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Economic Costs of Fetal Alcohol Spectrum Disorders. by Henrick Harwood. FASD Field Trainers Meeting Orlando, Florida December 2, 2005. Overview. FAS costs US $4.6 billion in 2004 About $17 per capita; $17,000 per FAS

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Economic Costs of Fetal Alcohol Spectrum Disorders

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Economic costs of fetal alcohol spectrum disorders

Economic Costs of Fetal Alcohol Spectrum Disorders

byHenrick Harwood

FASD Field Trainers Meeting

Orlando, FloridaDecember 2, 2005



  • FAS costs US $4.6 billion in 2004

    • About $17 per capita; $17,000 per FAS

  • US has up to 41,000 alcohol impacted (FASD) births/yr. or about 4,100 FAS births

  • An FAS birth carries lifetime health/special ed costs of $753,000 ($258,000 today) although can be as high as $3.7 million ($1.4 million)

  • Including quality of life, FAS prevention may be “cost effective” at up to $516,000 per child

  • FAS is among the most costly birth defects

  • State FAS cost estimates are presented

Economic costs of alcohol abuse 1

Economic Costs of Alcohol Abuse1

  • $184.6 B in 1998; $670 per capita; 2.1% of GDP

  • Medical consequences of FAS$2.9

  • Lost earnings due to FAS$1.2

  • Specialty alcohol services$7.5

  • Medical consequences, other$16.0

  • Lost earnings, mortality$36.5

  • Lost earnings, morbidity$86.4

  • Lost earnings, crime/victims$10.1

  • Crashes, fires, justice$24.1

1 Source: Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods,and Data. Report prepared by The Lewin Group for the National Institute on Alcohol Abuse and Alcoholism, 2000. Available at

This effort

This Effort

  • Develop new estimates for FASD

  • Update prior estimates by The Lewin Group (1998)

    • Cost to the US of FAS in a year

  • Review of literature by C. Lupton of NGIT

  • Update and extend analyses published in 1986

    • Cost of a “child born with FAS”

  • Address cost effectiveness, quality adjusted life years and willingness to pay

General findings from the literature

General Findings from the Literature

  • The majority of the literature focuses solely on FAS

  • Literature related to FAE is limited

    • ARBD and ARND are rarely mentioned

  • Cost estimates for treatment services related to FAS vary considerably

Different types of economic studies

Different Types of Economic Studies

  • Cost of illness

  • Cost effectiveness

  • Cost benefits

Concepts behind cost of illness

Concepts Behind Cost of Illness

  • Assess overall burden on the economy in use and loss of resources per year

  • Consequences (epidemiology)

    • Primary and comorbid health, social/justice system

  • Causality (epidemiology)

    • Attribution factors

  • Costs (economics)

    • Approach to valuation, discounting

Coi often called gee whiz numbers

COI Often Called “Gee Whiz” Numbers

  • More readily grasped than a large variety of diverse impact estimates: a single number

  • These numbers can be “large”

    • Attention commanding

    • Can be compared to other budgets and problems

  • Suggest something SHOULD be done

  • Do not tell us WHAT should be done

    • Prevention versus treatment or other strategies

Components of economic costs

Components of Economic Costs

  • Direct Costs (actual use of goods and services)

    • Health system (physical and mental)

    • Educational, social, justice systems (not transfers)

  • Indirect Costs (foregone potential productivity)

    • Mortality

    • Morbidity/disability

    • Incarceration/crime career

  • Intangible Costs

    • Loss of quality of life, experience of pain and suffering

    • Not generally included in cost of illness estimates

Prevalence of fasd

Prevalence of FASD

  • “At risk” drinking women 18-44 years (past month) (CDC’s BRFSS)

    • Binge (5+ drinks/occasion): 13.4%

    • Heavy (more than 1 drink/day): 5.8%

    • Binge or heavy: 14.9%

  • FAS prevalence range:

    • 0.5 to 2.0 cases per 1,000 live births

  • FAE believed much more prevalent than FAS

    • up to 10 in 1,000 live births for FAS and FAE

Lifetime prevalence of secondary disabilities for fas versus fae



Lifetime Prevalence of Secondary Disabilities for FAS versus FAE













Streissguth et al. 1996

Valuation of indirect disease burden

Valuation of Indirect Disease Burden

  • Deaths

  • Morbidity: sickness; lost days; impaired days

  • Human capital

    • Current market value of productivity

    • Present discounted value lost future productivity

  • Willingness to pay (up to $6 million/life)

  • Quality adjusted life years (QALY) ($50-100,000)

  • Disability adjusted life years (DALY)

  • Years of potential life lost (YPLL)

Economic cost of fas in u s in 2004

Economic Cost of FAS in U.S., in 2004

  • National

    • Direct: $2.66 billion

    • Indirect: $1.90 billion

    • Total: $4.56 billion

Major direct cost components

Major Direct Cost Components

Major direct cost components cont

Major Direct Cost Components (cont.)

