17. chris doran ace alcohol vine presentation

31
National Drug and Alcohol Research Centre Assessing Cost-Effectiveness (ACE) of interventions to reduce burden of harm from alcohol misuse: ACE Alcohol Associate Professor Chris Doran National Drug and Alcohol Research Centre, University of New South Wales

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Page 1: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Assessing Cost-Effectiveness (ACE) of

interventions to reduce burden of harm

from alcohol misuse:

ACE Alcohol

Associate Professor Chris Doran

National Drug and Alcohol Research Centre,

University of New South Wales

Page 2: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Alcohol in Australia

• Alcohol plays an important role in the social fabric of Australian culture

• In 2004, out of a population of 20 million, almost 1.5 million Australians consumed alcohol daily, 6.8 million on a weekly basis and a further 5.5 million on a less-than-weekly basis

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Drinking levels in the Australian Male Population

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

+

Age Group

%

Harmful

Hazardous

Low

Abstainer

Hazardous: between 20-40g and 40-60g of pure alcohol daily for women and men, respectivelyHarmful: > 40g and > 60g of pure alcohol daily for women and men, respectively

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Drinking levels in the Australian Female Population

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+

Age Group

%

Harmful

Hazardous

Low

Abstainer

Hazardous: between 20-40g and 40-60g of pure alcohol daily for women and men, respectivelyHarmful: > 40g and > 60g of pure alcohol daily for women and men, respectively

Page 5: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Alcohol consequences

• Alcohol consumption has health and social consequences via intoxication (drunkenness), dependence (habitual, compulsive, long-term heavy drinking), and other biochemical effects

• There are causal relationships between average volume of consumption and more than 60 types of disease and injury

• Alcohol consumption was estimated to cost the Australian health system $5.5 billion in 1998-99 due to lost productivity, health care costs, and costs related to road traffic accidents and crime (Collins and Lapsley, 2002).

Page 6: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Aim of ACE-Alcohol

• Chisholm et al (2005) reported first comprehensive assessment of cost-effective interventions to reduce burden of harm from alcohol misuse

• Aim of ACE-Alcohol is to assess the cost-effectiveness of interventions to reduce the burden of morbidity and mortality due to hazardous and harmful alcohol misuse in Australia

• Hazardous: between 20-40g and 40-60g of pure alcohol daily for women and men, respectively (NHMRC,)

• Harmful: > 40g and > 60g of pure alcohol daily for women and men, respectively (NHMRC)

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National Drug and Alcohol Research Centre

Examples from Australia: Assessing Cost-Effectiveness (ACE) studies

ACE–Heart Disease (NHMRC 2000-2003) 20 + interventions for prevention of coronary heart disease

ACE–Mental Health (DHS Vic/CW 2001-2004) 20 + interventions for depression, schizophrenia, anxiety and

ADHD

ACE-Obesity (DHS Vic 2004-2005) Focus on childhood interventions

ACE-Prevention (NHMRC 2005-2009) 100 interventions prevention NCD + 50 interventions

cure/infectious disease control

University of QueenslandSchool of Population Health

Page 8: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Assessing Cost-Effectiveness studies: methods

• Understand natural history of disease (from burden of disease study)

• Analyse current practice: % receiving intervention(s); adherence

• Efficacy/effectiveness from literature• Impact in routine Australian health services?• Model change in health outcomes (often over a lifetime)

in DALYs• Difference in costs of intervention & cost offsets• Cost-effectiveness ratios in $$/DALY• Mix of most cost-effective interventions

Page 9: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

ACE-Alcohol interventions

• A technical advisory panel selected interventions

• From a list of over 50 interventions, 13 interventions considered of high priority, based on intervention efficacy and political feasibility

• Narrowed to 10 interventions that were focused on the adult population and had sufficient evidence to support the cost-effectiveness analyses.

Page 10: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

ACE-Alcohol interventions

• Taxation • Simulated as a removal of the current value-added tax on alcohol

and equalisation of the alcohol excise rate charged per litre of alcohol across all alcoholic beverage categories.

• Advertising bans• Restricts alcohol promotion and advertising, such as advertising on

billboards and sponsorship of community events.

• Licensing controls• Restricts the purchase of alcohol by limiting the number of hours

and/or days of sale. Changes must be legislated and enforced to have effect.

Page 11: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

ACE-Alcohol interventions

• Brief intervention

• GPs screen patients using the Alcohol Use Disorders Identification Test (AUDIT), counsel patients consuming alcohol at hazardous or harmful levels, provide written materials and provide follow-up consultation

• A second intervention is also evaluated, which combines brief intervention with telemarketing, to boost GP recruitment, and GP support, to encourage more GPs to deliver alcohol advice.

