Comparing health gains, costs and cost-effectiveness of 100s of interventions in Australia and New Zealand: an online interactive league table.

BACKGROUND: This study compares the health gains, costs, and cost-effectiveness of hundreds of Australian and New Zealand (NZ) health interventions conducted with comparable methods in an online interactive league table designed to inform policy. METHODS: A literature review was conducted to identify peer-reviewed evaluations (2010 to 2018) arising from the Australia Cost-Effectiveness research and NZ Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programmes, or using similar methodology, with: health gains quantified as health-adjusted life years (HALYs); net health system costs and/or incremental cost-effectiveness ratio; time horizon of at least 10 years; and 3% to 5% discount rates. RESULTS: We identified 384 evaluations that met the inclusion criteria, covering 14 intervention domains: alcohol; cancer; cannabis; communicable disease; cardiovascular disease; diabetes; diet; injury; mental illness; other non-communicable diseases; overweight and obesity; physical inactivity; salt; and tobacco. There were large variations in health gain across evaluations: 33.9% gained less than 0.1 HALYs per 1000 people in the total population over the remainder of their lifespan, through to 13.0% gaining > 10 HALYs per 1000 people. Over a third (38.8%) of evaluations were cost-saving. CONCLUSIONS: League tables of comparably conducted evaluations illustrate the large health gain (and cost) variations per capita between interventions, in addition to cost-effectiveness. Further work can test the utility of this league table with policy-makers and researchers.

Potential effect of real-world junk food and sugar-sweetened beverage taxes on population health, health system costs and greenhouse gas emissions in New Zealand: a modelling study.

Poor diet is a major risk factor for excess weight gain and obesity-related diseases, including cardiovascular diseases, type 2 diabetes mellitus, osteoarthritis and several cancers. This paper aims to assess the potential impacts of real-world food and beverage taxes on change in dietary risk factors, health gains (in quality-adjusted life years (QALYs)), health system costs and greenhouse gas (GHG) emissions as if they had all been implemented in New Zealand (NZ). Ten taxes or tax packages were modelled. A proportional multistate life table model was used to predict resultant QALYs and costs over the remaining lifespan of the NZ population alive in 2011, as well as GHG emissions. QALYs ranged from 12.5 (95% uncertainty interval (UI) 10.2 to 15.0; 3% discount rate) per 1000 population for the import tax on sugar-sweetened beverages (SSB) in Palau to 143 (95% UI 118 to 171) per 1000 population for the excise duties on saturated fat, chocolate and sweets in Denmark, while health expenditure savings ranged from 2011 NZ$245 (95% UI 188 to 310; 2020 US$185) per capita to NZ$2770 (95% UI 2140 to 3480; US$2100) per capita, respectively. The modelled taxes resulted in decreases in GHG emissions from baseline diets, ranging from -0.2% for the tax on SSB in Barbados to -2.8% for Denmark's tax package. There is strong evidence for the implementation of food and beverage tax packages in NZ or similar high-income settings.

Can a Greenhouse Gas Emissions Tax on Food also Be Healthy and Equitable? A Systemised Review and Modelling Study from Aotearoa New Zealand.

Policies to mitigate climate change are essential. The objective of this paper was to estimate the impact of greenhouse gas (GHG) food taxes and assess whether such a tax could also have health benefits in Aotearoa NZ. We undertook a systemised review on GHG food taxes to inform four tax scenarios, including one combined with a subsidy. These scenarios were modelled to estimate lifetime impacts on quality-adjusted health years (QALY), health inequities by ethnicity, GHG emissions, health system costs and food costs to the individual. Twenty-eight modelling studies on food tax policies were identified. Taxes resulted in decreased consumption of the targeted foods (e.g., -15.4% in beef/ruminant consumption, N = 12 studies) and an average decrease of 8.3% in GHG emissions (N = 19 studies). The "GHG weighted tax on all foods" scenario had the largest health gains and costs savings (455,800 QALYs and NZD 8.8 billion), followed by the tax-fruit and vegetable subsidy scenario (410,400 QALYs and NZD 6.4 billion). All scenarios were associated with reduced GHG emissions and higher age standardised per capita QALYs for Maori. Applying taxes that target foods with high GHG emissions has the potential to be effective for reducing GHG emissions and to result in co-benefits for population health.

