Fetal alcohol spectrum disorder: a systematic review of the cost of and savings from prevention in the United States and Canada.

BACKGROUND AND AIMS: Fetal alcohol spectrum disorder (FASD) is a preventable condition that imposes a significant financial burden on societies. Funding of FASD prevention is a small portion of the total expenditures associated with FASD. This paper aimed to review the literature on the costs of and savings from prevention of FASD and present a model for the United States and Canada of projected savings based on expansion of existing evidence-based prevention models. METHODS: A systematic review of published literature on the cost of FASD prevention was conducted and experts in the field were interviewed. Studies that reported the cost of primary prevention of FASD were eligible for further consideration. RESULTS: Applying evidenced-based prevention programs to women at highest risk to have a future child with FASD greatly reduces the cost of prevention. In the United States, one case of FASD can be prevented for as little as USD $20 200 - 47 615. Cost of prevention is considerably less expensive than cost of care for a case of FASD. CONCLUSION: Expansion of risk-based prevention strategies for fetal alcohol spectrum disorder in the United States and Canada would be an economically efficient and worthwhile investment for society.

A Multicountry Updated Assessment of the Economic Impact of Fetal Alcohol Spectrum Disorder: Costs for Children and Adults.

AIM: To conduct a systematic review and quantitative analysis of the world literature on the economic impact of fetal alcohol spectrum disorder (FASD). METHODS: A comprehensive literature review was conducted using multiple electronic databases and reference materials. RESULTS: Thirty-two studies from 4 countries met the inclusion criteria (United States [n = 20], Canada [n = 9], Sweden [n = 2], and New Zealand [n = 1]). The studies reported the economic impact of FASD on health care, special education, residential care, criminal justice system, productivity losses due to morbidity and premature mortality, productivity losses of caregivers of children with FASD, and intangible costs. The economic estimates vary considerably due to the different methodologies used by different studies. The mean annual cost for children with FASD was estimated to be $22,810 and for adults $24,308. Residential costs for children with FASD were 4-fold greater than for adults with FASD. The costs of lost productivity for adults were 6.3-fold greater than for children. CONCLUSIONS: The data on the economic burden of FASD are scarce, and the existing estimates likely underestimate the full economic impact of this disorder on the affected individuals, their caregivers, and society. However, the current research is sufficient to demonstrate that FASD is a serious public health problem associated with tremendous economic burden.

Counting the costs of drinking alcohol during pregnancy.

Researchers are starting to shed light on the true extent of alcohol consumption during pregnancy. Svetlana Popova talks to Fiona Fleck.

Societal costs of fetal alcohol syndrome in Sweden.

OBJECTIVE: To estimate the annual societal cost of fetal alcohol syndrome (FAS) in Sweden, focusing on the secondary disabilities thought feasible to limit via early interventions. METHODS: Prevalence-based cost-of-illness analysis of FAS in Sweden for 2014. Direct costs (societal support, special education, psychiatric disorders and alcohol/drug abuse) and indirect costs (reduced working capacity and informal caring), were included. The calculations were based on published Swedish studies, including a register-based follow-up study of adults with FAS, reports and databases, and experts. RESULTS: The annual total societal cost of FAS was estimated at €76,000 per child (0-17 years) and €110,000 per adult (18-74 years), corresponding to €1.6 billion per year in the Swedish population using a prevalence of FAS of 0.2 %. The annual additional cost of FAS (difference between the FAS group and a comparison group) was estimated at €1.4 billion using a prevalence of 0.2 %. The major cost driver was the cost of societal support. CONCLUSIONS: The cost burden of FAS on the society is extensive, but likely to be underestimated. A reduction in the societal costs of FAS, both preventive and targeted interventions to children with FAS, should be prioritized. That is, the cost of early interventions such as placement in family homes or other forms of housing, and special education, represent unavoidable costs. However, these types of interventions are highly relevant to improve the individual's quality of life and future prospects, and also, within a long-term perspective, to limit the societal costs and personal suffering.

The Economic Burden of Fetal Alcohol Spectrum Disorder in Canada in 2013.

