The cost of medical care for patients with diabetes, hypertension and both conditions: does alcohol use play a role?

OBJECTIVE: To estimate and compare the medical costs of individuals with diabetes and/or hypertension relative to a matched sample of individuals with neither condition, and determine if these costs are significantly influenced by alcohol use. RESEARCH DESIGN AND METHODS: Data were obtained from a sample of 799 patients from eight primary care clinics in south-central Wisconsin between 2001 and 2002. Medical care costs were calculated within four categories [hospital and emergency room (ER) costs, clinic costs, medication costs and total cost] for three chronic disease samples [diabetes only (n = 89), hypertension only (n = 299), and both diabetes and hypertension (n = 209)] as well as a matched sample with neither diabetes nor hypertension (n = 202). Annual medical care costs were estimated using a combination of insurance billing records, self-reported information and chart review. All cost data pertain to a 12-month period in 2001-2002. In addition to a descriptive analysis of costs across medical service categories and samples, we also conducted multivariate analyses of total cost, controlling for patient demographics, education, employment, smoking, and comorbidities, such as heart disease, hyperlipidaemia, liver disease, chronic back pain, asthma, depression, anxiety and bronchitis. RESULTS: The estimated differential in total annual medical cost (relative to the control group) was USD 2183 for diabetes only, USD 724 for hypertension only and USD 3402 for diabetes and hypertension. Alcohol use did not significantly impact medical care costs amongst individuals with diabetes and/or hypertension. CONCLUSIONS: These cost estimates can serve as an important and useful reference source for doctors, insurance companies, health maintenance organizations (HMOs) and policy makers as they try to anticipate the future medical care needs and associated costs for diabetic and hypertensive patients.

Using the drug abuse screening test (DAST-10) to analyze health services utilization and cost for substance users in a community-based setting.

The dual purpose of this study was to: (1) determine whether problematic drug users, defined through the Drug Abuse Screening Test (DAST-10), exhibited differences in health services utilization and cost relative to a combined group of non-problematic drug users and non-drug users; and (2) assess whether the findings were similar to those for chronic drug users (CDUs) and injecting drug users (IDUs). Results showed that health services utilization and total cost were very similar for problematic drug users defined through quantity-frequency (i.e., CDU, IDU) and diagnostic (i.e., DAST-10) criteria. Findings suggest that quantity/frequency criteria for problematic drug use were reasonable approximations for diagnostic-based measures.

The impact of problem drinking on employment.

Social cost studies report that alcohol use and misuse impose a great economic burden on society, and over half of the total economic costs are estimated to be due to the loss of work productivity. Controversy remains, however, as to the magnitude and direction of the effects of alcohol consumption on productivity. Furthermore, most of the studies have looked at the relationship between problem drinking and wages. This paper investigates the impact of problem drinking on employment by analysing a random sample of men and women of prime working age from six Southern states in the US (Alabama, Arkansas, Georgia, Louisiana, Mississippi and Tennessee). The data set contains 4898 females and 3224 males, with information on both employment and problem drinking. To eliminate the bias that may result from single-equation estimation, we used a bivariate probit model to control for possible correlation in the unobservable factors that affect both problem drinking and employment. We find no significant negative association between problem drinking and employment for both men and women, controlling for other covariates. The findings are consistent with other research and highlight several methodological issues. Furthermore, the study suggests that estimates of the costs of problem drinking may be overstated owing to misleading labour supply relationships.

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.

Using cost and financing instruments for economic evaluation of substance abuse treatment services.

Standardized economic evaluation instruments are an important tool in the analysis of change and performance of addiction treatment. Nevertheless, compared to other health care sectors, economic evaluation of addiction treatment is still rare. The present paper proposes two comprehensive economic evaluation instruments that are methodologically sound and that meet the objectives of comprehensiveness, standardization, and comparability. The Drug Abuse Treatment Cost Analysis Program (DATCAP) can be used to estimate the economic cost of treatment services; the Drug Abuse Treatment Financing Analysis Program (DATFin) is a companion instrument and analyzes the complexity and change of treatment financing. This paper outlines the contents of each instrument and, for illustrative purposes, presents results from several case studies. Suggestions for updates and enhancements for each instrument are also discussed.

