PhD thesis by Bolette Pedersen
A high alcohol intake increases the risk of complications after surgery and treatment is resourceintensive. It has been estimated that the annual extra costs of alcohol-related complications in surgery is about €29 to 48 per capita in Denmark. No studies have previously investigated the cost and cost-effectiveness of alcohol cessation intervention in acute fracture surgery. This PhD thesis concerned a larger Scandinavian research programme Scand-Ankle. One of the aims of the programme is to evaluate the effect of a new Gold Standard Programme for alcohol cessation intervention (GSP-A) for patients in acute fracture surgery regarding postoperative complications, alcohol intake and cost-effectiveness in a randomised design (RCT).
The thesis was based on three studies; a systematic review of the efficacy of disulfiram (DIS) for patients with alcohol use disorders (AUD), an interview study on patient approaches to the GSP-A in relation to surgery and a cost-effectiveness study of the GSP-A at the time of acute fracture surgery.
Eleven RCTs were included in the systematic review. Most studies showed that supervised DIS had a significant effect on short-term abstinence, whereas the long-term effect on abstinence was unknown. The interview study was conducted prior to the RCT and included patients with a high alcohol intake undergoing fracture surgery. The study clarified that all patients found alcohol cessation intervention relevant in relation to surgery, and about half of the patients were ready or partly ready to participate in the GSP-A. Findings from these two studies - and existing evidence from GSP for smoking cessation intervention - were used to describe the 6-week GSP-A; a structured education programme with weekly visits (5 in total) supported by DIS, B vitamins and alcohol withdrawal prophylaxis.
The GSP-A has now showed a significant effect on the number of abstainers in the 6-week perioperative period; 58% in the intervention versus 14% in the control group. The health economic evaluation was based on the first 46 randomised ankle fracture patients from Bispebjerg and Hvidovre University Hospitals included in the effect evaluation of the GSP-A on perioperative abstinence. The incremental cost-effectiveness analysis on the direct and indirect costs in the 6- week perioperative period showed that the GSP-A was less expensive than treatment as usual; €16,957 versus €19,212 with an insignificant (p=0.359) average reduction in costs per patient of €2,255 (95% CI: €-6,852 to 1,625). The difference was mainly due to lower hospital costs in the intervention group; €13,647 versus €16,034, but not significantly so (p=0.337). The incremental cost-effectiveness ratio (ICER) was €-5,425 per patient achieving abstinence. Furthermore, the analyses revealed that the GSP-A was less costly and more effective in more than 90% of the cases. For a willingness to pay up to €5,000 the probability that the GSP-A was cost-effective was almost 100%. Future data collection in the Scand-Ankle study will conclude on the cost- effectiveness of the GSP-A on postoperative complications, alcohol intake on longterm as well as health-related quality of life (cost-utility).