Benefit-cost analysis of addiction treatment: methodological guidelines and empirical application using the DATCAP and ASI

OBJECTIVE: To provide detailed methodological guidelines for using the Drug Abuse Treatment Cost Analysis Program (DATCAP) and Addiction Severity Index (ASI) in a benefit-cost analysis of addiction treatment. DATA SOURCES/STUDY SETTING: A representative benefit-cost analysis of three outpatient programs was conducted to demonstrate the feasibility and value of the methodological guidelines. STUDY DESIGN: Procedures are outlined for using resource use and cost data collected with the DATCAP. Techniques are described for converting outcome measures from the ASI to economic (dollar) benefits of treatment. Finally, principles are advanced for conducting a benefit-cost analysis and a sensitivity analysis of the estimates. DATA COLLECTION/EXTRACTION METHODS: The DATCAP was administered at three outpatient drug-free programs in Philadelphia, PA, for 2 consecutive fiscal years (1996 and 1997). The ASI was administered to a sample of 178 treatment clients at treatment entry and at 7-months postadmission. PRINCIPAL FINDINGS: The DATCAP and ASI appear to have significant potential for contributing to an economic evaluation of addiction treatment. The benefit-cost analysis and subsequent sensitivity analysis all showed that total economic benefit was greater than total economic cost at the three outpatient programs, but this representative application is meant to stimulate future economic research rather than justifying treatment per se. CONCLUSIONS: This study used previously validated, research-proven instruments and methods to perform a practical benefit-cost analysis of real-world treatment programs. The study demonstrates one way to combine economic and clinical data and offers a methodological foundation for future economic evaluations of addiction treatment.     

Assessing the cost and willingness to pay for voluntary HIV counselling and testing in Kenya

OBJECTIVE: Voluntary counselling and testing (VCT) should be an important component in a country's HIV/AIDS prevention and care strategy. However, the high cost of VCT raises concerns about the affordability of VCT in low-income countries. This study was designed to assess the costs of VCT and to identify potential ways of introducing VCT more affordably. METHODOLOGY: An economic evaluation was performed of VCT services in two rural health centres in Thika District and an urban health centre in Nairobi, Kenya. A contingent valuation study was also performed among VCT clients. Estimates were developed regarding the national cost of offering VCT services in Kenya. RESULTS: VCT added US dollars 6800 per year to the average cost of providing services at each of these three health centres. The evaluation revealed that the incremental cost, from the government's perspective, of adding VCT is approximately 16 dollars per client. The estimated incremental cost per client is significantly less than a previous cost estimate in Kenya which estimated a cost per client of 26 dollars. The difference in cost estimates is in part attributable to the emphasis of this project on integrating VCT services into existing health centres, rather than creating stand-alone sites. The cost of VCT services might be further reduced to as little as 8 dollars per client if a government health worker could perform the counselling. A contingent valuation study indicated that most VCT clients would be willing to pay at least 2 dollars for the service. However, if the full cost of the service were charged to the client, less than 5% of clients indicated they were willing and able to pay for the service. CONCLUSIONS: Integrating services into existing health centres can significantly reduce the cost of VCT. Additional cost reductions may be feasible if health centre staff are hired to perform the counselling. Furthermore, it appears that some level of cost recovery from VCT clients is feasible and can contribute to sustainability, although it is very unlikely that the full cost of the service could be recovered from the clients. The national provision of VCT in all Kenyan health centres is likely to be an affordable option, although additional operational research is required to determine the most appropriate way of scaling up VCT services throughout the country.     

Completion rates of clients discharged from drug and alcohol treatment programs in Washington State.

OBJECTIVES. The primary goal of this study was to analyze completion rates of clients in drug and alcohol abuse treatment programs in Washington State and to assess the factors associated with treatment completion. A secondary goal was to examine the utility of a state information system as a source of evaluative data. METHODS. Analyses were conducted of 5827 client records contained in the Washington State Substance Abuse Monitoring System, representing a census of public clients discharged during the last quarter of 1990 from all state-funded alcohol and drug treatment programs in four treatment modalities. Logistic regression was performed to determine the independent predictors of treatment completion. RESULTS. Completion rates were highest for intensive inpatient alcohol treatment (75%) and lowest for intensive outpatient drug programs (18%). Factors associated with treatment completion included screening at a referral assessment center, education, age, ethnicity, and existence of a secondary drug problem. CONCLUSIONS. The fit between clients and treatment programs may be an important factor explaining why some clients complete treatment and others drop out. State client information systems are an important source of data for analyzing treatment completion and other outcomes.     