The Impact of Transport on Population Health and Health Equity for Maori in Aotearoa New Zealand: A Prospective Burden of Disease Study.

BACKGROUND: The land transport system influences health via a range of pathways. This study aimed to quantify the amount and distribution of health loss caused by the current land transport system in Aotearoa New Zealand (NZ) through the pathways of road injury, air pollution and physical inactivity. METHODS: We used an existing multi-state life table model to estimate the long-term health impacts (in health-adjusted life years (HALYs)) and changes in health system costs of removing road injury and transport related air pollution and increasing physical activity to recommended levels through active transport. Health equity implications were estimated using relative changes in HALYs and life expectancy for Maori and non-Maori. RESULTS: If the NZ resident population alive in 2011 was exposed to no further air pollution from transport, had no road traffic injuries and achieved at least the recommended weekly amount of physical activity through walking and cycling from 2011 onwards, 1.28 (95% UI: 1.11-1.5) million HALYs would be gained and $7.7 (95% UI: 10.2 to 5.6) billion (2011 NZ Dollars) would be saved from the health system over the lifetime of this cohort. Maori would likely gain more healthy years per capita than non-Maori, which would translate to small but important reductions (2-3%) in the present gaps in life expectancy. CONCLUSION: The current transport system in NZ, like many other car-dominated transport systems, has substantial negative impacts on health, at a similar level to the effects of tobacco and obesity. Transport contributes to health inequity, as Maori bear greater shares of the negative health impacts. Creating a healthier transport system would bring substantial benefits for health, society and the economy.

Prescribing Smartphone Apps for Physical Activity Promotion in Primary Care: Modeling Study of Health Gain and Cost Savings.

BACKGROUND: Inadequate physical activity is a substantial cause of health loss worldwide, and this loss is attributable to diseases such as coronary heart disease, diabetes, stroke, and certain forms of cancer. OBJECTIVE: This study aims to assess the potential impact of the prescription of smartphone apps in primary care settings on physical activity levels, health gains (in quality-adjusted life years [QALYs]), and health system costs in New Zealand (NZ). METHODS: A proportional multistate lifetable model was used to estimate the change in physical activity levels and predict the resultant health gains in QALYs and health system costs over the remaining life span of the NZ population alive in 2011 at a 3% discount rate. RESULTS: The modeled intervention resulted in an estimated 430 QALYs gained (95% uncertainty interval 320-550), with net cost savings of 2011 NZ $2.2 million (2011 US $1.5 million) over the remaining life span of the 2011 NZ population. On a per capita basis, QALY gains were generally larger in women than in men and larger in Maori than in non-Maori. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions on intervention uptake and decay. For example, the scenario analysis with the largest benefits, which assumed a 5-year maintenance of additional physical activity levels, delivered 1750 QALYs and 2011 NZ $22.5 million (2011 US $15.1 million) in cost savings. CONCLUSIONS: The prescription of smartphone apps for promoting physical activity in primary care settings is likely to generate modest health gains and cost savings at the population level in this high-income country. Such gains may increase with ongoing improvements in app design and increased health worker promotion of the apps to patients.

Disease-related income and economic productivity loss in New Zealand: A longitudinal analysis of linked individual-level data.

