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. Author manuscript; available in PMC: 2016 Apr 15.
Published in final edited form as: J Alcohol Drug Educ. 2015 Aug;59(2):25–42.

A cost analysis of web-enhanced training to reduce alcohol sales to intoxicated bar patrons

Timothy F Page 1, Dawn M Nederhoff 2, Alexandra M Ecklund 3, Keith J Horvath 4, Toben F Nelson 5, Darin J Erickson 6, Traci L Toomey 7
PMCID: PMC4833209  NIHMSID: NIHMS745353  PMID: 27087708

Abstract

Objective

The purpose of this study was to document the development and testing costs of the Enhanced Alcohol Risk Management (eARM) intervention, a web enhanced training program to prevent alcohol sales to intoxicated bar patrons and to estimate its implementation costs in a “real world”, non-research setting.

Methods

Data for this study were obtained retrospectively from a randomized controlled trial of the eARM intervention, which was conducted across 15 communities in a Midwestern metropolitan area. Inputs and their costs were obtained from records maintained during the randomized controlled trial. Total development and testing costs were computed, and implementation costs were estimated with input from the research team. The average implementation cost per establishment was calculated by dividing the total estimated implementation cost by the number of establishments that participated in the study. This provides an estimate of the resources needed to support a broader dissemination of interventions such as eARM.

Results

Direct development and testing costs were $484,904. Including the University's overhead cost rate of 51 percent, total development and testing costs were $732,205. Total estimated implementation costs were $179,999 over a 12 month period. The average cost per establishment was $1,588.

Conclusions

Given the large damage liability awards faced by establishments that serve alcohol to drunk drivers, establishments or their insurance companies may be willing to pay the $1,588 estimated implementation cost in order to limit their exposure to these large damage awards. Therefore, making interventions such as eARM available could be an effective and sustainable policy for reducing alcohol-related incidents.

Introduction

Alcohol use is associated with many types of crime. Alcohol is estimated to be involved in 58 percent of property crime, 54 percent of assaults, 39 percent of fatal traffic crashes, and 55 percent of rapes (Miller, Levy, Cohen, & Cox, 2006; National Highway Traffic Safety Administration, 2014). In addition, over 20 percent of hospitalized injuries are attributable to alcohol use (Miller & Spicer, 2012). Nationally, costs associated with excessive drinking were estimated to be $223.5 billion for 2006 (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011). Alcohol-related costs are also high locally (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011). Leaders throughout the country would like information to help decrease these alcohol-related problems and costs. Serving practices of alcohol establishments contribute to these alcohol-related problems (Graham & Wells, 2001; Graham, Schmidt, & Gillis, 1996; Naimi, Nelson, & Brewer, 2009).

Conditions within establishments that serve alcohol directly influence the blood alcohol content (BAC) levels of their customers (Carlini, et al., 2014; Byrnes, Miller, Johnson, & Voas, 2014). Functional impairment and risk of alcohol-related problems increase monotonically with higher BAC levels (Ferrara, Zancaner, & Giorgetti, 1994; Moskowitz, Burns, & Williams, 1985). Over-consumption of alcohol at licensed establishments has been directly linked to alcohol-related problems such as traffic crashes and violence. At higher BAC and impairment levels, customers are more likely to be involved in aggressive events within establishments (Graham & Wells, 2001; Graham, Schmidt, & Gillis, 1996). Individuals who over-consume alcohol and then drive often report on premise establishments as the source of their last alcohol consumed (Naimi, Nelson, & Brewer, 2009; Truong & Sturm, 2007; Wood, McLean, Davidson, & Montgomery, 1995).

Most alcohol establishments have a high likelihood of selling alcohol to obviously intoxicated patrons(Andreasson, Lindewald, & Rehnman, 2000; Freisthler, Gruenewald, & Treno, 2003; Lenk, Toomey, & Erickson, 2006; Toomey, et al., 1999; Toomey, et al., 2004; Buvik & Rossow, 2015), despite state laws prohibiting alcohol sales to these individuals in most states (Mosher, et al., 2009). The over-service of alcohol may increase availability of alcohol, leading to increased alcohol consumption and a wide range of problems, including traffic crashes and intentional and unintentional violence (Edwards, et al., 1994; Watt, Purdie, Roche, & Mcclure, 2006).

