| | Primary Care Intervention to Reduce Alcohol Misuse: Ranking Its Health Impact and Cost EffectivenessBackgroundThe U.S. Preventive Services Task Force (USPSTF) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardized rating for the clinically preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services. MethodsA systematic review of the literature from 1992 through 2004 to identify relevant randomized controlled trials and cost-effectiveness studies was completed in 2005. Clinically preventable burden (CPB) was calculated as the product of effectiveness times the alcohol-attributable fraction of both mortality and morbidity (measured in quality-adjusted life years or QALYs), for all relevant conditions. Cost effectiveness from both the societal perspective and the health-system perspective was estimated. These analyses were completed in 2006. ResultsThe calculated CPB was 176,000 QALYs saved over the lifetime of a birth cohort of 4,000,000, with a range in sensitivity analysis from −43% to +94% (primarily due to variation in estimates of effectiveness). Screening and brief counseling was cost-saving from the societal perspective and had a cost-effectiveness ratio of $1755/QALY saved from the health-system perspective. Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving. ConclusionsThese results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems. So many preventive services are effective that it is difficult for patients, payers, providers, and purchasers to know which ones are most important to focus on with limited time or resources. In order to provide such an aid to prioritization, the National Commission on Prevention Priorities was created by Partnership for Prevention with funding from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). The first ranking of prevention priorities was published in 2001, with an update and addition of other services added in 2006.1, 2 As part of the 2006 update, a brief alcohol misuse screening and counseling intervention ranked in the top five, ahead of nearly 20 other effective services. This paper provides the information on which that ranking was based, and the first cost–utility analysis of screening and brief intervention. In 2004, the United States Preventive Services Task Force (USPSTF) released its recommendation for primary care interventions for alcohol problems. It gave a B rating for “screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women.”3, 4 The USPSTF found evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but do place them at risk for increased morbidity and mortality. It also found evidence that brief behavioral counseling interventions with follow-up in such patients can produce small-to-moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer. Finally, it identified some limited evidence that such interventions lead to positive health outcomes 4 or more years post-intervention, and that screening and behavioral counseling reduce alcohol-related morbidity. Since alcohol misuse is a serious common health problem, even indirect evidence that it can be affected by interventions in primary care suggests the need for such interventions. But if primary care settings are to focus their quality improvement and individual patient-care efforts on those conditions that have the greatest effects on health and the best cost effectiveness, it is important to have evidence-based information about the relative priority of all effective preventive services. Yarnall et al.5 has shown that if primary care clinicians tried to provide each of the services recommended by the USPSTF for each patient seen, it would take 7.5 hours per day for just that task.5 Thus, some prioritization information seems absolutely necessary. Methods  The ability to compare different preventive services depends on applying the same methods to each service, which was done by utilizing the methods described previously.6 This article’s methods adhere to the approach used with other services, but the description here is focused on the issues and details that are unique to this topic. Additional details of the models not presented here are available online.7 The approach used here was to estimate the health impact and cost effectiveness of regular screening for alcohol misuse by brief instruments such as CAGE (Cut-down, Annoyed, Guilty and Eye opener alcohol use disorders test) and AUDIT (Alcohol Use Disorders Identification Test) questionnaires, followed by evaluation of initial positives and brief counseling of true positives. Health impact was estimated by the clinically preventable burden (CPB), defined as the burden of disease prevented by the service when delivered regularly over the lifetime of a birth cohort of 4,000,000 individuals. Cost effectiveness was defined as the net gain in lifetime costs of delivering the service divided by net quality-adjusted life years (QALYs). The CPB and cost-effectiveness estimates were used to assign priority scores on a scale of 1 to 5 (5 being the highest) in order to depict the relative value of preventive services.6 Literature Search and Abstraction In 2005 a systematic review of the literature to help ensure comparability of the estimates used to rank preventive services was completed.2, 6 The literature review and estimates focused on randomized controlled trials (RCTs) of interventions that could be conducted in busy primary care practices on most of their alcohol-misusing patients, and that were tested under conditions consistent with those criteria. Trials of more intensive counseling or of interventions involving many follow-up contacts were eliminated as not feasible and outside the scope of