Letter: Estimating the economic cost of substance abuse treatment

Few studies have estimated the economic costs and benefits of substance abuse treatment services. This paper introduces a data collection instrument and method for estimating the economic cost of substance abuse treatment programs. The Drug Abuse Treatment Cost Analysis Program (DATCAP) is based on standard economic principles and the method has recently been tested in two drug abuse intervention studies. Findings from case studies at three treatment programmes are presented to demonstrate the feasibility and reliability of the instrument. The estimation methods and results can be used by treatment programmes for self-evaluation purposes and by researchers who are interested in performing cost-effectiveness or benefit-cost analyses of substance abuse services. © 1997 John Wiley & Sons, Ltd.     

Program Characteristics and the Length of Time Clients are in Substance Abuse Treatment

Is there a relationship between the characteristics of drug addiction treatment programs and an important correlate of better outcomes, the length of time clients are in treatment? Previous research has consistently shown longer periods in treatment and a range of services each have a salutary effect on client outcomes after treatment. Much of this research has examined the characteristics of clients. Program attributes are another important consideration. Multivariate analysis of data collected from a national survey of outpatient drug addiction treatment programs shows offering a range of services along with several other program characteristics are relevant to the duration of treatment. When a range of services are available, this has a positive association with both the number of months programs report clients are in treatment and with the number of counseling sessions programs report clients receive over the course of treatment. Ultimately, this should lead to better outcomes for clients.     

Designated case managers as facilitators of medical and psychosocial service delivery in addiction treatment programs

This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs was used to study clients from long-term residential, outpatient, and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.     

Criminal outcomes and costs of treatment services for injecting and non-injecting heroin users: evidence from a national prospective cohort survey

OBJECTIVES: To assess the incremental cost-effectiveness of drug addiction treatment programmes provided in the UK by the National Health Service and not-for-profit agencies in terms of crime-related outcomes. All costs and crime-related outcomes were implicitly evaluated relative to a 'no treatment' alternative. METHODS: Longitudinal observational data on a national sample of heroin addicts referred to addiction treatment services throughout England were re-analysed. Predictions from a Poisson random-effects model were used to estimate the incremental effectiveness and cost-effectiveness of treatment programmes. Interaction variables were used to assess whether the injecting of heroin on entry to treatment had an impact on cost-effectiveness. RESULTS: The findings rejected the null hypothesis that increasing time in treatment (and therefore treatment cost) has no mean crime prevention effect on clients referred for community-based methadone treatment, treatment delivered within specialist drug dependency units and residential rehabilitation programmes (P < 0.05). However, the size of the cost per unit of effect based on model predictions was sensitive to the exclusion of a small group of outlying observations. The interaction between client injecting status and time in treatment was found to be statistically significant (P < 0.05), with an estimated reduction in treatment cost-effectiveness across all treatment programmes for clients who reported injecting drugs at treatment intake. CONCLUSIONS: Whilst the analyses did not include an evaluation of the effect of treatment programmes on client health and quality of life and stopped short of providing a social weighting for the predicted reduction in crimes, they do offer a useful starting point for establishing the cost-effectiveness of treating heroin addiction. The onus is on public decision-makers to decide whether the predicted reductions in crime are worth the opportunity costs of investing extra resources in a major expansion of treatment services.     

Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”?

OBJECTIVE: To examine costs and monetary benefits associated with substance abuse treatment. DATA SOURCES: Primary and administrative data on client outcomes and agency costs from 43 substance abuse treatment providers in 13 counties in California during 2000-2001. STUDY DESIGN: Using a social planner perspective, the estimated direct cost of treatment was compared with the associated monetary benefits, including the client's costs of medical care, mental health services, criminal activity, earnings, and (from the government's perspective) transfer program payments. The cost of the client's substance abuse treatment episode was estimated by multiplying the number of days that the client spent in each treatment modality by the estimated average per diem cost of that modality. Monetary benefits associated with treatment were estimated using a pre-posttreatment admission study design, i.e., each client served as his or her own control. DATA COLLECTION: Treatment cost data were collected from providers using the Drug Abuse Treatment Cost Analysis Program instrument. For the main sample of 2,567 clients, information on medical hospitalizations, emergency room visits, earnings, and transfer payments was obtained from baseline and 9-month follow-up interviews, and linked to information on inpatient and outpatient mental health services use and criminal activity from administrative databases. Sensitivity analyses examined administrative data outcomes for a larger cohort (N=6,545) and longer time period (1 year). PRINCIPAL FINDINGS: On average, substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487, representing a greater than 7:1 ratio of benefits to costs. These benefits were primarily because of reduced costs of crime and increased employment earnings. CONCLUSIONS: Even without considering the direct value to clients of improved health and quality of life, allocating taxpayer dollars to substance abuse treatment may be a wise investment.     

