevenson LY, Kelly JA. Costeffectiveness
of a community-level HIV risk reduction intervention. Am J
Public Health. 1998 Aug; 88(8):1239-1242.
Objectives: The authors evaluated the cost-effectiveness of a community-level HIV
prevention intervention that used peer leaders to endorse risk reduction among gay men.
Methods: A mathematical model of HIV transmission was used to translate reported
changes in sexual behavior into an estimate of the number of HIV infections averted.
Results: The intervention cost $17,150, or about $65 000 per infection averted, and was
therefore cost saving, even under very conservative modeling assumptions.
Conclusions: For this intervention, the cost of HIV prevention was more than offset by
savings in averted future medical care costs. Community-level interventions to prevent HIV
transmission that use existing social networks can be highly cost-effective. - Pinkerton SD, Holtgrave DR, Jemmott JB. Economic analysis of an HIV risk
reduction intervention for male African American adolescents. J Acquir
Immune Defic Syndr. 2000; 25:164-172.
Purpose: To evaluate the cost-effectiveness of a cognitive-behavioral HIV risk reduction
intervention for African-American male adolescents that has previously been shown to be
effective at reducing sexual risk taking.
Methods: Standard techniques of cost-utility analysis were employed. A societal
perspective and a 3% discount rate were used in the main analysis. Program costs were
ascertained retrospectively. A mathematical model of HIV transmission was used to
translate observed changes in sexual behavior into an estimate of the number of HIV
infections the intervention averted. Intervention effects were assumed to last for 1 year. For
each infection averted, the corresponding savings in future HIV-related medical care costs
and QALYs were estimated. The overall net cost per QALY saved (cost-utility ratio) was then
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-9
calculated. Sensitivity analyses were performed to assess the robustness of the main
results.
Results: The cost-utility ratio was approximately $57,000 U.S. per QALY saved when
training costs were included, and $41,000 U.S. per QALY saved when they were excluded.
The intervention appeared substantially more cost-effective when the analysis was
restricted to the subgroup of participants who reported being sexually active at baseline.
Assumptions about the prevalence of HIV infection and the duration of intervention
effectiveness also greatly affected the cost-utility ratio.
Conclusions: The HIV prevention intervention was moderately cost-effective in comparison
with other health care programs. Selectively implementing the intervention in high–HIV
prevalence communities and with sexually active youth can enhance cost-effectiveness. - Pinkerton SD, Holtgrave DR, Valdiserri RO. Cost-effectiveness of HIVprevention
skills training for men who have sex with men. AIDS. 1997;
11:347-357.
Objective: A previous study empirically compared the effects of two HIV-prevention
interventions for men who have sex with men: (1) a safer sex lecture and (2) the same
lecture coupled with a 1.5-hour skills training group session. The skills-training intervention
led to a significant increase in condom use at 12-month follow-up, compared with the
lecture-only condition. The current study retrospectively assesses the incremental costeffectiveness
of skills training to determine whether it is worth the extra cost to add this
component to an HIV-prevention intervention that would otherwise consist of a safer sex
lecture only.
Design: Standard techniques of incremental cost-utility analysis were employed.
Methods: A societal perspective and a 5% discount rate were used. Cost categories
assessed included staff salary, fringe benefits, quality assurance, session materials, client
transportation, client time valuation, and costs shared with other programs. A Bernoulliprocess
model of HIV transmission was used to estimate the number of HIV infections
averted by the skills-training intervention component. For each infection averted, the
discounted medical costs and QALYs saved were estimated. One- and multi-way sensitivity
analyses were performed to assess the robustness of base-case results to changes in
modeling assumptions.
Results: Under base-case assumptions, the incremental cost of the skills training was less
than $13,000 (or about $40 per person). The discounted medical costs averted by
incrementally preventing HIV infections were over $170,000; more than 21 discounted
QALY were saved. The cost per QALY saved was negative, indicating cost-savings. These
results are robust to changes in most modeling assumptions. However, the model is
moderately sensitive to changes in the per-contact risk of HIV transmission.
