< Previous | Contents | Next >

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

CHAPTER THIRTEEN CONCLUSIONS AND RECOMMENDATIONS

INTRODUCTION

13.1 This report has reviewed evidence on the effectiveness and cost-effectiveness of interventions aimed at reducing alcohol misuse. This chapter is in three parts. The first part summarises the main findings relating to each of the outputs requested in the specification, with particular emphasis on the key conclusions that can be drawn from the available evidence. The second part summarises the implementation issues that need to be considered and the third sets out recommendations for the future, both in terms of interventions that should be pursued and the actions required to improve the evidence base.

Review Conclusions

Summary of available evidence

Effectiveness

13.2 The main findings relating to interventions that are supported by the evidence base are summarised in table 13.1. In terms of the effectiveness review, there is a strong and relevant evidence base to show that:

• the use of price increases, via taxation, and brief interventions will reduce the number of problem drinkers;
• effective screening tools to detect problem drinkers are available (CAGE and AUDIT);
• detoxification services and relapse prevention, through appropriate psychosocial and pharmacological treatments, are effective.

13.3 There is evidence that legislative interventions to reduce permitted blood alcohol levels for drivers, to raise the legal drinking age and to control outlet density have been effective but this evidence relates mainly to the US. There is no certainty that the results would transfer to the UK, where there is a different cultural attitude towards alcohol. Evidence from the US and Australia supports the effectiveness of random breath testing of drivers but similar arguments may apply. There is no clear evidence of effectiveness relating to prevention of alcohol misuse, mainly because of the weaknesses of the research carried out. Some effects on knowledge and attitudes have been found but none relating to drinking behaviour.

Cost-effectiveness

13.4 The cost-effectiveness review found evidence to support the cost-effectiveness of:

• brief interventions;
• home and outpatient detoxification;
• outpatient treatment for relapse prevention; and
• the use of acamprosate as an adjunct treatment in relapse prevention.

13.5 None of the costs were taken from UK settings but the results for brief interventions and for acamprosate have been confirmed using UK cost data. In general, regardless of the country setting, home treatment and outpatient treatment are likely to be cost-effective alternatives to inpatient treatment provided that they are at least as effective. The only UK cost-effectiveness result related to the relative cost-effectiveness of specialist workers in screening for alcohol misuse in a general hospital setting. The cost-effectiveness of random breath testing and server training programmes depends upon the cost-offsets achieved, and these may be lower in the UK than in the US settings in which these studies took place. One Australian study has shown that thiamine supplementation of full strength beer is cost-effective in the prevention of Wernicke-Korsakoff syndrome.

General issues

13.6 Interventions that do not appear in table 13.1 are not necessarily ineffective but no strong evidence to support them has been found in the review. It should be noted that because the effectiveness evidence has been taken from existing reviews, there may be individual studies providing evidence of effectiveness that have not been included here. The size and strength of the evidence base is very variable but it is apparent that interventions are required across all areas. The different types of intervention are not substitutes for each other but tackle different aspects of the alcohol misuse problem. There is much less evidence about cost-effectiveness than effectiveness.

13.7 No attempt has been made to rank the interventions and the data available would not permit this to be carried out in a robust way. It may not be particularly helpful to rank the interventions in any case, as they are not direct alternatives. One study that has attempted to rank interventions in terms of effectiveness was discussed in chapter 11 and demonstrates some of the problems (Miller et al; 1998). Whilst this approach provides a useful indicator of the balance of evidence on effectiveness, the ranking is influenced by the number of studies carried out.

13.8 A more useful approach to ranking interventions would be based on cost-effectiveness. However, the data required to permit such a ranking are not available in the literature. Consistent, robust and comparable information on the costs and outcomes of all interventions would be required. Even if this information were available, such a ranking would have to be interpreted with care. There is an inherent danger with ‘league tables’ that they are taken to mean that resources should only be applied to the intervention that tops the list, whereas such rankings are more useful as a guide to the investment of resources at the margin. That is, they may indicate that more benefit can be obtained by reallocating some (but not necessarily all) resources from less beneficial uses to more beneficial uses. Given that the interventions considered here are not direct substitutes, judgement still requires to be exercised in specific resource allocation decisions.

Measures which have been evaluated for effectiveness and cost-effectiveness

Effectiveness

13.9 This report has identified a large amount of research over a wide range of topics. The results have been presented in chapters 4-11 and a summary of the measures supported by evidence was presented above (para 13.8 - 13.). The extent and quality of the research varies between types of intervention. Treatment interventions have been subject to the most rigorous evaluations and the literature contains a number of meta-analyses of well-conducted randomised controlled trials. There is a large volume of research in the area of prevention but the study designs and the resulting evidence are weak. Policy interventions and the effects of legislation and enforcement have been less well researched.

Cost-effectiveness

13.10 The volume of cost-effectiveness literature is much smaller and is strongest in the areas of brief interventions and relapse prevention. A weakness of this area is that most studies have not been conducted alongside effectiveness studies but have modelled results based on values obtained from the literature. Few studies have addressed the health benefits of interventions with the result that outcomes in terms of cost per life year are rarely produced in the literature.

Categorisation by type of intervention

13.11 The interventions have been categorised according to the ‘stage’ of drinking behaviour that they address:

Additional results have been presented in chapter 11 relating to the location of services, services for particular population subgroups and requirements for education and training. Chapter 12 has considered evaluations in Scotland.

