The relationship between alcohol consumption and self-reported health status using the EQ5D: Evidence from rural Australia

doi:10.1016/j.socscimed.2008.09.017

Social Science & Medicine

Volume 67, Issue 11, December 2008, Pages 1717-1726

https://doi.org/10.1016/j.socscimed.2008.09.017 Get rights and content

Abstract

Alcohol misuse represents one of the leading causes of preventable death, illness and injury in Australia. Extensive research exists estimating the effect of risky alcohol use on mortality, but little research quantifies the impact of risky alcohol consumption on morbidity. Such estimates are required to more precisely measure the benefit of interventions aimed at reducing risky alcohol use. Ordered probit and tobit models are used in this research to analyse the impact of risky drinking on self-reported health status using questionnaire data from an age and gender stratified sample drawn from 20 rural communities in New South Wales which are part of a large randomised controlled trial of community based alcohol interventions. It is found that risky alcohol use is associated with lower self-reported health; however, the average effect is small apart for those drinking at very-high risk. The effect of alcohol on morbidity, derived from the current analyses, is lower than that commonly used in current economics analyses. If this is accurate for geographical regions other than rural Australia, then from a policy viewpoint, these economic analyses may tend to overemphasise interventions which are morbidity reducing, such as taxation, and place undue focus on alcohol as a risk factor and consequently adversely impact resource allocation decisions.

Introduction

The relationship between alcohol consumption and health is complex and multidimensional. Despite evidence of a positive effect on Coronary Heart Disease (CHD), stroke and diabetes mellitus associated with light to moderate regular drinking, the major body of evidence suggests alcohol misuse represents a preventable risk factor for death, illness and injury (Babor, Caetano, & Casswell, 2003). In Australia in 2003, for example, high alcohol dependence contributed to over a third of alcohol related harm (Begg et al., 2007).

Although a number of studies have quantified rates of alcohol related mortality (English et al., 1995, Holman et al., 1990, Ridolfo and Stevenson, 2001), estimates of alcohol related morbidity are more limited (Rehm, Gmel, Sempos, & Trevisan, 2003a). One study which did look at non-fatal health outcomes found a J-shaped relationship between alcohol intake and probability of self-reported suboptimal health (Poikotainen, Vartianen, & Korhonen, 1996).

Economic evaluations of interventions aimed at reducing alcohol harms typically estimate the impact of alcohol morbidity in terms of quality adjusted life years (QALY's) lost or alternatively disability adjusted life years (DALY's) gained (Drummond, O'Brien, Stoddart, & Torrance, 1997). One method of quantifying alcohol related DALY's involved a panel of medical experts estimating the extent to which excessive alcohol use contributes to a range of health states, using the person trade off technique (Stouthard et al., 1997). Their estimate, effectively a weight for the effect of alcohol misuse on morbidity, represents the amount of time spent in full health which is equivalent to spending 1 year in the diseased state. The weight for problem drinking (including physical and psychological problems caused by excessive alcohol intake) was found to be 0.89 (95% CI: 0.85–0.94), implying that problem drinkers' quality of life is, on average, reduced by 11%, compared with non-problem drinkers. The wide variance around this estimate reflects both the large variation in responses and the relatively small number of experts involved; these estimates are being updated as part of the global burden of disease study.

A further problem with these estimates, commonly referred to as the ‘Dutch Weights’, is that no classification exists to assign individuals as problem drinkers based on their level of alcohol consumption, or other commonly measured dimensions of alcohol use, such as dependence. Nevertheless the Dutch Weights, representing one of the only consistent data sets available, continue to be used in major economic and epidemiological studies (Chisholm et al., 2004, Mathers et al., 2001, Mortimer and Segal, 2006).

As an alternative to experts' opinions, the current study uses self-reported data on health and alcohol use from individuals in rural Australia, to estimate the morbidity associated with their alcohol use. This study has four aims. Firstly, to identify the alcohol risk level and health status of individuals in a number of rural communities in NSW, Australia. Secondly, to examine the differences in mean health status across different alcohol risk levels. Thirdly, to identify which health domains are affected by alcohol risk status. Fourthly, to quantify the effect of alcohol risk level on quality of life in rural Australia.

