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Cost-effectiveness of strategies to market and train primary health care physicians in brief intervention techniques for hazardous alcohol use
PII: S0277-9536(98)00063-X
Soc. Sci. Med. Vol. 47, No. 2, pp. 203±211, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0277-9536/98 $19.00 + 0.00
COST-EFFECTIVENESS OF STRATEGIES TO MARKET AND TRAIN PRIMARY HEALTH CARE PHYSICIANS IN BRIEF INTERVENTION TECHNIQUES FOR HAZARDOUS ALCOHOL USE MICHELLE K. GOMEL,1*{ SONIA E. WUTZKE,1 DEBORAH M. HARDCASTLE,2 HELEN LAPSLEY3 and ROBERT B. REZNIK4 1
Department of Psychological Medicine, University of Sydney, Sydney, Australia, 2Division of General Practice, Western Sydney Area Health Service, Sydney, Australia, 3School of Health Services Management, University of New South Wales, Sydney, Australia and 4Medical Director, EliLilly, formerly Public Health Unit, Central Sydney Area Health Service, Sydney, Australia
AbstractÐThe cost-eectiveness of strategies to market and train primary care physicians in brief intervention for hazardous alcohol consumption was examined. Physicians were randomly assigned to one of three marketing strategies designed to promote the ``uptake'' of a brief intervention package for hazardous and harmful alcohol consumption. The strategies were direct mail, tele-marketing, or academic detailing. One hundred and twenty-seven of those physicians who requested the package during the marketing phase (phase 1) and who also agreed to participate in the training and support phase of the project (phase 2) were matched into one of three training and support conditions: training and no support, training and minimal support, training and maximal support. An additional 34 physicians were randomly selected and assigned to a control condition. The ultimate aim of training and support was to maximise physician screening and counselling rates. Tele-marketing was found to be more costeective than academic detailing and direct mail in promoting the uptake of the package. For the training and support phase costs and eects increased with the level of support, hence the issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome. # 1998 Elsevier Science Ltd. All rights reserved Key wordsÐbrief intervention, alcohol, primary health care, training programs, marketing, costeectiveness
INTRODUCTION
Many studies have shown that brief intervention for hazardous alcohol use is eective for reducing hazardous alcohol intake in family practice patients (Bien et al., 1993; WHO Brief Intervention Study Group, 1996). Although more substantial evidence for the economic justi®cation for brief intervention is needed, it is reasonable to assume that it will result in cost savings (Heather, 1995). The outlays are relatively low, the exposure level is high and there are demonstrated eects. However, impact on alcohol related problems at the community level will be determined by the degree to which the intervention is adopted and used by family physicians. Determining economically viable strategies to encourage family physicians' use of brief intervention strategies for alcohol is therefore a critical phase of work which *Author for correspondence. {Michelle K. Gomel is now with the `Nations for Mental Health Action Programme on Mental Health for Underserved Populations', Division of Mental Health and Prevention of Substance Abuse, World Health Organization, Geneva, Switzerland. 203
complements demonstrations of the intervention's eectiveness. Given an ideal world in which there were no restrictions on health care resources, considerations of eectiveness would be the major criteria for making decisions about the type of strategy to disseminate brief intervention programs to physicians. However, given decreasing health budgets and the increased pressure on health care services to justify expenditure, cost considerations are crucial. The research literature contains many examples of studies examining the cost-eectiveness of comprehensive health promotion/disease prevention programs (Rogers et al., 1981; Hall et al., 1988; Pelletier, 1991) and also of programs targeting lifestyle problems such as smoking (Cummings et al., 1989; Elixhauser, 1990), alcohol (Tolley and Rowland, 1991), hypertension (Erfurt and Foote, 1984; Johannesson and Fagerberg, 1992), and physical activity (Hatziandreu et al., 1988). However, controlled studies comparing the costeectiveness of strategies to disseminate and diuse health interventions to health professionals are scarce. Soumerai and Avorn (1986) compared three conditions to reduce inappropriate prescribing prac-
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tices of physicians. Academic detailing (face-to-face visits) combined with print materials was found to be more cost-eective than print materials alone or a control condition. Although not meeting the criteria for a cost-eectiveness study, Cockburn et al. (1992) report a costing of three approaches for disseminating a smoking intervention kit to general practitioners. An educational facilitator approach was 24 times more expensive than that of a mailed approach, while a courier approach was twice as expensive as the mail approach. There were no signi®cant dierences in physicians' utilisation of the kit across interventions and overall, utilisation of the kit was low (Cockburn et al., 1992). Previously we reported a comparison of the eectiveness of marketing strategies to promote family physicians uptake of an early intervention program for hazardous alcohol use called Drink-less (Gomel et al., 1996; Hardcastle et al., submitted) and also the eectiveness of training and support strategies in enhancing the utilisation of the Drink-less program (Gomel et al., 1996; Gomel et al., in preparation). In this paper we use a cost-eectiveness framework to compare the eectiveness of these strategies. The endpoints were process outcomes and related to physicians uptake of the package and their use of the package with patients. The economic evaluation is conducted from the viewpoint of the resource provider, in this case a government department.
METHOD
Sample and research design The methodology and interventions have been described in detail previously (Gomel et al., 1994, 1996; Hardcastle et al., submitted). The study population comprised physicians within a 45 km radius of a large urban hospital in Sydney, Australia. Only one physician per practice was selected. Physicians were excluded from the trial if they had fewer than 1400 consultations per year and if they worked in a 24 h medical centre. Phase 1. From a sampling frame of 1759 practices, 628 family physicians were randomly selected and assigned to one of three marketing conditions using proportional sampling techniques for the age, gender and activity level of the physician, and the socioeconomic status of the practice area. The three conditions were direct mail, tele-marketing and academic detailing. In each of the conditions a brief intervention package for hazardous alcohol consumption (Drink-less; Gomel et al., 1994) was marketed to physicians. In the direct mail condition, physicians received a promotional brochure outlining the package. In both the tele-marketing and academic detailing conditions a standardised sales script was used to market Drink-less. In the telemarketing condition, marketing was conducted on
the phone while in the academic detailing condition marketing was conducted at the practice site. Phase 2. This involved an evaluation of physicians use of the Drink-less package across varying levels of training and support. Receptionists (or physicians) were required to screen patients for hazardous alcohol use using AUDIT (Alcohol Use Disorders Identi®cation Test; Saunders et al., 1993) prior to the physician consultation. Physicians were then required to advise ``hazardous'' drinkers on how to reduce their alcohol consumption or on how to abstain (an advice handycard was provided for this purpose) and then to provide the patient with a self-help booklet. The 161 physicians who requested the package in the marketing phase and who also agreed to participate in a three month evaluation of their use of Drink-less, were matched on each of the variables described above as well as initial marketing condition into one of three training and support conditions: no support, minimal support and maximal support. An additional sample of physicians was randomly selected to comprise a control condition. The number of physicians assigned to each condition was 35, 45, 40 and 42 for the control, no, minimal and maximal support conditions, respectively. In the control condition, physicians and receptionists had the package delivered to their practice but received no training or support in how to implement Drink-less. In the no-support condition, physicians and receptionists received initial training in the use of the package but no support was provided over the three month program implementation period. In the minimal support condition, initial training as per the no support condition was provided. In addition, data collection reminders were provided to physicians and receptionists by telephone a fortnight after initial training and thereafter to receptionists every two weeks. In the maximal support condition, physicians and receptionists received initial training and ongoing support on program implementation issues through alternate telephone contact and practice visits every two weeks. Advice and support addressed attitudes and beliefs of the GP and receptionist, patient intervention issues, and structural/logistic issues. Measurement Research sta completed monitoring forms and log books to enable the calculation of the major costs of the marketing and training and support conditions. For each strategy there were four stages of work; development, training, piloting and implementation. The development stage involved all aspects related to the development of the marketing and training and support strategies; the training stage involved training sta to implement the protocol relating to strategies; the piloting stage involved further training and familiarization with the proto-
Cost-eective marketing and training strategies in primary care
col and ensuring that there were no practical problems associated with the implementation of strategies and the implementation phase involved the implementation of the ®nal revised strategy.
