Out of touch or on the money: Do the clinical objectives of addiction treatment coincide with economic evaluation results?

A pilot economic evaluation of computerized cognitive behavioral therapy for alcohol use disorder as an addition and alternative to traditional therapy

BACKGROUND

Computer-based delivery of cognitive behavioral therapy (CBT) may be a less costly approach to increase dissemination and implementation of evidence-based treatments for alcohol use disorder (AUD). However, comprehensive evaluations of costs, cost-effectiveness, and cost-benefit of computer-delivered interventions are rare.

METHODS

This study used data from a completed randomized clinical trial to evaluate the cost-effectiveness and cost-benefit of a computer-based version of CBT (CBT4CBT) for AUD. Sixty-three participants were randomized to receive one of the following treatments at an outpatient treatment facility and attended at least one session: (1) treatment as usual (TAU), (2) CBT4CBT plus treatment as usual (CBT4CBT+TAU), or (3) CBT4CBT plus brief monitoring.

RESULTS

Median protocol treatment costs per participant differed significantly between conditions, Kruskal-Wallis H(2) = 8.40, p = 0.02, such that CBT4CBT+TAU and CBT4CBT+monitoring each cost significantly more per participant than TAU. However, when nonprotocol treatment costs were included, total treatment costs per participant did not differ significantly between conditions. Median incremental cost-effective ratios (ICERs) revealed that CBT4CBT+TAU was more costly and more effective than TAU. It cost $35.08 to add CBT4CBT to TAU to produce a reduction of one additional drinking day per month between baseline and the end of the 8-week treatment protocol: CBT4CBT+monitoring cost $33.70 less to produce a reduction of one additional drinking day per month because CBT4CBT+monitoring was less costly than TAU and more effective at treatment termination, though not significantly so. Net benefit analyses suggested that costs of treatment, regardless of condition, did not offset monthly costs related to healthcare utilization, criminal justice involvement, and employment disruption between baseline and 6-month follow-up. Benefit-cost ratios were similar for each condition.

CONCLUSIONS

Results of this pilot economic evaluation suggest that an 8-week course of CBT4CBT may be a cost-effective addition and potential alternative to standard outpatient treatment for AUD. Additional research is needed to generate conclusions about the cost-benefit of providing CBT4CBT to treatment-seeking individuals participating in standard outpatient treatment.

The insights of health and welfare professionals on hurdles that impede economic evaluations of welfare interventions

BACKGROUND

Four hurdles associated with economic evaluations in welfare interventions were identified and discussed in a previous published literature review. These hurdles include (i) 'Ignoring the impact of condition-specific outcomes', (ii) 'Ignoring the impact of QoL externalities', (iii) 'Calculation of costs from a too narrow perspective' and (iv) 'The lack of well-described & standardized interventions'. This study aims to determine how healthcare providers and social workers experience and deal with these hurdles in practice and what solutions or new insights they would suggest.

METHODS

Twenty-two professionals of welfare interventions carried out in Flanders, were interviewed about the four described hurdles using a semi-structured interview. A thematic framework was developed to enable the qualitative analysis. The analysis of the semi-structured interviews was facilitated through the use of the software program QRS NVivo 10.

RESULTS

The interviews revealed a clear need to tackle these hurdles. The interviewees confirmed that further study of condition-specific outcomes in economic evaluations are needed, especially in the field of mental health and stress. The proposed dimensions for the condition-specific questionnaires varied however between the groups of interviewees (i.e. general practitioners vs social workers). With respect to QoL externalities, the interviewees confirmed that welfare interventions have an impact on the social environment of the patient (friends and family). There was however no consensus on how this impact of QoL externalities should be taken into account in welfare interventions. Professionals also suggested that besides health care costs, the impact of welfare interventions on work productivity, the patients' social life and other items should be incorporated. Standardization appears to be of limited added value for most of the interviewees because they need a certain degree of freedom to interpret the intervention. Furthermore, the target population of the interventions is diverse which requires a tailor-made approach.

CONCLUSION

This qualitative research demonstrated that these hurdles occur in practice. The proposed solutions for these hurdles can contribute to the improvement of the methodological quality of economic evaluations of welfare interventions.

