Benefit-cost analysis of SBIRT interventions for substance using patients in emergency departments

Development of a brief bedside tool to screen women sexual assault survivors for risk of persistent posttraumatic stress six months after sexual assault

This study aims to develop and validate a brief bedside tool to screen women survivors presenting for emergency care following sexual assault for risk of persistent elevated posttraumatic stress symptoms (PTSS) six months after assault. Participants were 547 cisgender women sexual assault survivors who presented to one of 13 sexual assault nurse examiner (SANE) programs for medical care within 72 h of a sexual assault and completed surveys one week and six months after the assault. Data on 222 potential predictors from the SANE visit and the week one survey spanning seven broadly-defined risk factor domains were candidates for inclusion in the screening tool. Elevated PTSS six months after assault were defined as PCL-5 > 38. LASSO logistic regression was applied to 20 randomly selected bootstrapped samples to evaluate variable importance. Logistic regression models comprised of the top 10, 20, and 30 candidate predictors were tested in 10 cross-validation samples drawn from 80% of the sample. The resulting instrument was validated in the remaining 20% of the sample. AUC of the finalized eight-item prediction tool was 0.77 and the Brier Score was 0.19. A raw score of 41 on the screener corresponds to a 70% risk of elevated PTSS at 6 months. Similar performance was observed for elevated PTSS at one year. This brief, eight-item risk stratification tool consists of easy-to-collect information and, if validated, may be useful for clinical trial enrichment and/or patient screening.

Economic benefits of substance use disorder treatment: A systematic literature review of economic evaluation studies from 2003 to 2021

INTRODUCTION

The economic burden of substance use disorder (SUD) is significant, comprising costs of health care and social services, criminal justice resources, loss of productivity, and premature mortality. This study assembles and synthesizes two decades of evidence describing the benefits of SUD treatment across five main outcome domains; 1) health care utilization; 2) self-reported criminal activity by offense type; 3) criminal justice involvement collected from administrative records or self-reported; 4) productivity assessed through working hours or wages earned; and 5) social services (e.g., a day spent in transitional housing).

METHODS

This review included studies if they reported the monetary value of the intervention outcomes, most commonly through a cost-benefit or cost-effectiveness framework. The search included studies from 2003 to the present day as of this writing (up to October 15, 2021). Summary cost estimates were adjusted using the US Consumer Price Index (CPI) to reflect the 12-month benefits per client in USD 2021. We followed the PRISMA methodology for study selection and assessed quality using the Checklist for Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

The databases yielded 729 studies after removing duplicates, and we ultimately selected 12 for review. Studies varied widely regarding analytical approaches, time horizons, outcome domains, and other methodological factors. Among the ten studies that found positive economic benefits, reductions in criminal activity or criminal justice costs represented the largest or second largest component of these benefits (range $621 to $193,440 per client).

CONCLUSIONS

Consistent with previous findings, a reduction in criminal activity costs is driven by the relatively high societal cost per criminal offense, notably for violent crimes, such as aggravated assault and rape/sexual assault. Accepting the economic rationale for increased investment in SUD interventions will require recognizing that more benefits accrue to individuals by avoiding being victims of a crime than to governments through budget offsets resulting from savings in non-SUD program expenses. Future studies should explore individually tailored interventions to optimize care management, which may yield unexpected economic benefits to services utilization, and criminal activity data to estimate economic benefits across a broad range of interventions.

Costs, benefits, and net benefit of 13 inpatient substance use treatments for 14,947 women and men

In an attempt to replicate earlier findings that substance use disorder treatment (SUDTx) has monetary outcomes (benefits) for taxpayers that exceed treatment costs several times over for the average participant, costs of SUDTx were contrasted to observed costs of healthcare, criminal justice services, and economic assistance, plus potential increases in earned income, for 14,947 substance-using individuals treated at 13 intensive inpatient programs varying in gender sensitivity. Those who received higher levels of gender-sensitive treatment were expected to better offset treatment costs through greater reductions in subsequent service costs and economic assistance, and greater increases in earned income. Compared to the 24 months preceding treatment, archival data from state databases showed that use of health and criminal justice services, and receipt of economic assistance, actually increased during the 24 months following treatment, and that earned income decreased, resulting in unexpectedly negative net benefits, i.e., a net loss, from a taxpayer perspective. More gender-sensitive treatment was less costly per participant, however, making the net loss less for persons receiving more gender-sensitive treatment. Alternative explanations for these findings are explored, including utilization of archival records of service use rather than the more bias-sensitive self-reports of service use that others have examined previously. The importance of evaluating nonmonetary, as well as monetary, outcomes of substance use disorder (SUD) treatment is noted as well.