the USPSTF recommendation. Seventy meta-analyses and systematic reviews of alcohol-misuse treatments were identified in PubMed from January 1992 through September 3, 2004. Another 1667 original articles were found in PubMed from January 2000 through October 25, 2004, including some articles referenced in the systematic reviews. These articles were reviewed against the following criteria, all of which had to be met for abstraction: (1) all services must be delivered in the primary care setting, (2) the population must not be restricted to those dependent on alcohol, (3) there must be a control group, (4) each intervention arm must have at least 25 participants, (5) outcome measurements must include the percent of problem drinkers at baseline who were no longer problem drinkers at follow-up, and (6) outcomes must be measured for at least 6 months following intervention. In order to identify cost-effectiveness articles of screening and brief intervention, a PubMed literature search8 from January 1992 to December 5, 2004 was performed. To be eligible for abstraction, these studies needed to meet all of the following four criteria: (1) analyze brief interventions, not limited to alcoholism or alcohol dependence, (2) be conducted on a U.S. population and report costs in U.S. dollars, (3) analyze full cost effectiveness with health outcomes measured as years of life with or without quality adjustment, and (4) analyze interventions delivered in a primary care setting. Five economic analyses were identified that met the first criteria.9, 10, 11, 12, 13 However, none of these met the other three criteria. Model Estimation Clinically preventable burden and cost effectiveness were estimated using an algebraic model as described elsewhere.6, 8 The use of algebraic models rather than Markov models or microsimulations allowed more study resources to be devoted to producing consistent results across all services. Methods for producing consistent estimates of cost effectiveness across preventive services are outlined in a methods article and a detailed technical report.6, 8 These methods are consistent with the ‘reference case’ of the Panel on Cost Effectiveness in Health and Medicine (PCEHM).14 Keeping with these standards, the analysis from the societal perspective includes the value of patient time to obtain services and excludes productivity gains. All costs and benefits were discounted to their present value at the age of 18 using a 3% discount rate. Medical costs were updated to year 2000 dollars using the medical consumer price index (M-CPI), and all other costs were updated using the CPI for all items. Results of Literature Review and Model Specification The data points used in the model are shown in Table 1, along with their sources and the ranges over which each variable was explored in sensitivity analysis. All analyses were completed in 2006. | | |  | Variable | Base case | Data source references | Range for sensitivity analysis | |
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| Adherence, effectiveness, and efficacy (%) | | | | | |  Adherence with screening | 86.0 | 39, 40, 81, 94 | 80% to 95% | | | Average sensitivity of CAGE and AUDIT questionnaires | 70 | 116 | 60% to 90% | | | Effectiveness of counseling at changing behavior | 17.4 | 10, 17, 34, 39, 61, 81, 102, 110, 112, 115 | 10% to 35% | | | Efficacy of behavior change at reducing burden of acute conditions | 90 | Assumed | 75% to 100% | | | Efficacy of behavior change at reducing burden of chronic conditions | 25 | Assumed | 10% to 50% | | | Lifetime burden of alcohol-attributable illness | | | | | | Total alcohol-attributable QALYs lost | 0.662 | — | — | | | Alcohol-attributable life years lost to chronic conditions | 0.171 | Appendix A, Table 1 | ±20% | | | Alcohol-attributable life years lost to acute conditions | 0.366 | Appendix A, Table 1 | ±20% | | | Alcohol-attributable morbidity-related QALYs lost from acute conditions | 0.028 | Appendix A, Table 2 | ±40% | | | Alcohol-attributable morbidity-related QALYs lost from chronic conditions | 0.098 | Appendix A, Table 2 | ±40% | | | % of problem drinkers screened and counseled | 8.7 | 117 | 5 to 25 | | | Costs of screening and counseling | | | | | | Cost of 10-minute office visit | $43.63 | 118 | ±33% | | | Value of patient time and travel for office visit | $42.32 | 119 | ±50% | | | Portion of 10 minute office visit for screen | 10% | Assumed | 5% to 20% | | | Portion of visit for evaluating false positives | 20% | Assumed | 10% to 25% | | | Portion of visit for evaluating true positives | 50% | Assumed | 25% to 75% | | | Average specificity of CAGE & AUDIT | 85% | 116 | 75% to 95% | | | Screens per year among ages 18–54 | 1.0 | Assumed | 0.5 to 2 | | | Screens per year among ages 55+ | 0.5 | Assumed | 0.2 to 1.0 | | | Average annual prevalence of problem drinking between ages 18–54 | 25.01% | 120, 121 | 20% to 30% | | | Average annual prevalence of problem drinking after age 54 | 6.47% | 120, 121 | 4% to 10% | | | Disease costs | | | | | | Alcohol-attributable medical costs | $5143 | 122 | ±33% | | | Other alcohol-attributable costs, including alcohol-related crimes, motor vehicle crashes, fire destruction, and social welfare administration | $9136 | 122 | ±33% | | | Portion of non-medical alcohol-attributable costs preventable through behavior change (%) | 90 | Assumed | 75 to 100 | | | | |