Costs For this comparative cost analysis, overhead costs, for example, the provision and maintenance of premises, electricity and administration costs were excluded on the basis that they were common to all strategies (Drummond et al., 1994) and costs associated with patients' time were also excluded. Although research costs were monitored and calculated it was not appropriate to include them in cost-eectiveness analyses. The method of cost estimation for each resource input is detailed below. All costs are calculated in Australian dollars. Labour. Labour costs included sta time associated with travelling, making phone calls and the time involved in organising material to be mailed and training received. Sta time was valued as earnings plus oncosts which amounted to $19.05 per hour for research sta and $32.20 per hour for the project director. Because the distance travelled on any one trip to a primary care physician diered between conditions an average travel time per trip to a practice was calculated. This was used for estimating the costs associated with sta travel time for each strategy. The average travel time was derived by summing the time involved in travelling to deliver the Drink-less package to the primary health care physician's practice (training and support phase) for all conditions and dividing this by the sum of the number of trips made across all conditions. Travel costs. These were estimated according to the University of Sydney rate, based on the engine capacity of the car. The rate was $0.41 per km which includes petrol and depreciation for wear and tear. An average travel cost per trip was calculated from the average distance travelled per trip described above and was used for estimating travel costs for each strategy. Telephone costs. All general practices were located within a 45 km radius of the university of Sydney, therefore the cost of a phone call was calculated at the local rate of 25 cents per call. Mail costs. Costs of postage were calculated using 1995 postal charges for varying weights. Consumables. Consumables comprised the major and unique stationery items for the direct mail strategy (promotional brochure) and the academic detailing strategy (compendium and promotional contents). Cost estimates were based on the market price. Costs associated with mailing and phoning were calculated separately (see above) because these comprised major cost elements of the marketing and training and support strategies.
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Outcomes Phase 1. Uptake rate and recruitment rate were used as the two outcomes for the marketing phase. Uptake rate was the number of physicians requesting the Drink-less intervention package expressed as a percentage of those eligible to receive the package. This was calculated as: No: accepting package 100 No: offered package 1 The recruitment rate was the percentage of physicians agreeing to participate in the training and support phase of the project expressed as a function of the initial uptake rate. Recruitment required a commitment to assist an evaluation of the use of the package over a three month period and was calculated as: No: accepting package No: offered package
No: agree to participate 100 No: eligible to participate 1
Phase 2. Screening rate and intervention rate were used to compare the eectiveness of the training and support interventions. The number of patients screened per 100 physicians and the number of patients drinking at hazardous levels that received brief advice per 100 physicians was used to compare the cost-eectiveness of the interventions. The screening rate was de®ned as the number of patients screened expressed as a percentage of those eligible to be screened. Estimates of the number of people screened were obtained by counting the number of AUDIT questionnaires completed by patients at each practice. The denominator was based on Health Commission data and included all patients (16 years and over) who consulted their general practitioner during the three month study period, excluding repeat visits. The screening rate was calculated for each GP as: No: patients screened 100 No: eligible patients for screening 1 The intervention rate was de®ned as the total number of hazardous drinkers who were advised or given a self-help booklet expressed as a percentage of patients who were estimated to be at risk during the three month study period. The number advised or given a booklet was determined by tallying the number of AUDITS with a ``Y'' or ``N'' in ``counselled'' and ``booklet'' oce use boxes on the AUDIT questionnaire. Because very few physicians screened all eligible patients, it was necessary to estimate the total number of hazardous drinkers consulting their GP over the three months of the program. It was assumed
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that physicians ``actual'' detection rates (No. at risk/No. screened) accurately re¯ected the proportion of hazardous drinkers. This proportion was multiplied by the number of ``patients eligible for screening'' to estimate the total number of hazardous drinkers for the three month period. This assumed that there were minimal biases in the type of patients who were approached for screening. Intervention rate was calculated for each GP as: No: advised 100 Total No: of hazardous drinkers 1
Analysis Forty-eight physicians who did not screen patients had missing values for the number of patients eligible for screening and the proportion of patients who were hazardous drinkers. Missing values for each variable, respectively, were replaced by the grand mean of all physicians: 586.84 and 0.24. Eectiveness. w2 tests were used to compare uptake and recruitment rates for the marketing strategies; tele-marketing and academic detailing were each compared with direct-mail. Mann±Whitney tests were used to compare the eectiveness of the training and support strategies; each strategy was compared with the control condition. Cost-eectiveness. An incremental analysis examined the additional costs to derive additional units of output for each level of the intervention over the comparison group. In the marketing phase the comparison group was the direct mail strategy. In the training and support phase the comparison group was the control condition. In this way a ``usual'' practice condition was compared with more innovative strategies that could potentially be implemented. Incremental cost-eectiveness was calculated as: Cost of strategy ÿ Cost of comparison =Effect of strategy ÿ Effect of comparison: Three separate analyses were undertaken for each outcome measure: one that included all costs including development and training/piloting costs; one that excluded development costs; and one that
excluded both development and training/piloting costs. The results for the marketing phase and the training and support phase are reported separately. Sensitivity analysis. A sensitivity analysis was conducted to examine the eect of two major cost variations. The ®rst was relevant to the marketing phase and included the cost of producing the promotional brochure used in the direct mail strategy. The actual cost of the brochure was $5.07 when the order was for 250 brochures and this costing was used for a worse case scenario. However, in a best case scenario, the cost would be reduced to $1.50 per brochure by increasing the number of brochures to 2000 and using lighter weight paper, a situation that would arise if the brochures were mass produced. The second major cost variant relevant to both the marketing and training and support phase was the distance travelled and the labour costs associated with travel. In this study the average distance travelled per trip was 28.69 km and the average time spent travelling was 44.08 min. This was varied for a best and worse case scenario in which the average distance travelled per trip and the average time spent travelling was either reduced or increased by 30%.
RESULTS
Marketing phase Eectiveness. Uptake rates were signi®cantly higher for the tele-marketing strategy compared with the direct mail strategy (w2=45.56, p = 0.00) and for the academic detailing strategy compared with the direct mail strategy (w2=31.74, p = 0.00). Recruitment rates were also signi®cantly higher for the tele-marketing strategy compared with direct mail (w2=8.70, p = 0.00) and for the academic detailing strategy compared with direct mail (w2=20.51, p = 0.00) (see Table 1). Costs. Table 2 presents three dierent costings for each marketing strategy: all costs; costs excluding development costs; and costs excluding development and training costs. For all three costing outcomes tele-marketing was the least expensive strategy followed by direct mail. Academic detailing was the most expensive strategy.
Table 1. The numbers and percentages of physicians requesting the package and agreeing to participate in the three month training and support trial Strategy Direct mail Tele-marketing Academic detailing a
No. Uptake 119 146 99
No. eligible for uptake 247 182 126
No. agree to participate 44 61 54
Recruitment rateb No. approached to (%) participate Uptake ratea (%) 78 121 84
48.2 80.2 78.6
27.2 40.4 50.5
The number of physicians who accepted a package expressed as a percentage of eligible physicians who were oered the package: No. accepting package/No. eligible for uptake. The number of physicians agreeing to participate in a three month evaluation trial expressed as a function of the percentage of eligible physicians who were oered the package. (No. agree to participate/No. eligible for participation) (No. accepting package/No. oered package).
b
Cost-eective marketing and training strategies in primary care
207
Table 2. Marketing phase Ð The costs associated with each marketing strategy to promote the uptake and participation of physicians
Development stage Training and piloting stage Implementation stagea,b sta labour ±uptake ±participation Travel Postage Telephone ±uptake ±participation Consumables Total costa ±uptake ±participation Cost excluding development costsa ±uptake ±participation Cost excluding development and training/pilot costsa ±uptake ±participation
Direct mail
Tele-marketing
Academic detailing
$700.81 $43.47
$607.25 $254.09
$607.25 $679.79
$243.0 $293.0 $0.0 $112
$166.0
$2759.0
$0.0 $0.0
$1600.0 $0.0
$0.0 $15.0 $651
$50.0
$23.00
$0.0
$227.00
$1750.28 $1815.28
$1077.34
$5896.04
$1049.47 $1114.47
$470.09
$5288.79
$1006.0 $1071.0
$216.00
$4609.0
Cost-eectiveness. Tele-marketing was the most cost-eective strategy to encourage physicians to accept a Drink-less package and was more costeective than direct mail to encourage them to participate in a three month evaluation trial. This was regardless of whether development and/or training and piloting costs were included in the costing of strategies (see Tables 3 and 4). When development and training costs were excluded, tele-marketing cost $24.69 less than the direct mail strategy for each additional GP agreeing to take the package and $64.77 less than direct mail for each GP agreeing to participate in the three month evaluation. Although academic detailing was more eective than direct mail, it was substantially more costly. Academic detailing cost $118.52 more than the direct mail strategy for each additional GP agreeing to take a package and $151.85 more for each additional GP agreeing to participate in the three month evaluation.
