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EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: A LITERATURE REVIEW

CHAPTER ELEVEN OTHER ISSUES

Introduction

11.1 This chapter summarises literature that cuts across the interventions covered in the earlier chapters. The effectiveness reviews cover a study which has ranked interventions across a number of areas and studies relating to locations and specific population groups rather than interventions. Also included are reviews dealing with educational requirements of providers. The cost-effectiveness study relates to a general treatment programme but is of particular interest as it was carried out in Scotland. The cost-offset studies cover similar topics to the effectiveness reviews. The studies reviewed are summarised briefly in tables 11.3 (effectiveness) and 11.4 and 11.5 (cost studies) at the end of the chapter.

Effectiveness studies

Ranking of effectiveness evidence across treatments

11.2 A study by Miller et al (1998) has attempted to produce an effectiveness ranking across treatment areas (the so called "Mesa Grande"). The authors produced a cumulative effectiveness score (CES) for all interventions by weighting study outcomes by study quality and summing the scores. Study quality is assessed on 12 dimensions and results in a maximum possible methodological quality score (MQS) of 17. Study outcomes were scored as positive (+1) or strongly positive (+2), negative (-1) or strongly negative (-2). The resulting CES is a useful indicator of whether the balance of the evidence is negative or positive but as an indicator of the relative strength of evidence the comparison between scores is less helpful. A higher score may simply reflect the fact that more studies have been carried out for that intervention.

Table 11.1 Extract of results for cumulative effectiveness

11.3 The problem can be illustrated from the partial results reproduced in table 11.1. Brief interventions achieve the highest CES based on 19 positive studies and 9 negative studies. However, Acamprosate is placed 5th with only 3 positive studies. The CES per study is higher for Acamprosate than for brief interventions. There is no attempt to take into account the size of the effect that each intervention produces and the terminology used to describe interventions is not always clear.

Location studies

11.4 A number of reviews have addressed the provision of alcohol misuse interventions in particular settings. These reviews do not provide evidence about comparative effectiveness between the setting studied and other alternative settings. However, they may provide useful insights to the provision of services in these settings and possible models for intervention programmes.

Workplace

11.5 Two reviews have considered workplace interventions based on US data relating to employee assistance programmes (EAP) (Colantonio 1989; Roman and Blum 1996). These reviews do not provide very specific details of the interventions employed, although counselling is reported as the most frequent intervention in one review. Both reviews report positive findings from the workplace interventions but based on poor study designs. On this basis, one author supports EAP and the other does not. The relevance to the UK of such studies may be limited.

Prisons

11.6 A comprehensive review of interventions in the context of prisons has been carried out by McMurran (1995). The paper considers the issues raised by the characteristics of the client population, by the setting and the nature of the goals set. Structured cognitive-behavioural programmes are seen to be most effective but brief interventions may also be effective with problem drinkers. The author provides recommendations for an intervention programme for UK prisons based on the review of evidence.

Population groups

11.7 A number of reviews have considered the requirements of particular population groups with respect to alcohol misuse.

Women

11.8 Gender differences in treatment outcome appear to be small, with women achieving better results in the first 12 months of follow up while men have better results thereafter (Jarvis 1992). Nevertheless, gender issues may affect the process and outcomes for women.

Older people

11.9 Older adults are particularly susceptible to adverse medical outcomes from substance abuse (Fingerhood 2000). Brief interventions by primary care providers can have a major impact on preventing medical morbidity and improving quality of life. Treatment modalities for substance abuse in older people should be individualised to optimise success.

Education and training

11.10 Reviews of the education and training needs of professional groups also provide some useful discussion of the potential roles for different professional groups. The studies do not provide any information on the comparative effectiveness of professional groups, however. One general review considers whom to train and the content of courses (Roche 1998). The author argues that training for generalists is as important as that for specialist workers and that training should reflect the multi-disciplinary nature of the field.

Nurses

11.11 A review of the content of nurse education relating to alcohol found few studies on this topic (Arthur 1998). Relatively few hours were devoted to alcohol. Little attention was given to the skills required for assessment and intervention with problem drinkers. There was more reliance on specialist post-registration courses. This raises issues about the potential role of general nursing staff.

General practitioners

11.12 McAvoy (2000) draws comparisons between the UK, where there is no systematic approach to training related to alcohol problems, and the US and Australia, where a systematic approach has increased teaching hours related to alcohol problems. However, there is a lack of evidence relating the educational input to changes in medical behaviour and the cost-effectiveness of alternative strategies needs to be considered.

Cost-effectiveness

General Treatment Evaluation

11.13 The SECCAT study (McKenna et al, 1996) was a partial evaluation which aimed to quantify the costs and consequences of alcohol treatment, an important input to policy debate when determining the level of resource input to tackling alcohol problems. In the SECCAT study, a cohort of patients at the Alcohol Problems Clinic in Edinburgh were assessed for basic demographic and resource use data. Average health care utilisation costs and health related assessment instruments were used to assess the health and resource use changes following treatment. The sample consisted of 586 clients, 75% male, with a mean age 46 years. Of these, 76% had initial diagnosis of alcohol dependence and 21% of alcohol abuse. The treatment included various interventions at the APC, such as inpatient and outpatient treatment, ranging from intensive supportive therapy with individual counselling to detoxification with group therapy. Also included were disulfiram therapy and anti-depressants and recommendation to make contact with other agencies.