Effectiveness of Screening and Adherence The effectiveness of screening depends on four factors: adherence with screening, sensitivity of screening tools, effectiveness of counseling in producing behavior change, and efficacy of behavior change in reducing the health consequences of hazardous drinking. As a result of the literature searches plus review of references in identified articles, 101 effectiveness articles were identified for potential abstraction.10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114 Only 16 of these articles met the above inclusion criteria and were abstracted by two reviewers independently.10, 17, 27, 34, 39, 40, 46, 61, 75, 81, 92, 94, 102, 110, 112, 115 Four studies reported (or allowed calculation of) completion rates for screening questionnaires39, 40, 81, 94; the mean (86%) was used as the estimate of screening adherence. While the four-question CAGE instrument is the most popular screening tool used in primary care to detect alcohol-dependent drinkers, the 10-item AUDIT questionnaire includes questions about quantity, frequency, and binge behavior, as well as symptoms of alcohol dependence. The midpoint of the combined sensitivity ranges of the CAGE and AUDIT (70%) was used for the sensitivity estimate.116 Most of the RCTs that met inclusion criteria for feasibility in primary care practice studied heavy drinking and/or hazardous drinking. Heavy drinking was defined in different ways among these studies, but focused on those drinking more than a certain quantity of alcohol per week, while hazardous drinking focused on those drinking more than a certain amount per occasion. An additional complication was that most of the studies had <100% of subjects at baseline having whichever of these two problems were being tested. Therefore, reported results were used to compute reduction in problem drinking as the percent difference from the control-group level rather than using the percentage-point difference as frequently reported by the study authors. Six studies that were abstracted were not included in the analysis because of fatal flaws or limited numbers or age groups of subjects.27, 40, 46, 75, 92, 94 The final summary of effectiveness is based on the average effectiveness in 10 studies of reduction in heavy drinking,10, 17, 34, 39, 61, 81, 102, 110, 112, 115 seven of which also measured reduction in hazardous drinking.10, 17, 34, 39, 61, 112, 115 The mean rate of effectiveness for heavy drinking was 17.3% and that for hazardous drinking was 17.6%, for a composite effectiveness rate of 17.4% (9.8% to 30.1%). These estimates reflect behavior change at 6-months to 2-years post-intervention. In the absence of data about long-term and repeated interventions, it was assumed that the rate of 17.4% would be maintained over time with repeated intervention, while allowing for the possibility that effectiveness might wane to 10% over time or double to 35%. Data on the efficacy of behavior change in reducing the health consequences of alcohol misuse are available for only some of the many alcohol-attributable conditions. It was assumed that the burden for acute alcohol-attributable conditions (injuries) would be reduced by 90% among individuals who adhered to clinician advice, since some alcohol-attributable injuries would still occur at lower levels of consumption. However, because chronic alcohol-attributable disease requires long-term behavior change, it was assumed that chronic conditions would be reduced by only 25%. Broad ranges for these variables were explored in sensitivity analysis. Lifetime Burden of Alcohol-Attributable Disease To estimate lifetime burden of alcohol-attributable disease, current mortality and morbidity for each condition were multiplied by published estimates of each condition’s alcohol-attributable fraction (AAF) as documented in Appendix A (available online at www.ajpm-online.net). Mortality and morbidity have been reduced by screening and counseling practices. In order to estimate the total value of the service, the burden of deaths and illness that would have happened in the absence of screening was predicted first. Current mortality was influenced by the portion of the population screened and counseled, the effectiveness of counseling in changing behavior, and the effect of changing behavior in reducing burden. The estimates for these variables are described elsewhere in this section. In the Healthcare for Communities Survey, 8.7% of problem drinkers reported having been asked about drinking and receiving assistance beyond simple quit advice.117 Costs of Screening, History Taking, and Brief Counseling The costs of screening include both patient and physician time. The lifetime costs of initial screening with evaluation and counseling for those who screen positive were computed. Based on the average of Medicare reimbursement and the median of private sector charges,118 the price of a 10-minute office visit was $42.32 in Year 2000 dollars. It was assumed that 10% of that visit would be required for initial screening and that it would take 2 hours for patients at an average hourly earnings in 2000.119 False positives increase the costs of screening and history taking. The average specificity of the CAGE and AUDIT questionnaires was estimated as 85%.116 By assuming that false positives would require an additional 20% of a 10-minute office visit, true positive cases would require, on average, an additional 50% of a 10-minute visit for complete evaluation of positive screens. Annual screening and counseling are probably necessary from ages 18 to 54 to maintain the 12–month rate of effectiveness, but biennial screening might be sufficient after the age of 54 when the prevalence of heavy drinking falls. To estimate the lifetime costs of screening, history taking, and brief counseling, the years of life lived after the age of 18 from U.S. life tables120 were computed and the frequency of heavy drinking estimated. The distribution