BACKGROUND: Reducing disease can maintain personal individual income and improve societal economic productivity. However, estimates of income loss for multiple diseases simultaneously with thorough adjustment for confounding are lacking, to our knowledge. We estimate individual-level income loss for 40 conditions simultaneously by phase of diagnosis, and the total income loss at the population level (a function of how common the disease is and the individual-level income loss if one has the disease). METHODS AND FINDINGS: We used linked health tax data for New Zealand as a high-income country case study, from 2006 to 2007 to 2015 to 2016 for 25- to 64-year-olds (22.5 million person-years). Fixed effects regression was used to estimate within-individual income loss by disease, and cause-deletion methods to estimate economic productivity loss at the population level. Income loss in the year of diagnosis was highest for dementia for both men (US$8,882; 95% CI $6,709 to $11,056) and women ($7,103; $5,499 to $8,707). Mental illness also had high income losses in the year of diagnosis (average of about $5,300 per year for males and $4,100 per year for females, for 4 subcategories of: depression and anxiety; alcohol related; schizophrenia; and other). Similar patterns were evident for prevalent years of diagnosis. For the last year of life, cancers tended to have the highest income losses, (e.g., colorectal cancer males: $17,786, 95% CI $15,555 to $20,018; females: $14,192, $12,357 to $16,026). The combined annual income loss from all diseases among 25- to 64-year-olds was US$2.72 billion or 4.3% of total income. Diseases contributing more than 4% of total disease-related income loss were mental illness (30.0%), cardiovascular disease (15.6%), musculoskeletal (13.7%), endocrine (8.9%), gastrointestinal (7.4%), neurological (6.5%), and cancer (4.5%). The limitations of this study include residual biases that may overestimate the effect of disease on income loss, such as unmeasured time-varying confounding (e.g., divorce leading to both depression and income loss) and reverse causation (e.g., income loss leading to depression). Conversely, there may also be offsetting underestimation biases, such as income loss in the prodromal phase before diagnosis that is misclassified to "healthy" person time. CONCLUSIONS: In this longitudinal study, we found that income loss varies considerably by disease. Nevertheless, mental illness, cardiovascular, and musculoskeletal diseases stand out as likely major causes of economic productivity loss, suggesting that they should be prioritised in prevention programmes.

Should prioritising health interventions be informed by modelling studies? The case of cancer control in Aotearoa New Zealand.

In this viewpoint, we suggest that policymakers should prioritise health interventions by using evidence around health gain, impact on equity, health-system costs and cost-effectiveness. We take the example of the new cancer control agency in New Zealand, Te Aho o Te Kahu, and argue that its decision-making can now be informed by many methodologically compatible epidemiological and health economic analyses. These analyses span primary prevention of cancer (eg, tobacco control, dietary and physical activity interventions and HPV vaccination), cancer screening, cancer treatment and palliative care. The largest health gain and cost-savings from the available modelling work for New Zealand are seen in nutrition and tobacco control interventions in particular. Many of these interventions have potentially greater per capita health gain for Maori than non-Maori and are also found to be cost saving for the health sector. In summary, appropriate prioritisation of interventions can potentially both maximise health benefits as well as making best use of government funding of the health system.

Increased unemployment from the COVID-19 pandemic, what might be the adverse impacts on cardiovascular disease in Aotearoa/New Zealand and how might this be prevented?

Despite success with eliminating the COVID-19 pandemic in Aotearoa New Zealand (at least to early August 2020), the response to the pandemic threat has resulted in a range of negative social and economic impacts, including job losses. Understanding the health consequences of these impacts will be increasingly important in the 'recovery' phase. This article contributes to this understanding by exploring the relationship between unemployment and cardiovascular disease (CVD)-a major contributor to health loss in Aotearoa New Zealand. We reviewed the literature about the impact of unemployment on CVD. The totality of the evidence suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for middle-aged men. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Proportional multistate lifetable modelling of preventive interventions: concepts, code and worked examples.

Burden of Disease studies-such as the Global Burden of Disease (GBD) Study-quantify health loss in disability-adjusted life-years. However, these studies stop short of quantifying the future impact of interventions that shift risk factor distributions, allowing for trends and time lags. This methodology paper explains how proportional multistate lifetable (PMSLT) modelling quantifies intervention impacts, using comparisons between three tobacco control case studies [eradication of tobacco, tobacco-free generation i.e. the age at which tobacco can be legally purchased is lifted by 1 year of age for each calendar year) and tobacco tax]. We also illustrate the importance of epidemiological specification of business-as-usual in the comparator arm that the intervention acts on, by demonstrating variations in simulated health gains when incorrectly: (i) assuming no decreasing trend in tobacco prevalence; and (ii) not including time lags from quitting tobacco to changing disease incidence. In conjunction with increasing availability of baseline and forecast demographic and epidemiological data, PMSLT modelling is well suited to future multiple country comparisons to better inform national, regional and global prioritization of preventive interventions. To facilitate use of PMSLT, we introduce a Python-based modelling framework and associated tools that facilitate the construction, calibration and analysis of PMSLT models.