Responsible beverage service (RBS) training programs are frequently used to promote responsible alcohol service and reduce alcohol-related problems that originate in licensed alcohol establishments. These training programs may focus specifically on alcohol servers or managers of the establishments—or both. They may be implemented voluntarily by alcohol establishment owners or managers but state or local governments may also mandate participation in specific training programs as a condition of the alcohol license. As of January 1, 2013 (the most recent data available) nineteen U.S. states mandated some type of RBS training (http://alcoholpolicy.niaaa.nih.gov/).

The effectiveness of RBS training programs vary, with some showing minimal effects and others reducing patron BAC levels and traffic crashes (Holder & Wagenaar, 1994; Lang, Stockwell, Rydon, & Beel, 1998; McKnight J. A., 1989; Saltz & Stanghetta, 1997; Treno, Gruenewald, Lee, & Remer, 2007; Wallin, Gripenberg, & Andreasson, 2005). These mixed effects may be the result of several aspects of the training. Early training programs targeted only alcohol servers — attempting to train servers to slow service of alcohol, promote alcohol-free drinks, recognize signs of intoxication, and refuse service to intoxicated individuals (McKnight J. A., 1993). These programs focused on servers because the servers interact with patrons and should therefore be in the best position to decide whether or not to serve alcohol or control the speed of alcohol service to a patron. However, several studies conclude that support of management is essential for sustaining and increasing responsible beverage service among servers (Howard-Pitney, Johnson, Altman, Hopkins, & Hammond, 1991; McKnight J. , 1991; National Highway Traffic Safety Administration, 1986). Simply focusing on servers ignores the context in which servers make decisions about responsible service of alcohol (McKnight J. A., 1993; Saltz, 1989). Management, not servers, determines promotion policies and establishes expectations about responsible alcohol service within an establishment.

Offering standardized manager training simultaneously for multiple establishments is common and has the advantage of requiring fewer resources to implement. However, this approach has the disadvantage of not being able to address specific needs of individual managers and their establishments. As a result, this approach may not be effective as more tailored training that is administered one-on-one with establishment managers (Howard-Pitney, Johnson, Altman, Hopkins, & Hammond, 1991). Policy needs for a small neighborhood bar may be very different from those for a large, urban nightclub. Managers who have not previously developed written policies for their establishment may need to be guided through the process of policy adoption and implementation. Having managers attend group lectures and giving them written information about policies is unlikely to increase development and implementation of specific policies within the establishment, unless managers actually learn the skills necessary to develop and enact such policies (Bandura, 1977; Baranowski, Perry, & Parcel, 1997).

Recognizing the need to train managers on how to establish responsible beverage service policies for their establishments, researchers at the University of Minnesota developed an intensive, one-on-one training program for alcohol establishment managers called Alcohol Risk Management (ARM) (Toomey, et al., 2001; Toomey, et al., 2008). ARM trainers worked individually with establishments to determine their needs, recommend model policies, create an establishment-specific alcohol control policy manual, and introduce those policies to establishment staff in four face-to-face training sessions. In a randomized controlled trial, ARM training resulted in an initial reduction in the likelihood of sales to obviously intoxicated patrons, but these effects decayed by three months post training (Toomey, et al., 2008). In the ARM trial, we observed a 22% reduction in the odds of intervention establishments selling alcohol to obviously intoxicated patrons verses comparison sites immediately following the training intervention. Effects decayed, however, by three months post intervention. Our hope with eARM is to extend the effects. Selling alcohol to obviously intoxicated patrons is highly related to problems such as violence and drinking and driving. These public health problems are part of the large costs related to alcohol use. Understanding the cost of implementing a web-enhanced version of the program is a key aspect of the feasibility of promoting its widespread dissemination to reduce the adverse outcomes associated with over-serving alcohol. In an effort to sustain the initial effects of ARM, the team created a hybrid version of the program called Enhanced Alcohol Risk Management (eARM) that includes both in-person and online components.

