Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial.

BACKGROUND: Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs). METHODS: Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes. RESULTS: At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191-$16,171). CONCLUSION: This study provides experimental evidence supporting P4P as a cost-effective implementation strategy. TRIAL REGISTRATION: NCT01016704 .

Cost-effectiveness of motivational intervention with significant others for patients with alcohol misuse.

AIMS: To estimate the incremental cost, cost-effectiveness and benefit-cost ratio of incorporating a significant other (SO) into motivational intervention for alcohol misuse. DESIGN: We obtained economic data from the one year with the intervention in full operation for patients in a recent randomized trial. SETTING: The underlying trial took place at a major urban hospital in the United States. PARTICIPANTS: The trial randomized 406 (68.7% male) eligible hazardous drinkers (196 during the economic study) admitted to the emergency department or trauma unit. INTERVENTION: The motivational interview condition consisted of one in-person session featuring personalized normative feedback. The significant other motivational interview condition comprised one joint session with the participant and SO in which the SO's perspective and support were elicited. MEASUREMENTS: We ascertained activities across 445 representative time segments through work sampling (including staff idle time), calculated the incremental cost in per patient of incorporating an SO, expressed the results in 2014 US$, incorporated quality and mortality effects from a closely related trial and derived the cost per quality-adjusted life-year (QALY) gained. FINDINGS: From a health system perspective, the incremental cost per patient of adding an SO was $341.09 [95% confidence interval (CI) = $244.44-437.74]. The incremental cost per year per hazardous drinker averted was $3623 (CI = $1777-22,709), the cost per QALY gained $32,200 (CI = $15,800-201,700), and the benefit-cost ratio was 4.73 (95% CI = 0.7-9.66). If adding an SO into the intervention strategy were concentrated during the hours with highest risk or in a trauma unit, it would become even more cost-beneficial. CONCLUSIONS: Using criteria established by the World Health Organization (cost-effectiveness below the country's gross domestic product per capita), incorporating a significant other into a patient's motivational intervention for alcohol misuse is highly cost-effective.

Suicide and Suicidal Attempts in the United States: Costs and Policy Implications.

The national cost of suicides and suicide attempts in the United States in 2013 was $58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under-reporting increased the total cost to $93.5 billion or $298 per capita, 2.1-2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit-cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.

The Brief Treatment Cost Analysis Tool (TCAT-Lite) for Substance Abuse Treatment: Reliability and Application.

Although several costing instruments have been previously developed, few have been validated or applied systematically to the delivery of evidence-based practices (EBPs). Using data collected from 26 organizations implementing the same EBP, this paper examined the reliability, validity, and applicability of the brief Treatment Cost Analysis Tool (TCAT-Lite). The TCAT-Lite demonstrated good reliability-correlations between replications averaged 0.61. Validity also was high, with correlation of treated episodes per $100,000 between the TCAT-Lite and independent data of 0.57. In terms of applicability, cost calculations found that if all organizations had operated at optimal scale (124 client episodes per year), existing funds could have supported 64% more clients.