Sensitivity analysis. The sensitivity analysis examined best and worse case scenarios for variations in the costs of the marketing conditions after excluding development and training/piloting costs. These scenarios had most of their impact on the academic detailing and direct mail strategies as a result of the costs associated with travel and production of the promotional brochure, respectively. Costs for the tele-marketing strategy were not aected in either of these variations. Based on these best and worse case scenarios, incremental costs per uptake of a package were ÿ$10.77 to ÿ$24.69 for tele-marketing and $87.54 to $161.24 for academic detailing. The best and worse case scenarios for GP participation were ÿ$64.77 to ÿ$37.72 for the tele-marketing and $111.43 to $207.58 for academic detailing. Training and support phase Eectiveness. Table 5 presents the median screening and intervention rates for physicians for each strategy. Compared with the control condition, the
Table 3. Incremental cost eectiveness of marketing strategies for promoting uptake of the package Strategy
Costs per 100 physicians
Eects per 100 physiciansa
All costs included
Incremental C/Eb
Direct mail Tele-marketing Academic detailing
$1750.28 $1077.34 $5896.04
48.2 80.2 78.6
ÿ$21.0 $136.37
Direct mail Tele-marketing Academic detailing
Development costs excluded $1049.47 48.2 $470.09 80.2 $5288.79 78.6
ÿ$18.11 $139.45
Direct mail Tele-marketing Academic detailing a
Development and training/piloting costs excluded $1006.0 48.2 $216.0 80.2 $4609.0 78.6
ÿ$24.69 $118.52
The number of physicians requesting a Drink-less package. The incremental cost-eectiveness of each strategy over direct mail e.g. (cost strategy ÿ cost direct mail)/(eect strategy ÿ eect direct mail).
b
208
M. K. Gomel et al. Table 4. Incremental cost eectiveness of marketing strategies for promoting participation in the three month evaluation. Strategy
Costs per 100 physicians
Eects per 100 physiciansa
All costs included
Incremental C/Eb
Direct mail Tele-marketing Academic detailing
$1815.28 $1077.34 $5896.04
27.2 40.4 50.5
ÿ$55.9 $175.14
Direct mail Tele-marketing Academic detailing
Development costs excluded $1114.47 27.2 $470.09 40.4 $5288.79 50.5
ÿ$48.82 $179.16
Direct mail Tele-marketing Academic detailing
Development and training/piloting costs excluded $1071.0 27.2 $216.0 40.4 $4609.0 50.5
ÿ$64.77 $151.85
a
The number of physicians agreeing to participate in the 3 month training and support phase.
median screening rate was signi®cantly higher for physicians in the no support (Z = 2.03, p = 0.04) and the maximal support (Z = 2.99, p = 0.003) conditions but not for physicians in the minimal support strategy (Z = 1.68, p = 0.09). These results may have been signi®cant if larger sample sizes were used. Compared with the control condition, median advice rates for the estimated total number of hazardous drinkers were signi®cantly higher for physicians in the maximal support strategy (Z = 3.22; p = 0.001) but not for physicians in the no support (Z = 1.89; p = 0.06) or in the minimal support (Z = 1.69; p = 0.09) conditions. Costs. Table 6 presents three dierent costings for each training and support strategy: all costs; costs excluding development costs; and costs excluding development and training costs. For all three costing outcomes the control condition was the least expensive strategy followed by the no support strategy and then the minimal sup-
port strategy. Maximal support was the most expensive strategy. Cost-eectiveness. Cost-eectiveness ratios are presented in Table 7. The general pattern of results remains the same regardless of whether development and/or training and piloting costs were included in the costing of strategies (see Table 7). When development and training costs were excluded the no support strategy cost an extra 12 cents more than the control condition for each additional patient screened or an extra 86 cents for each additional hazardous drinker counselled. Compared to the control condition, minimal support cost an extra 22 cents for each additional patient screened or an additional $1.77 for each hazardous drinker counselled. The costs for additional patients screened and counselled was much higher for the maximal support strategy; each additional patient screened cost 86 cents or each additional hazardous drinkers patient counselled cost $4.70.
Table 5. The number of patients screened and advised and the median screening and intervention rates for training and support conditions
Strategy
No. screened
No. patients eligible for screening
No. advised
Total No. hazardous drinkersa
Median screening rateb
Median intervention ratec
Control 34 physicians 100 physicians
2585 7602.94
18427.14 54197.47
344 1011.76
3807.43 11198.32
0.00
0.00
No support 45 physicians 100 physicians
6952 15448.89
26248.09 58329.09
930 2066.67
7081.47 15736.60
0.14
0.07
Minimal support 40 physicians 100 physicians
6084 15210.0
24879.93 62199.83
789 1972.5
6066.12 15165.3
0.22
0.10
Maximal support 42 physicians 100 physicians
8199 19521
24926.21 59348.12
1346 3204.76
6231.18 14836.14
0.26
0.18
a
Total No. of hazardous drinkers was estimated for each GP on the basis of the actual proportion of hazardous drinkers identi®ed: The calculation was: (No. at risk/No. patients screened) (No. of patients who were eligible for screening). Median screening rate was used in eectiveness analyses. Screening rate was calculated for each GP as: No. patients screened/No. eligible patients for screening. c Median intervention rate was used in eectiveness analyses. Intervention rate was calculated for each GP as: No. advised/total No. of hazardous drinkers. b
Cost-eective marketing and training strategies in primary care
209
Table 6. Training and support phase Ð The costs associated with each training and support strategy to enhance screening and intervention rates Control Development stage Training and piloting stage Implementation stagea, Sta labour Travel Postage Telephone Total cost Total cost excluding development costs Total cost excluding development and training costs
No support
Minimal support
Maximal support
0.0 $0.0
$220.75 $734.42
$2020.0
$2987.0
$3583.0
$8760.0
$1353.0 $123.0 $60.0 $3556.0 $3556.0
$1310.0 $103.0 $66.0 $5421.17 $5200.42
$1386.0 $110.0 $179.0 $6268.61 $6047.86
$4632.0 $305.0 $126.0 $18,014.21 $15,846.56
$3556.0
$4466.0
$5258.0
$13,868.0
Sensitivity analyses. For the training and support phase, best and worse case scenarios were calculated using the 30% decrease and increase in the distance travelled to physicians and the associated sta time involved after excluding development and training costs. The incremental cost-eectiveness per each additional patient screened was 12 to 15 cents for no support; 17 to 27 cents for minimal support and 61 cents to $1.12 for maximal support. The incremental cost-eectiveness per each additional hazardous drinkers patient counselled was 59 cents to $1.13 for no support, $1.37 to $2.17 for minimal support and $3.36 to $6.04 for maximal support.
$220.75 $789.86
$2167.65 $1978.56
DISCUSSION
This study examined the cost-eectiveness of alternative strategies to disseminate a brief intervention program for hazardous alcohol consumption in general practice. In the marketing phase, both telemarketing and academic detailing produced signi®cantly higher uptake and recruitment rates than direct mail, however, tele-marketing was cheaper than both direct mail and academic detailing. When development and training/piloting costs were excluded tele-marketing was $25 cheaper than direct mail per additional physician requesting the Drink-
Table 7. Incremental cost-eectiveness of training and support strategies based on the number of patients screened and the number of hazardous drinkers who were advised Strategy
Costs per 100 physicians
Control
$3,556.0
No support
$5,421.17
Minimal support
$6,268.61
Maximal support
$18,014.21
Control
$3556.00
No support
$5200.42
Minimal support
$6047.86
Maximal support
$15846.56
Control No support Minimal support Maximal support a
Eects per 100 physiciansa (screened, advised)
Incremental C/Eb (screened, advised)
All costs included 7602.94 1011.76 15448.89 2066.67 15210.0 1972.50 19521.0 3204.76
$0.23 $1.77 $0.36 $2.82 $1.21 $6.59
Development costs excluded 7602.94 1011.76 15448.89 2066.67 15210.0 1972.50 19521.0 3204.76
$0.21 $1.56 $0.33 $2.59 $1.03 $5.60
Development and training/piloting costs excluded $3556.00 7602.94 1011.76 $4466.00 15448.89 2066.67 $5258.00 15210.0 1972.50 $13868.0 19521.0 3204.76
$0.12 $0.86 $0.22 $1.77 $0.86 $4.70
The number of patients screened and the number advised. The incremental cost-eectiveness of each strategy over the control condition: (cost of strategy ÿ cost of control)/ (eect of strategy ÿ eect of control).