of years of life with and without risky or harmful drinking were determined from age-group and gender-specific estimates of the prevalence of heavy drinking on at least one occasion per year for 2003.121 The average for the two broad age groups that correspond with the different frequencies in screening are shown in Table 1. Costs of Alcohol-Attributable Disease and Injury The per-capita expenditures were calculated from Harwood’s estimate of the annual societal costs of alcohol abuse,122 and were used to approximate lifetime costs. In calculating the cost savings from screening and counseling, the medical costs of alcohol-attributable disease and the costs of alcohol-related crimes, motor vehicle crashes, fire destruction, and social welfare administration (but not transfer payments of social welfare) were included. Costs in the absence of screening were calculated in the same manner as QALYs lost to alcohol in the absence of screening. The estimates of adherence with screening, sensitivity of screening, and effectiveness of counseling were used to estimate the cost savings achieved. Using the same rationale as for acute medical conditions, it was assumed that 90% of non-medical alcohol-attributable costs are preventable through behavior change. Results of Model: CPB and Cost Effectiveness Estimates Results of calculations before discounting are shown in Table 2. The predicted gain per person in the target population is 0.045 QALYs, or 0.052 QALYs saved per person who completes screening. To rank this service, CPB was estimated as the total, undiscounted QALYs saved in a birth cohort of 4,000,000, factoring in patient non-adherence: 176,000 QALYs saved. | | | | | Undiscounted | Discounted | |
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| | No screening | With screening | Increment with screening | No screening | With screening | Increment with screening | |
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| QALYs lost to alcohol misuse | 0.672 | 0.627 | −0.045 | 0.187 | 0.175 | −0.012 | | | Medical costs of initial screen | 0 | 179 | 179 | 0 | 88 | 88 | | | Medical costs of evaluation and brief advice | 0 | 171 | 171 | 0 | 84 | 84 | | | Patient time cost of initial screen | 0 | 174 | 174 | 0 | 86 | 86 | | | Patient time costs of evaluation and brief advice | 0 | 166 | 166 | 0 | 82 | 82 | | | Alcohol-attributable medical costs | 5218 | 4870 | −348 | 2281 | 2129 | −52 | | | Other alcohol-attributable costs | 9323 | 8444 | −879 | 4724 | 4279 | −445 | | | Total screening, treatment, and other costs | | | | 7005 | 6747 | −257 | | | Total medical screening and treatment costs | | | | 22,281 | 2301 | 21 | | | Clinically preventable burden for birth cohort of 4,000,000 | | | 177,029 | | | | | | Societal CE ($/QALY saved) | | | | | | Not defined | | | Medical sector CE ($/QALY saved) | | | | | | 1688 | | | | |
Without discounting, the lifetime costs of the service are divided nearly equally among clinician and patient time costs of screening and evaluation/counseling. Discounted results, including cost effectiveness, are shown in Table 2. Cost-effectiveness results are also presented from the health-system perspective in which all costs and savings outside the health system are excluded. If net costs were positive, the cost-effectiveness ratio from the societal perspective would be calculated by dividing the net discounted costs (−$254 lifetime per person in year 2000 dollars) by the discounted lifetime QALYs saved (0.012). However, the cost-effectiveness ratio is not defined when net costs are negative (i.e., net cost savings), and therefore the summary measure for cost effectiveness for ranking clinical preventive service is the net savings of $254 per person offered screening. When including medical care costs only by excluding both patient time costs and non-medical cost offsets (the “health-system perspective”), the resulting cost-effectiveness ratio is $1755/QALY saved. Sensitivity Analysis In single-variable sensitivity analysis, undiscounted QALYs saved per person and CPB were found to be highly sensitive to the effectiveness of counseling at changing behavior. They varied by −43% to +94% (0.026 to 0.091 QALYs per person). In multivariate analysis, combinations of three variables led to differences as great as −60% to +209% (0.081 to 0.138 QALYs per person). The lower estimates from multivariate sensitivity analysis would reduce the CPB priority score from its base-case score of 4 to a score of 3 (out of 5), and the higher multivariable sensitivity analysis would increase the score to a 5. This level of sensitivity in scores was typical of other service calculations.2 Net discounted savings are relatively small when measured as a percent of either discounted service costs or cost offsets. As a result, changes to variables that affect the estimates of service costs or savings often produced large changes to net costs and the cost-effectiveness ratio. Nine variables changed the net costs by more than 25% (Table 3). Despite some highly influential variables, net costs remained negative in single-variable sensitivity analysis except when changing the effectiveness of counseling in changing behavior. However, in multivariate sensitivity analysis, changes in combinations of three variables at a time resulted in a range of from −$1400 per person up to $98,800 per QALY saved (+$484 per person). The base case and the higher estimate of net savings from sensitivity analysis are consistent with a cost-effectiveness score of 5 (out of 5), while the estimated least cost-effective combination of variables is consistent with a cost-effectiveness score of 2. More than 10 combinations of