|
|
...on policy issues
|
|
www.ProjectCork.org
|
Spring 2004
|
Cost-effectiveness analysis of addiction treatment: Paradoxes of multiple outcomes.
Sindelar JL; Jofre-Bonet M; French MT; McLellan AT. Drug and Alcohol Dependence 73(1): 41-50, 2004. (40 refs.)
This paper identifies and illustrates the challenges of conducting cost-effectiveness analysis (CEA) of addiction treatments given the multiple important outcomes of substance abuse treatment (SAT). Potential problems arise because CEA is intended primarily for single outcome programs, yet addiction treatment results in a variety of outcomes such as reduced drug use and crime and increased employment. Methodological principles, empirical examples, and practical advice are offered on how to conduct an economic evaluation given multiple outcomes. An empirical example is provided to illustrate some of the conflicts in cost-effectiveness (CE) ratios that may arise across the range of outcomes. The data are from the Philadelphia Target Cities quasi-experimental field study of standard versus "enhanced" (e.g. case management and added social services) drug treatment. Outcomes are derived from of the Addiction Severity Index (ASI), while cost data were collected and analyzed using the Drug Abuse Treatment Cost Analysis Program (DATCAP). While the results are illustrative only, they indicate that cost-effectiveness ratios for each of several different outcomes can produce conflicting implications. These findings suggest that multiple outcomes should be considered in any economic analysis of addiction treatments because focusing on a single outcome may lead to inadequate and possibly incorrect policy inferences. However, incorporating multiple
outcomes into a CEA of addiction treatment is difficult. Cost-benefit analysis (CBA) may be a preferable and more appropriate approach in some cases. Copyright 2004, Elsevier Scientific Publishers Ireland, Ltd.
Cost-effectiveness analysis of the New South Wales adult drug court program.
Shanahan M; Lancsar E; Haas M; Lind B; Weatherburn D; Chen SL. Evaluation Review 28(1): 3-27, 2004. (19 refs.)
In New South Wales, Australia, a cost-effectiveness evaluation was conducted of an adult drug court (ADC) program as an alternative to jail for criminal offenders addicted to illicit drugs. This article describes the program, the cost-effectiveness analysis, and the results. The results of this study reveal that, for the 23-month period of the evaluation, the ADC was as cost-effective as were conventional sanctions in delaying the time to the first offense and more cost-effective in reducing the frequency of offending for those outcome measures selected. Although the evaluation was conducted using the traditional steps of a cost-effectiveness analysis, because of the complexity of the program and data limitations it was not always possible to adhere to textbook procedures. As such, each step involved in undertaking the cost-effectiveness analysis is discussed, highlighting the key issues faced in the evaluation. Copyright 2004, Sage Publications, Inc.
Implementation of evidence-based tobacco use cessation guidelines in managed care organizations.
Taylor CB; Curry SJ. Annals of Behavioral Medicine 27(1): 13-21, 2004. (39 refs.)
Background: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings. Purpose: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented. Methods: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation. Results: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined. Conclusions: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral
medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination. Copyright 2004, Lawrence Erlbaum Associates, Inc.
Processes and outcomes of substance abuse treatment within managed care: A preliminary report.
McNeese-Smith DK; Crook MW; Marinelli-Casey P; Rawson R. Journal of Addictions Nursing 14(2): 65-73, 2003. (41 refs.)
While managed care is changing substance abuse treatment (SAT), little is known about the relationship between managed care structures and SAT processes and outcomes. The purposes of this study are to describe: (1) client characteristics, (2) SAT processes provided by outpatient treatment under managed care, and (3) client outcomes in an insured and primarily employed population. Twenty SAT clients including equal numbers of males and females, in two Los Angeles settings were interviewed at three points before and after treatment. Instruments with established reliability and validity in SAT research, including the TCU Drug History Form and the Treatment Outcome Profile, were administered. Descriptive statistics were used to describe SAT clients, as well as processes and outcomes of treatment. Drug use scores before treatment averaged 5.95 (on a scale of one to eight). Processes of treatment showed a mean of 17.4 weeks of treatment, for an average intensity of 4.66 hours/week. Abstinence (n = 12) was accompanied by an increase in the quality of life for clients and satisfaction with treatment services. The severity of drug use by this insured, well-educated, and employed sample indicates that managed care must deal with serious drug and alcohol abuse. Copyright 2003, Taylor & Francis.
