Estimated Reductions in Influenza-related
Mortality among the Elderly through
Direct-to-Consumer Advertising
of Influenza Vaccine
Mitesh S Patel*
Matthew M. Davis#
*University of Michigan Medical School, and
#Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,
Division of General Internal Medicine, and Gerald R. Ford School of Public Policy,
University of Michigan
Influenza Mortality

Predominately and disproportionately impacts elderly

Rates of annual influenza vaccination among the elderly
are approximately 65%

Vaccination rates fall short of the Healthy People 2010
target of 90% and may be a concern on the national level
Direct-to Consumer (DTC) Advertising

Spending on DTC advertising rose from $266 million in
1994 to $3.2 billion in 2003

Effective method of increasing sales of prescription
pharmaceuticals

Could it be an effective method of increasing influenza
vaccination rates and achieving mortality benefits?
Research Objective

To examine the potential cost-effectiveness of a federal
program of DTC advertising for influenza vaccination of elders
Methods: Number Needed to Vaccinate

Number Needed to Vaccinate (NNV)

Quantifies the number of people that must be vaccinated to
prevent one all-cause death

Analogous to the Number Needed to Treat (NNT)

NNV =
1
___________________________________________________________________________________________________________________________
(population mortality rate) x (vaccine efficacy against mortality)
Methods: DTC Advertising and
Pharmaceutical Sales

DTC advertising in 1999
Spending
Change in Sales
24 Most heavily
advertised drugs
$1.338 billion
41.7%
Rest of the Market
$481 million
14.4%
Net Difference
$857 million
27.3%
Findlay. Pharmacoeconomics. 2001.
Methods: Vaccination Rate Increase
95
.
Influenza Elderly Vaccination Rate
90
85
80
75
70
65
.
60
2005
2006
2007
2008
2009
2010
Year
2011
2012
2013
2014
2015
Methods: Vaccination Rate Increase
95
Influenza Elderly Vaccination Rate
90
85
?
80
75
70
65
60
2005
2006
2007
2008
2009
2010
Year
2011
2012
2013
2014
2015
Methods: Vaccination Rate Increase
Influenza Elderly Vaccination Rate
95
90
85
80
75
70
65
60
2005
2006
2007
2008
2009
2010
Year
2011
2012
2013
2014
2015
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
194.1 million
+/- 10%
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
Population Mortality Rate
3
12.20
10
5 - 15
18.90
3
132.5/100,000
1.5 – 6
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
194.1 million
+/- 10%
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
Population Mortality Rate
3
12.20
10
5 - 15
18.90
3
132.5/100,000
1.5 – 6
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
194.1 million
+/- 10%
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
Population Mortality Rate
3
12.20
10
5 - 15
18.90
3
132.5/100,000
1.5 – 6
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
194.1 million
+/- 10%
Costs
DTC Advertising, $
Increase per year, %
Vaccine Dose, $
Increase per year, %
Vaccine Admin Fee, $
Increase per year, %
Population Mortality Rate
3
12.20
10
5 - 15
18.90
3
132.5/100,000
1.5 – 6
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
Vaccine Efficacy, %
Year 2006
67.61
56 – 76 (95% CI)
Elderly Population, millions
(Revaccinated Persons, %)
Year 2006
Year 2007
Year 2008
Year 2009
Year 2010
Year 2011
Year 2012
Year 2013
Year 2014
Year 2015
37.2 (60.0)
37.8 (69.9)
38.7 (74.2)
39.8 (77.5)
40.2 (81.9)
41.1 (83.1)
42.6 (83.5)
44.0 (85.0)
45.3 (86.2)
46.8 (86.6)
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
Vaccine Efficacy, %
Year 2006
67.61
56 – 76 (95% CI)
Elderly Population, millions
(Revaccinated Persons, %)
Year 2006
Year 2007
Year 2008
Year 2009
Year 2010
Year 2011
Year 2012
Year 2013
Year 2014
Year 2015
37.2 (60.0)
37.8 (69.9)
38.7 (74.2)
39.8 (77.5)
40.2 (81.9)
41.1 (83.1)
42.6 (83.5)
44.0 (85.0)
45.3 (86.2)
46.8 (86.6)
Methods: Model Parameters
Variable
Base Case
Estimate
Range for
Sensitivity
Analysis
Vaccine Efficacy, %
Year 2006
67.61
56 – 76 (95% CI)
Elderly Population, millions
(Revaccinated Persons, %)
Year 2006
Year 2007
Year 2008
Year 2009
Year 2010
Year 2011
Year 2012
Year 2013
Year 2014
Year 2015
37.2 (60.0)
37.8 (69.9)
38.7 (74.2)
39.8 (77.5)
40.2 (81.9)
41.1 (83.1)
42.6 (83.5)
44.0 (85.0)
45.3 (86.2)
46.8 (86.6)
Methods: Primary Outcome Measures