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Conclusions: Under most reasonable assumptions, the incremental costs of the skills
training were outweighed by the medical costs saved. Thus, not only is skills training
effective in reducing risky behavior, it is also cost-saving. - Pinkerton SD, Johnson-Masotti AP, Otto-Salaj LL, Stevenson LY, Hoffmann
RG. Cost-effectiveness of an HIV prevention intervention for mentally ill
adults. Mental Health Serv Res. 2001; 3:45-55.
Adults with severe mental illness are at high risk for HIV infection and transmission. Smallgroup
interventions that focus on sexual communication, condom use skills, and motivation
to practice safer sex have been shown to be effective at helping mentally ill persons reduce
their risk for HIV. However, the cost-effectiveness of these interventions has not been
established. We evaluated the cost-effectiveness of a 9-session small-group intervention for
women with mental illness recruited from community mental health clinics in Milwaukee,
Wisconsin. We used standard techniques of cost–utility analysis to determine the cost per
QALY saved by the intervention. This analysis indicated that the intervention cost $679 per
person, and over $136,000 per QALY saved. When the analysis was restricted to the subset
of women who reported having engaged in vaginal or anal intercourse in the 3 months prior
to the baseline assessment, the cost per QALY saved dropped to approximately $71,000.
These estimates suggest that this intervention is marginally cost-effective in comparison
with other health promotion interventions, especially if high-risk, sexually active women are
preferentially recruited. - Roux L, Pratt M, Yanagawa T, Yore M, Tengs TO. 2004.Measurement of the
value of exercise: a cost-effectiveness analysis of promoting physical
activity among adults. Poster session, CEA Methods and Applications, Health
Services Research.
Purpose: Our objective was to assess the cost-effectiveness of population-wide strategies
to promote physical activity in adults.
Methods: We developed a novel and comprehensive state-transition Markov model to
estimate the costs, health gains (QALYs), and cost-effectiveness of four alternate public
health strategies to promote physical activity. To identify strategies, we selected those that
were “strongly recommended” by the U.S. Task Force for Preventive Services. Interventions
exemplifying each of four strategies were evaluated. A community-wide campaign strategy
was represented by a multifactorial and multimedia-dependent health education
intervention. An intervention emphasizing the use of personal trainers and financial
incentives exemplified an individually-adapted health behavior change strategy. A social
support strategy was represented by an intervention that incorporated organized walking
groups, social gatherings, phone calls, and home visits. Finally, a strategy of enhanced
access was characterized by an intervention that exposed an entire community to an
environment conducive to an active lifestyle (e.g., new bicycle paths, fitness facility hour
extension). Each intervention was compared to a no intervention alternative. Efficacy
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estimates were obtained from randomized controlled trials. A systematic review of disease
burden by exercise status was used to assess the relative risk of five diseases (coronary
heart disease, ischemic stroke, colorectal cancer, breast cancer, and type 2 diabetes) for
each of the following physical activity levels: (1) inactive, (2) irregularly active, (3)
sufficiently active to minimally meet public health recommendations, and (4) highly active.
Quality of life data by disease state, exercise level, age, and gender were obtained using the
Quality of Well Being Scale. Longitudinal medical costs for the disease states were gathered
from a 400,000-member claims database and annualized using actuarial methods. Costs
and QALYs were assessed from a societal perspective over 10-, 20-, 30-, and 40-year time
horizons and discounted back to the present at 3%.
Results: While the most effective strategy focused on enhancing access to physical activity,
social support was the most cost-effective strategy at $6,400 per QALY, assuming a 40-year
time horizon. Enhanced access cost $34,000 per QALY, individually adapted cost $73,000
per QALY, and community campaign cost $110,000 per QALY. Results were sensitive to
intervention-related costs and efficacy.
Conclusion: For adults, social support offered the best value for money. However,
compared with other well-accepted preventive strategies, all physical activity promotion
strategies evaluated offered good value for money. - Secker-Walker RH, Holland RR, Lloyd CM, Pelkey D, Flynn BS. Costeffectiveness
of a community based research project to help women quit
smoking. Tobacco Control. 2005; 14:37-42.
Objective: To estimate the cost-effectiveness of a 4-year, multifaceted, community-based
research project shown previously to help women quit smoking.