Problem drinking, health services utilization, and the cost of medical care.

The purpose of this study was to examine the relationships between problem drinking, health services utilization, and the cost of medical care in a community-based setting. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-administered questionnaire designed to obtain important information on demographics, health status, morbidity, health care utilization, drug and alcohol use, and related lifestyle behaviors. The survey instrument also included the 10-item Michigan Alcoholism Screening Test (MAST-10), which was used to identify problematic alcohol users (PAUs). The empirical findings indicated that PAUs had a significantly higher number of outpatient visits, more emergency room episodes, and more admissions to a hospital than a combined group of nondrinkers and nonproblematic alcohol users (NPAUs). Analyses of total health care cost showed that the estimated differential in total cost for PAUs during the past year, including the interaction effect with problematic drug use, was $367. The total cost (full effect) for PAUs was composed of a main effect ($984) and an interaction effect (-$617). These findings have implications for substance abuse interventions and health care policy.

Service use and cost by mentally ill chemical abusers: differences by retention in a therapeutic community.

PURPOSE: Earlier research estimated the incremental costs and outcomes of a modified therapeutic community (modified TC) for mentally ill chemical abusers (MICAs) relative to a treatment-as-usual (TAU) control group. The present study extended the cost analysis by disaggregating the modified TC group into clients who completed the program (completers) and clients who dropped out (separaters). METHODS: Bivariate and multivariate analyses were conducted to estimate differences in treatment and other service costs among completers, separaters, and TAU. Subjects were sequentially assigned to the modified TC (n = 171) or TAU (n = 47), and the analysis period covered 12 months post-baseline. Using a standardized instrument to collect resource use and cost data, the estimated weekly cost per client in the modified TC was $554, with completers showing a larger average cost of treatment ($27,595) than separaters ($9,986). RESULTS: The average TAU subject had a much higher cost for other (non-modified TC) services ($29,795) relative to separaters ($22,048) or completers ($1,986). These findings suggest that, from baseline to the 12-month follow-up, the total cost of modified TC treatment and other services for completers may be slightly lower than the total cost for separaters or TAU subjects. Since the modified TC group had better outcomes than the TAU group, and the completers had better outcomes than the separaters, the modified TC program could be an effective mechanism to reduce the costs of service utilization as well as improve clinical outcomes. IMPLICATIONS: This detailed investigation into service utilization and cost provides policy-makers and program directors with valuable information regarding potentially cost-effective interventions and further underscores the importance of retention in treatment for this vulnerable population.

Chronic illicit drug use, health services utilization and the cost of medical care.

Few studies have examined the relationships between drug use, health services utilization and the cost of medical care for a community-based sample of drug users. The purpose of this study was to analyze recently collected data on chronic drug users (CDUs), CDUs who were also injecting drug users (IDUs) and non-drug users (NDUs) to determine whether these groups exhibited differences in health services utilization and cost. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-reported questionnaire administered to individuals who were recruited through community outreach activities in the USA. Annual differences in health services utilization between CDUs, IDUs and NDUs were estimated for three measures: number of times admitted to a hospital, number of outpatient visits and number of emergency room episodes. Results of this study indicate that CDUs and IDUs consumed significantly more inpatient and emergency care, but less outpatient services relative to NDUs. Analyses of total health care costs showed that CDUs and IDUs each generated about $1000 in excess services utilization per individual relative to NDUs. This research is the first study to compare differences in health services utilization and cost among out-of-treatment drug users relative to a matched group of non-users in a community-based setting. The findings suggest that health care providers and managed care organizations should consider policies that promote more ambulatory care and discourage emergency room and inpatient care among drug users. Innovative and culturally acceptable approaches may be necessary to provide incentives without posing unusual financial hardship.

Illicit drug use and emergency room utilization.

