Journal Club

1. Journal Club Alcohol and Health: Current Evidence March-April 2006 www.alcoholandhealth.org

2. Featured Article Cost-Benefit Analysis of a New Alcohol Biomarker, Carbohydrate Deficient Transferrin, in a Chronic Illness Primary Care Sample Dillie KS, et al. Alcohol Clin Exp Res. 2005;29(11):2008–2014. www.alcoholandhealth.org

3. Study Objective To estimate the costs and benefits of… • alcohol screening with carbohydrate-deficient transferrin (CDT) among primary care patients being treated for diabetes and/or hypertension www.alcoholandhealth.org

4. Study Design • Researchers used a decision-analysis model based on published data. • The model focused on patients being treated with medication for diabetes and/or hypertension. It assumed that… • 70 of 1000 simulated patients would drink heavily,* and • all who screened positive would receive brief intervention. *>90 drinks per month for men (>60 for women) www.alcoholandhealth.org

5. Users’ Guide for Economic Analysis of Clinical Practice • Are the results of the study valid? • What are the results? • Will the results help me in caring for my patients? www.alcoholandhealth.org

6. Are the Results of the Study Valid? • Did the analysis provide a full economic comparison of health care strategies? • Were the costs and outcomes properly measured and valued? • Was appropriate allowance made for uncertainties in the analysis? • Are estimates of costs and outcomes related to the baseline risk in the treatment population? www.alcoholandhealth.org

7. Did the analysis provide a full economic comparison of health care strategies? • Clinical effectiveness is established. • The analysis compared the following: • CDT testing plus case-finding by self-report (not a self-report screening test) • self-report alone (assumed sensitivity of 40%) • Screening with routinely recommended validated tools was not tested. www.alcoholandhealth.org

8. Were the costs and outcomes properly measured and valued? • The analysis adopts a societal perspective. • Costs were obtained from a clinical trial of screening and brief intervention in primary care, and appear to be quite accurate. • Outcomes were detected cases of heavy drinking and money saved. Quality-adjusted life years and health-state utilities were not measured. www.alcoholandhealth.org

9. Was appropriate allowance made for uncertainties in the analysis? • One-way and multivariate sensitivity analyses tested estimates across plausible ranges. • Uncertainties (such as the prevalence of heavy drinking in primary care and the number of high-cost events avoided) were discussed in the paper. www.alcoholandhealth.org

10. Are estimates of costs and outcomes related to the baseline risk in the treatment population? • The chosen population was primary care patients being treated for diabetes and/or hypertension. • But the data used in the models were not necessarily from patients being treated for these illnesses. • The data on CDT test characteristics came from a study in primary care where “many were being treated for chronic diseases such as diabetes and hypertension.” www.alcoholandhealth.org

11. Are estimates of costs and outcomes related to the baseline risk in the treatment population (continued)? • The data on screening and brief intervention came from… • a clinical trial that enrolled subjects waiting to see their primary care physicians for routine medical care, • other studies in primary care, and • population surveys. • Thus, whether the baseline risks, costs, and outcomes are specific to this population is unclear. www.alcoholandhealth.org

12. What Are the Results? • What were the incremental costs and outcomes of each strategy? • Do incremental costs and outcomes differ between subgroups? • How much does allowance for uncertainty change the results? www.alcoholandhealth.org

13. What were the incremental costs and outcomes of each strategy? • In 1000 patients, CDT testing would likely increase the number of detected cases of heavy drinking from… • 28 detected by self-report alone to 53 (of a maximum of 70). • This would save $212 per patient screened. www.alcoholandhealth.org

14. Do incremental costs and outcomes differ between subgroups? • Findings were robust across almost all estimates. • Using the lowest value for legal costs resulted in a net cost increase of about $118 per patient for screening with CDT and no subsequent intervention. www.alcoholandhealth.org

15. How much does allowance for uncertainty change the results? • In a Monte Carlo simulation, benefits outweighed costs of CDT testing in 83% of simulations. www.alcoholandhealth.org

16. Will the Results Help Me in Caring for My Patients? • Are the treatment benefits worth the harms and costs? • Could my patients expect similar health outcomes? • Could I expect similar costs? www.alcoholandhealth.org

17. Are the treatment benefits worth the harms and costs? • The analysis measured only monetary benefits (e.g., reduced medical, motor vehicle accident, and legal costs). • Since CDT testing was cost saving, at least in terms of dollars, it was worth it. • However, CDT testing was not compared with the minimum standard of care in clinical practice (i.e., a screening questionnaire). • So, it is not clear whether CDT would provide incremental benefit over standard care. www.alcoholandhealth.org

18. Could my patients expect similar health outcomes? • These outcomes would be expected in primary care settings (the data used for modeling were mainly from primary care studies). • It is not clear whether the population selected (patients with diabetes and/or hypertension) could expect the outcomes because… • no data specific to that population were used in the analyses. www.alcoholandhealth.org

19. Could I expect similar costs? • There is no reason to think that most of the costs will differ substantially. • But, since CDT is not widely available in the United States… • screening costs will likely vary and may be more than the estimated $30 per test. www.alcoholandhealth.org