Improving alcohol management in primary health care in Mexico: A return-on-investment analysis

INTRODUCTION

Alcohol screening, brief advice and referral to treatment (SBIRT) in primary health care is an effective strategy to decrease alcohol consumption at population level. However, there is relatively scarce evidence regarding its economic returns in non-high-income countries. The current paper aims to estimate the return-on-investment of implementing a SBIRT program in Mexican primary health-care settings.

METHODS

Empirical data was collected in a quasi-experimental study, from 17 primary health-care centres in Mexico City regarding alcohol screening delivered by 145 health-care providers. This data was combined with data from a simulation study for a period of 10 years (2008 to 2017). Economic investments were calculated from a public sector health-care perspective as clinical consultation costs (salary and material costs) and program costs (set-up, adaptation, implementation strategies). Economic return was calculated as monetary gains in the public sector health-care, estimated via simulated reductions in alcohol consumption, dependent on population coverage of alcohol interventions delivered to primary health-care patients.

RESULTS

Results showed that scaling up a SBIRT program in Mexico over a 10-year period would lead to positive return-on-investment values ranging between 21% in scenario 4 (confidence interval -8.6%, 79.5%) and 110% in scenario 5 (confidence interval 51.5%, 239.8%). Moreover, over the 10-year period, up to 16,000 alcohol-related deaths could be avoided as a result of implementing the program.

DISCUSSION AND CONCLUSIONS

SBIRT implemented at national level in Mexico may lead to substantial financial gains from a public sector health-care perspective.

ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use

BACKGROUND

Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use.

METHODS

We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months.

RESULTS

Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention.

CONCLUSIONS

This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

Economic Analysis of Brief Motivational Intervention Following Trauma Related to Drugs and Alcohol

BACKGROUND

Very few studies have conducted an economic assessment of brief motivational intervention (BMI) in patients experiencing traumatic injuries related to alcohol and/or substance use. Furthermore, findings concerning the potential long-term economic benefits of BMI applied in nursing are promising but very scarce.

OBJECTIVE

The purpose of this study was to analyze the costs and benefits associated with the application of a BMI program by nursing staff to patients hospitalized for trauma related to substance use.

METHODS

An analysis of costs and benefits was conducted in a nonrandomized study of a retrospective cohort of patients. An intervention and follow-up (of 10-52 months) of patients between 16 and 70 years of age admitted for traumatic injuries in University Hospital of Granada were carried out with a cohort of 294 patients (intervention = 162 vs. no intervention = 132) between 2011 and 2016. The National Health Service's perspective on the use of medical resources and the costs associated with intervention and recidivism was considered. A cost analysis with a 5-year time frame and a subsequent analysis of sensitivity were conducted.

RESULTS

Direct medical costs associated with trauma recidivism were significantly lower in patients who received BMI, as compared to patients who did not receive it, &OV0556;751.82 per patient (95% CI &OV0556;13.15 to &OV0556;1,490.48) in the first year. The cost-benefit ratio of &OV0556;74.92 at 4 years reflects National Health Service savings for each euro invested in BMI.

DISCUSSION

The implementation of BMI programs in nursing care may be profitable from an economic standpoint, justifying the inclusion of these programs in hospitals both because of their efficacy and the potential savings incurred by the health system. This study addresses the lack of evidence regarding the economic implications linked to the effectiveness of the intervention to reduce substance use and trauma recidivism. Results identify BMI delivered in hospitals by nurses as a technique that offers the potential for reducing costs linked to trauma recidivism. The research has important practical implications for hospital nurses and doctors.