Design: A quasi-experimental matched control design.
Setting: Two counties in Vermont and two in New Hampshire, USA.
Subjects: Women aged 18 to 64.
Methods: Costs were the grant-related expenditures converted to 2002 U.S. dollars.
Survey results at the end of the intervention were used to estimate the numbers of never
smokers, former smokers, light smokers, and heavy smokers in the intervention and
comparison counties, and 1986 life tables for populations of U.S. women categorized by
smoking status to estimate the gain in life expectancy.
Main Outcome Measures: Cost-effectiveness ratios, as dollars per life-year saved, for the
intervention only and for total grant costs (intervention, evaluation and indirect costs).
Results: The cost-effectiveness ratio for the intervention, in 2002 US$ per life-year saved,
discounted at 3%, was $1,156 (90% confidence interval [CI] $567 to infinity), and for the
total grant, $4,022 (90% CI $1,973 to infinity). When discounted at 5%, these ratios were
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$1,922 (90% CI $1,024 to $15,647), and $6,683 (90% CI $3,555 to $54,422),
respectively.
Conclusion: The cost-effectiveness ratios of this research project are economically
attractive and are comparable with other smoking cessation interventions for women. These
observations should encourage further research and dissemination of community based
interventions to reduce smoking. - Secker-Walker RH, Worden JK, Holland RR, Flynn BS, Detsky AS. A mass
media programme to prevent smoking among adolescents: costs and costeffectiveness.
Tobacco Control. 1997; 6:207-212.
Objective: To examine costs and cost-effectiveness ratios of a 4-year mass media program
previously shown to prevent the onset of smoking among adolescents.
Design: A matched control design.
Setting: Two cities in Montana, one in New York, and one in Vermont, USA.
Subjects: Students in grades 10 through 12 (ages 15 to 18).
Intervention: A 4-year mass media campaign to prevent the onset of smoking.
Main Outcome Measures: Cost per student potentially exposed to the mass media
campaign, cost per student smoker potentially averted, and cost per life-year gained. Cost
estimates were also made for a similar campaign that would be broadcast nationally in the
United States.
Results: In 1996 dollars, the cost of developing and broadcasting the mass media
campaign was $759,436, and the cost per student potentially exposed to the campaign
(n=18,600) was $41. The cost per student smoker averted (n = 1,023) was $754 (95% CI
= $531–$1,296). The cost per life-year gained discounted at 3% over the life expectancy
for young adult smokers was $696 (95% CI = $445–$1,269). The estimated cost of
developing and broadcasting a similar 4-year mass media campaign in all 209 American
media markets would be approximately $84.5 million, at a cost of $8 per student potentially
exposed to a national campaign, $162 per student smoker averted, and $138 (95% CI =
$88–$252) per life-year gained.
Conclusion: Estimates of the cost-effectiveness ratios of this mass media campaign in
preventing the onset of smoking showed it to be economically attractive and to compare
favorably with other preventive and therapeutic strategies.
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-13 - Sevick MA, Dunn AL, Morrow MS, Marcus BH, Chen GJ, Blair SN. Costeffectiveness
of lifestyle and structured exercise interventions in sedentary
adults: results of project ACTIVE. Am J Prev Med. 2000; 19(1):1-8.
Background: Project ACTIVE was a randomized clinical trial comparing two physical activity
interventions: lifestyle and traditional structured exercise. The two interventions were
evaluated and compared in terms of cost-effectiveness and ability to enhance physical
activity among sedentary adults.
Design: This was a randomized clinical trial.
Setting/Participants: The study included 235 sedentary but healthy community-dwelling
adults.
Intervention: A center-based lifestyle intervention that consisted of behavioral skills
training was compared to a structured exercise intervention that included supervised,
center-based exercise.
Main Outcome Measures: The main outcome measures of interest included cost, cardio
respiratory fitness, and physical activity.
Results: Both interventions were effective in increasing physical activity and fitness. At 6
months, the costs of the lifestyle and structured interventions were, respectively, $46.53
and $190.24 per participant per month. At 24 months, these costs were $17.15 and $49.31
per participant per month. At both 6 months and 24 months, the lifestyle intervention was
more cost-effective than the structured intervention for most outcomes measures.
