If smoking increases absences, does quitting reduce them?

OBJECTIVE: This study examined the impact of smoking, quitting, and time since quit on absences from work. METHODS: Data from the nationally representative Tobacco Use Supplements of the 1992/93, 1995/96, and 1998/99 Current Population Surveys were used. The study included full time workers aged between 18-64 years, yielding a sample size of 383 778 workers. A binary indicator of absence due to sickness in the last week was analysed as a function of smoking status including time since quit for former smokers. Extensive demographic variables were included as controls in all models. RESULTS: In initial comparisons between current and former smokers, smoking increased absences, but quitting did not reduce them. However, when length of time since quit was examined, it was discovered that those who quit within the last year, and especially the last three months, had a much greater probability of absences than did current smokers. As the time since quitting increased, absences returned to a rate somewhere between that of never and current smokers. Interactions between health and smoking status significantly improved the fit of the model. CONCLUSIONS: Smokers who quit reduced their absences over time but increase their absences immediately after quitting. Quitting ill may account for some but not all of this short run impact.

Innovations in treatment for drug abuse: solutions to a public health problem.

Illicit drug use is an important public health problem with broad social costs. The low effectiveness of prevention efforts leaves treatment of drug dependence as one of the most powerful means of fighting illicit drug use. Treatment reduces drug use and crime and increases individuals' functioning. However, programs that treat drug dependence have high dropout rates and low completion rates. In addition, some individuals continue to use drugs while in treatment, and relapse is common. Furthermore, only a fraction of those who need treatment receive it. Recently, there have been important innovations that reduce barriers and increase effectiveness of treatment. These innovations include new pharmacological agents, novel counseling strategies, promising ways to motivate, and treatment in new settings. This paper describes standard treatments and recent innovations designed to increase (a) effectiveness of treatment, (b) motivation to seek care, (c) access, (d) retention, and (e) cost-effectiveness. We provide criteria on how these innovations should be evaluated in order to determine which should be adopted, funded, and transferred to existing and future treatment programs.

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.

Day treatment versus enhanced standard methadone services for opioid-dependent patients: a comparison of clinical efficacy and cost.

OBJECTIVE: This study examined the differential efficacy and relative costs of two intensities of adjunctive psychosocial services--a day treatment program and enhanced standard care--for the treatment of opioid-dependent patients maintained on methadone hydrochloride. METHOD: A 12-week randomized clinical trial with 6-month follow-up was conducted in a community-based methadone maintenance program. Of the 308 patients who met inclusion criteria, 291 began treatment (day treatment program: N=145; enhanced standard care: N=146), and 237 completed treatment (82% of those assigned to the day treatment program and 81% of those receiving enhanced standard care). Two hundred twenty of the patients participated in the 6-month follow-up (75% of those in the day treatment program and 73% of those in enhanced standard care provided a follow-up urine sample for screening). Both interventions were 12 weeks in duration, manual-guided, and provided by master's-level clinicians. The day treatment was an intensive, 25-hour-per-week program. The enhanced standard care was standard methadone maintenance plus a weekly skills training group and referral to on- and off-site services. Outcome measures included twice weekly urine toxicology screens, severity of addiction-related problems, prevalence of HIV risk behaviors, and program costs. RESULTS: Although the cost of the day treatment program was significantly higher, there was no significant difference in the two groups' use of either opiates or cocaine. Over the course of treatment, drug use, drug-related problems, and HIV risk behaviors decreased significantly for patients assigned to both treatment intensities. Improvements were maintained at follow-up. CONCLUSIONS: Providing an intensive day treatment program to unemployed, inner-city methadone patients was not cost-effective relative to a program of enhanced methadone maintenance services, which produced comparable outcomes at less than half the cost.

Linking health-related quality-of-life indicators to large national data sets.

OBJECTIVE: This study investigated the feasibility and usefulness of linking algorithms for well known quality-of-life (QOL) indicators to large nationally representative databases. DESIGN AND SETTING: The National Medical Expenditure Survey (NMES) was utilised. We developed an algorithm to match the EuroQOL health indicator and drew on a previous match of the Health Utilities Index (HUI) in a companion paper. This process allowed the sensitivity and detail of health-related quality-of-life (HR-QOL) indicators to be combined with the benefits of large, nationally representative data sets. PATIENTS AND PARTICIPANTS: A total of 19,525 individuals aged 18 years and older (constituting a nationally representative sample of the non-institutionalised civilian population of the US contained within the 1987 NMES database) were investigated. INTERVENTIONS: Sensitivity analyses using several related specifications of each indicator were performed. We analysed the correlations of these alternatives for both the HUI and EuroQOL measures. Correlations between the HUI and EuroQOL measures were also examined. We investigated the construct validity by examining the performance of the HUI and EuroQOLs in empirical situations in which we had knowledge about the relationships (e.g. health decreases with age). MAIN OUTCOME MEASURES AND RESULTS: The benefits of HR-QOL measures can be achieved relatively cheaply and efficiently via linking rather than developing a large scale QOL survey. Although the NMES data allowed a good match with the EuroQOL and the HUI, the matches were not perfect. By examining the within-domain correlations and the between-domain correlations, we found that the alternate specifications within-domain were very similar and that the 2 HR-QOL indicators were comparable in many (but not all) aspects. CONCLUSIONS: The results of this study suggested good construct validity. Thus, linked HR-QOL measures of the types derived in this study may be useful in characterising the health of large populations, and in investigating the causes and consequences of health.