State parity laws and access to treatment for substance use disorder in the United States: implications for federal parity legislation

IMPORTANCE

The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment.

OBJECTIVE

To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment.

INTERVENTIONS

State-level SUD parity laws during the study period.

MAIN OUTCOMES AND MEASURES

State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance.

RESULTS

The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance.

CONCLUSIONS AND RELEVANCE

We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Economics of individualization in comparative effectiveness research and a basis for a patient-centered health care

The United States aspires to use information from comparative effectiveness research (CER) to reduce waste and contain costs without instituting a formal rationing mechanism or compromising patient or physician autonomy with regard to treatment choices. With such ambitious goals, traditional combinations of research designs and analytical methods used in CER may lead to disappointing results. In this paper, I study how alternate regimes of comparative effectiveness information help shape the marginal benefits (demand) curve in the population and how such perceived demand curves impact decision-making at the individual patient level and welfare at the societal level. I highlight the need to individualize comparative effectiveness research in order to generate the true (normative) demand curve for treatments. I discuss methodological principles that guide research designs for such studies. Using an example of the comparative effect of substance abuse treatments on crime, I use novel econometric methods to salvage individualized information from an existing dataset.

Medical and Mental Health Status Among Drug Dependent Patients Participating in a Smoking Cessation Treatment Study

Substance Abusers have a large number of medical and psychiatric problems, and 70-90% are smokers. The aim of this analysis was to examine the prevalence and correlates of medical and psychiatric problems in this sample of drug dependent patients who were participants in a multi-site study of smoking cessation interventions while engaged in substance abuse treatment. Descriptive analyses showed at baseline, 72.8% of participants had at least one medical problem and 64.1% had at least one psychiatric diagnosis. Medical problems correlated strongly with age, smoking severity, and pack-years; Psychiatric problems correlated with gender and ethnicity. Smoking cessation treatment was associated with a moderate reduction in the ASI Medical composite score. More research is needed on the possible effects of combined treatment of substance abuse and concurrent medical and psychiatric problems. Offering smoking cessation in conjunction with primary care may be a way to address the health needs of this population.

Substance use, education, employment, and criminal activity outcomes of adolescents in outpatient chemical dependency programs

Although the primary outcome of interest in clinical evaluations of addiction treatment programs is usually abstinence, participation in these programs can have a wide range of consequences. This study evaluated the effects of treatment initiation on substance use, school attendance, employment, and involvement in criminal activity at 12 months post-admission for 419 adolescents (aged 12 to 18) enrolled in chemical dependency recovery programs in a large managed care health plan. Instrumental variables estimation methods were used to account for unobserved selection into treatment by jointly modeling the likelihood of participation in treatment and the odds of attaining a certain outcome or level of an outcome. Treatment initiation significantly increased the likelihood of attending school, promoted abstinence, and decreased the probability of adolescent employment, but it did not significantly affect participation in criminal activity at the 12-month follow-up. These findings highlight the need to address selection in a non-experimental study and demonstrate the importance of considering multiple outcomes when assessing the effectiveness of adolescent treatment.

Economic evaluation of continuing care interventions in the treatment of substance abuse: recommendations for future research

The chronic and relapsing nature of substance abuse points to the need for continuing care after a primary phase of treatment. This article reviews the economic studies of continuing care, discusses research gaps, highlights some of the challenges of conducting rigorous economic evaluations of continuing care, and offers research guidelines and recommendations for future economic studies in this emerging field. Rigorous economic evaluations are needed by health care providers and policy makers to justify the allocation of scarce resources to continuing care interventions. The adoption of cost-effective continuing care services can reduce long-term consequences of addiction, thereby potentially increasing overall social welfare.