Fuelling walking and cycling: human powered locomotion is associated with non-negligible greenhouse gas emissions.

Reducing motorized transport and increasing active transport (i.e. transport by walking, cycling and other active modes) may reduce greenhouse gas (GHG) emissions and improve health. But, active modes of transport are not zero emitters. We aimed to quantify GHG emissions from food production required to fuel extra physical activity for walking and cycling. We estimate the emissions (in kgCO2e) per kilometre travelled for walking and cycling from energy intake required to compensate for increased energy expenditure, and data on food-related GHG emissions. We assume that persons who shift from passive modes of transport (e.g. driving) have increased energy expenditure that may be compensated with increased food consumption. The GHG emissions associated with food intake required to fuel a kilometre of walking range between 0.05 kgCO2e/km in the least economically developed countries to 0.26 kgCO2e/km in the most economically developed countries. Emissions for cycling are approximately half those of walking. Emissions from food required for walking and cycling are not negligible in economically developed countries which have high dietary-related emissions. There is high uncertainty about the actual emissions associated with walking and cycling, and high variability based on country economic development. Our study highlights the need to consider emissions from other sectors when estimating net-emissions impacts from transport interventions.

Prospective impact of tobacco eradication and overweight and obesity eradication on future morbidity and health-adjusted life expectancy: simulation study.

BACKGROUND: Interventions that reduce morbidity, in addition to mortality, warrant prioritisation. It is important to understand the magnitude of potential morbidity and health gains from changing risk factor distributions. We quantified the impact of tobacco compared with overweight/obesity eradication on future morbidity and health-adjusted life expectancy (HALE) for the New Zealand population alive in 2011. METHODS: Business-as-usual (BAU) future smoking rates were set based on past falling rates, but we assumed no future change in Body Mass Index (BMI) distribution, given historic trends. Population impact fractions and the percentage reduction in incidence rates for 16 tobacco-related and 14 overweight/obesity-related diseases (allowing for time lags) were calculated using the difference between BAU and eradication risk factor scenarios combined with tobacco and BMI incidence rate ratios. We used two multistate lifetable models to estimate HALE changes over the remaining lifespan and morbidity rate changes 30 years hence. RESULTS: HALE gains always exceeded life expectancy (LE) gains for overweight/obesity eradication (ie, absolute compression of morbidity), but for eradication of tobacco, the pattern was mixed. For example, among 32-year-olds in 2011, overweight/obesity eradication increased HALE by 2.06 years and LE by 1.21 years, compared with 0.54 and 0.50 years for tobacco eradication.Morbidity rate reductions 30 years into the future were considerably greater for overweight/obesity eradication (eg, a 15.8% reduction for 72-year-olds in 2041, or the cohort that was aged 42 years in 2011) than for tobacco eradication (2.7%). The same rate of morbidity experienced at age 65 years under BAU was deferred by 5 years with overweight/obesity eradication. CONCLUSIONS: Preventive programmes that reduce overweight and obesity have strong potential to reduce or compress morbidity, improving the average health status of ageing populations. This paper simulated eradication of tobacco and overweight/obesity; actual interventions will have lesser health impacts, but the relativities of morbidity to mortality gains should be similar.

Potential of active transport to improve health, reduce healthcare costs, and reduce greenhouse gas emissions: A modelling study.

