ORIGINAL ARTICLE

An Economic Evaluation of the Parent–Child Assistance Programfor Preventing Fetal Alcohol Spectrum Disorder in Alberta,Canada

Nguyen Xuan Thanh • Egon Jonsson •

Jessica Moffatt • Liz Dennett • Anderson W. Chuck •

Shelley Birchard

� Springer Science+Business Media New York 2014

Abstract 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.

Keywords Cost–effectiveness � Cost–benefit � Fetal

alcohol spectrum disorder � Parent–child assistance

program

Introduction

It is estimated that 1 % of Alberta’s population are living

with fetal alcohol spectrum disorder (FASD), which is a

lifelong disability including both cognitive and behavioural

deficits, as well as a range of physical problems caused by

exposure to alcohol during pregnancy. The total cost of

FASD (including cost of health, social, educational and

correctional services) in Alberta was estimated at $520

million in year 2009 (Thanh et al. 2011).

FASD is in principle entirely preventable, however,

there are many reasons for drinking during pregnancy,

which have to be addressed for successful prevention.

These may range from being unaware of being pregnant

during the early and vulnerable period of the fetus, to being

ignorant of the risks of drinking, and using alcohol as a

means of coping with challenging personal and socio-

economic circumstances. Whatever the reasons, effective

preventative strategies need to be identified, applied and

evaluated as to their outcomes.

Several approaches, from general awareness campaigns

to more intensive interventions aimed at women of child

bearing age who are addicted or abuse alcohol (high-risk

women), have been implemented in order to prevent

FASD. The Parent–Child Assistance Program (P-CAP) is

an example of a well-structured and targeted prevention

strategy aimed at high-risk women.

P-CAP is a 3-year home-visitation/case-management/

harm reduction mentorship intervention model, which was

initiated in 1991 by a research team at the University of

N. X. Thanh (&) � E. Jonsson � J. Moffatt � L. Dennett �A. W. Chuck

Institute of Health Economics, 1200, 10405 Jasper Ave.,

Edmonton, AB T5J 3N4, Canada

e-mail: tnguyen@ihe.ca

E. Jonsson

e-mail: ejonsson@ihe.ca

J. Moffatt

e-mail: jmoffatt@ihe.ca

L. Dennett

e-mail: ldennett@ihe.ca

A. W. Chuck

e-mail: achuck@ihe.ca

N. X. Thanh � E. Jonsson � L. Dennett � A. W. Chuck

University of Alberta, Edmonton, AB, Canada

E. Jonsson

University of Calgary, Calgary, AB, Canada

S. Birchard

Addiction and Mental Health Branch, Alberta Health,

Edmonton, AB, Canada

e-mail: shelley.birchard@gov.ab.ca

123

Adm Policy Ment Health

DOI 10.1007/s10488-014-0537-5

Washington (http://depts.washington.edu/pcapuw/). It

enrolls women who abuse substances (e.g. alcohol and/or

drugs) and are pregnant or up to 6 months postpartum. The

goal of P-CAP is to prevent subsequent alcohol and drug-

exposed births by encouraging the use of effective con-

traceptives and helping women decrease their use of

alcohol and drugs or abstain completely from them. Fur-

thermore, P-CAP aims to address the health and social

wellbeing of the mothers and their children by increasing

employment and reducing their dependency on welfare

income (Alberta P-CAP Council 2013).

To achieve these goals, mentors not only meet with

women in their home, but also provide community out-

reach to meet women in locations they frequent in the

community. At the initial contact, women are interviewed

to determine the family and community supports that they

may already be accessing, determine their goals, and

establish what other services may need to be accessed. It is

the women’s intentions and desires that drive the plan that

she and the mentor establish. The mentors are parapro-

fessionals who have at least 2 years of community-based

experience in social service settings working with indi-

viduals with complex needs and/or involved in high-risk

lifestyle. Mentors who have previously overcome their own

adversity are valued for this experience as it often becomes

the basis to solidify relationships with women involved in

P-CAP that have become mistrustful of services accessed

in the past. The mentor takes the woman to the appoint-

ments with healthcare professionals, mental health and/or

addiction appointments, physicians to discuss family

planning to support the women towards their goals which

may include family planning, parenting classes, vocational

training, and employment. Caseloads are kept to a man-

ageable fifteen clients. A majority of these cases are con-

sidered active clients which requires at the bare minimum

two meetings with the women, families and the women’s

support network per month. There may be more as needed

(Alberta P-CAP Council 2013).