• Residential treatment (+ pharmacotherapy)

• Based on extending current methods of treatment for people with alcohol dependence

• The intervention mix includes home, outpatient, rural, community residential and youth residential programs for detoxification, which typically last up to three weeks

• Residential treatment can be followed up with pharmacotherapy to reduce relapse in those who remit

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National Drug and Alcohol Research Centre

ACE-Alcohol interventions

• Random breath testing• Involves random breath testing stations (e.g. ‘booze buses’) to

detect and prevent driving with a blood alcohol concentration of more than 0.05, with coverage to achieve an average of one test per driver per year in Australia.

• Increase minimum legal drinking age• Increases the minimum age at which alcohol can be legally

purchased or consumed in public from 18 years to 21 years. Changes must be legislated and enforced to have an effect.

• Mass media ‘drink driving’ campaigns• A mass media campaign (television, radio, newspapers, billboards,

etc.) to encourage responsible alcohol consumption when driving.

Page 13: 17. chris doran ace alcohol vine presentation

ACE-Alcohol model

ACE-Alcohol model

Epidemiological data

Intervention data – costs – effects

Disease & injury treatment costs

Health gain (DALYs)Costs (AUS$)

Cost-effectiveness ratio ($/DALY)

Cost-effectiveness planesAcceptability curves

Uncertainty analysis

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National Drug and Alcohol Research Centre

Intervention target group

INTERVENTION TARGET GROUP

Taxation Population, 18+ yrs

Advertising bans Population, 18+ yrs

Licensing controls Population, 18+ yrs

Brief intervention Hazardous/harmful drinkers, 18-79 yrs

Residential treatment Alcohol dependants, 18-79 yrs

Random breath testing Population (drivers), 18+ yrs

Min. legal drinking age Population (drivers), 18-20 yrs

Drink driving campaign Population (drivers), 18+ yrs

Page 15: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Intervention effect

INTERVENTION MEASURE EFFECT

Taxation %g/day Incidence; YLD, Mortality

Advertising bans %g/day Incidence; YLD, Mortality

Licensing controls %g/day Incidence; YLD, Mortality

Brief intervention g/day Incidence; YLD, Mortality

Residential treatmentg/day

remission, relapse

Incidence; YLD, Mortality

Remission, relapse

Random breath testing %RTA YLD, Mortality

Min. legal drinking age %RTA YLD, Mortality

Drink driving campaign %RTA YLD, Mortality

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National Drug and Alcohol Research Centre

Results for each intervention against partial null

InterventionDALYs averted

Cost Offsets($million)

Intervention Cost

($million)

Net Cost($million)

Median CER($/DALY)

Taxation 11,000 -$57 $0.58 -$56 Dominant

Advertising bans 7,800 -$31 $20 -$12 Dominant

Licensing controls 2,700 -$11 $20 $8.7 $3,300

Brief int. 160 -$1.2 $2.3 $1.1 $6,800

Brief int. + tele. + support 340 -$2.6 $6.1 $3.5 $10,000

Res. treat. 190 -$1.7 $37 $35 $190,000

Res. treat. + naltrexone 460 -$4.4 $59 $55 $120,000

Random breath testing 2,300 -$17 $71 $54 $24,000

Min. legal drink age to 21 150 -$0.8 $0.64 -$0.16 Dominant

Drink driving mass media 1,500 -$11 $39 $28 $14,000

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National Drug and Alcohol Research Centre

Brief intervention

-$2

-$1

$0

$1

$2

$3

$4

$5

0 200 400 600 800 1,000

Mill

ion

s

DALYs averted

Ne

t c

os

t$50,000/DALYBI

BI+Tele+Supp

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National Drug and Alcohol Research Centre

Residential treatment

$0

$10

$20

$30

$40

$50

$60

0 200 400 600 800 1,000

Mill

ion

s

DALYs averted

Ne

t c

os

t$50,000/DALY

ResTreat

ResTreat+NTX

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Page 20: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Acceptability of intervention against partial null

InterventionProbability of being

cost-savingProbability of being

< $50,000/DALY

Taxation 100% 100%

Advertising bans 85% 100%

Min. legal drink age to 21 61% 100%

Brief int. 0% 100%

Licensing controls 5% 100%

Drink driving mass media 0% 81%

Random breath testing 0% 90%

Res. treat. + naltrexone 0% 0%

Page 21: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

CEA results of optimal expansion path

InterventionMedian ICER

($/DALY)Probability of being

cost-savingProbability of being

< $50,000/DALY

Taxation Dominant 100% 100%

Advertising bans Dominant 85% 100%

Min. legal drink age to 21 Dominant 59% 100%

Brief int. $7,000 0% 100%

Licensing controls $3,500 4% 100%

Drink driving mass media

$14,000 0% 80%

Random breath testing $26,000 0% 88%

Res. treat. + naltrexone $120,000 0% 0%

Page 22: 17. chris doran ace alcohol vine presentation

Intervention pathway

-$100

-$80

-$60

-$40

-$20

$0

$20

$40

$60

$80

$100

- 5,000 10,000 15,000 20,000 25,000 30,000

Mill

ion

s

DALYs averted

Inte

rve

nti

on

co

st

AdBans

RBT

Drink drive mass media

ResTreat+NTX

LicCont-OpHrs

Min. legaldrinking age

Brief Intervention

Tax-volumetric

Current practice

Page 23: 17. chris doran ace alcohol vine presentation

National Drug and Alcohol Research Centre

Key CEA results

• When combined as a package, the alcohol interventions could avert 26,000 DALYs (95%UI: 19,000 – 34,000 DALYs) at a total intervention cost of $210 million (95%UI: $190 million – $230 million).