Conclusions: A behaviorally-based lifestyle intervention approach in which participants are
taught behavioral skills to increase their physical activity by integrating moderate-intensity
physical activity into their daily lives is more cost-effective than a structured exercise
program in improving physical activity and cardio respiratory health. This study represents
one of the first attempts to compare the efficiency of intervention alternatives for improving
physical activity among healthy, sedentary adults. - Sullivan SD, Weiss KB, Lynn H, Mitchell H, Kattan M, Gergen PJ, Evans R. The
cost-effectiveness of an inner-city asthma intervention for children. J
Allergy Clin Immunol. 2002; 110(4):576-581.
Background: Comprehensive management efforts to reduce asthma morbidity among
children in urban areas with high levels of poverty and large minority populations have been
inconclusive. The National Cooperative Inner-City Asthma Study (NCICAS) demonstrated
improved symptom outcomes but did not evaluate cost-effectiveness in this population.
Objective: We sought to examine the incremental cost-effectiveness of a comprehensive
social worker–based education program and environmental control in children with asthma
stratified by baseline level of asthma control.
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-14
Methods: We performed a prospective cost-effectiveness analysis alongside a randomized
trial. A total of 1,033 children and their families residing in eight inner-city urban areas in
the United States were enrolled in the NCICAS. Outcomes included symptom-free days, cost
per symptom-free day gained, and annual costs of asthma morbidity compared by baseline
symptom control, previous hospitalization, and previous unscheduled physician visits.
Results: The NCICAS intervention significantly reduced asthma symptoms. First-year
intervention costs were $245 higher for the intervention children compared with those
receiving usual care. There were no additional intervention-related costs during the second
year. When compared with usual care, the intervention improved outcomes at an average
additional cost of $9.20 per symptom-free day gained (95% CI: –$12.56 to $55.29). The
intervention was cost saving in three strata of children with increasing asthma severity.
Conclusions: A multifaceted asthma intervention program reduced symptom days and was
cost-effective for inner-city children with asthma. In children with more severe disease, the
intervention was substantially more effective and reduced costs compared with that seen in
control children. Organizations serving this population should consider this strategy as part
of a comprehensive disease-management program for asthma. - Sweat M, O’Donnell C, O’Donnell L Cost-effectiveness of a brief video-based
HIV intervention for African American and Latino sexually transmitted
disease clinic clients AIDS. 2001; 15:781-787.
Background and Objectives: Decisions about the dissemination of HIV interventions need
to be informed by evidence of their cost-effectiveness in reducing negative health outcomes.
Having previously shown the effectiveness of a single-session video-based group
intervention (VOICES/VOCES) in reducing incidence of sexually transmitted diseases (STDs)
among male African American and Latino clients attending an urban STD clinic, this study
estimates its cost-effectiveness in terms of disease averted.
Methods: Cost-effectiveness was calculated using data on effectiveness from a randomized
clinical trial of the VOICES/VOCES intervention along with updated data on the costs of
intervention from four replication sites. STD incidence and self-reported behavioral data
were used to make estimates of reduction in HIV incidence among study participants.
Results: The average annual cost to provide the intervention to 10,000 STD clinic clients
was estimated to be US$447,005, with a cost per client of US$43.30. This expenditure
would result in an average of 27.69 HIV infections averted, with an average savings from
averted medical costs of US$5,544,408. The number of QALYs saved averaged 387.61, with
a cost per HIV infection averted of US$21,486.
Conclusions: This brief behavioral intervention was found to be feasible and cost saving
when targeted to male STD clinic clients at high risk of contracting and transmitting
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-15
infections, indicating that this strategy should be considered for inclusion in HIV prevention
programming. - Tao G, Remafedi G. Economic evaluation of an HIV prevention intervention
for gay and bisexual male adolescents. J Acquir Immune Defic Syndr Hum
Retrovirol. 1998; 17:83-90.
