Cost-effectiveness and equity impact of complex primary care interventions for disadvantaged populations

Background Reducing health inequity is essential. The FAIRSTEPS (Framework to Address Inequities in pRimary care using STakEholder PerspectiveS) study developed and prioritised 28 vignettes describing complex primary care interventions targeted to disadvantaged groups, through Delphi consensus ranking by primary care practitioners for feasibility and perceived usefulness.

Aim To build on FAIRSTEPS by quantifying potential impacts of prioritised vignettes on cost-effectiveness and health equity.

Design & setting Simplified distributional cost-effectiveness analysis (DCEA) in England.

Method Pragmatic literature searches were carried out around each vignette to identify the following: (1) available economic evidence; and (2) information about size and distribution of populations targeted. Economic evidence was quality assessed using adapted National Institute for Health and Care Excellence (NICE) appraisal checklists. Extracted cost and quality-adjusted life-year (QALY) data and population data, were combined with published distributions of health opportunity costs and baseline lifetime health, to estimate net health benefits and equity measures for each vignette.

Results Suitable cost-effectiveness evidence was identified for 17 of 28 vignettes, with variable study quality and applicability. Fourteen vignettes were both cost-effective and equity-generating, with the most beneficial on both dimensions relating to community champions for health promotion; integrated care for people sleeping rough, engaged in sex work, or using drugs; and weight-loss programmes targeted at people on low incomes.

Conclusion Simplified DCEA using published data can be used to provide additional evidence to help prioritise complex primary care interventions aimed at disadvantaged populations, although the analysis is hindered by low quality economic data and limited study comparability. Further research estimating baseline health and health opportunity cost distributions across disadvantaged groups would improve accuracy of health equity assessments.