Direct costs per year per fas case

Worst Case

Expected Case

Direct Costs per Year, per FAS Case

Health Cost/Year


Lifetime direct costs of a person with fas

Lifetime Direct Costs of a Person with FAS

  • Direct costs

    • Average $753,000

    • Maximum $3.7 million

  • Discounted Lifetime (3%)

    • Average: $258,000

    • Maximum: $1.3 million

Indirect costs of fas

Indirect Costs of FAS

  • Value of lost potential productivity

  • Human capital approach (PHS Guidelines)

  • Age/gender adjusted valuation: over $60,000/yr

  • In 2003 expected > $2.5 million at birth

    • Discounted $1.1 million

  • Mental disability/retardation due to FAS related to 20.5% reduction

  • $218,500 lifetime discounted loss per child

Indirect costs of fas1

Indirect Costs of FAS

  • Due to mental disability

  • 294,000 persons with FAS

    • 73,000 under 18 years; 221,000 over 17

    • Lost potential productivity worth $1.9 billion in 2004

      Incidence % Prod. Reduction

Severe 2.5%100.0%





Economic costs of fetal alcohol spectrum disorders

Source: MMWR Dec. 24, 2004/ 53(50); 1178-1181

State patterns of at risk drinking

State Patterns of “At Risk” Drinking

“At risk” means binge or heavy drinking in past month

State rates of female at risk drinking females age 18 44 years past month binge or heavy drinking

State Rates of Female “At Risk” Drinking Females age 18-44 years, Past Month Binge or Heavy Drinking

Estimated from 2002 BRFSS; U.S. average was 14.9%, or 8.4 million females

Fas annual costs by state 2004 in millions

FAS Annual Costs by State, 2004($ in millions)

Are fas interventions worth supporting

Are FAS InterventionsWorth Supporting?

  • IOM and NIAAA: very little strong research

  • Haven’t rigorously evaluated particular preventions

  • However, can look at potential benefit from successful prevention (Harwood and Napolitano, 1986)

  • What will benefits/savings be if save 1 child?

Cost effectiveness

Cost Effectiveness

  • Standard allows comparison across all of health (PHS Taskforce; Gold et al., 1996)

  • Compares medical interventions on the basis of cost to save a quality adjusted life year (QALY)

  • Medical interventions costing <$50,000/QALY are “generally” considered “cost effective”

Quality of life preference scores

Perfect health: 1.0

Moderate disability: .50


Gen. pop. 35-39: .86

Gen. pop. > 75 years: .71

Congest. heart failure: .20

Legal blindness: .48

Profound deafness: .59

Depression: .31

Schizophrenia: .31-.61

Children withdevelopmental disability

Severe: .40

Moderate: .60

Mild .80

Reading disability: .77

Quality of Life Preference Scores

Harvard Center for Risk Analysis, on-line catalog of

published disease state preference scores

Impact of fas on quality of life

Impact of FAS on Quality of Life

  • Conservative estimate: FAS reduces QALY by 17% or 11 years

  • Potential savings from preventing 1 case of FAS:

    • $550,000 in total value of QALY

    • $258,000 in discounted value of QALY

  • If an intervention costs less than $516,000 per FAS case prevented (discounted indirect plus direct costs), it would be considered “generally cost effective”

Comparison of birth defect costs

Comparison of Birth Defect Costs

  • Lifetime costs of a birth with FAS $516,000

    • $2 billion for a birth cohort (for 4,000 FAS cases)

  • A study published by CDC estimated costs of birth defects in 1992 at $8 billion ($12-15 billion now)

  • Prematurity costs about $16 billion/year

  • Spina bifida and anencephaly > $750,000/birth

  • Mental retardation & cerebral palsy >$900,000/birth

  • Vision and hearing defects cost $400-600,000/birth



  • FAS costs US $4.6 billion in 2004

  • An FAS birth carries lifetime direct costs of $753,000 ($258,000 today) although can be as high as $3.7 million

  • FAS costs/birth similar to other severe birth defects

  • Costs vary widely by state, based on size and rates of female “at risk” drinking (CA $581 mil. WY $9 mil.)

  • Costs probably low: need better data on FAE, mental health, criminal justice

  • Even “expensive” FAS prevention may be “cost effective”: up to $516,000 per child

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