b
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M. K. Gomel et al.
less package and $65 cheaper per additional GP agreeing to participate in the evaluation. In contrast, academic detailing was $119 and $152 more expensive than direct mail for each additional physician agreeing to take a package and agreeing to participate in the evaluation. The sensitivity analyses undertaken did not alter the pattern of results. While tele-marketing was more cost-eective than the others for promoting the uptake of the package, a decision about cost-eectiveness of strategies to promote participation in the evaluation can be debated depending on the relative importance the decision maker attributes to variables such as budget constraints and perceived value of the extra bene®ts. The second phase of the project examined the level of support required to enhance screening of patients and the counselling of those found to be at risk of hazardous alcohol consumption. Screening rates were signi®cantly higher for the no support and the maximal support conditions compared with the control condition. Despite the lower screening rates of physicians in the no support strategy compared with the maximal support strategy, the costs of this strategy for enhancing screening rates were considerably lower. The number of patients screened provides one indication of the eect of the training and support interventions. The crucial outcome measure in terms of community impact is the overall number of patients who were identi®ed as hazardous drinkers and advised. When intervention rates were used as the outcome measure, the minimal support condition proved both less eective and more expensive than the no-support condition. As such, minimal support would not be considered to be a cost-eective option. For the remaining three conditions, control, no support and maximal support, both costs and eects increased with the level of support with no change in the pattern of results despite undertaking sensitivity analyses. The issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome. Again, this becomes a decision requiring a value judgment and can not be answered simply from an evaluation of costs and eects. An interesting variation for future research would be to provide training and support via phone contact rather than visits. This variation would reduce the costs associated with travel to the practice and may in¯uence calculations of cost-eectiveness. Alternatively, an additional variation which may prove bene®cial could be a combined strategy in which academic detailing and initial training are provided in one session. This approach would reduce the additional costs required for a separate training visit and could prove more cost-eective than the use of a marketing strategy such as tele-
marketing that is then followed by an initial training session. Although not directly tested the results of the study suggest that this would not prove more cost-eective. After adjusting for the lower rates of participation for tele-marketing compared with academic detailing (40 vs. 50 physicians per 100 physicians approached), it would be necessary to approach 125 physicians with the tele-marketing strategy to achieve the equivalent participation of 50 physicians at a cost of $270. The approximate costs involved for academic detailing with the 50 physicians interested in participating would be $2300 (plus additional measured costs associated with a more lengthy training session for the receptionist and physician). Excluding these additional training costs and also assuming that the same number of patients would be screened and counselled for each strategy, tele-marketing followed by initial training would be more cost eective than an academic detailing strategy which also incorporated the initial training session (costs of $2570 vs. $4609, respectively). Previous studies have used program utilisation measures to assess the eectiveness of marketing strategies (Cockburn et al., 1992). However, in the current study, outcomes for the marketing phase were restricted to measures of uptake and recruitment, and outcomes for the training and support phase involved measures of program utilisation. It is possible that academic detailing on its own (with some modi®cations to the length of the visit to the GP) could have been more cost-eective than direct mail and tele-marketing in enhancing physicians screening and intervention rates. For example in relation to modifying physician prescribing practices, academic detailing has been found to be a more cost-eective strategy when compared with direct mail (Soumerai and Avorn, 1986). Yet in the current study, a comparison of the marketing strategies on measures of program utilisation was not the major question of interest. Based on other work (Davis et al., 1992), it seems that direct mail, and other less intensive strategies are not sucient to aect change in complex counselling behaviours for lifestyle health issues. The results of this study can not be directly compared with others in the literature because it is the ®rst study to examine the cost-eectiveness of marketing strategies and training and support strategies to encourage physicians' uptake and utilisation of a brief intervention package for hazardous alcohol consumption. However, it is of interest that common strategies to disseminate health information to physicians have been to send material/programs through the mail or to use academic detailing. While direct mail is cheaper than academic detailing, its eects have been more limited (Davis et al., 1992). Tele-marketing, a strategy that had not been explored previously was the cheapest strategy while producing equivalent eects to academic detailing.
Cost-eective marketing and training strategies in primary care
Some caution is needed in generalising the results of the study, particularly when a dierent intervention is used or when strategies are implemented in other countries. Firstly, the uptake and utilisation of an intervention will depend on the interest of the physician and the complexity of the intervention that is being disseminated. Secondly, the costs of strategies are likely to vary considerably depending on the country in which they are applied because of the cost dierentials associated with labour, transport, postage and material production costs. The framework used and the results of this research are of relevance to the dissemination and diusion of other health interventions to family physicians. Too often the cheapest strategy is used to promote interventions to physicians without consideration of the eectiveness of the strategy. Failure to achieve widespread change from a preventive intervention can often be attributed to failure at the implementation stage rather than to failure of the intervention. Thus the examination and incorporation of cost-eective dissemination strategies into a strategic plan to implement preventive medicine programs are important considerations for health care services. AcknowledgementsÐFunding for this research was provided by the Research into Drug Abuse Program, Commonwealth Department of Family Services and Health. The Northside Clinic and the Roads and Trac Authority have also provided sponsorship for additional components of the program. We would like to thank Mark Sumich, Lucinda Burns, Christy Chan and Chantal Caviness for their research assistance. Appreciation also goes to Gordon Calcino (Department of Family Services and Health), Martin Boland and Dennis Beissner (Health Insurance Commission) for their assistance with sampling. We would also like to express our gratitude to members of the project Steering Committee: Micheal Mira, Helena Britt, Jill Gordon and Greg Elliot who oered their valuable time and expertise. This study formed the model for strand III of the WHO collaborative study on disseminating early intervention in primary health care. The authors would like to acknowledge the valuable contributions made by the WHO Regional oce for Europe, as well as the support from the 35 collaborating investigators in the WHO study. REFERENCES
Bien, T. H., Miller, W. R. and Tonigan, J. S. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315±336. Cockburn, J., Ruth, D., Silagy, C., Dobbin, M., Reid, Z., Scollo, M. and Naccarella, L. (1992) Randomised trial of three approaches for marketing smoking cessation programmes to Australian general practitioners. British Medical Journal 304, 691±694. Cummings, S. R., Rubin, S. M. and Oster, G. (1989) The cost-eectiveness of counseling smokers to quit. JAMA 261, 75±79. Davis, D. A., Thomson, M. A., Oxman, A. D. and Haynes, R. B. (1992) Evidence for the eectiveness of
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CME: A review of 50 randomised controlled trials. JAMA 268, 111±117. Drummond, M. F., Stoddart, G. L. and Torrance, G. W. (1994) Methods for the Ecomomic Evaluation of Health Care Programmes. Oxford University Press, New York. Erfurt, J. C. and Foote, A. (1984) Cost-eectiveness of worksite blood pressure control programs. Journal of Occupational Medicine 26, 892±900. Elixhauser, A. (1990) The costs of smoking and the costeectiveness of smoking-cessation programs. Journal of Public Health Policy 11, 218-237. Gomel, M., Saunders, J. B., Burns, L., Hardcastle, D. and Sumich, M. (1994) Dissemination of early intervention for harmful alcohol consumption in general practice. Health Promotion Journal of Australia 4(2), 65±69. Gomel, M. K., Saunders, J. B., Wutzke, S. E., Hardcastle, D. M. and Carnegie, M. A. (1996) Implementation of early intervention for hazardous alcohol consumption in general practice. A ®nal report prepared for the Research into Drug Abuse Program: Department of Human Services and Health. July 1996. Sydney, Australia. Gomel, M. K., Mira, M., Saunders, J. B., Hardcastle D, Wutzke, S. and Reznik, R. A. Controlled trial of training and support conditions to enhance the use of brief interventions for hazardous alcohol use in primary health care. In preparation. Hall, J. P., Heller, R. F., Dobson, A. J., Lloyd, D. M., Sanson-Fisher, R. W. and Leeder, S. R. (1988) A costeectiveness analysis of alternative strategies for the prevention of heart disease. Medical Journal of Australia 148, 273±277. Hardcastle, D. M., Gomel, M. K., Sumich, M., Wutzke, S., and Saunders, J. B. A. controlled trial of strategies for disseminating brief interventions for hazardous alcohol use in primary care. Submitted. Hatziandreu, E. I., Koplan, J. P., Weinstein, M. C., Caspersen, C. J. and Warner, K. E. (1988) A cost-eectiveness analysis of exercise as a health promotion activity. American Journal of Public Health 78, 1417±1421. Heather, N. (1995) Treatment Approaches to Alcohol Problems. WHO Regional Publications, European Series, No. 65. WHO Regional Oce for Europe, Copenhagen. Johannesson, M. and Fagerberg, B. (1992) A health economic comparison of diet and drug treatment in obese men with mild hypertension. Journal of Hypertension 10, 1063±1070. Pelletier, K. R. (1991) A review and analysis of the health and cost-eectiveness outcome studies of comprehensive health promotion and disease prevention programs. American Journal of Health Promotion 5, 311±315. Rogers, P. J., Eaton, E. K. and Bruhn, J. G. (1981) Is health promotion cost eective? Preventive Medicine 10, 324±339. Saunders, J. B., Aasland, O. G., Babor, T. F., La Fuente, J. R. and Grant, M. (1993) Development of the Alcohol Use Disorders Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption Ð II. Addiction 88, 617±628. Soumerai, S. B. and Avorn, J. (1986) Economic and policy analysis of university-based drug ``detailing''. Medical Care 24, 313±331. Tolley, K. and Rowland, N. (1991) Identi®cation of alcohol related problems in a general hospital setting: a cost-eectiveness evaluation. British Journal of Addiction 86, 429±438. WHO Brief Intervention Study Group (1996) A crossnational trial of brief intervention with heavy drinkers. American Journal of Public Health 86, 948±955.
