Review and special article
Primary Care Intervention to Reduce Alcohol Misuse: Ranking Its Health Impact and Cost Effectiveness

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Background

The 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.

Methods

A 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.

Results

The 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.

Conclusions

These 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.

Section snippets

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

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.

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.

Without discounting, the lifetime costs of the service are divided nearly equally among clinician and patient time costs of screening and

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

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