The objective of this study was to evaluate the cost-effectiveness of an HIV prevention
intervention for gay and bisexual male adolescents. The intervention included individualized
risk assessment and counseling, peer education, optional HIV testing, and referrals to
needed services. From 1989 to 1994, 501 male volunteers, 13 to 21 years of age, who selfidentified
as gay/bisexual or as having had sex with men, completed pre-intervention and
post-intervention surveys to assess changes in HIV risk behavior. An HIV transmission
model was constructed to project the HIV seroprevalence in the target population over a 10-
year period from the self-reported number of partners for unprotected anal intercourse.
Cost-effectiveness was analyzed from a societal perspective. Total costs of the intervention,
including medical treatment costs saved, were projected to be US$1.1 million for the 10-
year period. The number of HIV infections averted and QALYs saved were projected to be 13
and 180, respectively. An incremental cost-effectiveness ratio was projected to be US$6,180
per QALY saved. The intervention was found to be cost-effective from the societal
perspective. In addition, HIV prevalence in the target population was projected to be 6.1%
without and 5.6% with intervention by the end of the 10-year period. This study highlights
that an HIV prevention program can be cost-effective even if the effects on behavior are
partial and short term. - Tosteson ANA, Weinstein MC, Hunink MGM, Mittleman MA, Williams LW,
Goldman PA, Goldman L. Cost-effectiveness of population wide educational
approaches to reduce serum cholesterol levels. Circulation. 1997; 95:24-30.
Background: The aim of this study was to estimate the cost-effectiveness of populationwide
approaches to reduce serum cholesterol levels in the U.S. adult population.
Methods and Results: This cost-effectiveness analysis used data from the literature and
the Coronary Heart Disease Policy Model and was based on the U.S. population aged 35 to - Study interventions were population-wide programs to reduce serum cholesterol levels
with costs and cholesterol-lowering effects similar to those reported from the Stanford
Three-Community Study, the Stanford Five-City Project, and in North Karelia, Finland. The
main outcome measures were cost-effectiveness ratios, defined as the change in projected
cost divided by the change in projected life-years when the population receives the
intervention compared with the population without the intervention. A population wide
program with the costs ($4.95 per person per year) and cholesterol-lowering effects (an
average 2% reduction in serum cholesterol levels) of the Stanford Five-City Project would
prolong life at an estimated cost of only $3,200 per year of life saved. Under a wide variety
of assumptions, a population-wide program would achieve health benefits at a cost
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-16
equivalent to that of many currently accepted medical interventions. Such programs would
also lengthen life and save resources under many scenarios, especially if the program
affected persons with preexisting heart disease or altered other coronary risk factors.
Conclusions: Population-wide programs should be part of any national health strategy to
reduce coronary heart disease. - Wang G, Macera CA, Scudder-Soucie B, Schmid T, Pratt M, Buchner D. Costeffectiveness
of a bicycle/pedestrian trail development in health promotion
Preventive Medicine. 2004; 38:237-242.
Background: A persistently low population level of physical activity is a challenge for public
health. Data on cost-effectiveness of environmental interventions are needed to inform the
development and implementing of such interventions.
Objective: To conduct cost-effectiveness analysis of bicycle/pedestrian trails.
Design: The costs of trail development and number of users of four trails in Lincoln,
Nebraska, were obtained. The costs were adjusted to 2003 dollars. The physical activityrelated
outcomes/items are number of users who were more physically active since they
began using the trails, number of users who were physically active for general health, and
number of users who were physically active for weight loss. Cost-effectiveness measures
were derived. Sensitivity analysis was performed.
Results: The annual trail development cost US$289,035, 73% of which was construction
cost. Of the 3,986 trail users, 88% were active at least 3 days a week. The average annual
cost for persons becoming more physically active was US$98 (range US$65–$253); the cost
was US$142 (range US$95–$366) for persons who are active for general health and
US$884 (range US$590–$2,287) for persons who are active for weight loss.
Conclusion: This analysis provides basic cost-effectiveness measures of bicycle/pedestrian
trails. Policy makers can use this information in making resource allocation decisions. - Wang LY, Crossett LS, Lowry R, Sussman S, Dent CW. Cost-effectiveness of a
school-based tobacco-use prevention program. Arch Pediatr Adolesc Med.