Soc. Sci. Med. Vol. 47, No. 2, pp. 203±211, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0277-9536/98 $19.00 + 0.00
COST-EFFECTIVENESS OF STRATEGIES TO MARKET AND TRAIN PRIMARY HEALTH CARE PHYSICIANS IN BRIEF INTERVENTION TECHNIQUES FOR HAZARDOUS ALCOHOL USE MICHELLE K. GOMEL,1*{ SONIA E. WUTZKE,1 DEBORAH M. HARDCASTLE,2 HELEN LAPSLEY3 and ROBERT B. REZNIK4 1
Department of Psychological Medicine, University of Sydney, Sydney, Australia, 2Division of General Practice, Western Sydney Area Health Service, Sydney, Australia, 3School of Health Services Management, University of New South Wales, Sydney, Australia and 4Medical Director, EliLilly, formerly Public Health Unit, Central Sydney Area Health Service, Sydney, Australia
AbstractÐThe cost-eectiveness of strategies to market and train primary care physicians in brief intervention for hazardous alcohol consumption was examined. Physicians were randomly assigned to one of three marketing strategies designed to promote the ``uptake'' of a brief intervention package for hazardous and harmful alcohol consumption. The strategies were direct mail, tele-marketing, or academic detailing. One hundred and twenty-seven of those physicians who requested the package during the marketing phase (phase 1) and who also agreed to participate in the training and support phase of the project (phase 2) were matched into one of three training and support conditions: training and no support, training and minimal support, training and maximal support. An additional 34 physicians were randomly selected and assigned to a control condition. The ultimate aim of training and support was to maximise physician screening and counselling rates. Tele-marketing was found to be more costeective than academic detailing and direct mail in promoting the uptake of the package. For the training and support phase costs and eects increased with the level of support, hence the issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome. # 1998 Elsevier Science Ltd. All rights reserved Key wordsÐbrief intervention, alcohol, primary health care, training programs, marketing, costeectiveness
INTRODUCTION
Many studies have shown that brief intervention for hazardous alcohol use is eective for reducing hazardous alcohol intake in family practice patients (Bien et al., 1993; WHO Brief Intervention Study Group, 1996). Although more substantial evidence for the economic justi®cation for brief intervention is needed, it is reasonable to assume that it will result in cost savings (Heather, 1995). The outlays are relatively low, the exposure level is high and there are demonstrated eects. However, impact on alcohol related problems at the community level will be determined by the degree to which the intervention is adopted and used by family physicians. Determining economically viable strategies to encourage family physicians' use of brief intervention strategies for alcohol is therefore a critical phase of work which *Author for correspondence. {Michelle K. Gomel is now with the `Nations for Mental Health Action Programme on Mental Health for Underserved Populations', Division of Mental Health and Prevention of Substance Abuse, World Health Organization, Geneva, Switzerland. 203
complements demonstrations of the intervention's eectiveness. Given an ideal world in which there were no restrictions on health care resources, considerations of eectiveness would be the major criteria for making decisions about the type of strategy to disseminate brief intervention programs to physicians. However, given decreasing health budgets and the increased pressure on health care services to justify expenditure, cost considerations are crucial. The research literature contains many examples of studies examining the cost-eectiveness of comprehensive health promotion/disease prevention programs (Rogers et al., 1981; Hall et al., 1988; Pelletier, 1991) and also of programs targeting lifestyle problems such as smoking (Cummings et al., 1989; Elixhauser, 1990), alcohol (Tolley and Rowland, 1991), hypertension (Erfurt and Foote, 1984; Johannesson and Fagerberg, 1992), and physical activity (Hatziandreu et al., 1988). However, controlled studies comparing the costeectiveness of strategies to disseminate and diuse health interventions to health professionals are scarce. Soumerai and Avorn (1986) compared three conditions to reduce inappropriate prescribing prac-
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tices of physicians. Academic detailing (face-to-face visits) combined with print materials was found to be more cost-eective than print materials alone or a control condition. Although not meeting the criteria for a cost-eectiveness study, Cockburn et al. (1992) report a costing of three approaches for disseminating a smoking intervention kit to general practitioners. An educational facilitator approach was 24 times more expensive than that of a mailed approach, while a courier approach was twice as expensive as the mail approach. There were no signi®cant dierences in physicians' utilisation of the kit across interventions and overall, utilisation of the kit was low (Cockburn et al., 1992). Previously we reported a comparison of the eectiveness of marketing strategies to promote family physicians uptake of an early intervention program for hazardous alcohol use called Drink-less (Gomel et al., 1996; Hardcastle et al., submitted) and also the eectiveness of training and support strategies in enhancing the utilisation of the Drink-less program (Gomel et al., 1996; Gomel et al., in preparation). In this paper we use a cost-eectiveness framework to compare the eectiveness of these strategies. The endpoints were process outcomes and related to physicians uptake of the package and their use of the package with patients. The economic evaluation is conducted from the viewpoint of the resource provider, in this case a government department.