three variables would produce a cost-effectiveness score of 2, and other combinations would produce a score of 3 or 4. Although regular screening and counseling are undoubtedly very cost effective, there is uncertainty as to whether it is cost saving. No data are available to quantify the relationship between the frequency of service delivery and the level of sustained behavior change. Figure 1, Figure 2 examine some scenarios by showing the effectiveness of counseling needed to obtain various cost-effectiveness thresholds at each frequency of service delivery. The frequencies shown on the horizontal axis are for individuals aged 18–54 years and in each case the frequency for ages 55+ is 50% lower. For example, at the base-case frequencies of annual screening and biennial screening for adults to age 54 and adults age 55+ (1.0 and 0.5 per year), sustained effectiveness of 10% would be needed to achieve cost neutrality from the societal perspective (Figure 1), 8.3% would be needed to achieve a cost-effectiveness ratio of $10,000/QALY, and so on. The figures show that if screening at or more frequent than the base-case levels achieve sustained effectiveness of 10% or less, then the cost savings found in the base case would not be realized. Further, substantially higher cost-effectiveness ratios may be realized even while leaving all other variables at their base-case estimates. Discussion Although wide variation in costs per QALY are produced by changes in the assumptions about effectiveness and the cost-effectiveness variables noted above, the mean of those ranges still results in a CPB score of 4 and cost-effectiveness score of 5 (on a 1–5 geometric scale).2 Among the 25 services studied, all given positive recommendations by the USPSTF, alcohol misuse achieved a combined score of 9, similar to screening for colorectal cancer, hypertension, or vision (adults over 64), and to influenza or pneumococcal immunization. In contrast to those other services, however, alcohol-misuse screening and counseling currently are delivered at much lower rates. In a national survey of problem drinkers, only 8.7% reported having been asked and counseled about their alcohol use in the last 12 months.117 Given the ever-growing competing priorities facing physicians, this is not surprising. It is also a problem that is similar to depression, in that physicians perceive that identifying it during an otherwise crowded office visit will necessitate a prolonged and perhaps awkward discussion with uncertain patient benefit. Others have found that brief interventions can be delivered at low costs on a one-time basis.13, 123 Fleming et al.9, 10 observed net medical cost savings with one-time screening and brief intervention in the TrEAT trial (Trial for Early Alcohol Treatment) and additional savings when health outcomes were monetized. Lindhold et al.12 found more intensive primary care programs could be very cost effective or cost saving, depending on long-term effectiveness. The findings of this paper suggest that investments in regular screening are likely to be very cost effective from the health-system perspective and to be cost saving from the societal perspective, thus adding to the literature that suggests alcohol screening and brief intervention in primary care is a valuable and underutilized service. Any study with multiple data points, assumptions, extrapolations, and dependence on highly aggregate data will have limitations. One problem is that the USPSTF focused on nondependent alcohol misuse, but studies of the disease burden and the effectiveness of brief counseling for alcohol misuse generally include dependent drinkers in the study population. Therefore, the estimates of these studies reflect the average for both dependent and nondependent problem drinkers. In usual practice, primary care clinicians would have limited ability to distinguish dependent and nondependent problem drinkers, so averaging across both groups likely provides a realistic estimate of overall effect. Data on the health and financial burden by type of alcohol misuse also are limited to a subset of the consequences of alcohol misuse. Data are lacking on the relationship between an individual’s disease risk and the probability of adhering with the steps necessary to achieve risk reduction. In particular, differences in adherence between dependent and nondependent alcohol misuse could be significant. The results of studies that use intention-to-treat analysis in entire populations and measure final health outcomes reflect differential adherence among subpopulations. Such studies would allow this modeling step to be bypassed and eliminate this data limitation. However, very few studies of brief counseling for alcohol misuse measure health outcomes, and none have long enough follow-up to observe differences in chronic conditions and associated mortality. Similarly, individuals with high baseline alcohol use are likely to have larger health benefits from moderating behavior than individuals with lower use. If the relationship between alcohol use and health risks is not linear, the simple population average estimates would tend to understate the benefits of behavior change. Whether or not CPB and cost effectiveness ultimately are understated depends on whether or not individuals with higher baseline alcohol use are equally likely to adhere with advice as individuals with lower baseline use. Relative to some behavioral preventive services, the literature on the effectiveness of clinician counseling in producing changes to hazardous drinking among nondependent drinkers is strong. However the available studies with longer-term follow-up indicate