Section snippets

Study sample

This research was conducted as part of the Alcohol Action in Rural Communities (AARC) project, a randomised controlled trial of community based alcohol interventions being conducted in 20 rural communities in New South Wales, Australia. A questionnaire was mailed to 8000 individuals from the 20 participating communities, in March 2005. Items related to health status, patterns and frequency of alcohol consumption, demographics and other relevant variables.

The population was stratified by gender

Demographics

Of the 7985 questionnaires received by participants, 3017 (38%) were returned with usable responses. The response rate and sample size for each age/gender group are given in Table 1. Females and older individuals responded more often. The overall response rate is lower than for the Australian National Drug Strategy Household Survey (NDSHS) which used a combination of drop & collect (48% response rate) and telephone interview (38% response rate) techniques (Australian Institute of Health and

Discussion

This study has examined the differences in mean health status across different alcohol risk levels using self-reported data from individuals in rural Australia. Before considering the main findings of this research, a number of caveats are worth noting.

Firstly, since the study relies on self-reported alcohol use and health ratings, drinking levels may have been underestimated (social desirability bias) and reported health levels may vary between individuals with the same health state

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However, the generic scales cited focus on evaluating the effects of alcohol misuse on HRQL and they ignore other intangible effects (family breakdown, social isolation, etc.), which may even have a greater impact on QoL than do health problems.3,4,21,22 This narrow focus can lead to a large underestimation of the impact of different scenarios of alcohol misuse and could explain the lack of responsiveness of these generic HRQL scales in detecting meaningful changes in QoL found in the empirical literature.18–20,14 In this line of reasoning, the suitability of these generic scales to measure the impact of alcohol misuse has been questioned.23
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Our findings confirm the benefits of adopting a heterogeneous approach to measure the effects of alcohol misuse. The estimated utilities could have both clinical and economic applications.
Estimar los efectos intangibles del consumo abusivo de alcohol en la calidad de vida del bebedor, según las preferencias sociales.
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Nuestros resultados confirman la conveniencia de adoptar un enfoque heterogéneo para medir los efectos del abuso del alcohol. Las utilidades estimadas podrían tener aplicaciones tanto clínicas como económicas.
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The EQ-5D and SF-6D are widely used generic HRQOL measures for deriving preference weights for physical and mental health conditions (Roberts et al., 2014; Sullivan et al., 2005), but few population-based studies have used them to report preference weights for differing levels of alcohol consumption. EQ-5D preference weights have been reported for alcohol use categories among study samples from rural Australia (Petrie et al., 2008), England (Essex et al., 2014; Maheswaran et al., 2013), and Finland (Saarni et al., 2008). In these studies, associations between EQ-5D preference weights and alcohol use were mixed—two studies found high-risk drinking was associated with lower preference weights (Essex et al., 2014; Petrie et al., 2008), while others did not (Maheswaran et al., 2013; Saarni et al., 2008).
Little is known about the cost-utility of population-based alcohol interventions. One barrier to research has been the lack of preference weights needed to calculate Quality Adjusted Life Years (QALYs). Preference weights can be estimated from measures of health-related quality of life (HRQOL). The objective of this study was to describe preference weights for the full spectrum of alcohol use.
This cross-sectional study included participants in both the National Health Interview Survey (NHIS; 1999–2002) and the Medical Expenditure Panel Survey (MEPS; 2000–2003). The AUDIT-C alcohol screen was derived from NHIS with scores categorized into 6 groups (0,1–3, 4–5, 6–7, 8–9, 10–12 points), ranging from nondrinking (0) to very severe unhealthy alcohol use (10–12). AUDIT-C scores were mapped to EQ-5D and SF-6D preference weights using the linked datasets and analyses adjusted for demographics.
Among 17,440 participants, mean EQ-5D and SF-6D preference weights were 0.82 (95% CI 0.82–0.83) and 0.79 (95% CI 0.79–0.80), respectively. Adjusted EQ-5D preference weights for nondrinking (0.80; 95% CI 0.79–0.81) and moderate unhealthy drinking (0.85; 95% CI 0.84–0.86) were significantly different from low-risk drinking (0.83; 95% CI 0.83–0.84), but no other differences were significant. Results for the SF-6D were similar.
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The cost-effectiveness of alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency and outpatient medical settings
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In addition, new abstainers have a lower utility than new below threshold drinkers, which can be because those who abstain now had more problems in the past and so still have lower utility, or/and reduced drinking is a better outcome than abstinence. The finding that those with more serious past problems had a lower utility than those with less serious past problems is consistent with the only other study that reported utility levels for different levels of alcohol consumption (Petrie et al., 2008). To collect data on social costs events (e.g., nights in jail) for the 6 months before and 6 months after SBIRT services, the research team conducted a separate survey of a subsample of patients (Bray et al., 2007).
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To examine the extent to which individual‐ and community‐ level characteristics account for differences in risky alcohol consumption.
A cross‐sectional postal survey of 2,977 randomly selected individuals from 20 regional communities in NSW, Australia. Individuals drinking at harmful levels on the AUDIT and for risk of harm in the short term and long‐term were identified. Multi‐level modelling of the correlates of risky alcohol consumption at the individual and community level was conducted.
There were differences between communities in alcohol consumption patterns. Being male, unmarried and reporting worse health were significant individual‐level correlates for drinking at levels for risk of harm in the long term. The number of GPs (+) and police (‐) were significant community characteristics. Being younger (≤25), unmarried, Australian born and with a larger income was associated with drinking at levels for risk of harm in the short term and harmful drinking on the AUDIT. The number of hotels and clubs was positively associated with drinking at levels for risk of harm in the short term.
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Third, the potential number of dependent drinkers was estimated using self-reported alcohol consumption on the AUDIT questionnaire in the AARC community survey. Given a response rate of 40% to this survey respondents may not be representative of their communities, since females and older people are overrepresented in the sample (Petrie et al., 2008), and those who completed the survey may under-report their drinking. Nevertheless, previous surveys have reported similar prevalence rates of alcohol dependence for males and females in Australia (Hall et al., 1999; Proudfoot and Teesson, 2002) and these survey data were not used to evaluate the effectiveness or cost-effectiveness of the intervention.
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Rural communities in New South Wales, Australia, were randomised into experimental (N = 10) and control (N = 10) communities. Tailored feedback on their prescribing of alcohol pharmacotherapies was mailed to GPs from the experimental communities (N = 115). Segmented regression analysis was used to examine within and between group changes in prescribing and alcohol dependence hospitalisation rates compared to the control communities. Incremental cost-effectiveness ratios (ICERs) were estimated per additional prescription of pharmacotherapies and per alcohol dependence hospitalisation(s) averted.
Post-intervention changes, relative to the control communities, in GPs’ prescribing rate trends in the experimental communities significantly increased for acamprosate (β = 0.24, 95% CI: 0.13–0.35, p < 0.001), and significantly decreased for naltrexone (β = −0.12, 95% CI: −0.17 to −0.06) per quarter. Quarterly hospitalisation trend rates for alcohol dependence, as principal diagnosis, significantly decreased (β = −0.07, 95% CI: −0.13 to −0.01, p < 0.05), compared to control communities. The median ICER per quarterly hospitalisation(s) averted due to intervention was Dominant (Dominant – $12,750).
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The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: Evidence from rural Australia
2011, Addictive Behaviors
This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice.
A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia.
Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and BI are increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197.
These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.