The short-term impact on economic outcomes of SBIRT interventions implemented in reproductive health care settings

OBJECTIVE

To estimate the impact of screening, brief intervention, and referral to treatment (SBIRT) administered in reproductive health care settings on a variety of economic outcomes, including general health care utilization, criminal activity, and motor vehicle crashes. Whether and by how much SBIRT affects economic outcomes are important unanswered questions related to the economic impact of this technique.

METHODS

We collected data as part of a randomized clinical trial that examined whether SBIRT delivered electronically (e-SBIRT) or by a clinician (SBIRT) is superior to enhanced usual care (EUC) for substance misuse. Participants were a convenience sample of 439 women from two reproductive health care centers who used cigarettes, risky amounts of alcohol, illicit drugs, or misused prescription medication. For each participant, we measured economic outcomes by self-report 6 months pre- and post-intervention. We used difference-in-differences regression models to estimate the impact of e-SBIRT and SBIRT, compared to EUC, on changes in each of the economic outcomes from pre- to post-intervention.

RESULTS

None of the difference-in-differences estimates weas statistically significant after adjusting for multiple comparisons.

CONCLUSION

In a population of women receiving routine care in reproductive health care settings, we did not find a significant effect of either e-SBIRT or SBIRT, compared to EUC, on general health care utilization, criminal activity, or motor vehicle outcomes. However, individual trials are typically underpowered to detect effects that are small but important from a public health perspective. These results may be crucial for future systematic reviews and meta-analyses to determine the economic impact of SBIRT programs from a variety of perspectives.

Alcohol screening and brief intervention in emergency departments: Review of the impact on healthcare costs and utilization

PURPOSE

To review the published evidence of the impact of alcohol screening and brief intervention (SBI) delivered in emergency departments (EDs) on healthcare utilization and costs.

PRINCIPAL RESULTS

This scoping review used existing literature reviews supplemented with an electronic database. We included studies if they assessed SBIs for alcohol delivered in an ED setting and reported healthcare utilization and/or costs. We abstracted methodological approaches and healthcare utilization outcomes from each study and categorized them based on substance of focus (alcohol only vs. alcohol and other substances). We updated cost estimates from each study to 2018 U.S. dollars. We identified seven studies published between 2010 and 2019 that met study inclusion criteria. Two of the seven studies evaluated SBI that targeted both alcohol and other substances. Six studies found a reduction in healthcare utilization or costs, and one found an increase in healthcare utilization.

MAJOR CONCLUSIONS

This literature review suggests that SBI delivered in ED settings can be a cost-reducing approach to treating excessive alcohol consumption, a factor that policy-makers and payers might consider in prioritizing interventions.

Feasibility of Brief Screening for At-Risk Gambling in Consumer Credit Counseling

Gambling disorder and problem gambling often lead to major suffering in the form of mental health problems, interpersonal conflict, and financial crises. One potential setting for detecting at-risk gambling is credit counseling as gambling problems may manifest themselves in the form of financial distress and bankruptcy. Research studies have not considered those seeking credit counseling as individuals at risk for gambling problems even though gambling may contribute to financial distress. Therefore, the current study sought to quantify the prevalence of at-risk gambling in credit counseling compared with national estimates, to compare at-risk gamblers in this population to lower risk individuals, and to assess the feasibility of gambling screening in these settings. Using a mixed methods approach, the current study found that almost 20% of callers to a national agency reported gambling behavior, and among those who gambled, they reported higher rates of problems related to gambling than the broader U.S. population, thus supporting the idea that screening in credit counseling may help identify those at risk. Low risk gamblers were slightly younger than non-gamblers, but no other differences in sociodemographic and financial status variables were found based on gambling risk status. Results from focus groups and individual interviews suggest that credit counselors and program administrators see the benefit to brief screening within their intake and counseling processes. Our findings suggest that gambling screening is feasible in consumer credit counseling and may be acceptable to staff and administrators at these agencies.

Cost-effectiveness of electronic- and clinician-delivered screening, brief intervention and referral to treatment for women in reproductive health centers

AIMS

To determine the cost-effectiveness of electronic- and clinician-delivered SBIRT (Screening, Brief Intervention and Referral to Treatment) for reducing primary substance use among women treated in reproductive health centers.