that effectiveness may wane after 12 months, and there are no studies of the long-term effectiveness (5+ years) with repeated screening and counseling. There was one study by Kristenson et al.124, 125 of a moderately intensive intervention over 2 years in individuals with high serum-gamma-glutamyltransferase (GGT) values that provided follow-up of 6 years, but that approach was judged to be infeasible in primary care and incomparable to the studies used in this analysis. Therefore, the long-term effectiveness of the repeated interventions that would occur in real-life practice is unknown, and the assumption was made that the 12-month effectiveness equals that of long-term repeated interventions. It also is possible that subjects in randomized trial intervention groups may have underreported their drinking when asked at follow-up about drinking behaviors they had been counseled to avoid. Other variables for which data are sparse are the proportion of nonfatal conditions that is attributable to alcohol, and the efficacy of reducing alcohol misuse in preventing all alcohol-attributable morbidity, mortality, and costs. The benefits and costs of the service for dependent problem drinkers are limited to what they would derive from brief counseling from a primary care clinician (as reflected in the estimate of effectiveness in counseling averaged across both dependent and nondependent problem drinkers). In practice, clinicians usually will refer the portion of dependent problem drinkers who are identified by screening to outside resources. For the portion that adheres to clinician recommendations to seek additional help, such services may lead to additional service costs, health benefits, and financial savings. These effects were not included in the estimates, due to data limitations. First, no estimates of rates of adherence with referrals to treatment for dependent drinking were found that could be generalized to the primary care setting. Studies that provide rates of successful referral relate to patients seen in emergency rooms and hospitals32, 38, 126, 127or are limited to patients with prior trauma.50 These studies report that approximately 25% of referral patients kept the first appointment with treatment for dependence, but generally do not report adherence with subsequent appointments or program completion. Individuals with dependence that are identified through a screen in primary care may be even less likely to follow through on a referral. Finally, cost effectiveness is highly unstable because net costs are very small relative to the costs of the service and the financial savings. Small changes to variables that affect total costs or savings can have a large impact on net costs and the cost-effectiveness ratio. However, it is worth noting that missing data on effectiveness of repeated counseling in producing sustained behavior change contribute substantial uncertainty to the model estimates. Despite these uncertainties and limitations, it is clear that brief screening and counseling for alcohol misuse in primary care is both more effective and more cost-effective than most other effective preventive services. Since current rates of providing this service are so low, it becomes an even more important target for improvement. It remains for primary care practices to learn how to incorporate it into routine practice in a way that is cost-effective for them and for payers and health plans to make reimbursement changes that will facilitate that change. This work has been supported by the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention through Partnership for Prevention. No financial disclosures were reported by the authors of this paper. Appendix A. Quality-Adjusted Life Years Lost Due to Alcohol-Attributable Mortality and Morbidity For each data point, the most recently available data were used unless more reliable estimates for an earlier year were available. To calculate clinically preventable burden (CPB), the burden of disease attributable to alcohol use was estimated first. This required that the portion of mortality and morbidity for each relevant condition that could be attributable to alcohol be estimated, and then multiply that alcohol-attributable fraction (AAF) by the mortality (years of life lost) and the morbidity (QALYs or quality-adjusted life years) for each condition. The estimates in Table A-1, Table A-2 have been scaled to 1,000,000 individuals (rather than 4,000,000) to facilitate comparisons to the per-person estimates reported in the article. | | | | Conditions | Alcohol-attributable fraction | Total deaths | Alcohol-attributable deaths | Average life expectancy | Years of life lost | |
|---|
| Chronic | | | | | | | | Acute pancreatitis | 0.24 | 1,017 | 244 | 13.8 | 3,375 | | | Alcohol abuse | 1 | 251 | 251 | 27.8 | 6,979 | | | Alcoholic cardiomyopathy | 1 | 257 | 257 | 20.8 | 5,349 | | | Alcohol dependence syndrome | 1 | 0 | 0 | 0.0 | 0 | | | Alcoholic polyneuropathy | 1 | 1.8 | 1.8 | 15.0 | 27 | | | Alcoholic gastritis | 1 | 15 | 15 | 22.4 | 342 | | | Alcoholic liver disease | 1 | 3,757 | 3,757 | 22.0 | 82,554 | | | Alcoholic psychosis | 1 | 146 | 146 | 13.4 | 2,391 | | | Breast cancer | 0.0085 | 15,012 | 128 | 15.4 | 1,967 | | | Chronic hepatitis | 0.013 | 83 | 1 | 15.0 | 16 | | | Chronic pancreatitis | 0.84 | 100 | 84 | 17.1 | 1,429 | | | Epilepsy | 0.15 | 392 | 59 | 23.3 | 1,372 | | | Esophageal cancer | 0.036 | 4,641 | 167 | 13.4 | 2,243 | | | Esophageal varices | 0.4 | 75 | 30 | 15.8 | 476 | | | Fetal alcohol syndrome | 0.47 | 25 | 12 | 11.9 | 139 | | | Gastroesophageal hemorrhage | 0.025 | 19,391 | 485 | 9.9 | 4,776 | | | Hypertension | 0.0018 | 