The purpose of this study was to document the development and testing costs of the eARM intervention and to estimate its implementation costs in a “real world”, non-research setting. Although RBS training programs and policies are common, we did not locate any studies that examined the cost of development or implementation of RBS training. Analysis of implementation costs is an important component for translating research findings into practice or policy (Damschroder, et al., 2009; Glasgow, Lichtenstein, & Marcus, 2003). This information will also be useful in future efforts to ascertain the cost-effectiveness and sustainability of other interventions designed to reduce alcohol-related problems.

Methods

Cost data for this study were obtained from a randomized controlled trial of the Enhanced Alcohol Risk Management (eARM) intervention, which is being conducted across 15 communities in a Midwestern metropolitan area. The purpose of the parent study from which cost data for the current study were obtained was to test whether eARM is an effective tool for reducing over-service of alcohol at bars and restaurants. eARM is a hybrid intervention that combines an interactive online training tool with individualized in-person trainings. eARM trainers meet in-person with managers to introduce eARM and discuss the value of alcohol control policies. Managers then complete online training that guides them through selection of policies to create a customized alcohol policy manual. Once policies are selected, an eARM trainer facilitates an in-person staff meeting to introduce policies and discuss implementation and compliance. Servers complete an online training on establishment-specific policies. Managers have access to a wide range of materials on the eARM website, including server training, policy implementation and enforcement tools. Once the core training is completed, eARM trainers continue to engage participants through multiple communication channels (e.g., telephone, e-mail, etc) to support ongoing policy implementation within their establishments.

Costs were assessed from two perspectives. First, the costs of developing and testing the intervention were measured from a research study perspective. Second, the estimated costs of implementing the intervention from the perspective of a municipality that might require establishments within their jurisdiction to adopt the intervention as a condition of their license were estimated.

Development and Testing Costs

Creating an intervention requires an internal development team that drives the design, content, and early testing of the intervention. Development and testing costs during this research study included the salaries of the development team: an intervention coordinator, principal investigator, and two co-investigators, and costs for website design and video production. Personnel involved in testing the intervention, after development, included an intervention coordinator, the principal investigator, and two trainers responsible for conducting meetings at each participating establishment. The Principal Investigator was the lead administrator on the project. She advised decisions on recruitment protocols, developed new curriculum, ensured that trainings were aligned with best practices, and met with community leaders such as police chiefs and directors of alcohol licensing divisions to promote the eARM program. The intervention coordinator was in-charge of the day-to-day implementation of eARM. She recruited participants, developed new materials for in-person trainings as well as the web and maintained the eARM website. The intervention coordinator also supervised the training staff, maintained their weekly field schedules and provided project materials. The two trainers were responsible for leading in-person sessions at bars and restaurants. One type of meeting conducted was a one-on-one meeting with a general manager. The second type of meeting was a staff meeting for all front-of-house staff to introduce the policies, role model leading a staff meeting for managers, and practice techniques for refusing service to obviously intoxicated patrons. The trainers also maintained contact with their participating managers through the eARM website, emails and telephone calls. Other non-personnel costs of implementing the intervention included expenses for marketing and recruitment of establishments, a list of state liquor license holders, informational binders and branded materials, incentives for participating establishments, telephone and internet costs, IT support, an annual licensing fee for the content management system (Sitecore) that supported the eARM website, office supplies, refreshments for establishment staff meetings, printing/photocopying, Microsoft Access database, other costs such as travel and mileage, and University indirect costs.

Estimated Implementation Costs

Inputs associated with implementing the intervention outside of a research setting once developed, such as by a municipality interested in reducing the number of drinking and driving incidents, included the same items as the intervention testing phase of the research study, excluding University indirect costs. The costs associated with input were estimated by project personnel based on observations and experience gained during the implementation portion of the research study after recruitment protocols and training systems were finalized. Costs were estimated for a 12 month period.