DESIGN

Cost-effectiveness analysis based on a randomized controlled trial.

SETTING

New Haven, CT, USA.

PARTICIPANTS

A convenience sample of 439 women seeking routine care in reproductive health centers who used cigarettes, risky amounts of alcohol, illicit drugs or misused prescription medication.

INTERVENTIONS

Participants were randomized to enhanced usual care (EUC, n = 151), electronic-delivered SBIRT (e-SBIRT, n = 143) or clinician-delivered SBIRT (SBIRT, n = 145).

MEASUREMENTS

The primary outcome was days of primary substance abstinence during the 6-month follow-up period. To account for the possibility that patients might substitute a different drug for their primary substance during the 6-month follow-up period, we also considered the number of days of abstinence from all substances. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves determined the relative cost-effectiveness of the three conditions from both the clinic and patient perspectives.

FINDINGS

From a health-care provider perspective, e-SBIRT is likely (with probability greater than 0.5) to be cost-effective for any willingness-to-pay value for an additional day of primary-substance abstinence and an additional day of all-substance abstinence. From a patient perspective, EUC is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is less than $0.18 and e-SBIRT is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is greater than $0.18.

CONCLUSIONS

e-SBIRT could be a cost-effective approach, from both health-care provider and patient perspectives, for use in reproductive health centers to help women reduce substance misuse.

Health Care Utilization After Paraprofessional-administered Substance Use Screening, Brief Intervention, and Referral to Treatment: A Multi-level Cost-offset Analysis

BACKGROUND

Authorities recommend universal substance use screening, brief intervention, and referral to treatment (SBIRT) for all (ie, universal) adult primary care patients.

OBJECTIVE

The objective of this study was to examine long-term (24-mo) changes in health care utilization and costs associated with receipt of universal substance use SBIRT implemented by paraprofessionals in primary care settings.

RESEARCH DESIGN

This study used a difference-in-differences design and Medicaid administrative data to assess changes in health care use among Medicaid beneficiaries receiving SBIRT. The difference-in-differences estimates were used in a Monte Carlo simulation to estimate potential cost-offsets associated with SBIRT.

SUBJECTS

The treatment patients were Medicaid beneficiaries who completed a 4-question substance use screen as part of an SBIRT demonstration program between 2006 and 2011. Comparison Medicaid patients were randomly selected from matched clinics in Wisconsin.

MEASURES

The study includes 4 health care utilization measures: outpatient days; inpatient length of stay; inpatient admissions; and emergency department admissions. Each outcome was assigned a unit cost based on mean Wisconsin Medicaid fee-for-service reimbursement amounts.

RESULTS

We found an annual increase of 1.68 outpatient days (P=0.027) and a nonsignificant annual decrease in inpatient days of 0.67 days (P=0.087) associated with SBIRT. The estimates indicate that the cost of a universal SBIRT program could be offset by reductions in inpatient utilization with an annual net cost savings of $782 per patient.

CONCLUSIONS

Paraprofessional-delivered universal SBIRT is likely to yield health care cost savings and is a cost-effective mechanism for integrating behavioral health services in primary care settings.

Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting

INTRODUCTION

Opioid use disorder (OUD) is increasing in prevalence throughout the world, with approximately three million individuals in the United States affected. Buprenorphine is a medication designed, researched, and effectively used to assist in OUD recovery.

OBJECTIVE

This narrative review discusses an approach to initiating buprenorphine in the emergency department (ED) for opioid-abuse recovery.