OBJECTIVE: To provide an empirical examination of the effect that chronic illicit drug use has on emergency room (ER) utilization, controlling for the potential biases introduced by correlation between unobservable determinants of chronic illicit drug use and ER utilization. DATA SOURCES/STUDY SETTING: From the National Household Survey on Drug Abuse 1994 (NHSDA94). STUDY DESIGN: Chronic illicit drug use and ER utilization are analyzed for 5,384 females and 4,177 males in 1994. The study uses a two-stage estimation technique. In the first stage, sociodemographic, drug use history, and drug use risk variables are used to estimate the probability that the subject is a chronic illicit drug user (CDU). In the second stage, the first-stage estimates provide information needed to test for the possibility of bias in the estimation of ER utilization. This bias is the result of the correlation between unobservable influences on the probability that the person is a CDU and the probability that he or she uses an ER. DATA COLLECTION/EXTRACTION METHODS: The data were collected through a multistage stratified sampling design. With the use of this methodology, the resulting data set provides the most comprehensive information on household drug use. PRINCIPAL FINDINGS: Without a correction for the possibility of endogeneity bias, chronic illicit drug use is a positive (for both males and females) and a significant (for females only) determinant of the probability of using an ER for medical treatment. After a correction for endogeneity, the influence of chronic drug use remains positive and significant for females and becomes significant for males. The corresponding change in probability for females is from 6 percent to 30 percent, while for males the increase is from an insignificant 0.1 percent to a significant 36 percent change. CONCLUSIONS: We estimate that chronic drug-using females and males, after adjustments for bias, increase the probability that they use an ER by more than 30 percent compared to their casual or non-drug-using counterparts. Therefore, policymakers and health services providers may consider designing programs to bring primary care and prevention services to facilities where drug users are more likely to seek access to care, within an ER setting.

Symptoms of dependence, multiple substance use, and labor market outcomes.

The prevalence and costs of alcohol and drug disorders pose a serious social concern for policymakers. In this paper, we use data from the National Household Surveys on Drug Abuse (NHSDA) to estimate simple descriptive statistics and analysis of variance (ANOVA) models of the relationship between symptoms of dependence and labor market outcomes for alcohol, cigarettes, marijuana, and other illicit drugs. For men, we find that substance use with symptoms of dependence is associated with both lower employment rates and fewer hours of work. For women, we find that substance use with symptoms of dependence is associated with lower employment rates, but we find no consistent evidence of a relationship between symptoms of dependence and the number of hours worked. Finally, all of our point estimates are smaller in magnitude when we control for multiple substance use, suggesting that comorbidities play a critical role in the relationship between substance use and labor market outcomes. Our results suggest that policymakers and researchers should consider the full spectrum of substance use and dependence rather than focusing on the simple use of a single substance.

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.

Benefit-cost analysis of residential and outpatient addiction treatment in the State of Washington.

A benefit-cost analysis of full continuum (FC) and partial continuum (PC) care was conducted on a sample of substance abusers from the State of Washington. Economic benefits were derived from client self-reported information at treatment entry and at 9 months postadmission using an augmented version of the Addiction Severity Index (ASI). Average (i.e., per client) economic benefits of treatment from baseline to follow-up for both FC and PC were statistically significant for most variables and in the aggregate. The overall difference in average economic benefit between FC and PC was positive ($8,053) and statistically significant, favoring FC over PC. The average cost of treatment amounted to $2,530 for FC and $1,138 for PC (p < .01). Average net benefits were estimated to be $17,833 (9.70) for FC and $11,173 (23.33) for PC, with values showing statistical significance (p < .05). Results strongly indicate that both treatment options generated positive and significant net benefits to society.

Can the Treatment Services Review be used to estimate the costs of addiction and ancillary services?

