Cost effectiveness of alcoholism treatment in partial hospital versus inpatient settings after brief inpatient treatment: 12-month outcomes

Prevalence and correlates of past-month suicidal thoughts, suicide attempts, and non-suicidal self-injury among adults in a partial hospital program

OBJECTIVE

This study examined the prevalence and cross-sectional correlates of past-month suicidal thoughts, suicide attempts, interrupted attempts, aborted attempts, and non-suicidal self-injury (NSSI) among patients seeking treatment at a partial hospitalization program (PHP).

METHOD

1063 patients (54% female, 87% white, mean age = 33.6 years) receiving treatment at a PHP completed self-report questionnaires and the Columbia-Suicide Severity Rating Scale as part of routine clinical monitoring upon admission to the program. We examined demographic and clinical cross-sectional correlates of self-injurious thoughts and behaviors (SITBs) using descriptive statistics, ordinal regression, and logistic regression analyses.

RESULTS

In the past month, 44.6% of patients reported active suicidal thoughts, 5.6% reported a suicide attempt, 1.8% reported an interrupted attempt, 5.5% reported an aborted attempt, and 16.6% reported NSSI. Inpatient referral source (ORs = 2.45-5.28), minority sexual orientation (ORs = 1.43-6.94), and more Borderline Personality Disorder (BPD) symptoms (ORs = 1.09-1.23) were each associated with at least three of the five SITBs examined.

CONCLUSIONS

This study highlights elevated rates of suicidal thoughts, suicide attempts, and NSSI in a partial hospital sample. Given that past attempts predict future attempts and death by suicide, support during the transition from inpatient to outpatient care via programs such as PHPs is needed. Patients referred from inpatient treatment, who identity as a sexual minority, and with more BPD symptoms may require additional support and safety monitoring. Further work is indicated to better understand how PHP patients' SITBs change during and after partial hospitalization.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?"

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.

Perceptions of partner drinking problems, regulation strategies and relationship outcomes

The current research evaluates how perceptions of one's partner's drinking problem relate to attempts to regulate partner behavior and relationship functioning, and whether this varies by perceptions of one's own drinking. New measures are offered for Thinking about your Partner's Drinking (TPD) and Partner Management Strategies (PMS). Participants included 702 undergraduates who had been in a romantic relationship for at least three months. Participants completed an online survey assessing perceptions of problematic drinking for one's self and partner, ways in which attempts were made to regulate or restrain their partner's drinking, relationship outcomes (i.e., satisfaction, commitment, trust, and need fulfillment), and alcohol use and consequences for self and partner. Factor analyses supported a single factor for Thinking about your Partner's Drinking (TPD) and two factors for the Partner Management Strategies (PMS) scale (i.e., punishment and reward). Results using structural equation modeling indicated that perceiving one's partner to have a drinking problem was associated with lower relationship functioning. Further, this association was mediated by strategies using punishment aimed at changing one's partner's drinking, but was not mediated by strategies using rewards. Finally, moderation results suggested that this relationship was not as detrimental for participants who perceived they also had an alcohol problem. In sum, perceiving one's partner to have a drinking problem was associated with relationship problems through punishing regulation strategies, and was weaker among individuals who also perceived themselves to have a drinking problem.

Cost-effectiveness of interventions to prevent alcohol-related disease and injury in Australia

AIMS

To evaluate cost-effectiveness of eight interventions for reducing alcohol-attributable harm and determine the optimal intervention mix.

METHODS

Interventions include volumetric taxation, advertising bans, an increase in minimum legal drinking age, licensing controls on operating hours, brief intervention (with and without general practitioner telemarketing and support), drink driving campaigns, random breath testing and residential treatment for alcohol dependence (with and without naltrexone). Cost-effectiveness is modelled over the life-time of the Australian population in 2003, with all costs and health outcomes evaluated from an Australian health sector perspective. Each intervention is compared with current practice, and the most cost-effective options are then combined to determine the optimal intervention mix.