Smoke in your eyes: the struggle over tobacco control in the European Union.
Duina F; Kurzer P. Journal of European Public Policy 11(1): 57-77, 2004. (94 refs.)
Throughout the decades, the European Commission has attempted to expand its regulatory authority beyond the mandate specified by the treaties. Between 1986 and 2002, the Commission struggled to expand its reach to public health by targeting tobacco advertising. Preparations for a directive lasted eight years. The European Court of Justice then struck down that directive in 2000. A weaker version was passed in 2002. What can explain such troubled history? In past attempts at expansion, the Commission could rely on advocacy groups to pressure hesitant member states. In this case, the Commission fell into a classic intergovernmental trap: countries took positions that directly reflected the 'fit' between the Commission's proposals and existing domestic approaches to tobacco. Partial success in 2002 came only because of transnational shifts in moral attitudes towards tobacco and the ascendancy of left-leaning political parties in key countries. We conclude by reflecting on the implications of the findings for future Commission initiatives. Copyright 2004, Taylor & Francis Group.
The costs of screening and brief intervention for risky alcohol use.
Zarkin GA; Bray JW; Davis KL; Babor TF; Higgins-Biddle JC. Journal of Studies on Alcohol 64(6): 849-857, 2003. (18 refs.)
Objective: The purpose of this study was to estimate provider-incurred costs of alcohol screening and brief intervention (SBI) for risky drinking as implemented in four managed care organizations (MCOs) participating in the Cutting Back project implemented by the , University of Connecticut Health Center. Method: Each MCO provided two comparable primary care clinics in which two different SBI models were implemented: the "Practitioner" (P) model and the "Specialist" (S) model. Risky drinkers were identified based on responses to a health appraisal form. They were administered the AUDIT to determine an appropriate intervention. Using data collected from these sites, we separately estimated start-up and ongoing implementation costs of the intervention. Results: SBI start-up costs per MCO ranged from approximately $86,000 to $115,000 across the four study MCOs. Across all four study MCOs, the estimated median ongoing implementation cost of administering the health appraisal was $0.25 per patient appraised, and the estimated median cost of screenings was $0.42 per patient screened. The estimated median cost of performing the brief intervention across the study MCOs was $2.59 per patient receiving the intervention in the S clinics and $3.43 per patient receiving the intervention in the P clinics. Labor costs dominated start-up and ongoing implementation. Technical assistance costs accounted for a significant proportion of start-up costs.
Implementation in the S model is less costly than in the P model, largely because of the S model's use of less expensive nonphysician labor. Conclusions: Our analysis suggests that the cost of SBI is modest, and MCOs may want to consider adopting SBI as an alcohol use prevention tool. Although our results suggest that the S model is less costly than the P model, clinic-level implementation factors may affect the relative costs of the S versus P models. Copyright 2003, Alcohol Research Documentation, Inc. Used with permission.
The effect of cigarette excise taxes on smoking before, during and after pregnancy.
Colman G; Grossman M; Joyce T. Journal of Health Economics 22(6): 1053-1072, 2003. (30 refs.)
Recent analyses suggest that cigarette excise taxes lower prenatal smoking. It is unclear, however, whether the association between taxes and prenatal smoking represents a decline among women of reproductive age or a particular response by pregnant women. We address this question directly with an analysis of quit and relapse behavior during and after pregnancy. We find that the price elasticity of prenatal quitting and postpartum relapse is close to one in absolute value. We conclude that direct financial incentives to stop smoking during and after pregnancy should be considered. Copyright 2003, Elsevier Science.
Only one in three people with alcohol abuse or dependence ever seek treatment.
Cunningham JA; Breslin FC. Addictive Behaviors 29(1): 221-223, 2004. (11 refs.)
The proportion of respondents who had a lifetime diagnosis of alcohol abuse or dependence who ever attended addiction treatment was determined using data from a Canadian population survey. Only one in three of these respondents had ever attended treatment for their alcohol concerns. Respondents' age and severity of alcohol problem (alcohol abuse versus dependence) were significantly associated with addiction treatment attendance. Copyright 2004, Elsevier Science.
The effects of price and policy on marijuana use: What can be learned from the Australian experience?
Williams J. Health Economics 13(2): 123-137, 2004. (17 refs.)