BACKGROUND: Physical inactivity contributes substantively to disease burden, especially in highly car dependent countries such as New Zealand (NZ). We aimed to quantify the future health gain, health-sector cost-savings, and change in greenhouse gas emissions that could be achieved by switching short vehicle trips to walking and cycling in New Zealand. METHODS: We used unit-level survey data to estimate changes in physical activity, distance travelled by mode, and air pollution for: (a) switching car trips under 1km to walking and (b) switching car trips under 5km to a mix of walking and cycling. We modelled uptake levels of 25%, 50%, and 100%, and assumed changes in transport behaviour were permanent. We then used multi-state life table modelling to quantify health impacts as quality adjusted life years (QALYs) gained and changes in health system costs over the rest of the life course of the NZ population alive in 2011 (n = 4.4 million), with 3% discounting. FINDINGS: The modelled scenarios resulted in health gains between 1.61 (95% uncertainty interval (UI) 1.35 to 1.89) and 25.43 (UI 20.20 to 30.58) QALYs/1000 people, with total QALYs up to 112,020 (UI 88,969 to 134,725) over the remaining lifespan. Healthcare cost savings ranged between NZ$127million (UI $101m to 157m) and NZ$2.1billion (UI $1.6b to 2.6b). Greenhouse gas emissions were reduced by up to 194kgCO2e/year, though changes in emissions were not significant under the walking scenario. CONCLUSIONS: Substantial health gains and healthcare cost savings could be achieved by switching short car trips to walking and cycling. Implementing infrastructural improvements and interventions to encourage walking and cycling is likely to be a cost-effective way to improve population health, and may also reduce greenhouse gas emissions.

Effects of Health-Related Food Taxes and Subsidies on Mortality from Diet-Related Disease in New Zealand: An Econometric-Epidemiologic Modelling Study.

BACKGROUND: Health-related food taxes and subsidies may promote healthier diets and reduce mortality. Our aim was to estimate the effects of health-related food taxes and subsidies on deaths prevented or postponed (DPP) in New Zealand. METHODS: A macrosimulation model based on household expenditure data, demand elasticities and population impact fractions for 18 diet-related diseases was used to estimate effects of five tax and subsidy regimens. We used price elasticity values for 24 major commonly consumed food groups in New Zealand, and food expenditure data from national Household Economic Surveys. Changes in mortality from cardiovascular disease, cancer, diabetes and other diet-related diseases were estimated. FINDINGS: A 20% subsidy on fruit and vegetables would result in 560 (95% uncertainty interval, 400 to 700) DPP each year (1.9% annual all-cause mortality). A 20% tax on major dietary sources of saturated fat would result in 1,500 (950 to 2,100) DPP (5.0%), and a 20% tax on major dietary sources of sodium would result in 2,000 (1300 to 2,700) DPP (6.8%). Combining taxes on saturated fat and sodium with a fruit and vegetable subsidy would result in 2,400 (1,800 to 3,000) DPP (8.1% mortality annually). A tax on major dietary sources of greenhouse gas emissions would generate 1,200 (750 to 1,700) DPP annually (4.0%). Effects were similar or greater for Maori and low-income households in relative terms. CONCLUSIONS: Health-related food taxes and subsidies could improve diets and reduce mortality from diet-related disease in New Zealand. Our study adds to the growing evidence base suggesting food pricing policies should improve population health and reduce inequalities, but there is still much work to be done to improve estimation of health impacts.

Greater accordance with the Dietary Approaches to Stop Hypertension dietary pattern is associated with lower diet-related greenhouse gas production but higher dietary costs in the United Kingdom.

