Prevention as long term cost control – part 2
In part one of this blog I explored our well documented failure to implement well evidence prevention and the notion of whether long term cost increase is driven by cost per case or increased number of cases.
Here I will explore some further examples of how prevention can reduce disease burden (and cost), some ways in which prevention can increase the value of CURRENT spend and finish with some obvious counter arguments.
1) Preventable burden of disease
There are many examples of other disease areas where an increased focus on primary prevention might attenuate future burden of disease and cost. This is illustrated below.
|One third of dementia is vascular thus in theory a proportion of it preventable by vascular risk management.
Vascular dementia is principally attributed to stroke and TIA, both of these are controllable risk factors with aggressive prevention and vascular risk management.
|It is easy to make the case (both clinically and epidemiologically) about reducing the future cost and morbidity associated with heart failure with improved primary prevention of heart attacks.
|There is excellent evidence about interventions to prevent falls- for example exercise in those that are frail.
There is also increasingly interesting evidence that structured exercise can slow frailty.
There is a far more convincing evidence base (albeit most of it observational) that mass improvements in exercise across population of middle aged can in effect act as primary prevention of frailty on a population basis. Here it is worth considering the literature on healthy ageing, and the notion of making improvements to health in mid adult life to early old age to delay onset of frailty and complications of morbidity. The potential here is vast.
|A recent CDC study highlighted the vast (and probably untapped) potential to improve the uptake of stop smoking interventions.
This study suggests that a campaign to improve stopping smoking carries a cost per life-year saved of less than $200 before discounting, ranking it among the most cost-effective preventive interventions. The CDC’s investment in this campaign represents less than the cost of 3 days of the $8 billion the tobacco industry spends annually on promotion and marketing. There is a similar but less well developed UK evidence base.
2) Prevention as a means to improve value in current health care spending.
Sticking with cigarettes for now, arguably the single largest cause of morbidity mortality and cost.
There is excellent evidence that hospital based stop smoking interventions can improve the value in current care, at a very low cost per QALY. A Canadian study recently found that from the hospital payer’s perspective, delivery of the hospital based smoking cessation interventions can be considered cost effective:–
“with 1-year cost per QALY gained of $1386, and lifetime cost per QALY gained of $68 (Canadian). Furthermore the study found that In the first year, the provision of the hospital based stop smoking interventions to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths.”
There is good evidence that non smokers have better response to biologic medicines, anti rheumatic drugs, better chance of conception as a result of IVF, less post operative complications, faster recovery and shorter length of stay.
Thus there is a good to compelling evidence base that interventions implemented at scale to large populations have massive potential to improve the value of current spend on hospital care – thus optimising value of the current spend on healthcare.
This is obviously a happy bi product of the primary purpose of stopping smoking, CVD and cancer prevention in the long run.
So there are four pieces of information suggesting that prevention is a critical component of long term cost control. I will bet a months salary that we under implement prevention, or ignore it, on a grand scale.
3) Counter arguments to prevention as cost control
Prevent or delay
There is a valid argument that all this prevention stuff simply delays illness (and costs) further down the line and the same costs will be accrued in that system but later.
Its more complex than this
There are other technical factors such as discounting, demographic factors such as population growth and ageing, and the introduction of new technologies. These all need to be taken into account.
And I am not disputing this complexity
Its not new.
There is also a valid argument that none of this is earth shatteringly new, and the above will not lead us to different actions. This is entirely true. There are a number of (very important) factors that should be borne in mind when translating these examples into generalisiable lessons.
4) Continued under implementation of prevention leads to reduced efficiency
We under implement prevention, there are missed opportunities to prevent and were we to get better this would, in the medium term at least, lead to more efficiency – less disease in a system and thus lower costs and possibly better outcomes.
“Rising disease prevalence and new medical treatments account for nearly two-thirds of the rise in spending. To be effective, reforms should focus on health promotion, public health interventions, and the cost-effective use of medical care.” 
We should focus considerably more energy and resources than we currently do toward the prevention agenda. This requires considerably more than a little bit of rhetoric in our 5 year plans.
We have an excellent track record of ignoring this, and often focus our time, energy and resources on addressing small, negligible or no improvements in population morbidity profile (sometimes at great cost) at the expense of ramping up our approach to prevention. We spend vast sums we spend on un-evidenced interventions or interventions we KNOW have little to no impact on cost, or interventions where we spend large sums on interventions well above normal thresholds of cost effectiveness.
We ignore prevention at our peril.
 Clegg et al http://ageing.oxfordjournals.org/content/43/5/687.short?rss=1 Age Ageing (2014) 43 (5): 687-695. doi: 10.1093/ageing/afu033
 The Rise In Health Care Spending And What To Do About It. http://content.healthaffairs.org/content/24/6/1436.full
 Centre for Health Economics. Financial mechanisms for integrating funds for health and social care: an evidence review. http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP97_Financial_mechanisms_integrating_funds_healtthcare_social_care_.pdf
 Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients. :
http://jama.jamanetwork.com/article.aspx?articleID=1910109.JAMA. 2014;312(13):1305-1312. doi:10.1001/jama.2014.11492.