Table 11.2 Treatment costs:SECCAT

11.14 At follow up, 41 out of 212 patients had been abstinent over the whole 6 months. Nineteen patients had no days of complete abstinence. Patients show much worse health compared with population norms using SF36. The average APC treatment cost was £429.14, GP costs were £52.73, and 'other' costs £569.41. Average drug costs of £82.70 gave an average cost of treatment of £1133.98.

11.15 A shortcoming of the study is that costs and effects not combined as such. The authors divide the results into quartiles and show that the most abstinent group made less use of emergency care. For the other groups results are ambiguous, showing the middle quartiles using more resources than the most and least abstinent. Mean health care costs were £1134, of which 38% were related to APC treatment. Mean total health service costs are quartile 1=£783, quartile 2=£1443, quartile 3=£1446 and quartile 4=£862. For APC costs, those completely abstinent or not at all abstinent over the 6 month period show the lowest costs. Regressions showed age was negatively related to average total cost but the explanatory power of regressions was low. Alcohol dependent patients were shown to have a greater use of health service resources than alcohol abusers. High rates of absence from work and accidents and legal contacts were recorded but these are not costed. Over 20% had had an accident at home compared to 2-4% from GHS data as a population norm.

11.16 SECCAT is a very limited study based on observational data. The study does show that alcohol clients have poor quality of life as measured by SF36. However, there are complexities between the sub groups as abusers have lower use of services than dependent patients. Alcohol dependence may be more significant than abuse in generating costs. Therefore costs could be saved by preventing the progression from abuse to dependence. The study results do show complexities within the patient group and resource use is related to diagnosis and clinical outcomes.

Cost offsets

11.17 A substantial body of literature regarding cost-offset effects is evident in the USA. The main hypothesis is based on patients' utilisation of health care being reduced following alcohol treatment. Initially patients have a pre-treatment utilisation of health care which exceeds the average use in the wider population. Once treatment is completed, utilisation of health care is reduced, with the savings often exceeding the actual cost of the treatment. Several cost-offsets studies are outlined here, although their relevance to the UK is highly questionable as the size of any saving in health care utilisation will be very much smaller.

Treatment type and offset effects

11.18 Holder and Blose (1992) used a population of employees at a large mid-western manufacturing company to investigate the impact of alcohol treatment on total health care costs. A longitudinal study design was used examining the records of employees filing claims for alcohol treatment with the employer's insurance programme between 1974 and 1987. A total of 3,729 alcoholics were identified, of which 3,068 received treatment. The data on employees receiving alcohol treatment were compared to a population with severe alcohol related conditions but receiving no specific alcohol treatment. A multivariate analysis was used to compare pre and post-treatment levels of health care.

11.19 Employees were divided into two groups. Group A had uninterrupted insurance coverage for the final 48 pre-treatment months and the first 48 post treatment months. The study results showed that pre-treatment, treated alcoholics averaged $159 per month whilst untreated alcoholics averaged $171. Following treatment, treated individuals’ costs averaged $228/month (including cost of alcohol treatment) whereas untreated alcoholics averaged $346 per month. For a second group, who had 14 years of continuous enrolment in the insurance system, after controlling for group differences, the average monthly health care costs of treated alcoholics were 24% lower than for untreated, with adjusted means of $162 and $201 respectively.

11.20 Holder and Blose conclude that following alcohol treatment, health care costs for treated alcoholics drop an estimated 23% to 55% below cost levels that exist immediately prior to treatment. However, the costs do not appear to drop until about six months after treatment due to the cost impacts of the alcohol treatment itself.

Age, gender and cost offsets

11.21 Blose and Holder (1991) conducted an analysis of age and sex effects based on the same USA data set as the 1992 paper. No gender differences were found in health care costs after treatment, with post treatment monthly averages almost identical: $143 for men and $141 for women. However, health care cost reductions after treatment were found in the younger age groups (under 30 years and 31-50 years) whilst those aged over 50 experienced increasing costs. The under 30 age group experienced an average reduction of $34 a month following treatment, and the 31-50 group experienced a reduction of $59 a month. Those aged 51 and over experienced a sizeable increase of $133 per month.

11.22 Holder and Blose's cost-offset studies illustrate that cost-offset effects are evident in US insurance data, but the effects may not be experienced equally by all groups.

Relevance to the UK

11.23 Unfortunately, since the majority of studies are based in the USA, the applicability to the UK is very limited. Firstly, the health care system in the USA is non-comparable, based heavily on an insurance system. The medical records of insurance companies and self-insured employers provide data sets with which to investigate the cost-offset hypothesis. However, the incentives to use care and price faced by the user of care are dependent upon the type of insurance system, which is not comparable with the UK NHS. Secondly, the hospital billing systems used to compute treatment costs also limit generalisability to the UK since costs in such a system are unlikely to apply to the UK health care system. Thirdly, the client population in the USA and the range of alcohol problems and sociological factors surrounding the use of alcohol are not the same as in the UK, together with a background of different legislation and licensing of alcohol products.

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