• The costs of intervention would be partly offset by an estimated reduction of $130 million (95%UI: $64 million – $220 million) in the costs of treating alcohol-related diseases and injuries.

• The location of current practice in the north-east quadrant, relative to the intervention pathway, highlights the substantial amount of population health that could be gained with more effective investment of the health dollars currently spent on alcohol interventions.

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National Drug and Alcohol Research Centre

Second-stage filter criteria

Strength of evidence

• The level of evidence is modest

• Evidence ranges from hypothetical modelling of effect (taxation), to

pooled time series data (e.g. advertising bans) to meta-analyses of

randomised controlled trials (e.g. brief intervention).

• The order of interventions in the expansion pathway may change if

interventions prove to be more or less effective than predicted by

current evidence.

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National Drug and Alcohol Research Centre

Equity • Population-wide interventions such as changes to taxation and

advertising bans may be more equitable than targeted

interventions such as residential treatment and brief intervention,

which relies on access to a GP with the time to screen and deliver

the intervention.

• This may disadvantage those in regional areas, where GPs are in

short supply and residential detoxification facilities more limited,

but this is unlikely to be a major issue in Australia.

Second-stage filter criteria

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National Drug and Alcohol Research Centre

Second-stage filter criteriaAcceptability• Alcohol industry and public are likely to see interventions that target

hazardous or harmful drinkers as being more acceptable than interventions that affect all alcohol consumers

• Manufacturers and retailers may fear a reduction in demand for alcohol due to changes in alcohol consumption behaviour and/or restrictions on retailing and marketing opportunities, while consumers may fear increases in price and loss of accessibility.

• Increasing the minimum legal drinking age is likely to be particularly unacceptable to those under 21 years of age.

• The impact on employment in the service industry in this age group would also need to be considered.

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National Drug and Alcohol Research Centre

Second-stage filter criteria

Feasibility and sustainability• Those interventions that are based on one-off legislative

changes (e.g. changes to taxation and the minimum legal drinking age) may be most feasible and sustainable because the systems and infrastructure to implement and monitor the changes are already in place.

• The feasibility and sustainability of brief intervention and residential treatment are less certain because they depend on an adequate workforce of motivated GPs and other staff to provide counselling and other treatment.

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National Drug and Alcohol Research Centre

Second-stage filter criteria

Feasibility and sustainability• Sustainability of intervention effectiveness is an important unknown

in the cost-effectiveness analysis.

• Some interventions, such as advertising bans and random breath testing, are supported by more than 20 years of time series data that suggest a sustained effect, but for other interventions, such as residential treatment, the trials are relatively short-term and the sustainability of intervention effect is unclear.

• Differences in intervention sustainability could affect the order of interventions in the expansion pathway

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National Drug and Alcohol Research Centre

Second-stage filter criteriaSide-effects• There is little potential for population health loss due to alcohol

intervention.

• Although loss of protective effects of alcohol for ischaemic heart

disease and gallbladder and bile duct disease may occur, these would

be more than out-weighed by health gains from all other diseases and

injuries, at the population level.

• There is good potential for positive effects that we have not included in

our analyse, such as productivity gains generated by decreases in

alcohol-related disease and injury, road traffic accidents, violence and

crime.

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National Drug and Alcohol Research Centre

Conclusions

• There are a number of interventions available to policy makers to reduce the burden of harm from alcohol misuse

• The aim of ACE-Alcohol has been to assess the cost-effectiveness of a range of these interventions

• For the interventions that have been evaluated (seven preventive interventions and one treatment intervention), prevention is, in all cases, more cost-effective than treatment

• When combined as a package, the alcohol interventions could avert 26,000 DALYs at a net cost of $80 million

• Changes to taxation and banning of alcohol advertising should be a high priority

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National Drug and Alcohol Research Centre

Key project staff

Linda Cobiac, Angela Wallace, Shamesh Naidoo, Isaac Asamoah, Kathryn Arnett

Christopher Doran, Theo Vos, Wayne Hall, Greg Fowler

Investigators on ACE-Alcohol

This project was funded by the Alcohol Education Rehabilitation Foundation (AERFDOCS/2005-MW/GF1069).