PURPOSE: The economic costs of addiction treatment and ancillary services are of great interest to substance abuse treatment providers, researchers, and policymakers. This paper examines whether a widely used treatment evaluation instrument, the Treatment Services Review (TSR), can be used to estimate the costs of addiction and ancillary services. METHODS: The fifth edition of the TSR (TSR-5) is carefully reviewed and critiqued for cost estimation purposes. Unit cost estimates and sources are presented for most of the service delivery units on the TSR-5, and important missing service measures are identified. A cost analysis method is proposed that is based on data from the TSR. RESULTS: A variety of unit cost estimates are offered so that researchers and practitioners will understand how this financial information is compiled. However, the investigation determined that the TSR-5 is not currently structured for a comprehensive cost analysis of treatment services. The potential benefits and limitations of the TSR-5 as a cost analysis tool are identified and explained. In addition, recommended changes to the TSR-5 are suggested and described. IMPLICATIONS: Although not originally developed for economic evaluation purposes, with some modifications and enhancements, the TSR is an instrument that is capable of facilitating an economic cost analysis of addiction treatment and ancillary services. By combining service utilization information from a revised TSR (i.e., TSR-6) with reliable unit cost estimates for those services, future evaluation studies will be able to provide more standardized estimates of the costs of addiction and ancillary services for different types of treatment clients. When joined with outcome data, the TSR-6, along with the proposed cost module, can also be used to determine cost-effectiveness and benefit-cost ratios for subgroups of patients and treatment components.

Modified therapeutic community for mentally ill chemical abusers: outcomes and costs.

Several studies have established that the personal and social consequences of substance abuse are extensive and costly. These consequences are frequently compounded by mental illness. Although interventions that target mentally ill chemical abusers (MICAs) present several challenges, the potential benefits of successful interventions are significant. This article presents outcomes and costs of a modified therapeutic community (TC) intervention for homeless MICAs. Outcomes at follow-up are compared with those for a control group of homeless MICAs receiving standard services in a "treatment-as-usual" (TAU) condition. Annual economic costs for the modified TC and the average weekly cost of treating a single client are estimated. Treatment and other health service costs at 12 months postbaseline are compared for modified TC and TAU clients. The results of this study indicate that, suitably modified, the TC approach is an effective treatment alternative for homeless MICAs, with the potential to be highly cost-effective relative to standard services.

Health care need and utilization: a preliminary comparison of injection drug users, other illicit drug users, and nonusers.

This paper investigates the relationship between chronic drug use and the health care system. Data from 536 African-American, Hispanic, and non-Hispanic White men and women were analyzed to determine independent risk factors for three outcome variables: 1) Need for health care treatment, 2) Utilization of health care treatment, and 3) Failure to receive needed treatment. Nine independent demographic, health, and drug-use history variables were assessed in logistic regression models. Chronic drug users were more likely in the past year to need health care treatment, were as likely to receive some health care treatment, and were more likely not to receive needed treatment than were nonusers.

Cost of employee assistance programs: comparison of national estimates from 1993 and 1995.

The cost and financing of mental health services is gaining increasing importance with the spread of managed care and cost-cutting measures throughout the health care system. The delivery of mental health services through structured employee assistance programs (EAPs) could be undermined by revised health insurance contracts and cutbacks in employer-provided benefits at the workplace. This study uses two recently completed national surveys of EAPs to estimate the costs of providing EAP services during 1993 and 1995. EAP costs are determined by program type, worksite size, industry, and region. In addition, information on program services is reported to determine the most common types and categories of services and whether service delivery changes have occurred between 1993 and 1995. The results of this study will be useful to EAP managers, mental health administrators, and mental health services researchers who are interested in the delivery and costs of EAP services.

Economic evaluation of breast cancer screening: A review.

PURPOSE: The authors provide a review of the economic evaluation literature of breast cancer screening and identify important trends and gaps in the literature. OVERVIEW: Healthcare resources are limited and economic evaluation plays a critical role in resource allocation, healthcare policy, and clinical decisions. Many economic evaluations of medical practice, however, are unreliable and do not use appropriate analytic techniques. Three important trends were observed. First, two economic evaluation methods are dominant. Second, a wide range of cost estimates exists across studies. Third, a lack of standardization exists across studies with regard to basic economic evaluation principles. These findings should be considered when conducting future research, analyzing economic evaluations of breast cancer screening, and developing clinical guidelines. CLINICAL IMPLICATIONS: Concerns about cost containment in healthcare make it necessary for physicians and clinical administrators to take an active role in resource allocation decisions at the clinical level. For instance, the recent debate on the proper age to begin annual mammography screening involves both resource allocation and clinical issues. Thus, it is important for physicians and clinical administrators to be familiar with the economic evaluation literature of breast cancer screening, economic evaluation methodology, and the associated shortcomings of published estimates.