The effect of substance abuse treatment on Medicaid expenditures among general assistance welfare clients in Washington state

Little is currently known about the effect of substance abuse treatment on Medicaid expenses and other health care costs for welfare clients. This study examined the association between substance abuse treatment and reductions in medical care expenditures (primarily Medicaid expenses) for General Assistance (GA) welfare clients in Washington State. The treatment group included 3,235 GA clients who received treatment during 2000 or 2001. The comparison group included 4,863 GA clients who needed substance abuse treatment but did not receive it. Substance abuse treatment was associated with a reduction (p < .01) in medical expenses of approximately 2,500 US dollars annually. This estimated savings equaled the cost of treatment and represented approximately 35 percent of the annual Medicaid expenses incurred by GA clients with substance abuse problems.     

Fiscal outcomes of the closing of Central State Hospital: An analysis of the costs to state government

This study reports estimates of the preclosure and postclosure costs of mental health services for patients directly affected by the closing of Central State Hospital. The data come from state budget documents and from the billing records of the community mental health centers serving the discharged clients. On average, it cost Indiana approximately $68,347 (in 1995 dollars) to provide 12 months of state hospital care for this client cohort in fiscal year 1993. In contrast, during the first year following the closure, the average per patient cost to the state was $55,417. When clients were served exclusively in community care settings, the average annual per patient cost was $40,618. The analyses suggest that the closing reduced the costs of caring for this cohort of patients by approximately 18.9%. A significant portion of the cost savings to the state mental health budget was achieved by shifting some of the direct patient care costs to Medicaid/Medicare.The analyses and conclusions reported here are the sole responsibility of the author and do not necessarily reflect the position or opinions of the funding institutions, the individuals named in the acknowledgments section, the agencies that participated in this study, or Indiana University.He is also with the Indiana Consortium for Mental Health Services Research in Bloominton.     

Employment outcomes among AFDC recipients treated for substance abuse in Washington State

In 1996, Congress passed sweeping welfare reform, abolishing the Aid to Families with Dependent Children (AFDC) program. Each state now administers its own welfare-to-work program under broad federal guidelines, which require eligible adult recipients to work or perform community service. High-risk welfare recipients, especially those with chemical dependency problems, face significant obstacles in their efforts to achieve greater self-sufficiency under the new welfare-to-work programs. State databases were used to track employment outcomes for AFDC clients admitted to treatment for chemical dependency in Washington State during a two-year period. Exposure to treatment was associated with a greater likelihood of becoming employed and with increased earnings for those who became employed. Ensuring that welfare recipients with substance abuse problems have access to appropriate treatment and vocational services is critical if welfare-to-work programs are to promote greater economic self-sufficiency.     

Service Delivery in Substance Abuse Treatment: Reexamining “Comprehensive” Care

Substance abuse treatment clients present with an array of service needs in various life domains. Ideal models of addiction treatment incorporate provision or linkages to services to meet clients’ multiple needs; in turn, these wraparound and supportive services are associated with improvements in client retention and treatment outcomes. Using data from large samples of specialty addiction treatment providers in the public and private sectors, this article examines the extent and organizational correlates of the comprehensiveness of service delivery. Multivariate models indicate that private sector treatment facilities offer more “core” medical and treatment services, whereas public sector programs offer more wraparound and supportive services. However, both sectors fall short of the ideal model of service comprehensiveness in terms of absolute number of services offered. These findings raise concerns regarding the quality and availability of needed services for treatment of addiction.     

Improving publicly funded substance abuse treatment: the value of case management.

OBJECTIVES: This study evaluated the impact of case management on client retention in treatment and short-term relapse for clients in the publicly funded substance abuse treatment system. METHODS: A retrospective cohort design was used to study clients discharged from the following four modalities in 1993 and 1994: short-term residential (3112 clients), long-term residential (2888 clients), outpatient (7431 clients), and residential detox (7776 clients). Logistic regression models were used to analyze the impact of case management after controlling for baseline characteristics. RESULTS: The odds that case-managed clients reached a length of stay previously identified as associated with more successful treatment were 1.6 (outpatient programs) to 3.6 (short-term residential programs) times higher than the odds for non-case-managed clients. With the exception of outpatient clients, the odds of case-managed clients' being admitted to detox within 90 days after discharge (suggesting relapse) were about two thirds those of non-case-managed clients. The odds of case-managed detox clients' transitioning to post-detox treatment (a good outcome) were 1.7 times higher than the odds for non-case-managed clients. CONCLUSIONS: Case management is a low-cost enhancement that improves short-term outcomes of substance abuse treatment programs.     

Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington,DC

Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs—persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.

KEY FINDINGS

• ▪Housing retention of severely disabled and chronically homeless individuals having extensive service needs, each alcohol dependent and homeless for a minimum of 5 years at intake, was 97% in the first year and 84% in the second year.
• ▪Highly distressed individuals showed significant reduction in psychiatric symptoms within the first year of housing, with client-centered housing support and voluntary psychiatric treatment provided as desired by the client.
• ▪Psychiatrically disabled and alcohol-dependent individuals can make significant mental and behavioral health improvements in recovery within a year of housing without abstinence or treatment compliance demands upon enrollment and with voluntary addiction treatment as desired by the client.
• ▪Demand for intensive ACT services was reduced to much less intensive and costly community support services for 14% of clients within 2 years.

Individuals who remain chronically homeless frequently suffer debilitating effects of serious mental illness and addiction. These frequently co-occurring disorders represent an extremely difficult hurdle for individuals to overcome. Typical housing programs demand sobriety and compliance with psychiatric and behavioral treatment as a condition of admission and continued enrollment. A more realistic, compassionate, and effective approach provides housing without such prerequisites and instead provides immediate access to permanent housing with supports as a foundation for recovery.     

Longitudinal Effects of LAAM and Methadone Maintenance on Heroin Addict Behavior

Levo-alpha-acetylmethadol maintenance (LAAM) was compared to methadone maintenance (MM) on the behavioral performance of 315 heroin addicts before, during, and after 12 months of fully subsidized treatment. Assessments of drug use, criminal behavior, HIV risk behaviors, and employment and residential status were obtained at treatment intake and at 6, 12, and 18 months after admission. Treatment retention and in-treatment suppression of heroin use were significantly better for the LAAM group than for the MM group. Improvements were also noted during treatment in criminal behavior, criminal justice involvement, and employment status, and there were reductions in injection HIV risk and number of sexual partners. Most significant effects were primarily related to active participation in maintenance treatment. Under subsidized treatment, retention rates were two to four times that of similar clients in local community programs during the same period. LAAM was a useful and a potentially important addition to treatment options for opiate addiction, conferring greater retention and opiate suppression benefits. Its removal from application provides a historical lesson concerning the introduction of new medications into addiction health services. Douglas Longshore died December 2005.     

Evaluation of an Asthma Disease Management Program in a Medicaid Population

In 2002, an asthma disease management program was initiated in Washington State in the US. The program was designed for clients of the state’s Medicaid program, which provides health coverage for qualified low-income state residents. In response to the escalating cost of healthcare and because of concerns about the quality of care, the Washington State Legislature mandated implementation of this disease management program as a pilot project to assist individuals to improve their health. Medicaid administrators used a carefully designed process to identify client needs and to obtain proposals for disease management programs.The asthma program seeks to narrow the gap between the standards of care and its practice. In particular, the program aims to provide patients with a richer understanding of asthma and how to control it. This is accomplished through disease education, symptom awareness and management, trigger avoidance, self-monitoring, and education on recommended medication strategies. The program is based on the US National Institutes of Health’s published guidelines on the optimal treatment of asthma.Enrollment of Medicaid clients into the asthma program began in April 2002. This article describes three approaches to evaluation of the first 3 years of the program: (i) 3 years of self-reported client data; (ii) an independent evaluation of the first year’s changes in utilization and quality of care; and (iii) an actuarial analysis of cost effectiveness. The first study used vendor-reported data collected during initial and follow-up assessments. The authors of this first study also reported the results of a satisfaction survey conducted on behalf of the vendor. The independent evaluation conducted by the University of Washington relied on medical record review and claims analysis, and reported statistical analysis of pre/post comparisons. The actuarial study also reported pre/post comparisons using an analysis of claims per member per month in periods before the program started and at 1 and 2 years of program operations.Clients were assessed according to several dimensions of health including self-management, symptoms, functional status, medication management, and trigger management. Numerous interventions were provided to study participants including access to round-the-clock telephone consultation with a registered nurse, self-care education, alerts sent to the primary provider, and symptom issue follow-up. The asthma disease management program outcomes provide evidence of initial success for those clients who completed the reassessment process. The results of the first 3 years of participation in the program indicate trends toward improved health status and client satisfaction with the program. Long-term evaluation will be necessary to determine if the program reduces costs and closes the quality chasm. If successful, this program could serve as a model for programs with similar clients and similar challenges.     

Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?

This study focused on (1) whether disparities in timely receipt of substance use services can be explained in part by the characteristics of the community in which the clients reside and (2) whether the effect of community characteristics on timely receipt of services was similar across racial/ethnic groups. The sample was composed of adults receiving publicly funded outpatient treatment in Washington State. Treatment data were linked to data from the US census. The outcome studied was “Initiation and Engagement” in treatment (IET), a measure noting timely receipt of services at the beginning of treatment. Community characteristics studied included community level economic disadvantage and concentration of American Indian, Latino, and Black residents in the community. Black and American Indian clients were less likely to initiate or engage in treatment compared to non-Latino white clients, and American Indian clients living in economically disadvantaged communities were at even greater risk of not initiating treatment. Community economic disadvantage and racial/ethnic makeup of the community were associated with treatment initiation, but not engagement, although they did not entirely explain the disparities found in IET.     

Services for clients of community support programs in rural Wisconsin

To improve understanding of services provided or coordinated by rural community support programs (CSPs) for people with severe mental illness, this article identifies services most used by clients and the amounts of services used. Data on publicly funded services for more than 900 clients in 13 rural CSPs in a midwestern state have been analyzed. Virtually all clients were Caucasian. Information about types and amounts of client services for 12 consecutive months was obtained from county information systems, local records, and Medicaid claims. Most CSP clients use case management, community support, medication checks, counseling, and medication counseling services. Much smaller percentages use other outpatient, residential, vocational, and inpatient services. Significant amounts of only two services, case management and community support, are reported. The findings emphasize the ability of rural mental health providers to supply general services, but some limitation in provision of specialized services and facilities. The research for this article was supported by funding from the National Institute of Mental Health (MH 43555).     

Home Sweet Home? Community Care for Older People in Australia

Community care provision for older Australians is growing in places and options, based on older people's preference to stay in their own homes, coupled with its cost efficiency compared to long-term residential care. Australia's aging population, cultural diversity, and dispersed population in rural and remote areas presents significant challenges in meeting these care needs. The objective of this review is to provide a critical overview of community care services in Australia, from its origin in the 1940s through to the current array of programs that deliver care. Barriers to access for these programs, growth in funding and expenditure, evidence of client satisfaction and the problems of workforce provision are presented. It is not clear how the growing future demands for care programs, resulting from greater client expectation, increasingly complex care needs and a diminishing workforce of paid and unpaid carers, will be met. However, the economic burden is anticipated to be manageable. Despite seemingly well-structured programs, the current multiplicity and rigidity of services means care provided is sometimes unsatisfactory at the point of delivery. It remains to be seen therefore if services can be expanded, modified and developed to address current deficiencies and meet future demands. The reality of timely and equitable care for all older Australians living in the community is elusive at present. The ongoing rationing of residential care beds coupled with people's desires to stay in their own homes means community care is here to stay. The future inevitably presents huge challenges to those planning, implementing and providing care in this setting.     

Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States

Estimates of the direct medical costs attributable to human papillomavirus (HPV) can help to quantify the economic burden of HPV and to illustrate the potential benefits of HPV vaccination. The purpose of this report was to update the estimated annual direct medical costs of the prevention and treatment of HPV-associated disease in the United States, for all HPV types. We included the costs of cervical cancer screening and follow-up and the treatment costs of the following HPV-associated health outcomes: cervical cancer, other anogenital cancers (anal, vaginal, vulvar and penile), oropharyngeal cancer, genital warts, and recurrent respiratory papillomatosis (RRP). We obtained updated incidence and cost estimates from the literature. The overall annual direct medical cost burden of preventing and treating HPV-associated disease was estimated to be $8.0 billion (2010 U.S. dollars). Of this total cost, about $6.6 billion (82.3%) was for routine cervical cancer screening and follow-up, $1.0 billion (12.0%) was for cancer (including $0.4 billion for cervical cancer and $0.3 billion for oropharyngeal cancer), $0.3 billion (3.6%) was for genital warts, and $0.2 billion (2.1%) was for RRP.