Social costs of robbery and the cost-effectiveness of substance abuse treatment

Reduced crime provides a key benefit associated with substance abuse treatment (SAT). Armed robbery is an especially costly and frequent crime committed by some drug-involved offenders. Many studies employ valuation methods that understate the true costs of robbery, and thus the true social benefits of SAT-related robbery reduction. At the same time, regression to the mean and self-report bias may lead pre-post comparisons to overstate crime reductions associated with SAT. Using 1992-1997 data from the National Treatment Improvement Evaluation Study (NTIES), we examined pre-post differences in self-reported robbery among clients in five residential and outpatient SAT modalities. Fixed-effect negative binomial regression was used to examine incidence rate reductions (IRR) in armed robbery. Published data on willingness to pay to avoid robbery were used to determine the social valuation of these effects. Differences in IRR across SAT modalities were explored to bound potential biases.All SAT modalities were associated with large and statistically significant reductions in robbery. The average number of self-reported robberies declined from 0.83/client/year pre-entry to 0.12/client/year following SAT (p<0.001). Under worst-case assumptions, monetized valuations of reductions in armed robbery associated with outpatient methadone and residential SAT exceeded economic costs of these interventions. Conventional wisdom posits the economic benefits of SAT. We find that SAT is even more beneficial than is commonly assumed.

An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery

Using data from 1,162 people entering treatment and followed up (> 94%) for 8 years, this article examines the relationship between the duration of abstinence (1 month to 5 or more years) and other aspects of recovery (e.g., health, mental health, coping responses, legal involvement, vocational involvement, housing, peers, social and spiritual support), including the trend and at what point changes occur. It also examines how the duration of abstinence at a given point is related to the odds of sustaining abstinence in the subsequent year. The findings demonstrate the rich patterns of change associated with the course of long-term recovery.

Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients' symptom severity

This study evaluated a patient-treatment matching strategy intended to improve the effectiveness and cost-effectiveness of acute treatment for dual-diagnosis patients. Matching variables were the severity of the patient's disorders and the program's service intensity. Patients (N = 230) with dual substance use and psychiatric disorders received low or high service-intensity acute care in 1 of 14 residential programs and were followed up for 1 year (80%) using the Addiction Severity Index. Patients' health care utilization was assessed from charts, Department of Veterans Affairs (VA) databases, and health care diaries; costs were assigned using methods established by the VA Health Economics Resource Center. High-severity patients treated in high-intensity programs had better alcohol, drug, and psychiatric outcomes at follow-up, as well as higher health care utilization and costs during the year between intake and follow-up than did those in low-intensity programs. For moderate-severity patients, high service intensity improved the effectiveness of treatment in only a single domain (drug abuse) and increased costs of the index stay but did not increase health care costs accumulated over the study year. Moderate-severity patients generally had similar outcomes and health care costs whether they were matched to low-intensity treatment or not. For high-severity patients, matching to higher service intensity improved the effectiveness of treatment as well as increased health care costs. Research is needed to establish standards by which to judge whether the added benefits of high-intensity acute care justify the extra costs.

Cost-effectiveness of public sector substance abuse treatment

Costs and cost-effectiveness of public sector substance abuse treatment in 2 California counties with similar substance abuse treatment system histories are compared; one county (MidState) has adopted managed care principles. As hypothesized, MidState's costs for the index treatment episode were significantly lower than SouthState's, although unexpectedly because of lower outpatient utilization. Treatment benefits in the 7 Addiction Severity Index functional areas were examined through cost-effectiveness analyses. MidState can claim greater cost-effectiveness for its treatment dollars for significant improvement in alcohol and medical functioning (compared to unsuccessful clients and those reporting no problems). When comparing both improved clients and those maintaining no problems to unsuccessful clients, MidState is more cost-effective for improving alcohol, medical, legal, and family/social functioning; and 3 outcomes important to community stakeholders and taxpayers (legal, medical, and psychiatric functioning) are more cost-effective than alcohol, drug, and employment improvement.

A research agenda for economic evaluation of substance abuse services

Economic analyses of substance abuse interventions play a critical role in informing the decision makers involved in funding these programs. Despite the emergence of new and more effective interventions, the adoption of costlier services still demands justification based on economic evidence. Updated and more rigorous economic information allows patients, health care professionals, insurance companies, policymakers, and others to allocate scarce resources more efficiently. To prepare for the next wave of addiction health services research, this article presents background information on the economics of addiction health services, reviews recent empirical and methodological contributions, and provides 15 research recommendations.