Implementation costs were summed and then divided by the number of establishments recruited to participate in the intervention during that time period. One hundred thirteen establishments were recruited to participate in the intervention during that time period. This calculation yielded an average cost per establishment. As some costs were fixed and some variable, there are likely to be scale economies associated with the implementation of the intervention. To investigate possible scale economies associated with implementation, the number of participating establishments and variable costs associated with implementing the intervention in additional establishments were increased. Average costs per establishment were then calculated assuming greater numbers of establishments by proportionally increasing the variable costs associated with implementation. These methods follow closely those previously published on the estimation of online intervention implementation costs (Page, Horvath, Damilenko, & William, 2012).

Results

Data for development and implementation costs incurred for development are reported in Table 1. During the development phase, the intervention coordinator dedicated 75 percent effort to the project for $38,250 in salary. Including the 36 percent fringe rate, the total cost of the intervention coordinator was $52,020 during the development phase. The principal investigator dedicated 15 percent effort to the project for a total of $26,020, including the 36 percent fringe rate. Two co-investigators also participated in the development of the intervention at 10 percent effort and a 41.3 percent fringe rate. Their costs during the development phase were $12,454 and $11,652. The web vendor contracted to develop the web-based component of the intervention cost $234,000, and video production for the intervention cost $8,100. Total development costs were $344,256.

Table 1. eARM development and implementation cost incurred during research and development phase.

Development Costs Cost ($)
Intervention Coordinator 52,020
Principal Investigator 26,030
Co-investigator 12,454
Co-investigator 11,652
Contract Web Vendor 234,000
Contract Video Production 8,100
Implementation Costs
Intervention Coordinator 35, 547
Principal Investigator 9,758
Lead Trainer 40,553
Trainer 28,243
Marketing and recruitment 1,000
List of state license holders 820
eARM binders and branded materials 4,370
Incentives (including prizes) 11,500
Telephone/Internet 1,200
IT support 700
Sitecore CMS license fee 1,000
Office supplies 200
Refreshments for establishments staff meetings 675
Printing/Photocopying 1,590
Access database built for tracking recruits 2,000
Other costs (travel mileage, etc.) 1,492
Total Direct Costs 484,904
University Indirect cost (51%) 247,301
Total Development and Testing Costs 732,205
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During the intervention implementation phase, project personnel accounted for the majority of costs. Costs for the intervention coordinator (50 percent effort) and principal investigator (5 percent effort) were $35,547 and $9,758, respectively, including fringe. Costs for the two trainers (one trainer devoted 70 percent effort to the project and the other 50 percent) were $40,553 and $28,243 including fringe. Other testing costs amounted to $24,419 for total testing costs of $135,737. Direct development and testing costs were $484,904. Including the University's overhead cost rate of 51 percent, total development and testing costs were $732,205.

Estimated implementation costs of the eARM intervention outside of a research setting are listed in Table 2. Costs are similar to those incurred during the implementation phase, with a few exceptions needed for implementation outside of a controlled research setting. The research team estimated that implementation outside of a University research environment would require a full-time intervention coordinator, a full time lead trainer, and a trainer devoting 75 percent effort to implementing the intervention. Hosting the website with IT support on an external server would cost approximately $350 per month, or $4200 per year, and prize costs would be lower as establishments would not be paid to participate in the program. Other costs would be the same as those incurred during the intervention testing phase. Total estimated implementation costs were $179,999. Assuming that 113 establishments would be recruited, the average cost per establishment would be $1,588. Assuming that the variable costs associated with increasing the number of establishments are the trainers' time, recruitment expenses, incentives, office supplies, refreshments for staff meetings, and travel mileage, each additional establishment recruited would add an additional $819 to the total implementation cost. Achieving a scale of 200 establishments would reduce per establishment costs to $1,375.

Table 2. Estimated implementation costs of eARM outside of a research setting.