2001 Sep; 155:1043-1050.
Objective: To determine the cost-effectiveness of a school-based tobacco-use prevention
program.
Design: Using data from the previously reported 2-year efficacy study of the Project
Toward No Tobacco Use (TNT), we conducted a decision analysis to determine the costeffectiveness
of TNT. The benefits measured were life years saved, QALYs saved, and
medical care costs saved, discounted at 3%. The costs measured were program costs. We
quantified TNT’s cost-effectiveness as cost per life year saved and cost per QALY saved.
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-17
Intervention: A 10-lesson curriculum designed to counteract social influences and
misconceptions that lead to tobacco use was delivered by trained health educators to a
cohort of 1,234 seventh grade students in eight junior high schools. A two-lesson booster
session was delivered to the eighth grade students in the second year. The efficacy
evaluation was based on 770 ninth grade students who participated in the program in the
seventh and eighth grades and in both the baseline and the 2-year follow-up survey.
Results: Under base-case assumptions, at an intervention cost of $16,403, TNT prevented
an estimated 34.9 students from becoming established smokers. As a result, we could
expect a saving of $13,316 per life year saved and a saving of $8,482 per QALY saved.
Results showed TNT to be cost saving over a reasonable range of model parameter
estimates.
Conclusions: TNT is highly cost-effective compared with other widely accepted prevention
interventions. School-based prevention programs of this type warrant careful consideration
by policy makers and program planners. - Wang LY, Yang Q, Lowry R, Wechsler H. Economic analysis of a school-based
obesity prevention program. Obesity Research. 2003; 11(11):1313-1324.
Objective: To assess the cost-effectiveness and cost-benefit of Planet Health, a schoolbased
intervention designed to reduce obesity in youth of middle-school age children.
Research Methods and Procedures: Standard cost-effectiveness analysis methods and a
societal perspective were used in this study. Three categories of costs were measured:
intervention costs, medical care costs associated with adulthood overweight, and costs of
productivity loss associated with adulthood overweight. Health outcome was measured as
cases of adulthood overweight prevented and QALYs saved. Cost-effectiveness ratio was
measured as the ratio of net intervention costs to the total number of QALYs saved, and
net-benefit was measured as costs averted by the intervention minus program costs.
Results: Under base-case assumptions, at an intervention cost of $33,677 or $14 per
student per year, the program would prevent an estimated 1.9% of the female students
(5.8 of 310) from becoming overweight adults. As a result, an estimated 4.1 QALYs would
be saved by the program, and society could expect to save an estimated $15,887 in medical
care costs and $25,104 in loss of productivity costs. These findings translated to a cost of
$4,305 per QALY saved and a net saving of $7,313 to society. Results remained costeffective
under all scenarios considered and remained cost-saving under most scenarios.
Discussion: The Planet Health program is cost-effective and cost-saving as implemented.
School-based prevention programs of this type are likely to be cost-effective uses of public
funds and warrant careful consideration by policy makers and program planners.
Guide to Analyzing the Cost-Effectiveness of Community Public Health Approaches
B-18 - Weaver M, Krieger J, Castorina J, Walls M, Ciske S. Cost-effectiveness of
combined outreach for the pneumococcal and influenza vaccines. Arch
Intern Med. 2001; 161(1):111-120.
Background: We conducted a cost-effectiveness analysis as part of a randomized,
controlled trial of a community-based outreach initiative to promote the pneumococcal and
influenza vaccines for people aged 65 years or older.
Methods: The analysis was based on primary data from the trial on the increase in
vaccination rates and cost of the intervention, and published estimates of the effectiveness
of the vaccines and cost of treatment. We performed partial stochastic analyses based on
the confidence intervals (CIs) of the effectiveness of the intervention and of the vaccines.