Drinking, problem drinking, and productivity.

This chapter surveys and critiques the recent economic literature dealing with the relationships between labor market productivity and alcohol use and misuse. The focus here is twofold. First is to present and discuss the relevant conceptual issues that must be appreciated in assessing such relationships. Second is to summarize and assess the empirical findings that have been offered in the literature.

Linking the health utilities index to National Medical Expenditure Survey data.

Measures of health-related quality of life (HR-QOL) are becoming increasingly important in assessing the effects of chronic illness and healthcare interventions designed to treat them. Obtaining measures of HR-QOL for a nationally representative sample of individuals would enhance understanding of health status in the US, and promote further study of the economic causes and effects of health status. This study reports on our efforts to link a prominent HR-QOL scale, the Health Utilities Index Mark I (HUI), to the National Medical Expenditure Survey (NMES). Six distinct algorithms were constructed for linking the HUI to NMES. These alternative linkage algorithms yielded HUI measures that were highly intercorrelated (p = 93 to 99%). Multivariate regression analyses performed to predict variations in HR-QOL revealed that the HUI exhibited good predictive validity--the HUI demonstrated lower quality of life for a variety of chronic illnesses, and wealthier individuals and better educated individuals had a higher quality of life. In contrast to some previous HR-QOL research, the present analysis demonstrates that: (i) cancer is negatively and significantly related to quality of life; and (ii) smoking is negatively and significantly related to quality of life. Overall, the results suggest that the HUI linkages to NMES provide reliable and valid measures of quality of life. As such, items from the NMES can be grouped and linked in such a way as to obtain health state utility values. These values should be of use to those who wish to understand the global health of the US population for policy-making efforts.

Women and work: tipplers and teetotalers.

We seek to understand better the puzzling finding that, for women, alcoholism appears to be positively associated with the probability of being employed. Using the 1988 Alcohol Survey of the National Health Interview Survey, we find that this association holds for white women only. For white women, alcoholism and early drinking are associated with higher educational attainment, a smaller family size and a lower probability of being married. In turn, these human capital indicators are associated with greater labour supply, thus helping to explain the curious positive relationship between alcoholism and employment for women. An advance in this paper over our previous work is to examine life-time abstention from alcohol and its association with employment and human capital variables. We find that lifetime abstention is associated with lower employment, unemployment and education and greater propensity to be married for both white and non-white women.

Alcoholism and income: the role of indirect effects.

The potential pathways by which alcoholism might affect income are examined using data on males from the New Haven site of the Epidemiologic Catchment Area (ECA) data set to illustrate important indirect, and direct, effects of alcoholism on income. The detrimental indirect effects occur through reduction of educational attainment and increased probability of divorce. Because both educational attainment and marriage positively influence income, the adverse impact of alcoholism on both of these variables translates into lower income for alcoholics. The implications should lead researchers to distinguish more carefully between the direct and indirect costs of this condition. Policy analysts also should explore the financial impact of early onset when they look at overall costs. Because this has often been underestimated, fewer resources are devoted to prevention and treatment of alcoholism than a considered awareness of the problem would indicate is warranted.

An assessment of the anticompetitive effects of preferred provider organizations.

Although preferred provider organizations (PPOs) sponsored by third parties are likely to offer benefits to society through increased competition, those sponsored by providers may generate a risk of anticompetitive collusion. Such cartellike collusion could result in price fixing, less aggressive utilization review, and restrictions on entry and innovation in the market. In this article, we provide guidance on the potential risks posed by provider-sponsored PPOs. We suggest that public policy should generally promote PPOs and remove regulatory barriers to their growth because of their cost containment potential. Policy design should, however, reflect an awareness of the potential anticompetitive outcomes of provider-sponsored PPOs and should promote antitrust oversight of their activities.

Behaviorally caused loss of health and the use of medical care.

This paper extends the analysis of the demand for medical care to an aspect which has previously been ignored: variations in expected, as opposed to experienced, cause of losses of health and the current use of medical care. Losses of health which cannot be prevented by the prior use of medical care are hypothesized to decrease the use of medical care by reducing the rate of return to investments in health, ceteris paribus. The reduction in the rate of return occurs both because these losses curtail the length of the stream of benefits to the use of medical care and because prior use of medical care is not effective in reducing the occurrence of these types of loss. Empirical findings support this hypothesis. Results suggest that differences in expected losses may account for some of the differences in utilization of medical care by sex.