A cost-effectiveness analysis of domestic radon remediation in four primary care trusts located in Northamptonshire, UK
Introduction
Radon, a radioactive gas, is a threat to human health when found in even moderate concentrations in domestic buildings. Those living in such conditions face an increased risk of lung cancer from the additional exposure to radiation in the respiratory tract caused by the gas. Studies by authors in [1], [2], [3], [4] all support a link between radon and lung cancer and Phillips and Denman [5] have estimated that in the UK some 2000 deaths a year result from exposure to radon. Darby et al. [4] and [6] also stress that the risk from radon is a linear one and that there is no threshold below which exposure is safe. Where radon gas is found, therefore, a public health issue arises that will be of concern to health professionals, policy makers, and the general public.
The existence of radon in the built environment is associated with certain geological formations and, as a result, tends to be concentrated in particular geographical areas. Green et al. [7] identify where these occur in England and Wales. The UK’s National Radiological Protection Board (NRPB) has designated localities where more than 1% of domestic properties have radiation levels over 200 (Becquerels per cubic metre) Bq m−3 as “Affected Areas”. The county of Northamptonshire, UK, has been included amongst these since 1992.
In Northamptonshire, the prevalence of radon reflects the underlying geology of sedimentary rocks from the Lower and Middle Jurassic periods. Radon levels are especially high where Northampton Sand Ironstone, Upper Lincolnshire Limestone, Marlstone Rock Bed and glacial sand and gravel are found. Phillips et al. [8] have moreover suggested that high levels of permeability in the rocks found in the county lead to higher levels of radon exposure in the county’s buildings than would otherwise be expected.
In response to the potential health hazard represented by radon, the NRPB has defined a UK Action Level for domestic properties of 200 Bq m−3. Where exposure is above this level, householders are advised to take steps to remediate against radon. An increasing literature exists, however, which shows that many householders either do not wish or do not consider it necessary to remediate. Phillips et al. [8], Bradley et al. [9], Denman and Phillips [10], Ryan and Kelleher [11] and Eunkyung Park et al. [12] identify such tendencies. And Warner et al. [13] have suggested that individual householders may actually be rational not to remediate, given the strong likelihood that they will not live in a high-radon property all their lives.
In addition to the inertia among householders, some authors have been sceptical of the benefits to be had from remediating against radon. Warner et al. [13], [14] argue that residential mobility among householders means that the risks faced by individuals from radon are lower than claimed because exposure rarely takes place over a whole lifetime. Abelson [15], Peterson [16], and Cohen [17] all cast doubt on the efficacy of remediation measures. In Northamptonshire, Coskeran et al. [18] questioned the cost-effectiveness of radon remediation within certain parts of the county. And Denman et al. [19] have suggested that it is actually householders least at risk from the effects of exposure to radon that remediate, a result indicating that remediation efforts are not always properly targeted.
Taken together, these issues place policy-makers in a dilemma. On the one hand, they face a demonstrable threat to public health from the existence of radon gas. But, on the other hand, the inaction of householders suggests that measures to deflect the threat will be hard to implement. Against such a background, this paper attempts to address aspects of the current policy predicament in two ways.
First, it links the conduct of remediation programmes to a key set of local public policy-making bodies within the county of Northamptonshire, namely, the primary care trusts (PCTs). As relatively new organisations, the PCTs have not yet developed full intelligence on the nature of the radon problem they face. The results obtained in this study, therefore, will be valuable for the development of public health policy within these trusts.
Second, applying cost-effectiveness analysis allows comparison of costs involved in radon remediation with those of other interventions that can either reduce the risk of contracting lung cancers or be used in treating the condition. By considering the extra years of life gained from averting or treating lung cancers, it is possible to judge how radon remediation compares with the cost-effectiveness of other forms of health intervention.4 Policy-makers within PCTs can then more effectively determine a use of resources that gives the best outcome for their client populations.
In the next section, the nature of the PCTs in Northamptonshire and their role within the public health policy-making process are discussed. Section 3 considers the methods and data used to estimate the cost-effectiveness of radon remediation in Northamptonshire’s PCTs. In Section 4, the results obtained from this study are reported and Section 5 discusses the significance of these results for policy makers. Section 6 concludes with recommendations for action in the PCTs.
Section snippets
Primary care trusts in Northamptonshire
The UK government set up PCTs across England and Wales in the period after 1999. Since 2002, they have had the prime responsibility for planning health services within their local communities and for framing policy on public health matters. PCTs are, consequently, relatively new organisations with developing agendas to meet the health needs of their local populations.
In total, five PCTs, to varying degrees, serve the county of Northamptonshire. No data were available for this study on
Method
The paper uses a significantly expanded version of a data series employed in [18]. In that earlier work, properties in Northamptonshire where householders had carried out remediation were analysed by postcode areas, the postcode of a property being a six- or seven-character representation of its location. Properties have now, however, been classified by the PCT in which they are located. This classification was carried out using postcode data on each property in combination with the NHS User
Results
Fig. 2 shows the reduction in average levels of exposure to radiation brought about by remediation in Northamptonshire’s PCTs. In all four, reductions in average readings per household were >80%. As these results indicate, remediation of properties by a contractor following best practice will lead to average radiation levels after remediation that are well below the NRPB’s Action Level.
More details on the impact of the remediation programmes on exposure to radiation are given in Table 3 for
Discussion
The results presented in Section 4 indicate how cost-effectiveness can vary between geographically proximate PCTs when faced with a similar policy problem. In terms of cost-effectiveness, therefore, tackling radon remediation would, on the average, be more appropriate in Northamptonshire Heartlands PCT than in Northampton PCT. But even in Northampton, as is discussed later in this section, there is a case for seeing radon remediation as cost-effective.