METHOD
Sample and research design The methodology and interventions have been described in detail previously (Gomel et al., 1994, 1996; Hardcastle et al., submitted). The study population comprised physicians within a 45 km radius of a large urban hospital in Sydney, Australia. Only one physician per practice was selected. Physicians were excluded from the trial if they had fewer than 1400 consultations per year and if they worked in a 24 h medical centre. Phase 1. From a sampling frame of 1759 practices, 628 family physicians were randomly selected and assigned to one of three marketing conditions using proportional sampling techniques for the age, gender and activity level of the physician, and the socioeconomic status of the practice area. The three conditions were direct mail, tele-marketing and academic detailing. In each of the conditions a brief intervention package for hazardous alcohol consumption (Drink-less; Gomel et al., 1994) was marketed to physicians. In the direct mail condition, physicians received a promotional brochure outlining the package. In both the tele-marketing and academic detailing conditions a standardised sales script was used to market Drink-less. In the telemarketing condition, marketing was conducted on
the phone while in the academic detailing condition marketing was conducted at the practice site. Phase 2. This involved an evaluation of physicians use of the Drink-less package across varying levels of training and support. Receptionists (or physicians) were required to screen patients for hazardous alcohol use using AUDIT (Alcohol Use Disorders Identi®cation Test; Saunders et al., 1993) prior to the physician consultation. Physicians were then required to advise ``hazardous'' drinkers on how to reduce their alcohol consumption or on how to abstain (an advice handycard was provided for this purpose) and then to provide the patient with a self-help booklet. The 161 physicians who requested the package in the marketing phase and who also agreed to participate in a three month evaluation of their use of Drink-less, were matched on each of the variables described above as well as initial marketing condition into one of three training and support conditions: no support, minimal support and maximal support. An additional sample of physicians was randomly selected to comprise a control condition. The number of physicians assigned to each condition was 35, 45, 40 and 42 for the control, no, minimal and maximal support conditions, respectively. In the control condition, physicians and receptionists had the package delivered to their practice but received no training or support in how to implement Drink-less. In the no-support condition, physicians and receptionists received initial training in the use of the package but no support was provided over the three month program implementation period. In the minimal support condition, initial training as per the no support condition was provided. In addition, data collection reminders were provided to physicians and receptionists by telephone a fortnight after initial training and thereafter to receptionists every two weeks. In the maximal support condition, physicians and receptionists received initial training and ongoing support on program implementation issues through alternate telephone contact and practice visits every two weeks. Advice and support addressed attitudes and beliefs of the GP and receptionist, patient intervention issues, and structural/logistic issues. Measurement Research sta completed monitoring forms and log books to enable the calculation of the major costs of the marketing and training and support conditions. For each strategy there were four stages of work; development, training, piloting and implementation. The development stage involved all aspects related to the development of the marketing and training and support strategies; the training stage involved training sta to implement the protocol relating to strategies; the piloting stage involved further training and familiarization with the proto-
Cost-eective marketing and training strategies in primary care
col and ensuring that there were no practical problems associated with the implementation of strategies and the implementation phase involved the implementation of the ®nal revised strategy.
Costs For this comparative cost analysis, overhead costs, for example, the provision and maintenance of premises, electricity and administration costs were excluded on the basis that they were common to all strategies (Drummond et al., 1994) and costs associated with patients' time were also excluded. Although research costs were monitored and calculated it was not appropriate to include them in cost-eectiveness analyses. The method of cost estimation for each resource input is detailed below. All costs are calculated in Australian dollars. Labour. Labour costs included sta time associated with travelling, making phone calls and the time involved in organising material to be mailed and training received. Sta time was valued as earnings plus oncosts which amounted to $19.05 per hour for research sta and $32.20 per hour for the project director. Because the distance travelled on any one trip to a primary care physician diered between conditions an average travel time per trip to a practice was calculated. This was used for estimating the costs associated with sta travel time for each strategy. The average travel time was derived by summing the time involved in travelling to deliver the Drink-less package to the primary health care physician's practice (training and support phase) for all conditions and dividing this by the sum of the number of trips made across all conditions. Travel costs. These were estimated according to the University of Sydney rate, based on the engine capacity of the car. The rate was $0.41 per km which includes petrol and depreciation for wear and tear. An average travel cost per trip was calculated from the average distance travelled per trip described above and was used for estimating travel costs for each strategy. Telephone costs. All general practices were located within a 45 km radius of the university of Sydney, therefore the cost of a phone call was calculated at the local rate of 25 cents per call. Mail costs. Costs of postage were calculated using 1995 postal charges for varying weights. Consumables. Consumables comprised the major and unique stationery items for the direct mail strategy (promotional brochure) and the academic detailing strategy (compendium and promotional contents). Cost estimates were based on the market price. Costs associated with mailing and phoning were calculated separately (see above) because these comprised major cost elements of the marketing and training and support strategies.
205
Outcomes Phase 1. Uptake rate and recruitment rate were used as the two outcomes for the marketing phase. Uptake rate was the number of physicians requesting the Drink-less intervention package expressed as a percentage of those eligible to receive the package. This was calculated as: No: accepting package 100 No: offered package 1 The recruitment rate was the percentage of physicians agreeing to participate in the training and support phase of the project expressed as a function of the initial uptake rate. Recruitment required a commitment to assist an evaluation of the use of the package over a three month period and was calculated as: No: accepting package No: offered package
No: agree to participate 100 No: eligible to participate 1
Phase 2. Screening rate and intervention rate were used to compare the eectiveness of the training and support interventions. The number of patients screened per 100 physicians and the number of patients drinking at hazardous levels that received brief advice per 100 physicians was used to compare the cost-eectiveness of the interventions. The screening rate was de®ned as the number of patients screened expressed as a percentage of those eligible to be screened. Estimates of the number of people screened were obtained by counting the number of AUDIT questionnaires completed by patients at each practice. The denominator was based on Health Commission data and included all patients (16 years and over) who consulted their general practitioner during the three month study period, excluding repeat visits. The screening rate was calculated for each GP as: No: patients screened 100 No: eligible patients for screening 1 The intervention rate was de®ned as the total number of hazardous drinkers who were advised or given a self-help booklet expressed as a percentage of patients who were estimated to be at risk during the three month study period. The number advised or given a booklet was determined by tallying the number of AUDITS with a ``Y'' or ``N'' in ``counselled'' and ``booklet'' oce use boxes on the AUDIT questionnaire. Because very few physicians screened all eligible patients, it was necessary to estimate the total number of hazardous drinkers consulting their GP over the three months of the program. It was assumed
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that physicians ``actual'' detection rates (No. at risk/No. screened) accurately re¯ected the proportion of hazardous drinkers. This proportion was multiplied by the number of ``patients eligible for screening'' to estimate the total number of hazardous drinkers for the three month period. This assumed that there were minimal biases in the type of patients who were approached for screening. Intervention rate was calculated for each GP as: No: advised 100 Total No: of hazardous drinkers 1
Analysis Forty-eight physicians who did not screen patients had missing values for the number of patients eligible for screening and the proportion of patients who were hazardous drinkers. Missing values for each variable, respectively, were replaced by the grand mean of all physicians: 586.84 and 0.24. Eectiveness. w2 tests were used to compare uptake and recruitment rates for the marketing strategies; tele-marketing and academic detailing were each compared with direct-mail. Mann±Whitney tests were used to compare the eectiveness of the training and support strategies; each strategy was compared with the control condition. Cost-eectiveness. An incremental analysis examined the additional costs to derive additional units of output for each level of the intervention over the comparison group. In the marketing phase the comparison group was the direct mail strategy. In the training and support phase the comparison group was the control condition. In this way a ``usual'' practice condition was compared with more innovative strategies that could potentially be implemented. Incremental cost-eectiveness was calculated as: Cost of strategy ÿ Cost of comparison =Effect of strategy ÿ Effect of comparison: Three separate analyses were undertaken for each outcome measure: one that included all costs including development and training/piloting costs; one that excluded development costs; and one that
excluded both development and training/piloting costs. The results for the marketing phase and the training and support phase are reported separately. Sensitivity analysis. A sensitivity analysis was conducted to examine the eect of two major cost variations. The ®rst was relevant to the marketing phase and included the cost of producing the promotional brochure used in the direct mail strategy. The actual cost of the brochure was $5.07 when the order was for 250 brochures and this costing was used for a worse case scenario. However, in a best case scenario, the cost would be reduced to $1.50 per brochure by increasing the number of brochures to 2000 and using lighter weight paper, a situation that would arise if the brochures were mass produced. The second major cost variant relevant to both the marketing and training and support phase was the distance travelled and the labour costs associated with travel. In this study the average distance travelled per trip was 28.69 km and the average time spent travelling was 44.08 min. This was varied for a best and worse case scenario in which the average distance travelled per trip and the average time spent travelling was either reduced or increased by 30%.
RESULTS
Marketing phase Eectiveness. Uptake rates were signi®cantly higher for the tele-marketing strategy compared with the direct mail strategy (w2=45.56, p = 0.00) and for the academic detailing strategy compared with the direct mail strategy (w2=31.74, p = 0.00). Recruitment rates were also signi®cantly higher for the tele-marketing strategy compared with direct mail (w2=8.70, p = 0.00) and for the academic detailing strategy compared with direct mail (w2=20.51, p = 0.00) (see Table 1). Costs. Table 2 presents three dierent costings for each marketing strategy: all costs; costs excluding development costs; and costs excluding development and training costs. For all three costing outcomes tele-marketing was the least expensive strategy followed by direct mail. Academic detailing was the most expensive strategy.
