Brief physician advice to problem drinkers resulted in economic benefits
Fleming MF, Mundt MP, French MT, et al. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 2000 Jan;38:7-18
QUESTION: In patients with drinking problems, is brief advice given by a physician cost effective?
Design
Cost benefit analysis of a randomised controlled trial with 12 months of follow up.
Setting
17 community clinics in Wisconsin, USA comprising practices of 64 family physicians and general internists.
Patients
774 patients who were 18-65 years of age (62% men)
and drank > 14 alcoholic drinks/week ( > 168 g
alcohol/wk) ( > 11 drinks/week for women [ > 132 g
alcohol/wk]*). Exclusion criteria were pregnancy,
attendance at an alcohol treatment programme or
symptoms of alcohol withdrawal in the previous year,
physician advice to change alcohol use in the previous
three months, consumption of > 50 drinks/week
( > 600 g alcohol/wk), or symptoms of suicide.
Intervention
Patients were allocated to a brief physician advice intervention (n = 392) or a control group (n = 382). The
intervention consisted of printed feedback on health
behaviours and previous problem drinking, adverse
effects of alcohol, drinking cues, and diary cards.
Intervention group patients had two 15 minute
physician visits one month apart and follow up
telephone calls. Control group patients received a
general health booklet.
Main cost and outcome measures
Main clinical outcomes were change in alcohol use,
healthcare use, and change in alcohol related events. The
costs were considered from the perspective of the clinic
(equipment and personnel) and patient (lost wages and
transportation). The economic benefits pertained to
reductions in healthcare use, legal events, and motor
vehicle accidents.
Main results
Patients who received the brief physician intervention
had greater reductions in alcohol use than patients in
the control group. Intervention group patients reported
fewer days of hospitalisation than control group
patients (p = 0.046) and were involved in fewer motor
vehicle accidents and criminal events, but the difference
with control group patients was not statistically
significant. The total clinic cost (initial screening, assessment, intervention sessions, staff training sessions, and
follow up telephone calls) was US$64 933 ($165.65
(about £100) per intervention patient). Patient resource
costs (travel and lost worktime) were $15 277 ($38.97
per patient). The total cost of the intervention was
$80 210 ($205 per intervention patient). The saving in
service utilisation cost was $195 448 ($523 per patient).
The saving in legal events and motor vehicle accidents
was $228 071 ($629 per patient). The total benefit of the
brief intervention was $423 519 ($1151 per patient)
(p = 0.009). The net benefit per patient was $947. The
benefit cost ratio was $56 263 for every $10 000
invested.
Conclusions
In patients with drinking problems, brief advice given by a physician was cost effective for both patients and the healthcare system. The net benefit per patient was US$947 (about £600).
COMMENTARY
The study by Fleming et al gives further evidence that early
intervention with non.dependent heavy drinkers is effective
in changing drinking behaviour. Patient selection by opportunistic screening, and the simplicity of the intervention
make this study particularly attractive for primary care. The
mean level of consumption would hardly raise eyebrows in
normal practice, and might result in a brief mention of recommended limits. This is basically what the control group
receives. The study shows that a structured approach,
focused around individual patients and their drinking
patterns, is much more effective.
The study presents a robust attempt at calculating a
financial cost benefit analysis for the health intervention. The
use of "opportunity cost" is germane to the real world of
medicine, where questions revolve around the allocation of
limited resources. The conclusion that resource allocation to
primary prevention produces major overall resource
savings, particularly in secondary care, will be of great
relevance to total healthcare purchasers or providers such as
primary care trusts. The benefits are not restricted to the
healthcare system. Accidents, injuries, and crime were all
shown to decrease after the intervention, although some of
the variables failed to reach statistical significance when
taken individually. This is not just an intervention that saves
hospitals money; it also improves the patients' lives, and
makes society a safer place!
Some questions arise from a lack of detail. We do not
know the take up rate of the intervention or the number of
patients lost to follow up. There is no indication about
whether intervention group patients visited their primary
care physicians less, which would be an obvious benefit to
those physicians delivering the intervention. Some break.
down of the benefits by level of consumption would be useful. Is there any benefit in targeting the group drinking just
over "safe" limits? The figures showing healthcare use also
suggest that the benefit may not be sustained at the 12
month follow up point, and it would be interesting to know
whether the effects of the intervention continue, or whether
further "top up" intervention is required.
Pete Sudbury, Heatherwood and Wexham Park Hospitals Trust, Slough, Berkshire, UK
* 1 drink equals 1.5 units of alcohol
studentBMJ 2000;08:347-394 October ISSN 0966-6494