AIM: To estimate the economic burden and cost attributable to Fetal Alcohol Spectrum Disorder (FASD) in Canada in 2013. METHODS: This cost-of-illness study examined the impact of FASD on the material welfare of the Canadian society in 2013 by analyzing the direct costs of resources expended on health care, law enforcement, children and youth in care, special education, supportive housing, long-term care, prevention and research, as well as the indirect costs of productivity losses of individuals with FASD due to their increased morbidity and premature mortality. RESULTS: The costs totaled approximately $1.8 billion (from about $1.3 billion as the lower estimate up to $2.3 billion as the upper estimate). The highest contributor to the overall FASD-attributable cost was the cost of productivity losses due to morbidity and premature mortality, which accounted for 41% ($532 million-$1.2 billion) of the overall cost. The second highest contributor to the total cost was the cost of corrections, accounting for 29% ($378.3 million). The third highest contributor was the cost of health care at 10% ($128.5-$226.3 million). CONCLUSIONS: FASD is a significant public health and social problem that consumes resources, both economic and societal, in Canada. Many of the costs could be reduced with the implementation of effective social policies and intervention programs.

Costs of Fetal Alcohol Spectrum Disorder in the Canadian Criminal Justice System.

We reviewed literature to estimate the costs of Fetal Alcohol Spectrum Disorder (FASD) in the Canadian Criminal Justice System (CJS), and to update the total costs of FASD in Canada. The results suggest FASD is costlier than previous estimates. The costs of FASD associated with the CJS are estimated at $3.9 billion a year, with $1.2 billion for police, $0.4 billion for court, $0.5 billion for correctional services, $1.6 billion for victims, and $0.2 billion for third-party. The updated total costs of FASD in Canada are $9.7 billion a year, of which CJS accounts for 40%, healthcare 21%, education 17%, social services 13%, and others 9%.

The cost of lost productivity due to fetal alcohol spectrum disorder-related premature mortality.

BACKGROUND: Individuals with Fetal Alcohol Spectrum Disorder (FASD) have increased mortality as compared to the general population. OBJECTIVES: To estimate the productivity losses due to premature mortality of individuals with FASD in Canada in 2011. METHODS: A demographic approach with a counterfactual scenario in which nobody in Canada is born with FASD was used. Population estimates were calculated using data on the labour force, unemployment rate, and average weekly wage obtained from Statistics Canada. The number of FASD-related deaths, coded in the International Classification of Diseases, version 10, was estimated based on data from Statistics Canada and pooled prevalence estimates of the major disease conditions associated with FASD were obtained from a meta-analysis. The estimates of FASD-related mortality rates served as a basis for the length of working life span estimation. Once the number of working years lost to premature deaths was derived, productivity losses were computed. RESULTS: It was estimated that in total 327 individuals with FASD aged 20 to 69 (almost twice as many men as women) died in Canada in 2011. As a result, there were 2,877 years of potential employment lost, which translated to a loss ranging from $88 million to $126 million. This amount represents the increase in national income, had there been no premature mortality from FASD and the workers with FASD had been typical members of the labour force (without compromised productivity due to FASD). CONCLUSIONS: The estimates of productivity losses further reinforce the value of FASD prevention as a primary strategy.

An economic evaluation of the parent-child assistance program for preventing fetal alcohol spectrum disorder in Alberta, Canada.

Parent-Child Assistance Program (P-CAP) is a 3-year home visitation/harm reduction intervention to prevent alcohol exposed births, thereby births with fetal alcohol spectrum disorder, among high-risk women. This article used a decision analytic modeling technique to estimate the incremental cost-effectiveness ratio and the net monetary benefit of the P-CAP within the Alberta Fetal Alcohol Spectrum Disorder Service Networks in Canada. The results indicate that the P-CAP is cost-effective and support placing a high priority not only on reducing alcohol use during pregnancy, but also on providing effective contraceptive measures when a program is launched.

Productivity losses because of morbidity attributable to fetal alcohol spectrum disorder in Canada: a demographic approach.