Table 1. The numbers and percentages of physicians requesting the package and agreeing to participate in the three month training and support trial Strategy Direct mail Tele-marketing Academic detailing a
No. Uptake 119 146 99
No. eligible for uptake 247 182 126
No. agree to participate 44 61 54
Recruitment rateb No. approached to (%) participate Uptake ratea (%) 78 121 84
48.2 80.2 78.6
27.2 40.4 50.5
The number of physicians who accepted a package expressed as a percentage of eligible physicians who were oered the package: No. accepting package/No. eligible for uptake. The number of physicians agreeing to participate in a three month evaluation trial expressed as a function of the percentage of eligible physicians who were oered the package. (No. agree to participate/No. eligible for participation) (No. accepting package/No. oered package).
b
Cost-eective marketing and training strategies in primary care
207
Table 2. Marketing phase Ð The costs associated with each marketing strategy to promote the uptake and participation of physicians
Development stage Training and piloting stage Implementation stagea,b sta labour ±uptake ±participation Travel Postage Telephone ±uptake ±participation Consumables Total costa ±uptake ±participation Cost excluding development costsa ±uptake ±participation Cost excluding development and training/pilot costsa ±uptake ±participation
Direct mail
Tele-marketing
Academic detailing
$700.81 $43.47
$607.25 $254.09
$607.25 $679.79
$243.0 $293.0 $0.0 $112
$166.0
$2759.0
$0.0 $0.0
$1600.0 $0.0
$0.0 $15.0 $651
$50.0
$23.00
$0.0
$227.00
$1750.28 $1815.28
$1077.34
$5896.04
$1049.47 $1114.47
$470.09
$5288.79
$1006.0 $1071.0
$216.00
$4609.0
Cost-eectiveness. Tele-marketing was the most cost-eective strategy to encourage physicians to accept a Drink-less package and was more costeective than direct mail to encourage them to participate in a three month evaluation trial. This was regardless of whether development and/or training and piloting costs were included in the costing of strategies (see Tables 3 and 4). When development and training costs were excluded, tele-marketing cost $24.69 less than the direct mail strategy for each additional GP agreeing to take the package and $64.77 less than direct mail for each GP agreeing to participate in the three month evaluation. Although academic detailing was more eective than direct mail, it was substantially more costly. Academic detailing cost $118.52 more than the direct mail strategy for each additional GP agreeing to take a package and $151.85 more for each additional GP agreeing to participate in the three month evaluation.
Sensitivity analysis. The sensitivity analysis examined best and worse case scenarios for variations in the costs of the marketing conditions after excluding development and training/piloting costs. These scenarios had most of their impact on the academic detailing and direct mail strategies as a result of the costs associated with travel and production of the promotional brochure, respectively. Costs for the tele-marketing strategy were not aected in either of these variations. Based on these best and worse case scenarios, incremental costs per uptake of a package were ÿ$10.77 to ÿ$24.69 for tele-marketing and $87.54 to $161.24 for academic detailing. The best and worse case scenarios for GP participation were ÿ$64.77 to ÿ$37.72 for the tele-marketing and $111.43 to $207.58 for academic detailing. Training and support phase Eectiveness. Table 5 presents the median screening and intervention rates for physicians for each strategy. Compared with the control condition, the
Table 3. Incremental cost eectiveness of marketing strategies for promoting uptake of the package Strategy
Costs per 100 physicians
Eects per 100 physiciansa
All costs included
Incremental C/Eb
Direct mail Tele-marketing Academic detailing
$1750.28 $1077.34 $5896.04
48.2 80.2 78.6
ÿ$21.0 $136.37
Direct mail Tele-marketing Academic detailing
Development costs excluded $1049.47 48.2 $470.09 80.2 $5288.79 78.6
ÿ$18.11 $139.45
Direct mail Tele-marketing Academic detailing a
Development and training/piloting costs excluded $1006.0 48.2 $216.0 80.2 $4609.0 78.6
ÿ$24.69 $118.52
The number of physicians requesting a Drink-less package. The incremental cost-eectiveness of each strategy over direct mail e.g. (cost strategy ÿ cost direct mail)/(eect strategy ÿ eect direct mail).
b
208
M. K. Gomel et al. Table 4. Incremental cost eectiveness of marketing strategies for promoting participation in the three month evaluation. Strategy
Costs per 100 physicians
Eects per 100 physiciansa
All costs included
Incremental C/Eb
Direct mail Tele-marketing Academic detailing
$1815.28 $1077.34 $5896.04
27.2 40.4 50.5
ÿ$55.9 $175.14
Direct mail Tele-marketing Academic detailing
Development costs excluded $1114.47 27.2 $470.09 40.4 $5288.79 50.5
ÿ$48.82 $179.16
Direct mail Tele-marketing Academic detailing
Development and training/piloting costs excluded $1071.0 27.2 $216.0 40.4 $4609.0 50.5
ÿ$64.77 $151.85
a
The number of physicians agreeing to participate in the 3 month training and support phase.
median screening rate was signi®cantly higher for physicians in the no support (Z = 2.03, p = 0.04) and the maximal support (Z = 2.99, p = 0.003) conditions but not for physicians in the minimal support strategy (Z = 1.68, p = 0.09). These results may have been signi®cant if larger sample sizes were used. Compared with the control condition, median advice rates for the estimated total number of hazardous drinkers were signi®cantly higher for physicians in the maximal support strategy (Z = 3.22; p = 0.001) but not for physicians in the no support (Z = 1.89; p = 0.06) or in the minimal support (Z = 1.69; p = 0.09) conditions. Costs. Table 6 presents three dierent costings for each training and support strategy: all costs; costs excluding development costs; and costs excluding development and training costs. For all three costing outcomes the control condition was the least expensive strategy followed by the no support strategy and then the minimal sup-
port strategy. Maximal support was the most expensive strategy. Cost-eectiveness. Cost-eectiveness ratios are presented in Table 7. The general pattern of results remains the same regardless of whether development and/or training and piloting costs were included in the costing of strategies (see Table 7). When development and training costs were excluded the no support strategy cost an extra 12 cents more than the control condition for each additional patient screened or an extra 86 cents for each additional hazardous drinker counselled. Compared to the control condition, minimal support cost an extra 22 cents for each additional patient screened or an additional $1.77 for each hazardous drinker counselled. The costs for additional patients screened and counselled was much higher for the maximal support strategy; each additional patient screened cost 86 cents or each additional hazardous drinkers patient counselled cost $4.70.
Table 5. The number of patients screened and advised and the median screening and intervention rates for training and support conditions
Strategy
No. screened
No. patients eligible for screening
No. advised
Total No. hazardous drinkersa
Median screening rateb
Median intervention ratec
Control 34 physicians 100 physicians
2585 7602.94
18427.14 54197.47
344 1011.76
3807.43 11198.32
0.00
0.00
No support 45 physicians 100 physicians
6952 15448.89
26248.09 58329.09
930 2066.67
7081.47 15736.60
0.14
0.07
Minimal support 40 physicians 100 physicians
6084 15210.0
24879.93 62199.83
789 1972.5
6066.12 15165.3
0.22
0.10
Maximal support 42 physicians 100 physicians
8199 19521
24926.21 59348.12
1346 3204.76
6231.18 14836.14
0.26
0.18
a
Total No. of hazardous drinkers was estimated for each GP on the basis of the actual proportion of hazardous drinkers identi®ed: The calculation was: (No. at risk/No. patients screened) (No. of patients who were eligible for screening). Median screening rate was used in eectiveness analyses. Screening rate was calculated for each GP as: No. patients screened/No. eligible patients for screening. c Median intervention rate was used in eectiveness analyses. Intervention rate was calculated for each GP as: No. advised/total No. of hazardous drinkers. b
Cost-eective marketing and training strategies in primary care
209
Table 6. Training and support phase Ð The costs associated with each training and support strategy to enhance screening and intervention rates Control Development stage Training and piloting stage Implementation stagea, Sta labour Travel Postage Telephone Total cost Total cost excluding development costs Total cost excluding development and training costs
No support
Minimal support
Maximal support
0.0 $0.0
$220.75 $734.42
$2020.0
$2987.0
$3583.0
$8760.0
$1353.0 $123.0 $60.0 $3556.0 $3556.0
$1310.0 $103.0 $66.0 $5421.17 $5200.42
$1386.0 $110.0 $179.0 $6268.61 $6047.86
$4632.0 $305.0 $126.0 $18,014.21 $15,846.56
$3556.0
$4466.0
$5258.0
$13,868.0
Sensitivity analyses. For the training and support phase, best and worse case scenarios were calculated using the 30% decrease and increase in the distance travelled to physicians and the associated sta time involved after excluding development and training costs. The incremental cost-eectiveness per each additional patient screened was 12 to 15 cents for no support; 17 to 27 cents for minimal support and 61 cents to $1.12 for maximal support. The incremental cost-eectiveness per each additional hazardous drinkers patient counselled was 59 cents to $1.13 for no support, $1.37 to $2.17 for minimal support and $3.36 to $6.04 for maximal support.