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^☆: This research was conducted as part of a larger study, the Alcohol Action in Rural Communities (AARC) project (ACTRN012607000123448) which was funded by a grant from the Alcohol Education and Rehabilitation Foundation (AERF). The authors would like to thank Courtney Breen for coordination of survey development and data collection, Derek Headey, the AARC investigators and three anonymous reviewers for their expert advice. The usual disclaimer applies.

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The relationship between alcohol consumption and self-reported health status using the EQ5D: Evidence from rural Australia☆

Abstract

Introduction

Section snippets

Study sample

Demographics

Discussion

Journal of Health Economics

2004 National Drug Strategy Household Survey: first results

Alcohol: No ordinary commodity—A consumer's guide to public policy

AUDIT: The Alcohol Use Disorder Identification Test: Guidelines for use in primary health care

The burden of disease and injury in Australia 2003

Prospective study of moderate alcohol consumption and mortality in US male physicians

Archives of Internal Medicine

Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis

Journal of Studies on Alcohol

Adolescent onset of the gender difference in lifetime rates of major depression

Archives of General Psychiatry

Prospective study of depression and risk of heavy alcohol use in women

American Journal of Psychiatry

Researching the rural-metropolitan health differential using ‘social determinants of health’

Australian Journal of Rural Health

Mortality in relation to smoking: 50 years' observations on male British doctors

British Medical Journal

Methods for the economic evaluation of health care programmes