OBJECTIVE: The purpose of this study was to estimate the productivity losses due to morbidity of individuals with fetal alcohol spectrum disorder (FASD). METHOD: A demographic approach was used. Population estimates were calculated using data for the most recent available year (i.e., 2011) on the population of Canada by provinces, the labor force, unemployment rate, and the average weekly wage, all of which were obtained from Statistics Canada. To estimate the number of FASD cases in Canada in 2011, the prevalence of FASD, obtained from the available epidemiological literature, was applied to the general population of Canada. Assumptions made on the level of impairment that would affect the ability of individuals with FASD to participate in the workforce or reduce their productivity were based on data obtained from the current epidemiological literature and experts' opinions. To estimate the cost of FASD, a counterfactual scenario was used with an assumption that there is no one born with FASD in Canada. RESULTS: About 0.03% of the Canadian workforce experiences a loss of productivity because of FASD-attributable morbidity, which translates to aggregate losses ranging from $418 million Canadian dollars (CND) to $1.08 billion CND annually. CONCLUSIONS: FASD imposes a considerable economic toll on Canadian society and therefore requires more preventive efforts.

Addressing FASD in British Columbia, Canada: analysis of funding proposals.

BACKGROUND: Fetal Alcohol Spectrum Disorder is a preventable health issue affecting about 10% of the population. This research examined proposals submitted to a call for funding for projects to improve outcomes for people with fetal alcohol spectrum disorder (FASD). OBJECTIVES: The aim was to use the proposals as proxy for perceptions of needs held by practitioners in British Columbia, Canada, where considerable FASD-related education and awareness exists. METHODS: Content analyses were conducted and Chi-square tests were used to test the relationship between proposal foci, community size and the submitting agency's experience with FASD. RESULTS: Nine foci were found: Skill Development, Care, Training, Resource Development, Education, Transition, Peer Support, Research and Other. No statistically significant difference was found in proposal foci according to size of community, and only one focus, Research, was associated with agency experience. Proposals varied in intensity, timing, participants, and focus of change (people or environments). CONCLUSIONS: Analysis of the proposals provides a unique view into perceptions regarding ways to improve outcomes for people with FASD.

Fetal alcohol spectrum disorders: an overview for pediatric and adolescent care providers.

Fetal alcohol spectrum disorder (FASD) is a term used to describe the spectrum of conditions associated with prenatal alcohol exposure. These are characterized by facial dysmorphia, growth deficits and central nervous system abnormalities. FASDs are the most common preventable cause of intellectual disability in the United States and have high financial costs. Therefore, efforts at prevention are paramount. When an individual with an FASD goes undiagnosed and when appropriate interventions are not instituted, secondary disabilities such as substance abuse, school dropout, and criminal involvement are common with corresponding suffering endured by both the affected individual and the family. The diagnostic process opens up access to existing tools and resources, including the new American Academy of Pediatrics (AAP) FASD algorithm for the evaluation of FASDs, the new AAP FASD toolkit and evidence-based interventions specific to FASDs. Pediatric and adolescent clinicians are challenged to participate in the continuum of care from FASD prevention to identification, diagnosis, and management, including provision of supportive services for families in order for clinicians to make a difference in this 100% preventable disorder.

Looking further upstream to prevent fetal alcohol spectrum disorder in Canada.

Half of all pregnancies in Canada are unintended. Whether a pregnancy is intended or unintended has a bearing on the risk of prenatal alcohol exposure. Research indicates that women who experience an unintended pregnancy are significantly more likely to consume alcohol while pregnant. Most fetal alcohol spectrum disorder (FASD) prevention frameworks in Canada have adopted a mid-stream approach focused on preventing alcohol consumption among women who are already pregnant. Yet there is a second approach, further upstream, that is rarely discussed as an FASD prevention tool in this country - preventing unintended pregnancy itself. Improving access to long-acting reversible contraceptives for women and girls who are experiencing cost and access barriers to these methods could do much to stem the incidence of FASD and the prohibitive health and social costs associated with this disorder in Canada.

Costs of health services utilization of people with fetal alcohol spectrum disorder by sex and age group in Alberta, Canada.

