|Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis
|Chisholm D, Rehm J, van Ommeren M, Monteiro M
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.
This study examined the cost-effectiveness of personal or non-personal interventions, such as brief physician advice, taxation, roadside random breath testing, restricted hours of sale, and advertising bans, for reducing the global burden of hazardous alcohol use. The preferred strategies were population-wide measures, such as taxation, for populations with moderate-to-high levels of drinking and targeted strategies, such as breath testing, for populations with lower levels of drinking. Standard methods were used and this should ensure the validity of the authors’ conclusions.
Type of economic evaluation
This study examined the cost-effectiveness of various personal or non-personal interventions, such as brief physician advice, taxation, roadside random breath testing, restricted sales, and advertising bans, for reducing the global burden of hazardous alcohol use in 12 World Health Organization (WHO) epidemiological subregions.
The interventions were brief primary care physician advice, law enforcement by random breath test for drivers, policy and legislation (taxes on alcohol sales, drink-driving laws, reduced hours of sale, and advertising control), and mass media awareness campaigns. Each intervention was implemented for a period of 10 years and the background comparator was no intervention.
The following WHO regions were considered: Africa, the Americas, Europe, South East Asia, and Western Pacific. The setting was primary care.
The analysis was based on a state-transition population model with a lifetime horizon.
The clinical evidence was from a selection of relevant studies, including a 2004 global comparative risk assessment carried out by the WHO, and a review of the efficacy of measures to reduce alcohol misuse. Different sources were used for the different WHO regions that were generally grouped on the basis of their level of alcohol use (very high, high, low, or very low). The key input of the model was the alcohol-related mortality, which was from published studies.
Monetary benefit and utility valuations:
The disability weights were from a published study, called the Dutch Disability Weights for Diseases study.
Measure of benefit:
Disability-adjusted life-years (DALYs) were the summary benefit measure and a 3% annual discount rate was applied.
The economic analysis included the costs of the programme implementation (administration, training, and media) and patient costs (primary care visits). The resource use was estimated by costing experts from each subregion and validated against the literature for the programme implementation costs and it was estimated from published sources and authors’ opinions for the patient costs. The unit costs were derived from a review of the literature that was supplemented by primary data from several countries. The costs were in international dollars (INT$) and were discounted at an annual rate of 3%.
Analysis of uncertainty:
A series of one-way sensitivity analyses was carried out on the discount rate and age weighting. The best- and worst-case scenarios were generated by varying the total intervention costs and effectiveness rates. A probabilistic analysis, based on Monte Carlo simulation, was also carried out using optimistic and pessimistic ranges of values for the model inputs.
The intervention costs per million people per annum, ranged in the subregions from INT$ 0.04 million with a single intervention to INT$ 4.96 million with three interventions combined. The cheapest strategies were an advertising ban, restricted access, and then taxation, while the more expensive ones were random breath testing, brief physician advice, and the combinations of taxation and an advertising ban with or without brief advice.
The DALYs per million people per annum ranged from 10 with taxation to 3,988 with the combination of three interventions. In areas with a high prevalence of hazardous drinking, the most effective single interventions were taxation and brief advice. In subregions with low or moderate rates of hazardous drinking, single interventions produced lower benefits. The greatest benefits were achieved with the combined strategies.
In the six subregions with a high prevalence of heavy drinkers, taxation was the most cost-effective strategy, with an incremental cost per DALY averted, compared with no intervention, of around INT$ 100 to INT$ 600 (INT$ 90 to INT$ 500 if taxation was increased by 50%), while in subregions with a very low rate of hazardous alcohol use, random breath testing, compared with no intervention, was the optimal strategy (INT$ 420 to INT$ 550).
Age weighting was an influential input, but changes in this variable did not alter the relative ranking of the strategies. The probabilistic analysis revealed some uncertainty in the results.
The authors concluded that the preferred strategies were population-wide measures, such as taxation, for populations with moderate-to-high levels of hazardous drinking, while targeted strategies, such as breath testing or brief advice, were preferred for populations with lower levels of hazardous alcohol use.
A wide range of comparators was selected and they should have been appropriate. The key characteristics of each programme were reported. The background comparator of no intervention was valid.
The relevant sources of data were selected based on the authors’ knowledge of available studies. Some data were appropriately from WHO reports, which appear to have been valid sources of evidence for the burden of disease. Other data were from published studies, but their methods were not clearly reported. Despite the use of multiple sources, the authors did not question the homogeneity of the clinical inputs. DALYs were an appropriate benefit measure and they capture the impact of the interventions on a patient's health and allow cross-disease comparisons to be made. Little information was provided on the methods used to elicit the disability weights.
The authors did not explicitly report the economic viewpoint of the analysis. The cost categories related to both the health care system and the patients, but productivity losses were not considered and a societal perspective was not taken. The costs were listed as individual items, but little information was given on the unit costs, resource quantities, price year, and sources of data. The cost estimates were treated deterministically and alternative cost assumptions were considered in the sensitivity analysis.
Analysis and results:
The incremental approach used to synthesise the costs and benefits was appropriate. The results were extensively presented and discussed. Valid approaches were used to examine the issue of uncertainty, and the findings were clearly reported. Conventional discounting was applied to both the costs and the benefits, and the impact of alternative discounting or no discounting was tested in the sensitivity analysis. The authors stated that the inclusion of economic and social benefits from a reduction in productivity losses and alcohol-related crime and violence would have favoured all the interventions to unknown extents.
Standard methods were used and this should ensure the validity of the authors’ conclusions.
Chisholm D, Rehm J, van Ommeren M, Monteiro M. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. Journal of Studies on Alcohol 2004; 65(6): 782-793
Subject indexing assigned by NLM
Adolescent; Adult; Alcohol Drinking /economics /epidemiology /therapy; Cost-Benefit Analysis /economics /statistics & Female; Global Health; Health Care Costs /statistics & Humans; Male; Risk Factors; numerical data; numerical data
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Date abstract record published