DISCUSSION

Buprenorphine is a partial mu-opioid receptor agonist with high affinity and low intrinsic activity. Buprenorphine's long half-life, high potency, and 'ceiling effect' for both euphoric sensation and adverse effects make it an optimal treatment alternative for patients presenting to the ED with opioid withdrawal. While most commonly provided as a sublingual film or tablet, buprenorphine can also be delivered via transbuccal, transdermal, subdermal (implant), subcutaneous, and parenteral routes. Prior to ED administration, caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal. Following the evaluation of common opioid withdrawal symptoms, a step-by-step approach to buprenorphine can by utilized to reach a sustained withdrawal relief. A multimodal medication-assisted treatment (MAT) plan involving pharmacologic treatment, as well as counseling and behavioral therapy, is essential to maintaining opioid remission. Patients may be safely discharged with safe-use counseling, close outpatient follow-up, and return precautions for continued management of their OUD. Establishing a buprenorphine program in the ED involves a multifactorial approach to establish a pro-buprenorphine culture.

CONCLUSIONS

Buprenorphine is an evidence-based, safe, effective treatment option for OUD in an ED-setting. Though successfully utilized by many ED-based treatment programs, the stigma of 'replacing one opioid with another' remains a barrier. Evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing ED OUD treatment.

Test characteristics of a drug CAGE questionnaire for the detection of non-alcohol substance use disorders in trauma inpatients

BACKGROUND

Non-alcohol substance use disorders (drug use disorders [DUDs]) are common in trauma patients.

OBJECTIVE

To determine the test characteristics of a 4-item drug CAGE questionnaire to detect DUDs in a cohort of adult trauma inpatients.

METHODS

Observational cross-sectional cohort of 1,115 adult patients admitted directly to a level-one trauma center between September, 1994 and November, 1996. All participants underwent both a 4-item drug CAGE questionnaire and the substance use disorder section of a structured psychiatric diagnostic clinical interview (SCID) (DSM-IIIR criteria), administered by staff unaware of their clinical status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), positive (LR+) and negative likelihood ratios (LR-), and the area under the receiver operating curve (AUC) were calculated for each individual question and the overall questionnaire, using SCID-generated DUD diagnoses as the standard. Performance characteristics of the screen were also compared across selected sociodemographic, injury mechanism, and diagnostic sub-groups.

RESULTS

Subjects with DUDs were common (n = 349, 31.3%), including cannabis (n = 203, 18.2%), cocaine (n = 199, 17.8%), and opioids (n = 156, 14.0%). The screen performed well overall (AUC = 0.90, 95% CI: 0.88-0.91) and across subgroups based on age, sex, race, marriage status, income, education, employment status, mechanism of injury, and current/past DUD status (AUCs 0.75-1.00). Answering any one question in the affirmative had a sensitivity = 83.4% (95% CI: 79.1-87.1), specificity = 92.3% (95% CI: 90.2-94.1), PPV = 83.1%, LR+ = 10.8.

CONCLUSIONS

The 4-item drug CAGE and its individual questions had good-to-excellent ability to detect DUDs in this adult trauma inpatient population, suggesting its usefulness as a screening tool.

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Background

Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.

Objective

This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.

Methods

A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.

Results

Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.

Conclusions

To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.

Start-Up Costs of SBIRT Implementation for Adolescents in Urban U.S. Federally Qualified Health Centers

OBJECTIVE

Understanding the costs to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescent substance use in primary care settings is important for providers in planning for services and for decision makers considering dissemination and widespread implementation of SBIRT. We estimated the start-up costs of two models of SBIRT for adolescents in a multisite U.S. Federally Qualified Health Center (FQHC). In both models, screening was performed by a medical assistant, but models differed on delivery of brief intervention, with brief intervention delivered by a primary care provider in the generalist model and a behavioral health specialist in the specialist model.

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster randomized trial. SBIRT implementation costs were calculated using an activity-based costing methodology. Start-up activities were defined as (a) planning activities (e.g., changing existing electronic medical record system and tailoring service delivery protocols); and (b) initial staff training. Data collection instruments were developed to collect staff time spent in start-up activities and quantity of nonlabor resources used.

RESULTS

The estimated average costs to implement SBIRT were $5,182 for the specialist model and $3,920 for the generalist model. Planning activities had the greatest impact on costs for both models. Overall, more resources were devoted to planning and training activities in specialist sites, making the specialist model costlier to implement.

CONCLUSIONS

The initial investment required to implement SBIRT should not be neglected. The level of resources necessary for initial implementation depends on the delivery model and its integration into current practice.