OBJECTIVES: To estimate the annual health services utilization (HSU) cost per person with FASD by sex and age; the lifetime HSU cost per person with FASD by sex, and the annual HSU cost of FASD for Alberta by sex. METHODS: The HSU costs of FASD including physician, outpatient, and inpatient services were described by sex and age. The costs per person-year were estimated by multiplying the average number of hospitalizations, outpatient visits, and physician visits per person-year by the average cost of each service. The annual HSU cost of FASD for Alberta was estimated by multiplying the annual HSU cost per person with FASD by the number of people living with FASD in Alberta in 2012. The lifetime HSU cost per person with FASD was estimated by sex for several lifespans ranging from 10 to 70 years. RESULTS: The annual cost of HSU for people with FASD in Alberta was $259 million, of which FAS accounted for 26%. The annual HSU cost per person with FAS and FASD were $6,200 and $5,600, respectively. The incremental annual HSU cost per person with FAS is $4,100 and with FASD is $3,400 as compared to the general population. The lifetime (70 years) HSU cost per person with FAS was $506,000 and with FASD was $245,000. Males had higher HSU costs than females. HSU costs of FAS and FASD varied greatly by age group. CONCLUSION: The findings suggest that FASD is a public health issue in Alberta and can be used for economic evaluations of FASD intervention and/or prevention in the province.

Cost of speech-language interventions for children and youth with foetal alcohol spectrum disorder in Canada.

This study, which is part of a large economic project on the overall burden and cost associated with Foetal Alcohol Spectrum Disorder (FASD) in Canada, estimated the cost of 1:1 speech-language interventions among children and youth with FASD for Canada in 2011. The number of children and youth with FASD and speech-language disorder(s) (SLD), the distribution of the level of severity, and the number of hours needed to treat were estimated using data from the available literature. 1:1 speech-language interventions were computed using the average cost per hour for speech-language pathologists. It was estimated that ˜ 37,928 children and youth with FASD had SLD in Canada in 2011. Using the most conservative approach, the annual cost of 1:1 speech-language interventions among children and youth with FASD is substantial, ranging from $72.5 million to $144.1 million Canadian dollars. Speech-language pathologists should be aware of the disproportionate number of children and youth with FASD who have SLD and the need for early identification to improve access to early intervention. Early identification and access to high quality services may have a role in decreasing the risk of developing the secondary disabilities and in reducing the economic burden of FASD on society.

Potential impacts of the Alberta fetal alcohol spectrum disorder service networks on secondary disabilities: a cost-benefit analysis.

OBJECTIVES: To estimate the break-even effectiveness of the Alberta Fetal Alcohol Spectrum Disorder (FASD) Service Networks in reducing occurrences of secondary disabilities associated with FASD. METHODS: The secondary disabilities addressed within this study include crime, homelessness, mental health problems, and school disruption (for children) or unemployment (for adults). We used a cost-benefit analysis approach where benefits of the service networks were the cost difference between the two approaches: having the 12 service networks and having no service network in place, across Alberta. We used a threshold analysis to estimate the break-even effectiveness (i.e. the effectiveness level at which the service networks became cost-saving). RESULTS: If no network was in place throughout the province, the secondary disabilities would cost $22.85 million (including $8.62 million for adults and $14.24 million for children) per year. Given the cost of network was $6.12 million per year, the break-even effectiveness was estimated at 28% (range: 25% to 32%). DISCUSSION: Although not all benefits associated with the service networks are included, such as the exclusion of the primary benefit to those experiencing FASD, the benefits to FASD caregivers, and the preventative benefits, the economic and social burden associated with secondary disabilities will "pay-off" if the effectiveness of the program in reducing secondary disabilities is 28%.

Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada.

