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
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
Drinking levels in the Australian Male Population
0%
10%
20%
30%
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100%
15
-19
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-24
25
-29
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-39
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-44
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-54
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-59
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-69
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-79
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+
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
Drinking levels in the Australian Female Population
0%
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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
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).
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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)
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
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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
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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.
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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.
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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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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.
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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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
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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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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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Brief intervention
-$2
-$1
$0
$1
$2
$3
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$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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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
National Drug and Alcohol Research Centre
Acceptability of intervention against partial null
InterventionProbability of being
cost-savingProbability of being
< $50,000/DALY
Taxation 100% 100%
Advertising bans 85% 100%
Min. legal drink age to 21 61% 100%
Brief int. 0% 100%
Licensing controls 5% 100%
Drink driving mass media 0% 81%
Random breath testing 0% 90%
Res. treat. + naltrexone 0% 0%
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CEA results of optimal expansion path
InterventionMedian ICER
($/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%
Intervention pathway
-$100
-$80
-$60
-$40
-$20
$0
$20
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- 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
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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.
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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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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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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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.
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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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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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
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).