Michael T. French

BACKGROUND: This report describes the 48-month efficacy and benefit-cost analysis of Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled trial of brief physician advice for the treatment of problem drinking. METHODS: Four hundred eighty-two men and 292 women, ages 18-65, were randomly assigned to a control (n = 382) or intervention (n = 392) group. The intervention consisted of two physician visits and two nurse follow-up phone calls. Intervention components included a review of normative drinking, patient-specific alcohol effects, a worksheet on drinking cues, drinking diary cards, and a drinking agreement in the form of a prescription. RESULTS: Subjects in the treatment group exhibited significant reductions (p < 0.01) in 7-day alcohol use, number of binge drinking episodes, and frequency of excessive drinking as compared with the control group. The effect occurred within 6 months of the intervention and was maintained over the 48-month follow-up period. The treatment sample also experienced fewer days of hospitalization (p = 0.05) and fewer emergency department visits (p = 0.08). Seven deaths occurred in the control group and three in the treatment group. The benefit-cost analysis suggests a 43,000 dollars reduction in future health care costs for every 10,000 dollars invested in early intervention. The benefit-cost ratio increases when including the societal benefits of fewer motor vehicle events and crimes. CONCLUSIONS: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The report suggests that a patient's personal physician can successfully treat alcohol problems and endorses the implementation of alcohol screening and brief intervention in the US health care system.

BACKGROUND: Few studies have estimated the economic costs and benefits of brief physician advice in managed care settings. OBJECTIVE: To conduct a benefit-cost analysis of brief physician advice regarding problem drinking. DESIGN: Patient and health care costs associated with brief advice were compared with economic benefits associated with changes in health care utilization, legal events, and motor vehicle accidents using 6- and 12-month follow-up data from Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled clinical trial. SUBJECTS: 482 men and 292 women who reported drinking above a threshold limit were randomized into control (n = 382) or intervention (n = 392) groups. MEASURES: Outcomes included alcohol use, emergency department visits, hospital days, legal events, and motor vehicle accidents. RESULTS: No significant differences between control and intervention subjects were present for baseline alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorders, drug use, crimes, motor vehicle accidents, or health care utilization. The total economic benefit of the brief intervention was $423,519 (95% CI: $35,947, $884,848), composed of $195,448 (95% CI: $36,734, $389,160) in savings in emergency department and hospital use and $228,071 (95% CI: -$191,419, $757,303) in avoided costs of crime and motor vehicle accidents. The average (per subject) benefit was $1,151 (95% CI: $92, $2,257). The estimated total economic cost of the intervention was $80,210, or $205 per subject. The benefit-cost ratio was 5.6:1 (95% CI: 0.4, 11.0), or $56,263 in total benefit for every $10,000 invested. CONCLUSIONS: These results offer the first quantitative evidence that implementation of a brief intervention for problem drinkers can generate positive net benefit for patients, the health care system, and society.

Although fixed-effects models for panel data are now widely recognized as powerful tools for longitudinal data analysis, the limitations of these models are not well known. We provide a critical discussion of 12 limitations, including a culture of omission, low statistical power, limited external validity, restricted time periods, measurement error, time invariance, undefined variables, unobserved heterogeneity, erroneous causal inferences, imprecise interpretations of coefficients, imprudent comparisons with cross-sectional models, and questionable contributions vis-à-vis previous work. Instead of discouraging the use of fixed-effects models, we encourage more critical applications of this rigorous and promising methodology. The most important deficiencies—Type II errors, biased coefficients and imprecise standard errors, misleading p values, misguided causal claims, and various theoretical concerns—should be weighed against the likely presence of unobserved heterogeneity in other regression models. Ultimately, we must do a better job of communicating the pitfalls of fixed-effects models to our colleagues and students.

Economic evaluation methods for telemedicine include cost analysis, cost-effectiveness analysis, and benefit–cost analysis (BCA). Each has its strengths and weaknesses and often they don't give a complete picture. BCA is the most comprehensive of these three tools. A review of the literature was conducted to determine what has been done and what has not been done. The result of this review provides research guidelines for conducting BCA and introduces specific recommendations for future research. Telemedicine programs provide specialty health services to remote populations using telecommunications technology. This innovative approach to medical care delivery has been expanding for several years and currently covers various specialty areas such as cardiology, dermatology, and pediatrics. Economic evaluations of telemedicine, however, remain rare, and few of those conducted have accounted for the wide range of economic costs and benefits. Rigorous benefit–cost analyses of telemedicine programs could provide credible and comparative evidence of their economic viability and thus lead to the adoption and/or expansion of the most successful programs. To facilitate more advanced economic evaluations, this article presents research guidelines for conducting benefit–cost analyses of telemedicine programs, emphasizing opportunity cost estimation, commonly used program outcomes, and monetary conversion factors to translate outcomes to dollar values. The article concludes with specific recommendations for future research.