204,497 | 368 | 9.1 | 3,356 | | | Ischemic heart disease | 0.061 | 1,506 | 92 | 14.0 | 1,284 | | | Laryngeal cancer | 0.052 | 4,860 | 253 | 13.2 | 3,326 | | | Liver cancer | 0.4 | 4,836 | 1,934 | 15.7 | 30,342 | | | Liver cirrhosis, unspecified | 0.033 | 1,045 | 35 | 77.9 | 2,652 | | | Low birthweight/Prematurity | 0.057 | 2,530 | 144 | 14.0 | 2,020 | | | Oropharyngeal cancer | 0.4 | 41 | 16 | 15.5 | 251 | | | Portal hypertension | 0.0076 | 16,228 | 123 | 7.6 | 932 | | | Prostate cancer | 0.051 | 13,155 | 671 | 12.5 | 8,402 | | | Stroke, hemorrhagic | 0.031 | 11,659 | 361 | 7.7 | 2,766 | | | Stroke, ischemic | 0.017 | 3,490 | 59 | 6.6 | 394 | | | Supraventricular cardiac dysrrhythmia | | 309,009 | 9,692 | | 169,158 | | | Chronic total | 0.24 | 1,017 | 244 | 13.8 | 3,375 | | | Acute | | | | | | | | Air space transport | 0.18 | 196 | 35 | 28.8 | 1,013 | | | Alcohol poisoning | 1 | 75 | 75 | 33.3 | 2,492 | | | Aspiration | 0.18 | 408 | 74 | 13.6 | 997 | | | Child maltreatment | 0.16 | 294 | 47 | 72.1 | 3,392 | | | Drowning | 0.34 | 827 | 281 | 34.1 | 9,589 | | | Excessive blood alcohol level | 1 | 1.8 | 1.8 | 21.9 | 36 | | | Fall injuries | 0.32 | 7,243 | 2,318 | 9.4 | 21,888 | | | Fire injuries | 0.42 | 907 | 381 | 20.2 | 7,706 | | | Firearm injuries | 0.18 | 203 | 37 | 38.8 | 1,415 | | | Homicide | 0.47 | 4,339 | 2,039 | 41.5 | 84,638 | | | Hypothermia | 0.42 | 155 | 65 | 15.9 | 1,032 | | | Motor vehicle non-traffic crashes | 0.18 | 328 | 59 | 28.8 | 1,703 | | | Motor vehicle traffic crashes (men) | 0.33 | 8,263 | 2,722 | 37.0 | 100,691 | | | Motor vehicle traffic crashes (women) | 0.2 | 4,132 | 812 | 41.3 | 33,550 | | | Occupational and machine injuries | 0.18 | 468 | 84 | 25.2 | 2,120 | | | Other road vehicle crashes | 0.18 | 190 | 34 | 34.0 | 1,163 | | | Poisoning (not alcohol) | 0.29 | 2,760 | 800 | 34.1 | 27,329 | | | Suicide | 0.23 | 8,816 | 2,028 | 29.5 | 59,835 | | | Water transport | 0.18 | 186 | 34 | 33.5 | 1,122 | | | Acute total | | 39,790 | 11,926 | | 361,709 | | | Grand total | | 348,799 | 21,618 | | 530,867 | | | | |
| | | | Conditions | Alcohol-attributable fraction | Incidence rate | Alcohol-attributable disease cases | Type | Duration | QALY weight | AA QALYs lost | |
|---|
| Chronic | | | | | | | | | | Acute pancreatitis | 0.24 | 0.0010948071 | 14,789 | Inpatient stays | 0.058 | 0.3 | 256 | | | Alcohol abuse | 1 | 0.0003334185 | 18,767 | Inpatient stays | 1.6 | 0.3 | 9,008 | | | Alcohol dependence syndrome | 1 | 0.0005872147 | 33,052 | Inpatient stays | 1.6 | 0.3 | 15,865 | | | Alcoholic gastritis | 1 | 0.0000298584 | 1,681 | Inpatient stays | 0.058 | 0.3 | 29 | | | Alcoholic liver disease | 1 | 0.0002786782 | 15,686 | Inpatient stays | 7.8 | 0.2 | 24,470 | | | Alcoholic psychosis | 1 | 0.0006021439 | 33,892 | Inpatient stays | 1.6 | 0.3 | 16,268 | | | Breast cancer | 0.0085 | 0.0009925897 | 243 | New cases | 4.3 | 0.2 | 209 | | | Chronic pancreatitis | 0.84 | 0.0000995279 | 4,706 | Inpatient stays | 0.058 | 0.3 | 82 | | | Epilepsy | 0.15 | 0.0002687254 | 2,269 | Inpatient stays | 9.2 | 0.2 | 4,175 | | | Esophageal cancer | 0.036 | 0.0000630210 | 128 | New cases | 1.8 | 0.3 | 70 | | | Gastroesophageal hemorrhage | 0.47 | 0.0000646931 | 1,712 | Inpatient stays | 0.058 | 0.3 | 30 | | | Hypertension | 0.025 | See strokes below | | | | | | | Ischemic heart disease | 0.0018 | 0.010405644 | 1,054 | Inpatient stays | 0.058 | 0.3 | 18 | | | Laryngeal cancer | 0.061 | 0.0000490163 | 168 | New cases | 4.3 | 0.2 | 145 | | | Liver cancer | 0.052 | 0.0000770257 | 226 | New cases | 1.77 | 0.3 | 120 | | | Liver cirrhosis, unspecified | 0.4 | 0.0001691975 | 3,809 | Inpatient stays | 7.8 | 0.2 | 5,943 | | | Low birth weight/ Prematurity | 0.033 | 0.000154268 | 287 | Inpatient stays | 0.25 | 0.3 | 22 | | | Oropharyngeal cancer | 0.057 | 0.0001512504 | 485 | New cases | 4.3 | 0.2 | 417 | | | Prostate cancer | 0.0076 | 0.0025141264 | 523 | New cases | 4.5 | 0.2 | 471 | | | Stroke | 0.043 | 0.0024881980 | 6,022 | Inpatient stays | 7.8 | 0.4 | 18,789 | | | Supraventricular cardiac dysrrhythmia | 0.017 | 0.0022344018 | 2,138 | Inpatient stays | 0.058 | 0.3 | 37 | | | Chronic total | | | 141,635 | | | | 96,420 | | | Acute | | | | | | | | | | Air space transport | 0.18 | 0.0023325110 | 24,665 | Injuries | 0.077 | 0.3 | 569 | | | Alcohol poisoning | 1 | See poisoning below | | | | | | | Aspiration | 0.18 | 0.0001112050 | 1,416 | Injuries | 0.077 | 0.3 | 33 | | | Child maltreatment | 0.16 | 0.0045711630 | 10,749 | Injuries | 0.115 | 0.3 | 372 | | | Drowning | 0.34 | 0.0000045621 | 95 | Injuries | 0.077 | 0.3 | 2 | | | Fall injuries | 0.32 | 0.0241142810 | 525,979 | Injuries | 0.077 | 0.3 | 12,138 | | | Fire injuries | 0.42 | 0.0016581250 | 39,947 | Injuries | 0.077 | 0.3 | 922 | | | Firearm injuries | 0.18 | 0.0000580598 | 602 | Injuries | 0.115 | 0.3 | 21 | | | Homicide and assault | 0.47 | 0.0070389760 | 180,342 | Injuries | 0.115 | 0.3 | 6,243 | | | Motor vehicle traffic crashes | 0.29 | 0.0096394490 | 232,358 | Injuries | 0.077 | 0.3 | 5,362 | | | Occupational and machine injuries | 0.18 | 0.0013293210 | 13,602 | Injuries | 0.077 | 0.3 | 314 | | | Poisoning | 0.29 | 0.0018290890 | 30,468 | Injuries | 0.077 | 0.3 | 703 | | | Suicide and self harm | 0.23 | 0.0013852150 | 17,385 | Injuries | 0.115 | 0.3 | 602 | | | Water transport | 0.18 | included in air space transport above | | | | | | Acute total | | | 1,077,605 | | | | 27,280 | | | Grand total | | | 1,219,240 | | | | 123,700 | | | | |