This research examines the responsiveness of the demand for marijuana to changes in its money price and criminal status using data on individuals from the Australian National Drug Strategy's Household Surveys (NDSHS). The results suggest that both the prevalence of marijuana use and the conditional demand for marijuana in the general population are responsive to changes in its money price. Significant differences are found in the effect of price on participation in marijuana use across age-groups, with participation by youth more price sensitive than participation by older age-groups. Similarly, the effect of the legal status of marijuana use on the participation decision is found to differ across age-groups and gender. Specifically, decriminalisation is associated with an increases in the prevalence of use by males over the age of 25. There is no evidence that decriminalisation significantly increases participation in marijuana use by either young males or females, or that decriminalisation increases the frequency of use among marijuana users. Copyright 2004, John Wiley & Sons, Ltd.
The relative contribution of outcome domains in the total economic benefit of addiction interventions: A review of first findings. (review).
McCollister KE; French MT. Addiction 98(12): 1647-1659, 2003. (53 refs.)
This paper provides a focused summary of the relative contribution of addiction intervention outcomes to total economic benefit, based upon a compilation of published economic studies from the United States. The relevant literature was searched extensively, and 11 economic studies were selected for review. The selected addiction interventions address both alcohol use/abuse and illicit drug use/abuse and represent various treatment modalities, including a brief physician intervention and long-term residential programs. Study participants included community-based drug users, pregnant and/or parenting women, problem drinkers, and criminal offenders. These studies estimated the economic benefits of an addiction intervention(s) in terms of one or more of the following outcome domains: criminal activity, health services utilization, employment earnings, and expenditures on illicit drugs and alcohol. The primary finding of this review was that avoided criminal activity was the greatest economic benefit of addiction interventions and contributed more, as a separate outcome domain, to the total economic benefit of addiction interventions than any other outcome domain. Reduced utilization of health care services was also a noteworthy economic benefit of addiction interventions. This study provides a detailed exposition of economic benefits estimation and highlights the potential impact of individual
outcomes, thus providing a useful resource for substance abuse researchers and administrators as they design and evaluate future interventions Copyright 2003, Society for the Study of Addiction to Alcohol and Other Drugs.
The substance abuse services cost analysis program (SASCAP): A new method for estimating drug treatment services costs.
Zarkin GA; Dunlap LJ; Homsi G. Evaluation and Program Planning 27(1): 35-43, 2004. (28 refs.)
To determine whether drug abuse treatment services are cost-effective, policy makers need accurate estimates of the cost of treatment services. The objective of our analysis was to develop a new method for estimating the costs of specific drug treatment services and to apply that method to 170 methadone treatment clinics that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project. Our method extends previous research by including both indirect labor and nonlabor resources in service cost estimates. We found that service cost estimates that included indirect labor and nonlabor resources were two to three times higher than those that only included direct labor costs. Service costs ranged from $8 per patient per week for ongoing medical services to $106 for a session of initial patient assessment and treatment planning. Over all services, indirect labor and nonlabor costs combined accounted for between 41 and 69% of the estimated total service costs. We conclude that studies that only include direct labor costs are seriously underestimating the true costs of providing treatment services. Our services cost estimation method is applicable not only to the cost estimation of other drug treatment modalities but also to the cost estimation of other health care services. Copyright 2004, Elsevier Science Ltd.
Violence risk factors in stalking and obsessional harassment: A review and preliminary meta-analysis. (review).
Rosenfeld B. Criminal Justice and Behavior 31(1): 9-36, 2004. (35 refs.)
The fear of violence is among the most common and debilitating concerns faced by stalking victims. This review summarizes the extant literature on stalking-related violence, highlighting risk factors unique to stalking as well as those common to most offender populations. In total, 13 published studies were found, encompassing 11 unique samples and 1,155 individuals. The overall rate of violence was 38.7%. Significant correlates of stalking-related violence included the presence of threats, substance abuse, and the absence of a psychotic disorder. Other strong correlates included a prior intimate relationship between victim and offender and a history of violent behavior. Results are discussed with respect to risk assessment strategies and future directions for stalking risk assessment research. Copyright 2004, Sage Publications.
What predicts which metropolitan areas in the USA have syringe exchanges?
Tempalski B; Friedman SR; Des Jarlais DC; McKnight C; Keem M; Friedman R. International Journal of Drug Policy 14(5/6): 417-424, 2003. (70 refs.)