Results: The cost-effectiveness ratio of the combined-outreach initiative as implemented
was $35,486 per QALY, whereas it was $53,547 per QALY for the pneumococcal vaccine and
$130,908 per QALY for the influenza vaccine. In partial stochastic analyses, the quasi-CI of
the combined-outreach initiative ranged from $15,145 to $152,311 per QALY. The costeffectiveness
ratio of the intervention targeted to people who had never received the
pneumococcal vaccine or who had not received the influenza vaccine in the previous year
was $11,771 per QALY, with a quasi-CI of $3,330 to $46,095 per QALY. With the use of the
projected cost of replicating the intervention, the cost-effectiveness ratio was $26,512 per
QALY for the initiative as implemented and $7,843 per QALY for a targeted initiative.
Conclusions: The community-based outreach initiative to promote the pneumococcal and
influenza vaccines was reasonably cost-effective. Further improvements in costeffectiveness
could be made by targeting the initiative or through lessons learned during the
first year that would reduce the cost of the initiative in subsequent years. - Zarkin GA, Lindrooth RC, Demiralp B, Wechsberg W. The cost and costeffectiveness
of an enhanced intervention for people with substance abuse
problems at risk for HIV. Health Serv Res. 2001; 36(2):335-357.
Objective: To estimate the costs, effectiveness, and cost-effectiveness of prevention
interventions for out-of-treatment substance abusers at risk for HIV. This is the first costeffectiveness
study of an AIDS intervention that focuses on drug use as an outcome.
Study Design: We examined data from the North Carolina Cooperative Agreement site (NC
CoOp). All individuals in the study were given the revised NIDA standard intervention and
randomly assigned to either a longer, more personalized enhanced intervention or no
additional intervention. We estimated the cost of each intervention and, using simple means
analysis and multiple regression models, estimated the incremental effectiveness of the
enhanced intervention relative to the standard intervention. Finally, we computed costeffectiveness
ratios for several drug use outcomes and compared them to a “back-of-theenvelope”
estimate of the benefit of reducing drug use.
Appendix B — Examples of Cost-Effectiveness Analyses of
Community Prevention Strategies in the Literature
B-19
Principal Findings: The estimated cost of implementing the standard intervention is
$187.52, and the additional cost of the enhanced intervention is $124.17. Costeffectiveness
ratios range from $35.68 to $139.52 per reduced day of drug use, which are
less than an estimate of the benefit per reduced drug day.
Conclusions: The additional cost of implementing the enhanced intervention is relatively
small and compares favorably to a rough estimate of the benefits of reduced days of drug
use. Thus, the enhanced intervention should be considered an important additional
component of an AIDS prevention strategy for out-of-treatment substance abusers. - Zhou F, Euler GL, McPhee SJ, Nguyen T, Lam T, Wong C, Mock J. Economic
analysis of promotion of hepatitis B vaccinations among Vietnamese-
American children and adolescents in Houston and Dallas. Pediatrics. 2003
Jun;111(6 Pt 1):1289-1296.
Objective: To ascertain the cost-effectiveness and benefit-cost ratios of two public health
campaigns conducted in Dallas and Houston in 1998–2000 for “catch-up” hepatitis B
vaccination of Vietnamese-Americans born 1984–1993.
Design: Program evaluation.
Setting: Houston and Dallas, Texas.
Participants: A total of 14 349 Vietnamese-American children and adolescents.
Interventions: Media-led information and education campaign in Houston, and community
mobilization strategy in Dallas. Outcomes were compared with a control site in Washington,
DC.
Main Outcome Measures: Receipt of 1, 2, or 3 doses of hepatitis B vaccine before and
after the interventions, costs of interventions, cost-effectiveness ratios for intermediate
outcomes, intervention cost per discounted year of life saved, and benefit-cost ratio of the
interventions.
Results: The number of children who completed the series of 3 hepatitis B vaccine doses
increased by 1176 at a total cost of $313,904 for media intervention, and by 390 and at
$169,561 for community mobilization. Costs per child receiving any dose, per dose, and per
completed series were $363, $101, and $267 for media intervention and $387, $136, and
$434 for community mobilization, respectively. For media intervention, the intervention cost
per discounted year of life saved was $9,954 and 131 years of life were saved; for
community mobilization, estimates were $11,759 and 60 years of life. The benefit cost ratio
was 5.26:1 for media intervention and 4.47:1 for community mobilization.
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