BACKGROUND: The Dietary Approaches to Stop Hypertension (DASH) diet is a proven way to prevent and control hypertension and other chronic disease. Because the DASH diet emphasizes plant-based foods, including vegetables and grains, adhering to this diet might also bring about environmental benefits, including lower associated production of greenhouse gases (GHGs). OBJECTIVE: The objective was to examine the interrelation between dietary accordance with the DASH diet and associated GHGs. A secondary aim was to examine the retail cost of diets by level of DASH accordance. DESIGN: In this cross-sectional study of adults aged 39-79 y from the European Prospective Investigation into Cancer and Nutrition-Norfolk, United Kingdom cohort (n = 24,293), dietary intakes estimated from food-frequency questionnaires were analyzed for their accordance with the 8 DASH food and nutrient-based targets. Associations between DASH accordance, GHGs, and dietary costs were evaluated in regression analyses. Dietary GHGs were estimated with United Kingdom-specific data on carbon dioxide equivalents associated with commodities and foods. Dietary costs were estimated by using national food prices from a United Kingdom-based supermarket comparison website. RESULTS: Greater accordance with the DASH dietary targets was associated with lower GHGs. Diets in the highest quintile of accordance had a GHG impact of 5.60 compared with 6.71 kg carbon dioxide equivalents/d for least-accordant diets (P < 0.0001). Among the DASH food groups, GHGs were most strongly and positively associated with meat consumption and negatively with whole-grain consumption. In addition, higher accordance with the DASH diet was associated with higher dietary costs, with the mean cost of diets in the top quintile of DASH scores 18% higher than that of diets in the lowest quintile (P < 0.0001). CONCLUSIONS: Promoting wider uptake of the DASH diet in the United Kingdom may improve population health and reduce diet-related GHGs. However, to make the DASH diet more accessible, food affordability, particularly for lower income groups, will have to be addressed.

The Preventable Risk Integrated ModEl and Its Use to Estimate the Health Impact of Public Health Policy Scenarios.

Noncommunicable disease (NCD) scenario models are an essential part of the public health toolkit, allowing for an estimate of the health impact of population-level interventions that are not amenable to assessment by standard epidemiological study designs (e.g., health-related food taxes and physical infrastructure projects) and extrapolating results from small samples to the whole population. The PRIME (Preventable Risk Integrated ModEl) is an openly available NCD scenario model that estimates the effect of population-level changes in diet, physical activity, and alcohol and tobacco consumption on NCD mortality. The structure and methods employed in the PRIME are described here in detail, including the development of open source code that will support a PRIME web application to be launched in 2015. This paper reviews scenario results from eleven papers that have used the PRIME, including estimates of the impact of achieving government recommendations for healthy diets, health-related food taxes and subsidies, and low-carbon diets. Future challenges for NCD scenario modelling, including the need for more comparisons between models and the improvement of future prediction of NCD rates, are also discussed.

Dietary greenhouse gas emissions of meat-eaters, fish-eaters, vegetarians and vegans in the UK.

The production of animal-based foods is associated with higher greenhouse gas (GHG) emissions than plant-based foods. The objective of this study was to estimate the difference in dietary GHG emissions between self-selected meat-eaters, fish-eaters, vegetarians and vegans in the UK. Subjects were participants in the EPIC-Oxford cohort study. The diets of 2,041 vegans, 15,751 vegetarians, 8,123 fish-eaters and 29,589 meat-eaters aged 20-79 were assessed using a validated food frequency questionnaire. Comparable GHG emissions parameters were developed for the underlying food codes using a dataset of GHG emissions for 94 food commodities in the UK, with a weighting for the global warming potential of each component gas. The average GHG emissions associated with a standard 2,000 kcal diet were estimated for all subjects. ANOVA was used to estimate average dietary GHG emissions by diet group adjusted for sex and age. The age-and-sex-adjusted mean (95 % confidence interval) GHG emissions in kilograms of carbon dioxide equivalents per day (kgCO2e/day) were 7.19 (7.16, 7.22) for high meat-eaters ( > = 100 g/d), 5.63 (5.61, 5.65) for medium meat-eaters (50-99 g/d), 4.67 (4.65, 4.70) for low meat-eaters ( < 50 g/d), 3.91 (3.88, 3.94) for fish-eaters, 3.81 (3.79, 3.83) for vegetarians and 2.89 (2.83, 2.94) for vegans. In conclusion, dietary GHG emissions in self-selected meat-eaters are approximately twice as high as those in vegans. It is likely that reductions in meat consumption would lead to reductions in dietary GHG emissions.