Cost-effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: A decision-making approach

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Abstract

We present the cost and cost-effectiveness of referral to an alcohol health worker (AHW) and information only control in alcohol misusing patients. The study was a pragmatic randomised controlled trial conducted from April 2001 to March 2003 in an accident and emergency department (AED) in a general hospital in London, England. A total of 599 adults identified as drinking hazardously according to the Paddington Alcohol Test were randomised to referral to an alcohol health worker who delivered a brief intervention (n = 287) or to an information only control (n = 312). Total societal costs, including health and social services costs, criminal justice costs and productivity losses, and clinical measures of alcohol consumption were measured. Levels of drinking were observably lower in those referred to an AHW at 12 months follow-up and statistically significantly lower at 6 months follow-up. Total costs were not significantly different at either follow-up. Referral to AHWs in an AED produces favourable clinical outcomes and does not generate a significant increase in cost. A decision-making approach revealed that there is at least a 65% probability that referral to an AHW is more cost-effective than the information only control in reducing alcohol consumption among AED attendees with a hazardous level of drinking.

Introduction

Alcohol misuse is implicated in up to 30% of adult Accident and Emergency Department (AED) attendances at a massive cost to both individuals and society (Cabinet Office, 2004). A recent report by the British Prime Minister's Strategy Unit estimated that the annual financial burden of alcohol misuse on society was between £18 and £20 billion, including £510 million in AEDs (Cabinet Office, 2003).

Descriptive cohort studies of people offered brief intervention for alcohol misuse suggest they may be beneficial (Wright et al., 1998). To date, the literature has mainly focussed on the clinical rather than the economic benefits of brief interventions. Studies dedicated to understanding the economic benefits of addiction interventions are rare (McCollister and French, 2003), but are of increasing importance since financial constraints and scarce health care resources dictate that we should consider the cost-effectiveness of health care interventions as well as their clinical effectiveness. There are a few published economic evaluations of brief interventions for alcohol misuse. Fleming et al., 2000, Fleming et al., 2002 compared monetary reductions in adverse drinking outcomes with the cost of treating alcohol misuse with brief intervention in a primary care setting. The per-patient benefit of the programme was estimated at $1151 over 12 months and $7985 over 48 months. One study evaluated screening and brief intervention in the AED setting: Kunz et al. (2004) randomised 294 individuals to brief intervention or control treatment in an AED in a poor, multi-ethnic inner city area. Evidence from this pilot study indicated that screening and brief intervention was relatively low in cost and potentially cost-effective.

Attempts to conduct a randomised trial of brief intervention in an AED have proved difficult (Peters et al., 1998), although evidence is accumulating that brief intervention for alcohol misuse in AEDs may have clinical benefit (Longabaugh et al., 2001, Monti et al., 1999, Wright et al., 1998). In a recent study, opportunistic identification and referral to an alcohol health worker (AHW) in an AED was demonstrated to be feasible and associated with lower levels of alcohol consumption over the following year (Crawford et al., 2004). This paper examines data from this most recent study, reporting a cost-effectiveness analysis of referral to an AHW delivering a brief intervention versus an information only control, in people attending an AED with a hazardous level of drinking.

Section snippets

Economic evaluation

A cost-effectiveness analysis was undertaken, involving the identification, measurement and valuation of both the costs and outcomes of an intervention and a comparator (Drummond et al., 1997). Costs included all services used, criminal justice resources and lost productivity. Outcomes were measured in terms of units of alcohol consumed per week.

Hypothesis

The primary economic hypothesis was that opportunistic identification and referral to an AHW is a more cost-effective approach to reducing alcohol

Patients

Five hundred and ninety nine patients were randomised to the experimental treatment (n = 287) or the control treatment (n = 312). Full service use data for both 6 and 12 months follow-up were available for 131 of the experimental treatment group and 159 of the control treatment group (48% of the total). Comparison of available baseline characteristics in Table 1 reveals that there were no significant differences in clinical characteristics between patients for which there is full service use

Discussion

Despite the well-documented burden of alcohol misuse on AED workloads (Cabinet Office, 2004), there has been very little research into the cost-effectiveness of interventions whose aim is to reduce levels of drinking among those attending an AED.

The study participants in both treatment groups used a wide range of health, social and voluntary sector services, as well as having a substantial level of contact with the criminal justice system. Although total costs were slightly higher in the

Acknowledgements

The Alcohol Education and Research Council funded the study. We would like to thank Steve Parrott for advice on the design of the service use questionnaire and Elisabeth Fenwick for advice on the cost-effectiveness acceptability curve. We are grateful to the patients who participated in the study, the alcohol health workers and the doctors—especially in Senior House Officer Teams 30, 31 & 32, and other staff in St. Mary's AED for recruiting study patients.

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