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| The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline |
| Hollis JF, McAfee TA, Fellows JL, Zbikowski SM, Stark M, Riedlinger K |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective was to examine six strategies to aid smoking cessation, based on telephone counselling and nicotine replacement therapy (NRT). The authors concluded that multiple counselling sessions with the offer of free NRT resulted in higher quit rates than less intensive strategies at similar costs. The reporting of the cost data was limited, but the methods were good and the authors’ conclusions appear to be robust. Type of economic evaluation Cost-effectiveness analysis Study objective The objective was to examine six strategies to aid smoking cessation, based on telephone counselling and nicotine replacement therapy (NRT). Interventions The six strategies were brief counselling without free NRT; brief counselling with the offer of free NRT; moderate counselling without free NRT; moderate counselling with the offer of free NRT; intensive counselling without free NRT; and intensive counselling with the offer of free NRT.
Brief counselling was one 15-minute telephone call, moderate counselling was an initial 40-minute call plus a brief follow-up call one or two weeks later, and intensive counselling was an initial 30- to 40-minute call plus up to four additional calls. Participants were randomised to each of the three levels of counselling with or without the offer of free NRT. Methods Analytical approach:The economic evaluation was based on data from a single trial with a one-year time horizon. The authors stated that a US state programme perspective was adopted.
Effectiveness data:The clinical data came from a randomised controlled trial. Between 26 January 2001 and 20 January 2003 there were 24,809 in-coming calls to the Oregon tobacco quitline and 6,018 callers were eligible for inclusion. Of these, 4,614 callers consented to participate and were randomised to counselling, with 872 in brief without NRT, 868 in brief with NRT, 718 in moderate without NRT, 715 in moderate with NRT, 720 in intensive without NRT, and 721 in intensive with NRT. The participants were followed-up at six and 12 months. Statistical analyses were carried out to justify the sample size and to compare the intervention groups. The primary clinical outcome was the proportion of participants reporting abstinence from tobacco for at least 30 days at the one-year follow-up. The primary analysis was intention-to-treat and two secondary analyses that both used multiple imputation methods to account for missing outcome data, were also presented.
Monetary benefit and utility valuations:None.
Measure of benefit:The summary benefit measure was the quit rate, which was derived directly from the effectiveness analysis.
Cost data:The main cost categories considered were training costs, delivery costs for each intervention (including labour, facility space, and supplies), labour costs (including salary and benefits for intervention, supervisory, and administrative staff), and NRT costs. The cost data for NRT came from pharmacy records and resource use was from the Oregon tobacco quitline. Ordinary least squares regression was used to calculate the mean total programme costs and standard deviations for participants in each intervention group. All costs were in 2004 US dollars ($) and any adjustments were made using the medical care component of the consumer price index.
Analysis of uncertainty:None. Results Over the one-year time horizon, in order of quit rate, with the offer of NRT, intensive counselling achieved the highest quit rate of 21.2% at a cost of per participant of $268 (SD 99), moderate counselling achieved a quit rate of 20.1% at a cost of $242 (SD 92), and brief counselling achieved a quit rate of 17.1% at a cost of $193 (SD 79).
Without the offer of NRT, intensive counselling achieved a quit rate of 14.3% at a cost of $132 (SD 57), moderate counselling achieved a quit rate of 13.8% at a cost of $107 (SD 33), and brief counselling achieved a quit rate of 11.7% at a cost of $67 (SD 20).
Cost-effectiveness ratios for all interventions compared with brief counselling without NRT were calculated. The incremental cost per smoker who quit was $2,112 (range 1,278 to 2,946) for intensive counselling with NRT, $2,109 (range 1,239 to 2,980) for moderate counselling with NRT, $2,467 (range 1,311 to 3,622) for brief counselling with NRT, $2,640 (range 1,161 to 4,120) for intensive counselling without NRT, and $1,912 (range 1,273 to 2,551) for moderate counselling without NRT. Authors' conclusions The authors concluded that multiple counselling sessions with the offer of free NRT resulted in higher quit rates than less intensive strategies at similar costs. CRD commentary Interventions:The selection of the comparators was appropriate in that they represented the usual practices in the authors' setting. They were all well described.
Effectiveness/benefits:The effectiveness data were based on a well-designed randomised controlled trial. Randomisation ensured the internal validity of the data and the high-quality features of the trial included: the detailed reporting of the sample selection procedure; the use of power calculations and the large sample; and the use of the intention-to-treat approach. The key effectiveness outcomes were assessed using appropriate statistical methods. The disease-specific summary measure of benefit might limit cross-disease comparisons, but the quit rate was a useful and meaningful outcome.
Costs:The analysis considered only the programme costs, which was appropriate for the stated perspective. The method used to derive the costs was described well, but the costs were not presented and their sources were only reported for the NRT. All costs were appropriately inflated and the price year was reported. The lack of detail on resource use and unit costs might limit the transferability of the results.
Analysis and results:An incremental analysis was not performed and five strategies were all compared with one least effective strategy. This was not appropriate as each strategy should be compared with the next best strategy (in effectiveness), excluding dominated and extendedly dominated strategies. Some appropriate statistical analysis was performed, but sensitivity analyses were not conducted to assess the parameter uncertainty. The authors highlighted some limitations of their analysis and stated that the main limitation was that the outcomes were self-reported by participants.
Concluding remarks:The reporting of the cost data was limited, but the methods were good and the authors’ conclusions appear to be robust. Funding Supported by a grant from the National Cancer Institute and nicotine patches were supplied by GlaxoSmithKline. Bibliographic details Hollis JF, McAfee TA, Fellows JL, Zbikowski SM, Stark M, Riedlinger K. The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline. Tobacco Control 2007; 16(Supplement 1): i53-i59 Indexing Status Subject indexing assigned by NLM MeSH Adult; Combined Modality Therapy; Cost-Benefit Analysis; Counseling /economics /methods; Delivery of Health Care /economics /organization & Female; Health Care Costs /statistics & Hotlines /economics; Humans; Male; Middle Aged; Nicotine /therapeutic use; Oregon; Patient Selection; Single-Blind Method; Smoking /prevention & Smoking Cessation /economics /methods; Telephone; Tobacco Use Disorder /therapy; administration; control; numerical data AccessionNumber 22007008314 Date bibliographic record published 15/04/2009 Date abstract record published 11/08/2010 |
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