$220.75 $789.86
$2167.65 $1978.56
DISCUSSION
This study examined the cost-eectiveness of alternative strategies to disseminate a brief intervention program for hazardous alcohol consumption in general practice. In the marketing phase, both telemarketing and academic detailing produced signi®cantly higher uptake and recruitment rates than direct mail, however, tele-marketing was cheaper than both direct mail and academic detailing. When development and training/piloting costs were excluded tele-marketing was $25 cheaper than direct mail per additional physician requesting the Drink-
Table 7. Incremental cost-eectiveness of training and support strategies based on the number of patients screened and the number of hazardous drinkers who were advised Strategy
Costs per 100 physicians
Control
$3,556.0
No support
$5,421.17
Minimal support
$6,268.61
Maximal support
$18,014.21
Control
$3556.00
No support
$5200.42
Minimal support
$6047.86
Maximal support
$15846.56
Control No support Minimal support Maximal support a
Eects per 100 physiciansa (screened, advised)
Incremental C/Eb (screened, advised)
All costs included 7602.94 1011.76 15448.89 2066.67 15210.0 1972.50 19521.0 3204.76
$0.23 $1.77 $0.36 $2.82 $1.21 $6.59
Development costs excluded 7602.94 1011.76 15448.89 2066.67 15210.0 1972.50 19521.0 3204.76
$0.21 $1.56 $0.33 $2.59 $1.03 $5.60
Development and training/piloting costs excluded $3556.00 7602.94 1011.76 $4466.00 15448.89 2066.67 $5258.00 15210.0 1972.50 $13868.0 19521.0 3204.76
$0.12 $0.86 $0.22 $1.77 $0.86 $4.70
The number of patients screened and the number advised. The incremental cost-eectiveness of each strategy over the control condition: (cost of strategy ÿ cost of control)/ (eect of strategy ÿ eect of control).
b
210
M. K. Gomel et al.
less package and $65 cheaper per additional GP agreeing to participate in the evaluation. In contrast, academic detailing was $119 and $152 more expensive than direct mail for each additional physician agreeing to take a package and agreeing to participate in the evaluation. The sensitivity analyses undertaken did not alter the pattern of results. While tele-marketing was more cost-eective than the others for promoting the uptake of the package, a decision about cost-eectiveness of strategies to promote participation in the evaluation can be debated depending on the relative importance the decision maker attributes to variables such as budget constraints and perceived value of the extra bene®ts. The second phase of the project examined the level of support required to enhance screening of patients and the counselling of those found to be at risk of hazardous alcohol consumption. Screening rates were signi®cantly higher for the no support and the maximal support conditions compared with the control condition. Despite the lower screening rates of physicians in the no support strategy compared with the maximal support strategy, the costs of this strategy for enhancing screening rates were considerably lower. The number of patients screened provides one indication of the eect of the training and support interventions. The crucial outcome measure in terms of community impact is the overall number of patients who were identi®ed as hazardous drinkers and advised. When intervention rates were used as the outcome measure, the minimal support condition proved both less eective and more expensive than the no-support condition. As such, minimal support would not be considered to be a cost-eective option. For the remaining three conditions, control, no support and maximal support, both costs and eects increased with the level of support with no change in the pattern of results despite undertaking sensitivity analyses. The issue to be considered is whether the additional cost incurred in moving from one strategy to another is warranted given the increase in the level of outcome. Again, this becomes a decision requiring a value judgment and can not be answered simply from an evaluation of costs and eects. An interesting variation for future research would be to provide training and support via phone contact rather than visits. This variation would reduce the costs associated with travel to the practice and may in¯uence calculations of cost-eectiveness. Alternatively, an additional variation which may prove bene®cial could be a combined strategy in which academic detailing and initial training are provided in one session. This approach would reduce the additional costs required for a separate training visit and could prove more cost-eective than the use of a marketing strategy such as tele-
marketing that is then followed by an initial training session. Although not directly tested the results of the study suggest that this would not prove more cost-eective. After adjusting for the lower rates of participation for tele-marketing compared with academic detailing (40 vs. 50 physicians per 100 physicians approached), it would be necessary to approach 125 physicians with the tele-marketing strategy to achieve the equivalent participation of 50 physicians at a cost of $270. The approximate costs involved for academic detailing with the 50 physicians interested in participating would be $2300 (plus additional measured costs associated with a more lengthy training session for the receptionist and physician). Excluding these additional training costs and also assuming that the same number of patients would be screened and counselled for each strategy, tele-marketing followed by initial training would be more cost eective than an academic detailing strategy which also incorporated the initial training session (costs of $2570 vs. $4609, respectively). Previous studies have used program utilisation measures to assess the eectiveness of marketing strategies (Cockburn et al., 1992). However, in the current study, outcomes for the marketing phase were restricted to measures of uptake and recruitment, and outcomes for the training and support phase involved measures of program utilisation. It is possible that academic detailing on its own (with some modi®cations to the length of the visit to the GP) could have been more cost-eective than direct mail and tele-marketing in enhancing physicians screening and intervention rates. For example in relation to modifying physician prescribing practices, academic detailing has been found to be a more cost-eective strategy when compared with direct mail (Soumerai and Avorn, 1986). Yet in the current study, a comparison of the marketing strategies on measures of program utilisation was not the major question of interest. Based on other work (Davis et al., 1992), it seems that direct mail, and other less intensive strategies are not sucient to aect change in complex counselling behaviours for lifestyle health issues. The results of this study can not be directly compared with others in the literature because it is the ®rst study to examine the cost-eectiveness of marketing strategies and training and support strategies to encourage physicians' uptake and utilisation of a brief intervention package for hazardous alcohol consumption. However, it is of interest that common strategies to disseminate health information to physicians have been to send material/programs through the mail or to use academic detailing. While direct mail is cheaper than academic detailing, its eects have been more limited (Davis et al., 1992). Tele-marketing, a strategy that had not been explored previously was the cheapest strategy while producing equivalent eects to academic detailing.
Cost-eective marketing and training strategies in primary care
Some caution is needed in generalising the results of the study, particularly when a dierent intervention is used or when strategies are implemented in other countries. Firstly, the uptake and utilisation of an intervention will depend on the interest of the physician and the complexity of the intervention that is being disseminated. Secondly, the costs of strategies are likely to vary considerably depending on the country in which they are applied because of the cost dierentials associated with labour, transport, postage and material production costs. The framework used and the results of this research are of relevance to the dissemination and diusion of other health interventions to family physicians. Too often the cheapest strategy is used to promote interventions to physicians without consideration of the eectiveness of the strategy. Failure to achieve widespread change from a preventive intervention can often be attributed to failure at the implementation stage rather than to failure of the intervention. Thus the examination and incorporation of cost-eective dissemination strategies into a strategic plan to implement preventive medicine programs are important considerations for health care services. AcknowledgementsÐFunding for this research was provided by the Research into Drug Abuse Program, Commonwealth Department of Family Services and Health. The Northside Clinic and the Roads and Trac Authority have also provided sponsorship for additional components of the program. We would like to thank Mark Sumich, Lucinda Burns, Christy Chan and Chantal Caviness for their research assistance. Appreciation also goes to Gordon Calcino (Department of Family Services and Health), Martin Boland and Dennis Beissner (Health Insurance Commission) for their assistance with sampling. We would also like to express our gratitude to members of the project Steering Committee: Micheal Mira, Helena Britt, Jill Gordon and Greg Elliot who oered their valuable time and expertise. This study formed the model for strand III of the WHO collaborative study on disseminating early intervention in primary health care. The authors would like to acknowledge the valuable contributions made by the WHO Regional oce for Europe, as well as the support from the 35 collaborating investigators in the WHO study. REFERENCES
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