Implementation Costs Costs ($)
Intervention Coordinator 64,700
Program director 6,470
Lead Trainer 51,760
Trainer 37,850
Marketing and recruitment 1,000
List of state license holders 820
eARM binders and branded materials 4,370
Incentives (including prizes) 800
Telephone/Internet 1,200
IT support 3,600
Sitecore CMS license fee 1,000
Office supplies 200
Refreshments for establishments staff meetings 675
Printing/Photocopying 1,590
Access database built for tracking recruits 2,000
Other costs (travel mileage, etc.) 1,364
Total Implementation Costs $179,399
Implementation costs per establishment (113 establishments) $1,588
Implementation cost per establishment (200 establishments) $1,375
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Discussion

This analysis estimated the costs of implementing a hybrid intervention designed to reduce alcohol sales to obviously intoxicated bar patrons. Assuming participation of 113 establishments, average intervention implementation costs per establishment were $1,588. Assuming participation of 200 establishments, average per establishment implementation costs were reduced to $1,375. One challenge of implementing the intervention outside of a research setting will be to ensure that a significant number of establishments are recruited and agree to use the intervention regularly. The number of establishments chosen for the cost analysis was the number recruited for the efficacy study. However, average implementation costs would vary with the number of participating establishments. Future studies should determine the optimal scale of implementation to maximize the cost effectiveness of the intervention; in other words, these studies should determine the minimum number of establishments needed to lower average costs to where the benefits of the intervention exceed its costs.

The current study did not report data on the intervention's efficacy. However, an earlier, face-to-face only version of the training program (Alcohol Risk Management; ARM) was effective in reducing alcohol sales to obviously intoxicated patrons (Toomey, et al., 2001; Toomey, et al., 2008). However, effects decayed within three months of the training. The hybrid version of the training was developed to attempt to create sustained effects. Future studies will analyze outcome measures in order to determine whether the potential cost savings from reduced alcohol sales to intoxicated patrons outweigh the costs of the intervention. Development costs were obtained in a University research setting, and would likely differ if developed by a private sector company. However, the policy-relevant costs are the implementation costs, and these are independent of the setting in which the intervention was developed.

In order for eARM to be an effective method for reducing alcohol sales to intoxicated bar patrons, and therefore reduce the likelihood of alcohol-related incidents such as drunk driving and violence, it must be made available to establishments in other municipalities and must also be adopted by establishments. It is likely that the intervention would need to be implemented by a local health department, and the health department would have to charge establishments a price equal to the average cost in order to break even. While the $1,588 intervention implementation cost could be considered a large sum of money for a small business, such as a local bar, the potential consequences of selling alcohol to intoxicated patrons are substantially larger. Many states have dram shop liability policies. These policies mean that alcohol establishments can be sued for over serving alcohol if the over-service results in an injury or death to themselves or a third party (Rammohan, et al., 2011). Recent news stories highlight the potential liability faced by bar owners for serving patrons too much alcohol. A Duluth, Georgia bar settled a lawsuit for $500,000 following a drinking and driving crash involving patrons of the bar who were served too much alcohol (Coleman, 2013). A bar in Beaumont, Texas settled a lawsuit for $1 million for selling alcohol to underage patrons who later died in a car crash (Yates, 2012). A jury awarded $1.7 million in damages to a Charlotte, North Carolina couple critically injured by an impaired driver who was served too much alcohol (Copeland, 2012). A jury also awarded $10.5 million to the family of a woman killed by an impaired driver with a BAC of 0.18 (Goldberg, 2013). These large damage liability awards suggests that establishments, or their insurance companies, may be willing to pay the $1,588 estimated implementation cost in order to limit their exposure to these large damage awards. Therefore, making interventions such as eARM available could be an effective policy for reducing alcohol-related incidents.

Contributor Information

Timothy F. Page, Department of Health Policy and Management, Florida International University.

Dawn M. Nederhoff, Department of Epidemiology and Community Health, University of Minnesota.

Alexandra M. Ecklund, Department of Epidemiology and Community Health, University of Minnesota.

Keith J. Horvath, Department of Epidemiology and Community Health, University of Minnesota.

Toben F. Nelson, Department of Epidemiology and Community Health, University of Minnesota.

Darin J. Erickson, Department of Epidemiology and Community Health, University of Minnesota.

Traci L. Toomey, Department of Epidemiology and Community Health, University of Minnesota.

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