MEASUREMENTS

Cost-effectiveness is measured in 2003 Australian dollars per disability adjusted life year averted.

FINDINGS

Although current alcohol intervention in Australia (random breath testing) is cost-effective, if the current spending of $71 million could be invested in a more cost-effective combination of interventions, more than 10 times the amount of health gain could be achieved. Taken as a package of interventions, all seven preventive interventions would be a cost-effective investment that could lead to substantial improvement in population health; only residential treatment is not cost-effective.

CONCLUSIONS

Based on current evidence, interventions to reduce harm from alcohol are highly recommended. The potential reduction in costs of treating alcohol-related diseases and injuries mean that substantial improvements in population health can be achieved at a relatively low cost to the health sector.

Effectiveness and cost-effectiveness of four treatment modalities for substance disorders: a propensity score analysis

OBJECTIVE

To assess the effectiveness and cost-effectiveness of four treatment modalities for substance abuse.

DATA SOURCES

The study used data from the Services Research Outcomes Study (SROS), a survey of 3,047 clients in a random sample of 99 drug treatment facilities across the United States. Detailed sociodemographic, substance use, and clinical data were abstracted from treatment records. Substance abuse outcome and treatment history following discharge from index facilities were assessed using a comprehensive interview with 1,799 of these individuals five years after discharge. Treatment success was defined in two ways: as abstinence and as any reduction in substance use.

STUDY DESIGN

Effectiveness and cost-effectiveness of four modalities were compared: inpatient, residential, outpatient detox/methadone, and outpatient drug-free. Clients were stratified based on propensity scores and analyses were conducted within these strata. Sensitivity analyses examined the impact of future substance abuse treatment on effectiveness and cost-effectiveness estimates.

PRINCIPAL FINDINGS

Treatment of substance disorders appears to be cost-effective compared to other health interventions. The cost per successfully treated abstinent case in the least costly modality, the outpatient drug-free programs, was 6,300 dollars (95 percent confidence intervals: 5,200-7,900 dollars) in 1990 dollars. There were only minor differences between various modalities of treatment with regard to effectiveness. However, modalities varied considerably with regard to cost-effectiveness. Outpatient drug-free programs were the most cost-effective. There was little evidence that relative effectiveness or cost-effectiveness of programs varied according to factors that were associated with selection into different programs.

CONCLUSIONS

Substance disorders can be treated most cost-effectively in outpatient drug-free settings. Savings from transitioning to the most cost-effective treatment modality may free resources that could be reinvested to improve access to substance abuse treatment for a larger number of individuals in need of such treatment.

Economic evaluation of alcohol treatment services

The objective of this paper is to summarize and critically review the most recent literature on economic evaluation of alcohol treatment services, identify information gaps, and suggest a research agenda for the future. The focus of the review is research published after 1995, although some of the earlier economic studies are also included. Research findings in the literature provide evidence for the following. First, for many alcoholics, day hospital treatment or even less intensive outpatient services are cost-effective alternatives to inpatient treatment. Second, alcoholism treatment often results in declining health care costs for alcoholics who are covered by private health insurance. Third, though the use of alcoholics anonymous (AA) as an alternative to more structured alcohol treatment services may be cost-effective, substance abuse outcomes from AA are sometimes less favorable and the risk of relapse is higher. Fourth, methods have recently been developed to estimate the dollar value of alcohol treatment outcomes such as avoided absenteeism, increased productivity, improved health, and avoided crime. Based on these findings and developments, new treatment approaches and changes in service delivery systems require a fresh perspective on the costs and benefits of alternative treatment services. The findings from economic evaluation studies must be reported in clear and nontechnical terms to an audience of clinicians and politicians so that they can be used in the process of decision making.