In 1999, Ernst et al. (1999) examined the efficacy of the

original P-CAP model for improving health and social

outcomes of high-risk substance-abusing mothers and their

children in Seattle, USA. The P-CAP clients were compared

to concurrently enrolled controls on a composite variable

comprised of indicators of alcohol/drug treatment, absti-

nence, family planning, child well-being, and connection to

services. The authors found that on average the clients

obtained higher scores, than controls on the composite

variable, as well as on every indicator. The clients who

spent more time with P-CAP advocates had more positive

outcomes (e.g. higher scores on the composite variable).

In 2005, Grant et al. (2005) examined outcomes among

216 women enrolled in the Washington State P-CAP and

using a pretest–posttest comparison across three sites: the

original demonstration (1991–1995), and the Seattle and

Tacoma replications (1996–2003). In the original demon-

stration, the P-CAP clients performed significantly better

than controls. Compared to the original demonstration,

outcomes at replication sites were maintained (for regular

use of contraception and use of reliable method; and

number of subsequent deliveries), or improved (for alco-

hol/drug treatment completed; alcohol/drug abstinence;

subsequent delivery unexposed to alcohol/drugs). The

authors concluded that the P-CAP model is effective over

time and across venues.

The P-CAP model has been replicated at many other

locations in North America, including the province of

Alberta where P-CAP models were applied with different

names: ‘‘first steps’’ in 1999 (by Catholic Social Services,

Bissell Center, and Lethbridge), ‘‘P-CAP’’ in 2000 (by

McMan, Calgary), and ‘‘Mothers to be Mentorship Pro-

gram’’ in 2001 (by Lakeland Center for FASD, Cold Lake)

(Alberta P-CAP Council 2013).

In 2003, the Alberta FASD Cross-Ministry Committee

(FASD-CMC) was established to plan and deliver provin-

cial government programs and services associated with

FASD. Within this initiative, the FASD Service Networks

were established to provide diagnostic, supportive, and

preventive services. P-CAP is one of the preventive ser-

vices provided by the networks since 2008. There are

currently 25 P-CAP programs across the province.

Between 2008 and 2011, there have been 366 P-CAP cli-

ents served by the networks (Alberta FASD-CMC 2013a).

In 2012, Rasmussen et al. (2012) demonstrated the First

Steps program to be effective in improving outcomes (e.g.

birth control use, welfare rates, and abstinence from alco-

hol and/or drugs) among women at-risk for giving birth to a

child with FASD in Alberta. However, to the best of our

knowledge, no P-CAP programs in Canada have ever been

evaluated in an economic perspective. This study includes

economic evaluations of both the cost–effectiveness and

cost–benefit implications of the Alberta FASD-CMC fun-

ded P-CAP.

Methods

We used a decision analytic modeling technique (Briggs

et al. 2006) to estimate the number of FASD cases pre-

vented by the publicly funded P-CAP program. In the cost–

effectiveness analysis, we estimated the incremental cost

per prevented case. In the cost–benefit analysis, we mon-

etized the number of prevented cases by using the dis-

counted incremental lifetime cost per case with FASD,

which is approximately $800,000 (Thanh et al. 2011). This

calculation was used in comparison with the actual cost of

P-CAP to estimate the net monetary benefit of the program.

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123

We used a societal perspective and converted all the costs

and benefits to 2013 Canadian dollars using the Bank of

Canada’s inflation calculator (http://www.bankofcanada.

ca/rates/related/inflation-calculator/), which is based on the

Consumer Price Index for Canada (Statistics Canada 2013).

