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Comparative Study
. 2008 Dec;86(4):581-600.
doi: 10.1111/j.1468-0009.2008.00535.x.

Revisiting rose: comparing the benefits and costs of population-wide and targeted interventions

Jennifer Ahern  1 , Matthew R Jones, Erin Bakshis, Sandro Galea
Affiliations
Comparative Study

Revisiting rose: comparing the benefits and costs of population-wide and targeted interventions

Jennifer Ahern et al. Milbank Q. 2008 Dec.

Abstract

Context: Geoffrey Rose's two principal approaches to public health intervention are (1) targeted strategies focusing on individuals at a personal increased risk of disease and (2) population-wide approaches focusing on the whole population. Beyond his discussion of the strengths and weaknesses of these approaches, there is no empiric work examining the conditions under which one of these approaches may be better than the other.

Methods: This article uses mathematical simulations to model the benefits and costs of the two approaches, varying the cut points for treatment, effect magnitudes, and costs of the interventions. These techniques then were applied to the specific example of an intervention on blood pressure to reduce cardiovascular disease.

Findings: In the general simulation (using an inverse logit risk curve), lower costs of intervention, treating people with risk factor values at or above where the slope on the risk curve is at its steepest (for targeted interventions), and interventions with larger effects on reducing the risk factor (for population-wide interventions) provided benefit/cost advantages. In the specific blood pressure intervention example, lower-cost population-wide interventions had better benefit/cost ratios, but some targeted treatments with lower cutoffs prevented more absolute cases of disease.

Conclusions: These simulations empirically evaluate some of Rose's original arguments. They can be replicated for particular interventions being considered and may be useful in helping public health decision makers assess potential intervention strategies.

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Figures

Figure 1
Figure 1
Targeted Intervention: Surface of Benefit in Cases Averted/Cost of the Intervention for a Targeted Intervention as the Cost of the Intervention (Cost/Person Treated) and the Cutoff for Treatment (Treatment Cutoff) Are Varied
Figure 2
Figure 2
Comparison of the Benefit/Cost of the Targeted Intervention and the Population-Wide Intervention while Varying the Treatment Cutoff and the Cost per Person Treated for the Targeted Intervention; Values Greater than 1 Favor the Population-Wide Treatment, and Values below 1 Favor the Targeted Treatment
Figure 3
Figure 3
Population-Wide Intervention: Surface of Benefit in Cases Averted/Cost of the Intervention for a Population-Wide Intervention as the Cost of the Intervention (Cost/Person Treated) and the Magnitude of the Effect of Treatment on the Risk Factor (Total Shift Effect) Are Varied
Figure 4
Figure 4
Comparison of the Benefit/Cost of the Population-Wide Intervention and the Targeted Intervention while Varying the Cost of the Intervention (Cost/Person Treated) and the Magnitude of the Effect of Treatment on the Risk Factor (Total Shift Effect) for the Population-Wide Intervention; Values Greater than 1 Favor the Population-Wide Treatment, and Values below 1 Favor the Targeted Treatment
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