Solberg L.I., Maciosek M.V., Edwards N.M.
American Journal of Preventive Medicine: 2008, 34(2), p. 143-152.
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In this comprehensive analysis, screening for risky drinking and brief advice was estimated to be among the most cost-effective preventive services GPs could offer, ranking alongside common interventions such as screening for high blood pressure or immunisation against influenza.
Summary The US Preventive Services Task Force has recommended screening and behavioural counselling interventions in primary care to reduce alcohol misuse. This study was designed to develop a standardised rating for the clinically preventable burden and cost-effectiveness of complying with that recommendation that would allow comparisons across many recommended services.
A systematic review of the literature from 1992 through 2004 to identify relevant randomised 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.
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 counselling 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 counselling one of the highest-ranking preventive services among the 25 effective services evaluated using standardised methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.
commentary The aim was to help US primary care practices prioritise preventive interventions to gain the greatest extension in healthy life span across their patient caseload. Screening for risky drinking and offering brief advice was judged among the most cost-effective, ranking alongside widespread interventions such as screening for high blood pressure or immunisation against influenza. Calculations were based on alcohol interventions which could be implemented across the at-risk population of a busy practice, typically taking 10 minutes repeated annually up to age 54. Studies suggested that at as a result, more than one in six extra problem drinkers would be in remission. Taking all costs and savings in to account (ie, not just those related to health or health services), society would save an estimated $254 per person offered screening.
Despite its high ranking, the authors noted that alcohol screening and advice are much less widely implemented than similarly cost-effective interventions. It follows that the greatest scope for improving health lies in extending their coverage. However, there are reasons why alcohol screening is relatively infrequent - notably, GPs' reluctance to 'artificially' introduce drinking in to consultations about other complaints. Given this, the big question mark is over whether substantial extension is realistic. Also, gains varied widely when the authors varied assumptions about the impact of counselling on drink-related problems. Such variation has been noted in studies, suggesting that the anticipated health gains can't be guaranteed in any particular context.
Last revised 01 December 2008. First uploaded