For each year 2006-2015 we estimated

Reduction in mortality

Cost per life-year saved =
∑Year = x
[cost (DTC + Vaccination)]
-
∑Year = (x-1)
Year=2006
[cost (DTC + Vaccination)]
Year=2006
__________________________________________________
∑Year = x [life-years saved] - ∑Year = (x-1) [life-years saved]
Year=2006
Year=2006
Results: Base Case –
First Year of Program
#
NNV
Elderly lives saved
Life-years saved
95% CI
Results: Base Case –
First Year of Program
#
95% CI
NNV
1,116
993 – 1,348
Elderly lives saved
1,999
1,656 – 2,247
Life-years saved
22,768
18,861 - 25,598
Results: Elderly Lives Saved
11000
Estimated Number of Elderly Lives Saved
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
2006
2007
2008
2009
2010
2011
2012
2013
2014
Year
Lower Bound Vaccine Efficacy
Upper Bound Vaccine Efficacy
Mean Vaccine Efficacy
2015
Results: Cost-Effectiveness of a 10-year
DTC Program for Influenza Vaccine
Overall
Vaccine
Efficacy (%)
(95% CI)
Cost of DTC
Advertising
Program
(millions
US$)
Cost of
Incremental
Increase in
Vaccination
(millions US$)
Incremental
Life-Years
Saved
Cost Per
Life-Year Saved
(US$)
(95% CI)
Year
Overall
Vaccination
Rate (%)
2006
71
67.61
(56 – 76)
194.1
69.4
22,768
11,573
(10,293 - 13,970)
2007
76
68.68
(57.07 – 77.07)
199.9
62.2
19,057
13,756
(12,259 – 16,555)
2008
79.75
69.15
(57.57 – 77.54)
205.9
50.5
14,324
17,900
(15,963 - 21,512)
2009
82.75
69.51
(57.90 – 77.90)
212.1
44.0
11,505
22,258
(19,860 – 26,721)
2010
85
69.99
(58.38 – 78.38)
218.4
35.4
8,552
29,685
(26,508 – 35,589)
Results: Cost-Effectiveness of a 10-year
DTC Program for Influenza Vaccine
Overall
Vaccine
Efficacy (%)
(95% CI)
Cost of
DTC
Advertising
Program
(millions
US$)
Cost of
Incremental
Increase in
Vaccination
(millions
US$)
Incremental
Life-Years
Saved
Cost Per
Life-Year Saved
(US$)
(95% CI)
Year
Overall
Vaccination
Rate (%)
2011
86.5
70.12
(58.51 – 78.51)
225.0
25.6
5,676
44,159
(39,440 – 52,921)
2012
87.75
70.16
(58.55 – 78.55)
231.7
23.5
4,790
53,291
(47,599 – 63,858)
2013
88.75
70.32
(58.71 – 78.71)
238.7
20.7
3,874
66,945
(59,809 – 80,183)
2014
89.5
70.45
(58.84 – 78.84)
245.9
17.0
2,925
89,884
(80,319 – 107,619)
2015
90
70.50
(58.89 – 78.89)
253.2
12.5
1,961
135,535
(121,121 – 162,255)
Results: Cost-Effectiveness of a 10-year
DTC Program for Influenza Vaccine
Overall
Vaccine
Efficacy (%)
(95% CI)
Cost of
DTC
Advertising
Program
(millions
US$)
Cost of
Incremental
Increase in
Vaccination
(millions
US$)
Incremental
Life-Years
Saved
Cost Per
Life-Year Saved
(US$)
(95% CI)
Year
Overall
Vaccination
Rate (%)
2011
86.5
70.12
(58.51 – 78.51)
225.0
25.6
5,676
44,159
(39,440 – 52,921)
2012
87.75
70.16
(58.55 – 78.55)
231.7
23.5
4,790
53,291
(47,599 – 63,858)
2013
88.75
70.32
(58.71 – 78.71)
238.7
20.7
3,874
66,945
(59,809 – 80,183)
2014
89.5
70.45
(58.84 – 78.84)
245.9
17.0
2,925
89,884
(80,319 – 107,619)
2015
90
70.50
(58.89 – 78.89)
253.2
12.5
1,961
135,535
(121,121 – 162,255)
2,225
360.9
95,434
27,096
(24,159 – 32,575)
TOTAL
Results: Overall Cost-Effectiveness
Overall Cost per Life Year Saved
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
Best Case
Base Case
Worst Case
Study Limitations

Mortality benefits of influenza vaccination

DTC advertising has only been studied for boosting
pharmaceutical sales

Medicare incurs greater program costs

Annual cost per average beneficiary is $5,400

Average life expectancy of elders in hypothetical cohort is 11.7
years
Summary

Overall the cost per life-year saved is about $27,000 for
the 10-year DTC promotion of influenza vaccine for the
elderly

Sensitivity analysis


Worst case

Cost per life-year saved < $40,000

Total lives saved > 7,000 lives
Total cost of DTC advertising over 10 years = $2.2 billion
Implications

First study to suggest potential benefits of DTC
advertising on public immunization efforts

DTC advertising directed towards elders may

Induce demand for influenza vaccine

Raise vaccination rates towards the target of 90%

Achieve mortality benefits

Be cost-effective for the Federal Government to pursue
Estimated Reductions in Influenza-related
Mortality among the Elderly through
Direct-to-Consumer Advertising
of Influenza Vaccine
Mitesh S Patel*
Matthew M. Davis#
*University of Michigan Medical School, and
#Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics,
Division of General Internal Medicine, and Gerald R. Ford School of Public Policy,
University of Michigan