Economic Evaluation of Internet-Based Interventions for Harmful

Original Paper

Economic Evaluation of Internet-Based Interventions for Harmful Alcohol Use Alongside a Pragmatic Randomized Controlled Trial

Matthijs Blankers^1,2, PhD; Udo Nabitz¹, PhD; Filip Smit^3,4, PhD; Maarten WJ Koeter², PhD; Gerard M Schippers², PhD

¹Department Jellinek, Arkin Mental Health Care, Amsterdam, Netherlands
²Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
³Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
⁴EMGO Institute, Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, Netherlands

Corresponding Author:
Matthijs Blankers, PhD

Department Jellinek
Arkin Mental Health Care
PO Box 75848
Amsterdam, 1070 AV
Netherlands
Phone: 31 611785270
Fax: 31 205905692
Email:

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ABSTRACT

Background: Internet interventions with and without therapist support have been found to be effective treatment options for harmful alcohol users. Internet-based therapy (IT) leads to larger and longer-lasting positive effects than Internet-based self-help (IS), but it is also more costly to provide.
Objective: To evaluate the cost effectiveness and cost utility of Internet-based interventions for harmful use of alcohol through the assessment of the incremental cost effectiveness of IT compared with IS.
Methods: This study was performed in a substance abuse treatment center in Amsterdam, the Netherlands. We collected data over the years 2008?2009. A total of 136 participants were included, 70 (51%) were female, and mean age was 41.5 (SD 9.83) years. Reported alcohol consumption and Alcohol Use Disorders Identification Test (AUDIT) scores indicated harmful drinking behavior at baseline. We collected self-reported outcome data prospectively at baseline and 6 months after randomization. Cost data were extracted from the treatment center?s cost records, and sex- and age-specific mean productivity cost data for the Netherlands.
Results: The median incremental cost-effectiveness ratio was estimated at ?3683 per additional treatment responder and ?14,710 per quality-adjusted life-year (QALY) gained. At a willingness to pay ?20,000 for 1 additional QALY, IT had a 60% likelihood of being more cost effective than IS. Sensitivity analyses attested to the robustness of the findings.
Conclusions: IT offers better value for money than IS and might therefore be considered as a treatment option, either as first-line treatment in a matched-care approach or as a second-line treatment in the context of a stepped-care approach.
Trial Registration: Netherlands Trial Register NTR-TC1155; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1155 (Archived by WebCite at http://www.webcitation.org/6AqnV4eTU)

(J Med Internet Res 2012;14(5):e134)
doi:10.2196/jmir.2052

KEYWORDS

Cost-benefit analysis; randomized controlled trial; alcohol-induced disorders; self-help; computer-assisted therapy

Harmful alcohol use is the number-3 leading contributor to global burden of disease [1] and causes 3.8% of global mortality [2], as well as losses in gross domestic product [3]. The majority of people with alcohol use disorders are not receiving any form of treatment, leading to a treatment gap [4]. Among the possible means of bridging this treatment gap is the use of accessible and efficient treatment, delivered over the Internet. Internet interventions with and without therapist support [5-8] have been found to be effective treatment options for harmful alcohol users and could perhaps be used sequentially in a stepped-care format. Internet-based therapy (IT) leads to larger and longer-lasting positive effects than Internet-based self-help (IS) in the treatment of depression [9,10], anxiety [10,11], and problem drinking [8]. However, IT is more costly to provide and more demanding for both participants and therapists. Thus, the research question is, ?Does the additional positive result of therapist support outweigh its additional cost?? We present an economic evaluation assessing the cost effectiveness and cost utility of IT compared with IS for harmful alcohol use. Recently, studies have been published on the cost effectiveness of Internet-based (self-help) interventions for depression [12], weight management [13], and harmful alcohol use [14]. The cost effectiveness of therapist support in Internet-based alcohol interventions has not yet been supported, however.

Study Design and Participants

We collected data for the cost effectiveness analysis alongside a pragmatic randomized controlled trial on the effectiveness of IT relative to IS and a waiting list, conducted in the Netherlands in 2008?2009. Because in economic evaluation the preferred comparison is between the intervention of interest (IT) and its best alternative, in this case IS, we do not present waiting list data in this paper.

We recruited applicants through jellinek.nl, a substance abuse treatment center website with 650,000 visitors annually [8]. For inclusion, applicants had to (1) be between 18 and 65 years old, (2) live in the Netherlands with health care insurance coverage, (3) have Internet access at home, (4) score above 8 on the Alcohol Use Disorders Identification Test (AUDIT) [15], (5) report a weekly consumption of more than 14 standard (10 g ethanol) drinking units, and (6) provide informed consent. Exclusion criteria were (1) prior substance abuse treatment, (2) a history of alcohol delirium or drug overdose, (3) a history of severe cardiovascular or gastrointestinal diseases, (4) a history of schizophrenia, epilepsy, or suicidal tendencies, (5) extensive substance use in the last month, and (6) unavailability of more than 2 weeks during the study. Of the 1720 who were assessed, 832 applicants were eligible for inclusion; 205 participants were included. Compared with all 832 eligible applicants, the 205 included participants reported somewhat higher baseline AUDIT scores, but this difference was not significant (mean 18.9, SD 4.98 vs mean 19.5, SD 5.13, t₂₀₄ = 1.617, P = .11). In the IT group, 48 received the allocated intervention, that is, they participated in treatment exercises and chat therapy. In IS, 57 received the intervention, which consisted of exercises only. Outcome data were collected at baseline, 3 months, and 6 months after randomization (Figure 1). The study design [16] and outcomes of the randomized controlled trial [8] were published elsewhere.

Interventions

Both IT and IS were based on a cognitive behavioral therapy and motivational interviewing treatment protocol [17]. In IS, participants were introduced to various treatment exercises. Without a therapist?s support, participants acquired skills and knowledge about coping with craving, drinking lapses, and peer pressure. IT was driven by 7 synchronous text-based chat-therapy sessions with a personal (Internet) cognitive behavioral therapy-trained therapist, lasting 40 minutes each, and accompanied by homework assignments. Each of the chat-therapy sessions had its own theme: monitoring and goal setting, self-control, and relapse prevention, for example.

Cost Measures

In this economic evaluation, we used the societal perspective. All costs related to IT and IS interventions, health care uptake, opportunity costs of the participant?s time, and productivity losses were included. All costs (Table 1) are expressed in euros and were indexed to the reference year 2010 using an inflation correction based on the Harmonized Index of Consumer Prices (HICP) [18].

Source: http://www.jmir.org/2012/5/e134/

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