Oxford house: a review of research and implications for substance abuse recovery and community research

After treatment for substance abuse, whether it is in hospital-based treatment programs, therapeutic communities, or recovery homes, many patients return to former high-risk environments or stressful family situations. Returning to these settings without a network of people to support abstinence increases chances of a relapse. As a consequence, substance abuse recidivism following treatment is high for both men and women. Alternative approaches need to be explored, and there are some promising types of recovery homes. From a public health perspective, a series of studies conducted at DePaul University suggests that one type of recovery home for alcohol abuse recovery has much potential. For example, within this self-help communal living setting, recovering alcoholics were able to maintain employment, thereby reducing their need for government subsidies. Maintaining employment for recovering alcoholics may promote increased personal responsibility, which may impact self-efficacy beliefs. These pilot studies, then, raised both theoretical and practical issues needing further evaluation.

The costs of crime and the benefits of substance abuse treatment for pregnant women

Although many pregnant, drug-dependent women report extensive criminal justice involvement, few studies have examined reductions in crime as an outcome of substance abuse treatment programs for pregnant women. This is unfortunate, because maternal criminal involvement can have serious health and cost implications for the unborn child, the mother and society. Using the Addiction Severity Index, differences in pre- and posttreatment criminal involvement were measured for a sample of 439 pregnant women who entered publicly funded treatment programs in Massachusetts between 1992 and 1997. Accepted cost of illness methods were supplemented with information from the Bureau of Justice Statistics to estimate the costs and benefits of five treatment modalities: detoxification only (used as a minimal treatment comparison group), methadone only, residential only, outpatient only, and residential/outpatient combined. Projected to a year, the net benefits (avoided costs of crime net of treatment costs) ranged from US$32,772 for residential only to US$3,072 for detoxification. Although all five modalities paid for themselves by reducing criminal activities, multivariate regressions controlling for baseline differences between the groups showed that reductions in crime and related costs were significantly greater for women in the two residential programs. The study provides economic justification for the continuation and possible expansion of residential substance abuse treatment programs for criminally involved pregnant women.

Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings

BACKGROUND

Few studies have estimated the economic costs and benefits of brief physician advice in managed care settings.

OBJECTIVE

To conduct a benefit-cost analysis of brief physician advice regarding problem drinking.

DESIGN

Patient and health care costs associated with brief advice were compared with economic benefits associated with changes in health care utilization, legal events, and motor vehicle accidents using 6- and 12-month follow-up data from Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled clinical trial.

SUBJECTS

482 men and 292 women who reported drinking above a threshold limit were randomized into control (n = 382) or intervention (n = 392) groups.

MEASURES

Outcomes included alcohol use, emergency department visits, hospital days, legal events, and motor vehicle accidents.

RESULTS

No significant differences between control and intervention subjects were present for baseline alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorders, drug use, crimes, motor vehicle accidents, or health care utilization. The total economic benefit of the brief intervention was $423,519 (95% CI: $35,947, $884,848), composed of $195,448 (95% CI: $36,734, $389,160) in savings in emergency department and hospital use and $228,071 (95% CI: -$191,419, $757,303) in avoided costs of crime and motor vehicle accidents. The average (per subject) benefit was $1,151 (95% CI: $92, $2,257). The estimated total economic cost of the intervention was $80,210, or $205 per subject. The benefit-cost ratio was 5.6:1 (95% CI: 0.4, 11.0), or $56,263 in total benefit for every $10,000 invested.

CONCLUSIONS

These results offer the first quantitative evidence that implementation of a brief intervention for problem drinkers can generate positive net benefit for patients, the health care system, and society.

Measuring treatment outcomes and client satisfaction in a partial hospitalization program

Mental health practitioners are increasingly being called on to evaluate the effectiveness of the treatment they provide. The partial hospitalization component of the mental health industry also has felt this call for outcome research. This article presents the results of one program's attempts to answer that call through an assessment of treatment outcome and client satisfaction at a partial hospitalization program. Participants (N = 287) were evaluated at admission, discharge, and 3-month follow-up. The article outlines the procedures used for assessment and uses the results as an example of the type of data that can be obtained through outcomes measurement. The article is intended to provide an example of program evaluation that is easy and inexpensive to administer.

