RTI International is a trade name of Research Triangle Institute The Costs of SBI: Findings from the literature Presented by Jeremy Bray, Gary Zarkin, and Michael Mills Presented at INEBRIA Annual Conference October 9, 2009

9/30/ Acknowledgments Funding –National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health –Grant R01 AA (PI: Jeremy Bray)

9/30/ Types of Economic Analysis Cost analysis –Describes resources used to provide SBI –First step in other types of economic analyses Cost-effectiveness analysis –Compares incremental effectiveness to incremental cost –Measures effectiveness in natural units Cost-benefit analysis –Directly compares benefits to costs –All outcomes monetized

9/30/ Why focus on the costs of SBI? Studies find the SBI is cost-effective when implemented in various settings (e.g. Solberg at al., 2008) When cost-effective it is relative to usual practice and is both more costly and more effective A combination of the incremental cost from usual practice, incremental effectiveness, and decision makers’ preferences for either of these will determine their level of support for SBI Knowledge of the various ‘types’ of costs for implementing SBI are needed to inform policy: start-up costs, quasi-fixed costs, and marginal costs Solberg, L. I., M. V. Maciosek, et al. (2008). Primary Care Intervention to Reduce Alcohol Misuse: Ranking Its Health Impact and Cost Effectiveness. American Journal of Preventive Medicine. 34(2): e143.

9/30/ Cost Analysis Research Questions What are the start-up costs of an SBI intervention? What is the cost per patient of screening? What are the annual operating costs of universal screening in a particular setting? What is the difference in costs of conducting a brief intervention in various settings (medical care versus specialty care)? What are the per member per month operating costs of an SBI program?

9/30/ Cost Analysis Methods Many possible cost estimates –Total annual implementation costs –Annual cost per participant (cost per slot) –Cost of an intervention episode –Cost of specific intervention activities (service- or activity- based costing) Different estimates require different methods –DATCAP –SASCAP –Other

9/30/ Potential Components of SBI Cost Analyses One-time startup costs Training (both initial and ongoing) Marketing Implementation costs –Interventionist labor costs –Space/lab/materials cost –Documentation/paperwork costs –Technical assistance –Administrative support costs

9/30/ Purpose of this Presentation Review SBI cost literature to assess –Activities for which cost estimates exist –Commonly used methods –Range of cost findings –Range of clinical protocols that have cost estimates

9/30/ Cost Estimation Challenges Costs differ by SBI implementation model –Self-administered screen vs. administered by a clinician –Physician vs health education interventionist –BI during current appointment or as separate/additional appointment Cost estimation methodologies and perspectives differ across studies producing inconsistent cost estimates –Need to implement activity/service-based costing such as SASCAP Perspective matters –Per patient screening is the least expensive SBI activity –For a population, screening is often the biggest contributor to cost Cost of screening a population differs depending on the health care setting (ED vs outpatient office)

9/30/ Literature Search Methods Databases such as EBSCOhost, PubMed, and JSTOR with keywords –cost screening alcohol –cost SBI alcohol –cost “brief intervention” alcohol Similar keyword searches in Google Scholar. Reviewed references of initial articles to determine additional sources of cost information or to receive more thorough cost information if initial source had been a cost-effectiveness or cost-benefit study

9/30/ Papers Reviewed Tolley & Rowland (1991) Fleming et al (2000) Broskowski & Smith (2001) Wutzke et al (2001) Kaner et al (2003) Zarkin et al (2003) Kunz et al (2004) Gentilello et al (2005) Mundt et al (2005) Barrett et al (2006) Setting Hospital Primary Care 5 Managed Care Organizations Hospital Emergency Department Primary Care Accident and Emergency Departments

9/30/ Costing Approaches Surveys of clinics and/or clinic managers Questionnaires for medical providers Questionnaires for MCO coordinators DATCAP (Drug Abuse Treatment Cost Analysis Program) Use of national salary estimates (median wages)

9/30/ Implementation of Screening Self-administered screening: 3 Screenings administered by a clinician: 5 Scored by receptionist: 1 Scored by a nurse: 4 Scored by a physician: 2 Time estimates for screening: 1 minute to 5 minutes for medical records and 5 minutes for nurse to score

9/30/ Implementation of Brief Intervention Sessions BI as part of current visit: 4 BI as additional visit: 2 Unclear whether current or additional visit: 2 Length of BI –Minimum: up to 5 minutes of general practitioner’s time (Wutzke et al. 2001) –Maximum: minutes (45 minute average) (Barrett et al. 2006)

9/30/ Preferred Methodology of Cost Estimation Total startup costs Annual quasi-fixed costs (e.g. recurring training) Marginal costs (cost per additional screen / BI) Annual quasi-fixed costs and marginal costs can be used to project ongoing costs when the population size and prevalence of at-risk drinking are known

9/30/ Cost Analysis Findings for Alcohol SBI Variation in costing methods and perspectives –Cost per screen per person –Cost per intervention episode –Cost per member per month Variation in cost estimates –Screening Lowest estimate: $0.31 / screen (Zarkin et al. 2003) Highest estimate: $ / (intervention) subject (Kunz et al. 2004) –BI Lowest estimate: $3.23 / BI by specialist; $4.27 / BI by physician (Zarkin et al. 2003) Highest estimate: $ / subject (Kunz et al. 2004)

9/30/ Conclusions Cost estimates vary widely and the existing cost literature provides little guidance to policy makers Additional cost research needs to develop more accurate estimates of the time to provide services The literature lacks regularity in type of costs reported Most articles need to provide greater detail on cost methodology, especially on cost components Articles need to provide a more thorough description of all parts of SBI implementation