HIV epidemics among IDUs vary widely across different cities in the USA [American Journal of Public Health 86 (5) (1996) 642]. Few studies have focused on how localities differ in regard to response to the HIV epidemic. While syringe exchange programmes (SEPs) are a response to HIV among IDUs, they are often unwelcome and difficult to set up even in communities hit hardest by the epidemic. It is important to understand what metropolitan area characteristics are related to when and if an SEP opens in a particular locality. Logistic regression models are used to explore how need, political factors, SEP diffusion from Tacoma (the first SEP), and metropolitan socioeconomic characteristics are related to SEP presence. Results indicate that need is not a significant predictor of having an SEP. Predictors were the percentage of the population who are men who have sex with men (AOR=6.95; 95% CI=1.29?x2013;37.49), and metropolitan area population (AOR=1.08 per 100,000; 95% CI=1.02?x2013;1.14). Predictors of having an SEP in a metropolitan area seem to be political factors and metropolitan area population size, not need among IDUs. Gay political influence and/or support may well facilitate SEP formation, and geographic diffusion may influence where SEPs are established. Copyright 2003, Elsevier Science, Ltd.
A simple cost-benefit analysis of brief interventions on substance abuse at Naval Medical Center Portsmouth.
Storer RM. Military Medicine 168(9): 765-768, 2003. (9 refs.)
To determine the impact of brief interventions on substance abuse at the Naval Medical Center Portsmouth, a retrospective review of all admissions in fiscal year 2001 was conducted. Patients receiving brief interventions had significantly lower readmission rates (12.6%) than those not receiving interventions (29.4%). For Internal Medicine patients, this difference was most pronounced: 15.4% as opposed to 40.0%. The average cost of a second admission was $17,834.31 overall but $23,690.78 for Internal Medicine specifically. The lower readmission rate associated with brief interventions represents a benefit of $606,366.54 saved at a cost of $31,508.50 for a cost-benefit ratio of 19:1. The data indicate a cost avoidance opportunity of $713,372.40 if all identified substance abuse patients received interventions. Perhaps most significant, the gap between expected and identified substance use disorders (3.7% vs. 25%) suggests 3,400 unidentified persons who could benefit from interventions. This represents an additional cost avoidance opportunity of $10,200,000.00. Copyright 2003, Association of Military Surgeons of the United States.
Argument for the legalization of industrial hemp.
Brady TC. San Joaquin Agricultural Law Review 1: 85-108, 2003. (167 legal refs.)
Industrial hemp as a cash crop in the United States has a history as old as the United States itself. ... These are just a few of the reasons that California should pass legislation legalizing the growing of industrial hemp allowing it to become an economically viable crop in California. ... However, since 1995, twenty-five states (Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Illinois, Iowa, Kentucky, Maine, Maryland, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Tennessee, Vermont, Virginia, West Virginia, and Wisconsin) have introduced legislation allowing for industrial hemp cultivation. ... According to the National Organization for the Reform of Marijuana Laws (NORML), "DEA officials have stonewalled several state efforts to enact industrial hemp cultivation and research bills by threatening to arrest any farmers contracted to grow the crop. ... A report published by the USDA in 2000 makes similar arguments regarding the small market for industrial hemp products such as bast fiber, hemp seed, and hemp oil. ... Once the DEA has received the scientific and medical evaluation from HHS, the Administrator will evaluate all available data and make a final decision whether to propose that a drug or other substance be controlled and into which schedule it should be placed. Copyright 2003, San Joaquin College of Law.
Distance traveled to outpatient drug treatment and client retention.
Beardsley K; Wish ED; Fitzelle DB; O'Grady K; Arria AM. Journal of Substance Abuse Treatment 25(4): 279-285, 2003. (15 refs.)
This study examined the association between approximate distance traveled to treatment, and treatment completion and length of stay, for 1,735 clients attending outpatient treatment in an urban area. Clients who traveled less than 1 mile were 50% more likely to complete treatment than clients who traveled more than 1 mile, after holding constant demographic variables and type of drug problem. Similarly, clients who traveled more than 4 miles were significantly more likely to have a shorter length of stay than clients who traveled less than 1 mile. These findings have important implications for the geographic placement of new treatment facilities, as well as the provision of transportation services to maximize treatment retention. Copyright 2003, Elsevier Ltd.
|