Study Population

The three hundred sixty-six (366) women, who have been

served by the Alberta FASD-CMC P-CAP from 2008 to

2011 (Alberta FASD-CMC 2013a), were the study popu-

lation in this study. As the outcome is number of prevented

FASD cases, only the alcohol users, who accounted for

44 % of the total (95 % confidence interval 29–60 %)

(Pelech et al. 2013) were included in the analysis. The

remaining 56 % of the sample were excluded because they

were drug users.

Time Horizon

As P-CAP is a 3-year home visitation intervention and there

are no Alberta P-CAP data following up after 3 years, we

used a time horizon of 3 years for this study. This means that

the estimated costs and benefits occur within a 3-year period.

Of note, for those women who have yet to complete 3 years

with the P-CAP, we assumed that if they stay for 3 years, the

impact of P-CAP on them would be the same as the impact of

P-CAP on those who have completed the program.

Discounting

We used an annual discount rate of 5 % (CADTH 2006) for

estimating the cost of P-CAP per woman over the 3-year

period and the discounted incremental lifetime cost per case

with FASD (Thanh et al. 2011) for estimating the monetary

benefit of P-CAP. To avoid double discounting the benefit,

the prevented cases of FASD were not discounted.

Model Structure

The model compares between two options: (1) P-CAP

exists and (2) P-CAP does not exist (Fig. 1).

In option 1, women with heavy alcohol consumption

[the severity of drinking was based on the addiction

severity index (McLellan et al. 1992) and heavy drinking

was defined as C3 drinks daily or C5 drinks at a time

(binge) monthly] entering P-CAP may stay in the program

for 3 years or quit before the end of 3 years. In our model

the completers will bear the full cost and impact of P-CAP

while we assume that the quitters will bear half of the cost

but there will be no impact because of P-CAP. The cost

assumption is based on the average that quitters quit at the

Fig. 1 Model structure: P-CAP

exists versus P-CAP does not

exist

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123

middle of the program and the impact assumption is con-

servative to avoid an overestimate of program benefits. Of

the women with heavy alcohol consumption entering

P-CAP, a proportion are pregnant at intake and the rest are

not (e.g. those who are post-delivery up to 6 months).

Among pregnant women at intake, women are in various

stages of pregnancy. For those who are in the 2nd and 3rd

trimesters of pregnancy at intake (Fig. 2) and those who are

not pregnant at intake or are pregnant at intake but giving no

live birth (Fig. 3), we considered that the impact of P-CAP is

only on the subsequent pregnancies if they have one. As there

are very few women who have more than one subsequent

pregnancy within 3 years (Rasmussen et al. 2012), we

included only the 1st subsequent pregnancy in the analysis.

For those who are in the 1st trimester of pregnancy at intake

and if they have a subsequent pregnancy (Fig. 2), we con-

sidered that the impact of P-CAP is on both pregnancies

(Pelech et al. 2013). We assumed that the impact of P-CAP

was maintained during the program time period. This

assumption is supported by studies in which the impact of

P-CAP is not only demonstrated after 3 years of the program,

but also after 12 and 24 months (Grant et al. 1996a, b).

Of the pregnant women, a proportion will have live

births and of these live births a portion will have an FASD.

We assumed that all live births are singleton. The impact of

P-CAP includes a reduction and abstinence from alcohol

and a reduced rate of subsequent pregnancy due to the

increased use of contraceptives. These will result in a

reduction of live births exposed to heavy alcohol con-

sumption during pregnancy, and therefore in a reduction of

the number of FASD cases. Option 2 is similar to option 1,

except there is no impact of P-CAP. This results in a higher

rate of subsequent pregnancy (due to lower use of contra-

ceptives) and all the live births exposed to heavy alcohol

consumption during pregnancy, thus resulting in more

FASD cases.

Fig. 2 Sub-model structure for

pregnant women at intake

Fig. 3 Sub-model structure for

women who are not pregnant at

intake or pregnant at intake but

giving no live birth

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Model Inputs

All the inputs for the model are shown in Table 1. Gen-

erally, we tried to use the actual data from Alberta’s FASD

service networks as much as possible. For some inputs

where the actual data was not available, we performed a

systematic review of the literature and a meta-analysis to

pool the findings in those studies.