BACKGROUND: Individuals with Fetal Alcohol Spectrum Disorder (FASD) constitute a special population that may be at particularly high risk for substance use. The purpose of the current study was to estimate the utilization of specialized addiction treatment services (SATS) and the associated cost, as a part of the total cost of health care associated with FASD in Canada. METHODS: The current study was a modeling study. Data on SATS by lifetime mental disorder status were obtained from the Drug and Alcohol Treatment Information System (DATIS) in Ontario, Canada for 2010/11. The number of clients with FASD who received SATS in Ontario in 2010/11 was estimated, assuming that approximately 37% (confidence interval: 21.6%-54.5%) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that their utilization rate of SATS is the same as those for people with a lifetime mental disorder. The data from DATIS was then extrapolated to the total Canadian population. RESULTS: The cost of SATS for clients with FASD in Canada in 2010/11 ranged from $1.65 million Canadian dollars (CND) to $3.59 million CND, based on 5,526 outpatient visits and 9,529 resident days. When the sensitivity analysis was performed the cost of SATS ranged from $979 thousand CND to $5.34 million CND. CONCLUSIONS: Special attention must be paid to at-risk groups of individuals such as those with FASD, in order to reduce the likelihood of the development of co-morbid substance abuse problems, and thus, reducing the overall burden on Canadian society.

Counting fetal alcohol spectrum disorder in Australia: the evidence and the challenges.

ISSUES: Alcohol exposure in utero is associated with a range of adverse outcomes in pregnancy and can cause long-term disability. Fetal alcohol spectrum disorder (FASD) is an umbrella term to describe a range of effects from prenatal alcohol exposure including fetal alcohol syndrome (FAS). Determining the prevalence of FASD is challenging. APPROACH: This narrative review collates information on the prevalence of FASD in Australia and documents the various methods used for attaining estimates and the limitations of the available data. KEY FINDINGS: Birth prevalence of FASD is most commonly measured through clinic-based studies, passive surveillance systems and active case ascertainment. Alcohol use in pregnancy and FAS in Australia is predominantly monitored through passive surveillance systems and under-ascertainment of cases is likely. State- and territory-based studies have reported birth prevalence rates of FAS of between 0.01 and 0.68 per 1000 live births. Prevalence rates of FASD have not been estimated in Australia. As reflected in the international data, Australian studies have found higher rates of FAS among some Indigenous communities. This likely reflects patterns of alcohol use and other socioeconomic risk factors. IMPLICATIONS: Under-recognition of FASD reflects incomplete and inconsistent data collections recording alcohol use in pregnancy, lack of awareness among health professionals and a lack of diagnostic and support services. CONCLUSION: Accurate measurement of FASD prevalence is crucial to inform policy, resource and service development in the areas of health, education, justice and community. There is a need for consensus on the collection and best use of data. [Burns L, Breen C, Bower C, O' Leary C, Elliott EJ. Counting fetal alcohol spectrum disorders in Australia: the evidence and the challenges. Drug Alcohol Rev 2013;32:461-467].

Cost of fetal alcohol spectrum disorder diagnosis in Canada.

BACKGROUND: Fetal Alcohol Spectrum Disorder (FASD) is underdiagnosed in Canada. The diagnosis of FASD is not simple and currently, the recommendation is that a comprehensive, multidisciplinary assessment of the individual be done. The purpose of this study was to estimate the annual cost of FASD diagnosis on Canadian society. METHODS: The diagnostic process breakdown was based on recommendations from the Fetal Alcohol Spectrum Disorder Canadian Guidelines for Diagnosis. The per person cost of diagnosis was calculated based on the number of hours (estimated based on expert opinion) required by each specialist involved in the diagnostic process. The average rate per hour for each respective specialist was estimated based on hourly costs across Canada. Based on the existing clinical capacity of all FASD multidisciplinary clinics in Canada, obtained from the 2005 and 2011 surveys conducted by the Canada Northwest FASD Research Network, the number of FASD cases diagnosed per year in Canada was estimated. The per person cost of FASD diagnosis was then applied to the number of cases diagnosed per year in Canada in order to calculated the overall annual cost. RESULTS: Using the most conservative approach, it was estimated that an FASD evaluation requires 32 to 47 hours for one individual to be screened, referred, admitted, and diagnosed with an FASD diagnosis, which results in a total cost of $3,110 to $4,570 per person. The total cost of FASD diagnostic services in Canada ranges from $3.6 to $5.2 million (lower estimate), up to $5.0 to $7.3 million (upper estimate) per year. DISCUSSION: As a result of using the most conservative approach, the cost of FASD diagnostic services presented in the current study is most likely underestimated. The reasons for this likelihood and the limitations of the study are discussed.