Alcohol-Attributable Fraction The AAFs were taken from direct AAFs reported on the Alcohol-Related Disease Impact (ARDI) website (http://apps.nccd.cdc.gov/ARDI/HomePage.aspx), but when ARDI reported indirect AAFs, AAFs from information provided on the ARDI website were calculated (dividing the number of alcohol-attributable deaths from the condition by the total deaths from that same condition). The AAFs were based upon the portion of mortality attributable to alcohol use and misuse (technically speaking, they are population-attributable fractions). The analysis was limited to those conditions in which the alcohol-attributable mortality reported by ARDI was >0. Lacking other data for most alcohol-attributable illnesses and injuries, the mortality-based AAFs were applied to morbidity data. Mortality (Years of Life Lost) As with most other services in this project, the projected lifelong burden of disease of a birth cohort using annual incidence rates over all relevant age groups was estimated. This provided an approximately correct estimate of the number of years of life lost, both overall and for each age group. For this service, the quality of this approximation varies from condition to condition, since previous risk factors and the medical technologies available to the current cross-section of age groups differ from those that a single birth cohort would face over time. In addition, the applicability of AAFs varies with changes in the alcohol-use rates and other risk factors in the population. AAFs that reflect the age distribution of the hypothetical birth cohort are likely to be somewhat different than the average AAFs used here, which reflect the age distribution of the current U.S. cross-section. For chronic conditions, the number of alcohol-attributable deaths per 1,000,000 population was computed from the age of 20 years for deaths from any cause. For acute conditions, the number of alcohol-attributable deaths was computed from the age of 15. For cases of low birth weight/prematurity, child maltreatment, and motor vehicle traffic crashes, years of life lived from birth were used. Mortality was estimated from 1998 death rate data, using the CDC Wonder engine (http://wonder.cdc.gov/mortSQL.html), which included mortality data for the same ICD-9 codes for the conditions as listed in the ARDI report. Whenever U.S. population estimates were needed for calculations, the 2000 census data were used.1 Whenever age- and gender-specific data were available, the calculations reflect weighted averages, but none of the AAFs presented are age-specific estimates. Morbidity (QALYs Lost) Alcohol-attributable QALYs lost to morbidity is the product of lifetime incidence of alcohol-attributable disease, duration of disease, and the associated quality-of-life reduction (QALY weight). For each condition, alcohol-attributable incidence was calculated as (the number of life years lived by a birth cohort of 1,000,000) × (the annual incidence of disease) × (the alcohol-attributable fraction). The annual incidence rate for cancer cases was based on 2002 incidence rates, age-adjusted to the 2000 population (unadjusted rates were not reported).2 Stroke incidence was approximated by the incidence of first stroke.3 Incidence data for many chronic conditions were not available, so when necessary, the estimate of annual inpatient stays was substituted. Thus, this may have overstated or understated the incidence, depending on how many individuals had an inpatient stay with a listed primary diagnosis during the course of their disease and how many had more than one such stay. To determine morbidity for the various conditions listed by the ARDI report, the following three references were used: •2001 National Hospital Discharge Survey for inpatient stays4 •2003 National Hospital Ambulatory Medical Care Survey for emergency department visits5 •an MMWR report on injury surveillance for detailed injury reports by age.6 Efforts were made to match each condition listed by ARDI with the closest condition in these three reference sources. The following conditions did not have detailed incidence information on morbidity in the three references listed above: alcoholic cardiomyopathy, alcoholic polyneuropathy, chronic hepatitis, esophageal varices, fetal alcohol syndrome, portal hypertension, excessive blood-alcohol level, motor-vehicle nontraffic crashes, hypothermia, and other road vehicle crashes. The nonfatal burden of these conditions was therefore not reflected in the estimates. The conditions omitted from the morbidity calculation consisted of 2.7% of mortality. If they included a similar portion of morbidity and had a duration of illness similar to the average of other included morbidities, then total alcohol-attributable QALYs lost (mortality plus morbidity) was understated by about one half of 1%. The impact is small because years of life lost contribute substantially more to QALYs than do illness or disability. The duration of illness for many conditions (all cancers, mental disorders, stroke, cirrhosis of the liver) were taken from closely corresponding (i.e., not always identical) disease categories of the Global Burden of Disease for Established Market Economies.7 The basis for injury duration is self-reported days of restricted activity. Hospitalizations other than injuries were assigned a duration of 3 weeks in order to be consistent with the approach used for other services. For morbid conditions, the estimates of the number of episodes in Table 2 may be overstated because the available hospitalization rates include younger individuals, for which the AAFs are not applicable. The prevalence of chronic conditions in those less than 35 years of age is very low, and therefore the resulting overstatement as a percent of total QALYs lost to alcohol is necessarily very small. 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