A structured instrument for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost Analysis Program (DATCAP)

Drug abuse treatment programs need to know the cost of the services they provide. Indeed, continued public and private funding is now being linked to cost and performance measures, and programs can use financial data to improve organizational efficiency. However, one of the dangers of promoting cost studies at treatment programs is that most program staff are not technically prepared to perform a cost analysis and little user-friendly information is available to offer assistance. Furthermore, not all cost methods are consistent, which can lead to noncomparable estimates that are difficult to use for policy or planning purposes. Our paper tries to fill this gap in the research literature and provide treatment programs with a much-needed technical assistance tool. Specifically, we present a structured and scientifically-based instrument for estimating the economic cost of treatment services. The Drug Abuse Treatment Cost Analysis Program (DATCAP) is described in detail along with a companion instrument to analyze treatment financing; the Drug Abuse Treatment Financing Analysis Program (DATFin). The components of both instruments are outlined and findings from a variety of actual case studies are presented. Lastly, we discuss the DATCAP User's Manual, which will enable individual programs to begin collecting the necessary data and estimating economic costs at their own clinics.

The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects

Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. In this review, we first consider the conceptual rationales that have been offered to support inpatient and outpatient treatment. Following that, the results of the relevant research on setting effects are presented. Five studies had significant setting effects favoring inpatient treatment, two studies found day hospital to be significantly more effective than inpatient treatment, and seven studies yielded no significant differences on drinking-related outcome variables. In all but one instance in which a significant effect emerged, patients in the 'superior' setting received more intensive treatment and patients were not 'preselected' for their willingness to accept random assignment to treatment in either setting. Studies finding significant setting effects also conducted more treatment contrasts (18.6 vs. 4.9), on average, and had a mean statistical power level of 0.71 (median 0.79) to detect a medium-sized effect, whereas studies with no significant findings had an average power level of 0.55 (median 0.57). When inpatient treatment was found to be more effective, outpatients did not receive a respite in the form of inpatient detoxification and the studies were slightly less likely to have social stability inclusion criteria and to use random assignment to treatment settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.

Economic evaluation of drug abuse treatment programs: methodology and findings

Research has shown that drug abuse treatment can help many individuals. Yet funding is often lacking for treatment because these programs compete for scarce resources with other important and effective social programs. This study shows how drug abuse treatment programs can be made more attractive to decision makers and funding agencies by first highlighting why economic evaluation is a critical component of drug abuse treatment research. Next, an evaluation methodology is presented that can be followed by program staff and researchers. The evaluation methodology includes aspects of cost-and-outcome analysis, cost-effectiveness analysis, and benefit-cost analysis. Methods and findings are then discussed from most of the major economic evaluation studies of drug and alcoholism treatment. Lastly, guidelines for conducting future economic evaluations are presented along with suggestions for how the results can be used for policy purposes and program planning.

The efficacy of controlled trials of alcohol misuse treatments in maintaining abstinence: a meta-analysis

Meta-analysis was used to establish the efficacy of various controlled alcohol misuse treatments in maintaining abstinence over short-term, 6-month, and 12-month follow-ups. Effect sizes were measured by odds ratio. Aggregate effect size differences between experimental and control groups were negligible. Only three of 15 studies found a clinically significant difference between treatment abstinence outcomes.

Cocaine abuse in methadone maintenance programs: integrating pharmacotherapy with psychosocial interventions

Cocaine abuse by methadone-maintained patients threatens to undermine the success of methadone programs by sustaining a drug-abusing lifestyle as well as contributing to the spread of HIV. The search for a pharmacotherapeutic agent for the treatment of cocaine has met with limited success. The most promising results emerge when specific agents, such as desipramine, are matched appropriately to specific patient characteristics, such as depression or antisocial personality disorder. For some patients, abstinence from cocaine may also require the addition of intensive psychosocial treatments that target the considerable problems faced by inner-city opioid-addicted individuals. This article discusses ways in which future research could be directed toward investigating the interaction between psychosocial services and pharmacologic treatments, while at the same time developing and testing hypotheses concerning appropriate patient-treatment matching variables.