A Meta Analysis of the Impact of SBI on Healthcare Utilization Presented by Jesse M. Hinde RTI International Presented at INEBRIA, Gateshead, UK October 9, 2009 This research was conducted under NIAAA grant no. R01 AA013925

Acknowledgements Co-Authors Funding Jeremy Bray, PhD Alexander Cowell, PhD Funding National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health Grant R01 AA013925 (PI: Jeremy Bray) 2/16/2019

Motivation: Broad Policy Support Ensuring Solutions.org: “Every dollar spent on SBI saves nearly four dollars in subsequent health care costs.” United States Preventative Services Task Force: “B” recommendation for SBI (some evidence that is reduce health care costs) U.S. Substance Abuse and Mental Health Services Administration (SAMHSA): SBI is associated with fewer hospital days and fewer ED visits SBI cost-benefit and cost-effectiveness demonstrates cost-savings Pending Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation: All U.S. Hospitals would have to implement SBI SBI saves hospitals money 2/16/2019

Support from the Literature D’Onofrio et al., 2002: Strongly recommends SBI to reduce ED/outpatient visits and hospitalizations after 32 article review Gentilello et al., 2005: SBI can potentially save $1.82 billion in health care costs annually Solberg et al., 2008: “Screening and brief counseling in primary care was cost-saving from the societal perspective and highly cost-effective from the health-system perspective.” 2/16/2019

Weaknesses in the Literature Systematic reviews and meta-analyses often focus on drinking outcomes, not health care utilization Whitlock et al. 2004: Only 1 of the 5 RCT studies that included health care measures showed reduced health care utilization Policy statements are only based on a few source projects (TrEAT) or articles (Gentilello 2004) 2/16/2019

Systematic Review Methods Search strategy: Targeted electronic journals using online databases EBSCOhost-PsycArticles; EBSCSO-host-Psychology & Behavioral Sciences Collection; Springer Online Journals System; PubMed Central; JSTOR Arts and Sciences Collections I and II Supplemented with GoogleScholar queries Reviewed references from identified articles, focusing on previous SBI systematic reviews and meta-analyses 2/16/2019

Systematic Review Methods cont… Key words Screening and brief intervention; alcohol brief intervention; SBI Health care utilization; health care; cost; effectiveness; cost-effectiveness Basic inclusion criteria Used SBI, brief interventions, or motivational interviewing Randomized controlled trial Presence of health care utilization outcomes 2/16/2019

Article Selection Process 2/16/2019

Included Primary Care Studies 2/16/2019

Included Emergency Department Studies 2/16/2019

Studies Included from Other Settings 2/16/2019

Preliminary Meta Analysis For each intervention and control condition, collected a post-baseline measure of the mean effect, standard deviation and sample N For each study, there are potentially multiple Follow-up points Utilization measures Intervention arms Stratified data by setting ED and primary care Stata v.10 with random effects 2/16/2019

Meta Analysis Specifications Calculated for both outpatient and inpatient measures Observations stratified by primary care and emergency department settings Only included observations for 12-month follow-ups. Excluded “other” settings. Excluded incomplete records (e.g. without sample N, mean effect, or standard deviation) 5 total articles (5 Outpatient, 4 Inpatient) 2/16/2019

Outpatient Measures 2/16/2019

Limitations Small sample size and clustering of articles Excludes several articles both for and against health care utilization reductions (N=11) 2 articles had no health care data 2 articles were excluded on setting (inpatient only setting) 3 articles did not have sufficient data to perform analyses 4 articles did not have a 12-month follow-up Project TrEAT was excluded due to incomplete data from the source articles 2/16/2019

Preliminary Conclusions Strong evidence of heterogeneity Large variation that is not random Outpatient: Significant negative effect for primary care setting Rejected null hypothesis for heterogeneity 2/16/2019

Preliminary Conclusions (cont’d) Inpatient: No significant effect of the standardized mean differences for both settings Significant evidence of heterogeneity Across all settings: No significant effect of the standardized mean differences 2/16/2019

Next Steps Review Score articles Complete review of literature that we have Search on other databases Seek out complete data from authors Score articles Score articles by qualitative analysis of studies, based on design (e.g. Vasilaki 2006) 2/16/2019

Next Steps (cont’d) Heterogeneity Meta Analysis Methodology Investigate role of intervention implementation setting Meta Analysis Methodology Methodology to handle clustering Meta-regression methods 2/16/2019

Outpatient Measures – Model 1 2/16/2019

Outpatient Measures – Model 2 2/16/2019

Inpatient Measures – Model 1 2/16/2019

Inpatient Measures – Model 2 2/16/2019