Targeting at sub-groups in the population

13.12 Within each results chapter, consideration has been given to the availability of evidence relating to particular population subgroups. With the exception of prevention, where the majority of research relates to children and young people, target populations tend to relate to drinking behaviour and associated problems rather than to demographic groups. Thus, for example, legislation may target under-age drinkers or previous drink drivers. Brief interventions are effective for problem drinkers but not for those dependent upon alcohol. They have also been found to be ineffective with pregnant women and this is thought to be because of the high abstinence rates in this group without any intervention. Studies that have specifically focussed on the needs of women and older people have been reviewed in chapter 11 and these highlight the possible organisational issues that should be addressed for these groups, rather than suggesting any differences in the impact of specific interventions.

Assessment of quality

Effectiveness

13.13 The effectiveness evidence has been taken from existing reviews and consideration has been given to the quality of the review process including whether or not the quality of the primary studies was assessed. In some areas, such as policy and legislation, research designs are limited by the nature of the intervention. In other cases, such as enforcement and prevention, insufficient attention has been paid to the research design and this has weakened the evidence base. The topics having the greatest amount of good quality research are brief interventions and relapse prevention. A considerable amount of research has been conducted in the US and in other countries. These results must always be interpreted with care, in order to assess their relevance to the UK. This issue has been addressed within each results chapter but it is worth emphasising that differences in culture, such as attitudes to under-age drinking, and in objectives, such as abstinence versus sensible drinking, may affect the results of research particularly in the areas of policy, legislation, enforcement and prevention.

Cost-effectiveness

13.14 The economic studies have been assessed against established guidelines for the conduct of economic evaluations. Few good quality economic evaluations have been undertaken and those presented within the results chapters are open to criticism, as noted in the accompanying discussion. The studies presented represent the current state of the art and can provide useful insights about the likely economic impact of interventions, provided that they are interpreted with care. This is particularly true when translating results from other countries and other health care systems. Cost data from other countries with insurance-based systems may overstate both the cost of the intervention and the savings that result from avoiding the future use of health care services.

Main gaps in the evidence base

13.15 The gaps in the evidence base have been reported within each of the main results chapters. There is a particular lack of sound evidence, applicable to the UK, in the area of policy, legislation and enforcement. More attention requires to be given to evaluating alcohol initiatives in the UK and these evaluations should be planned at an early stage in the development of an initiative. Despite a plethora of research, the evidence relating to prevention is weak and better research designs are required. In screening and treatment, there is a sound basis of evidence for a number of interventions but additional research would be beneficial. In all areas, there is a need for better economic studies.

Lessons about methods of evaluation

13.16 The methods of evaluation that are used in assessing treatments are well established and provide robust results when correctly applied to large enough samples. In some cases, the deficiencies in the evaluation of other types of intervention arise from the failure to adopt a similarly robust approach. For example, studies of preventive interventions in schools have frequently failed to provide adequate controls. However, interventions in areas such as policy and legislation cannot always be addressed by applying the same model. Better methods of policy evaluation are required to provide robust evidence where there is no access to random controls and these need to be developed and applied in a UK context to provide relevant information.

Implementation issues

13.17 This report has identified a number of interventions that have been demonstrated to be effective and may be cost-effective. These results will have to be interpreted alongside information about interventions that are already taking place. Both the impact which interventions will have upon strategic targets and the resources required to implement interventions will depend upon the extent to which they have already been deployed. It should also be noted that the effectiveness of these interventions has been demonstrated in research settings and requires to be confirmed in routine practice. Arrangements for auditing or monitoring the effectiveness of interventions will need to be put in place.

13.18 A potentially useful framework for considering implementation issues is provided in a recent study. This has reviewed the evidence relating to alcohol misuse strategies that are population based or target high-risk groups (Smart and Mann 2000). The number of studies is small and they have modelled results using a range of assumptions. However, there is a consistent finding that, for a given reduction in total alcohol consumption, the impact on alcohol-related problems is similar regardless of whether the change is achieved across the whole population or concentrated in higher risk groups. The costs of different strategies do not appear to have been taken into account.

RECOMMENDATIONS

Plan for Action

13.19 On the basis of the evidence reviewed, the two interventions most likely to impact on population targets for problem drinking are taxation and brief interventions. The potential size of the impact is uncertain. In the case of taxation, the effect depends upon the size of the price elasticity of demand and estimates of this vary. For brief interventions, the effect depends upon the extent to which such services are already being provided. It is recommended that the Plan for Action should support:

• the introduction of a brief intervention programme where this is not already provided; and
• the development of monitoring arrangements to assess the impact of these interventions at the national level.

13.20 At the level of the individual, effective treatment of withdrawal symptoms and relapse prevention programmes are also important. The limited economic evidence available suggests that alcohol treatments have cost-effectiveness ratios well below current UK benchmarks for efficiency and indeed some may be resource saving. It is recommended that the Plan for Action should support:

• improved access to treatment and relapse prevention; and

• the use of cost-effective alternatives, such as home detoxification, where appropriate.

Research Strategy

13.21 In common with many other areas of policy interest, the evidence base with regard to effectiveness and cost-effectiveness is incomplete. What is required is not simply more research but a more focussed use of research capacity and more accessible results. It is recommended that the Plan for Action should support:

• the prioritisation of policy evaluation and prevention as the areas requiring most development of the evidence base;
• better co-ordination of research effort with resources concentrated on fewer larger studies with longer term follow up;
• better knowledge management in terms of access to relevant research results;
• the fostering of an evaluation culture amongst those responsible for delivering services, focussed on outcomes and the monitoring of effectiveness; and
• guidelines for evaluation to assist in this process.

Table 13.1 Summary of Findings

< Previous | Contents | Next >