Specifically, the probability of women who stay in

P-CAP (91 %), the probability of alcohol users among

P-CAP women (44 %), the probability of women who are

pregnant at intake (49 %), the probability of pregnancy in

the 1st trimester at intake (16 %), the probability of women

having a live birth (87 %), the probability of women who

reduce alcohol use during enrollment in P-CAP (64 %),

and the probability of women who are abstinent from

alcohol during enrollment in P-CAP (11 %), were retrieved

from reports of Alberta’s FASD service networks (Pelech

et al. 2013; Alberta FASD Service Networks 2012).

The probability of subsequent pregnancy if P-CAP

exists (29 %) was retrieved from the First Steps program

(Rasmussen et al. 2012). The probability of subsequent

pregnancy if P-CAP did not exist (42 %) were estimated

based on the probability of subsequent pregnancy if P-CAP

exists (29 %) and the rates of contraceptive use before

(36 %) and after (56 %) the First Steps program (Ras-

mussen et al. 2012).

The probabilities of FASD among live births exposed to

heavy, reduced, or no maternal alcohol consumption during

pregnancy were estimated from a systematic literature

review in which we used a random effect model for the

meta-analysis (Borenstein et al. 2013). We performed a

comprehensive literature search in the following databases:

Medline, EMBASE, PsycINFO, CINAHL, Social Work

Abstracts, SocINDEX. The search included numerous

subject headings and keyword terms for the concepts of

FASD and drinking during pregnancy. These were com-

bined with study type terms to limit to epidemiological

studies (including case–control and cohort studies). We

limited the scope of the search to studies examining the

rate of FASD which results from in utero alcohol exposure.

We did not limit the search by country or year. Only

English studies were included in our search. Reference lists

of included studies were also searched in order to identify

further studies. Regarding inclusion and exclusion criteria,

we included only peer-reviewed epidemiological studies.

Table 1 Model inputs

Variable name Description Mean Low High Data sources

pStay Probability of women who stay in P-CAP 0.91 0.87 0.94 Alberta FASD Service

Networks (2012)

pAlcohol Probability of alcohol use among P-CAP women 0.44 0.29 0.60 Pelech et al. (2013)

pPregnant Probability of pregnancy at intake 0.49 0.43 0.55 Alberta FASD Service

Networks (2012)

pFirst Probability of pregnancy in the first trimester at intake 0.16 0.07 0.29 Pelech et al. (2013)

pLivebirth Probability of giving live births 0.87 0.80 0.92 Alberta FASD Service

Networks (2012)

pReduce Probability of women who reduce alcohol

use due to P-CAP

0.64 0.58 0.70 Alberta FASD Service

Networks (2012)

pAbstinence Probability of women who abstinence from alcohol

due to P-CAP

0.11 0.08 0.16 Alberta FASD Service

Networks (2012)

pBecomePregnant Probability of subsequent pregnancy if P-CAP exists 0.29 0.18 0.41 Rasmussen et al. (2012)

pBecomePregnant2 Probability of subsequent pregnancy if P-CAP

did not exist

0.42 0.29 0.54 Rasmussen et al. (2012)

pHeavyFASD Probability of FASD among heavily exposed

to alcohol during pregnancy

0.69 0.54 0.84 Autti-Ramo et al. (1992),

Astley (2010), Aronson et al.

(1985), Autti-Ramo (2000),

Kuehn et al. 2012; Godel

et al. (2000), Kyllerman et al.

(1985)

pReduceFASD Probability of FASD among reduced exposure

to alcohol during pregnancy

0.15 0.06 0.30 Autti-Ramo et al. (1992)

pAbstinenceFASD *Upper value of 95 % CI of probability of FASD

among light exposure to alcohol during pregnancy

0.00 0.00 0.10* Godel et al. (2000)

cFASD Incremental lifetime cost per case with FASD 800,000 640,000 960,000 Thanh et al. (2011)

cP-CAP P-CAP cost per woman over the 3 year period 19,782 15,826 23,739 Alberta FASD-CMC (2013a, b)

P-CAP Parent–Child Assistance Program, FASD fetal alcohol spectrum disorder

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123

Abstracts, systematic reviews, editorials, and thesis sub-

missions were excluded. Also, we excluded studies which

did not result in a FASD diagnosis. Details on the sys-

tematic review are available upon request.

