Cost-Effectiveness of Screening for Unhealthy Alcohol Use with %Carbohydrate Deficient Transferrin: Results From a Literature-Based Decision Analytic Computer Model

Authors

  • Alok Kapoor,

    1. From the Hospital Medicine Unit, Section of General Internal Medicine (AK), Boston Medical Center, Boston, Massachusetts; Division of General Internal Medicine, University of Pittsburgh School of Medicine (KLK, KJS, MSR), Pittsburgh, Pennsylvania; Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine (KJS, MSR), Pittsburgh, Pennsylvania; and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, and Department of Epidemiology and Youth Alcohol Prevention Center, Boston University School of Public Health (RS), Boston, Massachusetts.
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  • Kevin L. Kraemer,

    1. From the Hospital Medicine Unit, Section of General Internal Medicine (AK), Boston Medical Center, Boston, Massachusetts; Division of General Internal Medicine, University of Pittsburgh School of Medicine (KLK, KJS, MSR), Pittsburgh, Pennsylvania; Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine (KJS, MSR), Pittsburgh, Pennsylvania; and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, and Department of Epidemiology and Youth Alcohol Prevention Center, Boston University School of Public Health (RS), Boston, Massachusetts.
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  • Kenneth J. Smith,

    1. From the Hospital Medicine Unit, Section of General Internal Medicine (AK), Boston Medical Center, Boston, Massachusetts; Division of General Internal Medicine, University of Pittsburgh School of Medicine (KLK, KJS, MSR), Pittsburgh, Pennsylvania; Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine (KJS, MSR), Pittsburgh, Pennsylvania; and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, and Department of Epidemiology and Youth Alcohol Prevention Center, Boston University School of Public Health (RS), Boston, Massachusetts.
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  • Mark S. Roberts,

    1. From the Hospital Medicine Unit, Section of General Internal Medicine (AK), Boston Medical Center, Boston, Massachusetts; Division of General Internal Medicine, University of Pittsburgh School of Medicine (KLK, KJS, MSR), Pittsburgh, Pennsylvania; Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine (KJS, MSR), Pittsburgh, Pennsylvania; and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, and Department of Epidemiology and Youth Alcohol Prevention Center, Boston University School of Public Health (RS), Boston, Massachusetts.
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  • Richard Saitz

    1. From the Hospital Medicine Unit, Section of General Internal Medicine (AK), Boston Medical Center, Boston, Massachusetts; Division of General Internal Medicine, University of Pittsburgh School of Medicine (KLK, KJS, MSR), Pittsburgh, Pennsylvania; Section of Decision Sciences and Clinical Systems Modeling, University of Pittsburgh School of Medicine (KJS, MSR), Pittsburgh, Pennsylvania; and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, and Department of Epidemiology and Youth Alcohol Prevention Center, Boston University School of Public Health (RS), Boston, Massachusetts.
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Reprint requests: Alok Kapoor, 801 Massachusetts Avenue – Second Floor, Boston, MA 02118; Fax: 617-414-4676; E-mail: alok.kapoor@BMC.org

Abstract

Background:  The %carbohydrate deficient transferrin (%CDT) test offers objective evidence of unhealthy alcohol use but its cost-effectiveness in primary care conditions is unknown.

Methods:  Using a decision tree and Markov model, we performed a literature-based cost-effectiveness analysis of 4 strategies for detecting unhealthy alcohol use in adult primary care patients: (i) Questionnaire Only, using a validated 3-item alcohol questionnaire; (ii) %CDT Only; (iii) Questionnaire followed by %CDT (Questionnaire-%CDT) if the questionnaire is negative; and (iv) No Screening. For those patients screening positive, clinicians performed more detailed assessment to characterize unhealthy use and determine therapy. We estimated costs using Medicare reimbursement and the Medical Expenditure Panel Survey. We determined sensitivity, specificity, prevalence of disease, and mortality from the medical literature. In the base case, we calculated the incremental cost-effectiveness ratio (ICER) in 2006 dollars per quality-adjusted life year ($/QALY) for a 50-year-old cohort.

Results:  In the base case, the ICER for the Questionnaire-%CDT strategy was $15,500/QALY compared with the Questionnaire Only strategy. Other strategies were dominated. When the prevalence of unhealthy alcohol use exceeded 15% and screening age was <60 years, the Questionnaire-%CDT strategy costs less than $50,000/QALY compared to the Questionnaire Only strategy.

Conclusions:  Adding %CDT to questionnaire-based screening for unhealthy alcohol use was cost-effective in our literature-based decision analytic model set in typical primary care conditions. Screening with %CDT should be considered for adults up to the age of 60 when the prevalence of unhealthy alcohol use is 15% or more and screening questionnaires are negative.

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