These variations in cost-effectiveness
Conclusions
The study of four Northamptonshire PCTs suggests that the pursuit of radon remediation programmes within these PCTs is likely to be cost-effective provided sufficient householders remediate. This result is demonstrated by reference to standard criteria for determining cost-effectiveness for policy purposes in health care settings. Cost-effectiveness is shown to be better in PCTs where a higher percentage of properties above the NRPB’s Action Level of 200 Bq m−3 is found and where a greater
References (39)
- et al.
Time-activity modelling of domestic exposures to radon
Journal of Environmental Management
(2003) - et al.
Costs of conventional radical radiotherapy versus continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of patients with head and neck cancer or carcinoma of the Bronchus
Clinical Oncology
(1997) - et al.
US women physicians’ residential radon testing practices
American Journal of Preventive Medicine
(1998) - et al.
Radon-smoking synergy: a population-based behavioral risk reduction approach
Preventive Medicine
(1999) - et al.
Lung cancer risk from residential radon: a meta-analysis of eight epidemiological studies
Journal of the National Cancer Institute
(1997) - et al.
Risk of lung lancer associated with residential radon exposure in South-West England: a case-control study
British Journal of Cancer
(1998) - et al.
Case-control study on lung-cancer and residential radon in Western Germany
Am. J. Epidemiol
(2001) - et al.
Radon: a likely carcinogen at all exposures
Annals of Oncology
(2002) - et al.
Radon: a human carcinogen
Science Progress
(1997) - National Research Council. Health Effects of Exposure to Radon BEIR VI. Washington, DC: National Academy Press;...
Effectiveness of secondary radon protection in Northamptonshire houses
Environmental Management and Health
A review of the cost effectiveness of radon mitigation in domestic properties in Northamptonshire
Journal of Radiological Protection
A survey of householders’ mitigation strategy
European Journal of Public Health
Community involvement and risk perception at personal and societal levels
Health, Risk and Society
Effects of residential mobility on individual versus population risk of radon-related lung cancer
Environmental Health Perspectives
Towards a more realistic appraisal of the lung cancer risk from radon: the effects of residential mobility
American Journal of Public Health
Radon today: the role of flimflam in public policy
Regulation
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Lung-cancer reduction from smoking cessation and radon remediation: A preliminary cost-analysis in Northamptonshire, UK
2011, Environment InternationalCitation Excerpt :Responding to the health threat posed by domestic radon in the UK, the then National Radiological Protection Board (NRPB), now the Radiation Protection Division of the Health Protection Agency (HPA), established a residential Action Level of 200 Bq m− 3 (O'Riordan, 1990) and declared as radon Affected Areas those geographical entities where over 1% of measurements in the existing housing stock had found radon concentrations above the Action Level. Northamptonshire was declared a radon Affected Area in 1992 (Miles et al., 1992), and although campaigns encouraging householders in Affected Areas to test and remediate their homes have been initiated, public response to the risks posed by radon has hitherto been limited, affecting the health benefits and cost effectiveness achievable by remediation programmes (Coskeran et al., 2005). The observation that those most at risk from radon are demonstrably not being targeted by current radon remediation campaigns (Denman et al., 2004, 2005) stimulated consideration of whether local smoking cessation initiatives might assist in reducing radon-induced lung-cancers by reaching new at-risk population groups, which radon remediation programmes on their own had failed to involve.
A critical evaluation of the cost-effectiveness of radon protection methods in new homes in a radon Affected Area of England
2009, Environment InternationalCitation Excerpt :A further element in the results is how the estimates of cost-effectiveness for Options A to D were based on imputed values for both pre- and post-remediation radon levels. Although these reflected known characteristics of remediation in existing properties (Coskeran et al., 2005) and the local distribution of radon levels (Miles, 1998), their use introduces a potential for error. Problems also arise with the estimates for Options A, B and O, those involving radon-proof membrane installation, where inspection costs incurred in ensuring the proper installation of the radon-proof membranes were ignored.
Domestic radon remediation of U.K. dwellings by sub-slab depressurisation: Evidence for a baseline contribution from constructional materials
2008, Environment InternationalCitation Excerpt :Correction for the presence of the small (4 Bq m− 3) atmospheric contribution makes little discernible difference to the plotted outcomes. Despite widespread publicity regarding the health risks of domestic radon, the recommendations of National and Local Government that householders finding radon concentrations above the U.K. Action Level of 200 Bq m− 3 should take steps to remediate their properties, an increasing literature exists showing that inertia, skepticism and economics dissuade many householders from taking action (Coskeran et al., 2005). Although many such studies address the statistically-consolidated societal benefits of remediation applied collectively to a population (Coskeran et al., 2002, 2005), a significant fraction of the present data-set has formed the subject of a previous comparative analysis of the health benefits accruing to the individual as a result of the remediation of his/her home (Denman et al., 2004a,b, 2005).
A new methodology for cost-effectiveness studies of domestic radon remediation programmes: Quality-adjusted life-years gained within Primary Care Trusts in Central England
2006, Science of the Total EnvironmentCitation Excerpt :Properties were classified by PCT using postcode data for each property and the NHS User Postcode Directory, which maps individual postcodes within England and Wales to PCT boundaries. The approach to classification followed that in Coskeran et al. (2005) for an earlier data set. Table 1 shows, by PCT, the number of properties in the sample, the estimated percentage of properties above the NRPB Action Level, and the implied number of properties tested.