In total, 826 articles were found. Of these, 683 were

excluded after reviewing titles and abstracts, meaning 143

full text articles were retrieved. The lists of references for

these 143 articles were assessed and three additional articles

were included. After independently reviewing by two

authors (NXT and JM) seven studies were qualified for data

extraction (Autti-Ramo et al. 1992; Astley 2010; Aronson

et al. 1985; Autti-Ramo 2000; Kuehn et al. 2012; Godel et al.

2000; Kyllerman et al. 1985). However, only the probability

of FASD among live births exposed to heavy alcohol con-

sumption during pregnancy (69 %) was pooled from all

seven studies. The probability of FASD among live births

exposed to reduced alcohol consumption during pregnancy

(15 %) was assumed equal to the probability of FASD

among live births whose mothers stopped drinking during

pregnancy. This was pooled from the probabilities of FASD

among live births whose mothers stopped drinking in the 1st

and 2nd trimesters as reported by Autti-Ramo et al. (1992).

The probability of FASD among live births whose mothers

are abstinent from alcohol for entire pregnancy is 0 %.

Conservatively, in the sensitivity analysis we varied this to

10 %, which was the upper value of the 95 % confidence

interval of the probability of FASD among live births whose

mothers drink lightly as reported by Godel et al. (2000). Of

note, as we focused on FASD, studies only estimating

probabilities of Fetal Alcohol Syndrome (FAS) among pre-

natally alcohol exposed live births were not qualified for data

extraction in our systematic review.

Regarding cost inputs, the discounted incremental life-

time cost per case with FASD was taken from the litera-

ture. This cost was $742,000 in 2009 Canadian dollars

(Thanh et al. 2011). After being inflated to 2013 Canadian

dollars and rounding up, it is $800,000. The P-CAP cost

per woman per year ($6,918) was estimated by dividing the

actual annual spending for P-CAP (*2.5 million in fiscal

year 2011/12) (Alberta’s FASD-CMC 2013b) by the

number of women who have participated in P-CAP (366)

(Alberta FASD-CMC 2013a), and then inflating to 2013

Canadian dollars. After discounting 5 % annually (CADTH

2006) for the second and third years, the P-CAP cost per

woman over the 3 year period was estimated at $19,782.

Sensitivity Analysis

We performed a one-way sensitivity analysis for all the

inputs and reported the results by tornado diagrams

(Figs. 4, 5, 6). All the costs were varied by 20 % and all the

probabilities were varied between the lower and the upper

ends of 95 % confidence intervals (Table 1). Of note, we

did not perform the sensitivity analysis for the variation of

discount rate (0 and 3 %) as suggested by Canadian

Agency for Drugs and Technologies in Health (CADTH

2006) because this variation makes the P-CAP cost per

woman per the 3-year period vary within the range of the

cost ±20 %. In Figs. 4, 5, 6, EV stands for expected value

which is resulted from the mean inputs. The EV is varied

by the variation of each input parameter. The tornado

diagrams show the largest variation of the EV on the top

and the smallest at the bottom corresponding to the varia-

tions of input parameters in the legend box.

Stata MP 11 (StataCorp, 4905 Lakeway Drive, College

Station, Texas 77845 USA) and TreeAge Pro 2012 (Tre-

eAge Software, Inc., One Bank Street, Williamstown, MA,

01267 USA) were used for data analysis.

Results

Our model estimated that 56 live births with FASD would

be delivered by women who consumed alcohol during

pregnancy and who participated in the Alberta P-CAP

program. If the P-CAP program did not exist, that number

would have been 87. Therefore, the number of FASD cases

prevented by the P-CAP program was estimated at 31

(Table 2).

Table 2 also shows that the incremental cost per pre-

vented FASD case was $97,000 and the net monetary

benefit of the P-CAP program was $22 million.

The sensitivity analysis shows that the number of FASD

cases prevented by the P-CAP programs varied from 20 to

43, the incremental cost per prevented FASD case from

$72,000 to $153,000, and the net monetary benefit from

$13 million to $31 million (Figs. 4, 5, 6; Table 2).

The results of the model (all three outcome indicators) were

most sensitive to the likelihood of subsequent pregnancy, the

likelihood of alcohol use among P-CAP women, and either

likelihood of cases of FASD among live births exposed to

heavy alcohol consumption during pregnancy or the cost of

P-CAP, depending on the outcome indicators (Figs. 4, 5, 6).

Discussion

This is the first study estimating the incremental cost

effectiveness ratio (ICER) and the net monetary benefit of a

PCAP program. The results estimate that the program

prevented approximately 31 (range 20–43) cases of FASD

among the 366 clients in a 3-year period. The incremental

cost per prevented case (or ICER) is approximately

$97,000 (range $72,000–$153,000). The net monetary

benefit is approximately $22 million (range $13–$31 mil-

lion). Compared to the discounted incremental lifetime cost

Adm Policy Ment Health

123

Fig. 4 Tornado diagram of the

number of prevented FASD

cases (EV expected value)

Fig. 5 Tornado diagram of the

incremental cost per prevented

FASD case (EV expected value)

Adm Policy Ment Health

123

per case with FASD ($800,000) (Thanh et al. 2011), the

results indicate that the program is cost–effective and the

net monetary benefit is significant.

We should note that the benefit is likely underestimated

as the study did not include benefits from the reduction in

unemployment and welfare income dependence rates

among P-CAP participants.

According to Rasmussen et al. (2012) the First Steps pro-

gram in Alberta could reduce the unemployment rate from 99

to 87 % and the welfare income dependence rate from 92 to

72 %. If the Alberta P-CAP could do the same and if an

employed P-CAP woman could earn $23,6111 a year and the

welfare income was $17,1722 per women per year (National

Council of Welfare 2011), we would expect an extra benefit of

$2.3 million [employment: (99–87 %) 9 366 9 $23,611–$1

million ? welfare independent: (92–72 %) 9 366 9 $17,172–

$1.3 million] per year for the P-CAP. If the Alberta P-CAP’s

impact was the same as the P-CAP in Washington State (the

unemployment rate decreased from 96 to 71 % and the

welfare income dependence rate decreased from 71 to 26 %)

(Grant et al. 2005), the extra benefit would be approximately

$5 million per year.

Additionally, the benefit is likely underestimated as the

study did not include the benefits for the quitters who were

assumed to quite the program at 18 months on average

while the P-CAP may have significant outcomes after

12 months (Grant et al. 1996b).

Among the clients entering the PCAP program, 56 % are

abusing drugs (Pelech et al. 2013). This study did not include

the potential benefits of the P-CAP program on reduction of

drug abuse which clearly deserves further study.

In conclusion, this economic evaluation indicates that

P-CAP is cost–effective and produces a significant net

monetary benefit for Alberta. The sensitivity analyses point

at the increased use of contraceptives as a factor that has a

significant impact on the outcomes. This finding speaks for

placing a high priority not only on reducing alcohol use

during pregnancy but also on providing effective measures

for family planning and pregnancy protection when a

P-CAP program is launched.

Acknowledgments This study is financially supported by Alberta

Health. We are grateful to Teresa O’Riordan, Executive Director of

the Northwest Central Alberta FASD Network, Dr. Arto Ohinmaa,

University of Alberta School of Public Health, and Dr. Philip Jacobs,

University of Alberta Dept. of Medicine, for providing valuable

information.

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Fig. 6 Tornado diagram of the

net monetary benefit (EV

expected value)

Table 2 Cost–effectiveness and cost–benefit of P-CAP in Alberta

Base–case Range

Number of prevented

FASD cases

31 20–43

Incremental cost per

prevented FASD case

$97,000 $72,000–$153,000

Net monetary benefit $22 million $13–$31 million

P-CAP Parent–Child Assistance Program, FASD fetal alcohol spec-

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