Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial
Introduction
Under the Affordable Care Act, treatment of substance abuse disorders is integrated more closely with general medical services and can receive increased funding through Medicaid expansion (Buck, 2011, Dentzer, 2011). These provisions incentivize both public and private health care payers to identify and implement initiatives to control health costs and improve quality comparable to those for general health care. Adding economic analyses to successful clinical trials may be able to identify approaches that meet these important goals (Emanuel et al., 2012).
Because substance abuse disorders are chronic, relapsing disorders, long-term continuing treatment or aftercare is recommended to reduce the risk of relapse and expensive hospitalization (American Society of Addiction Medicine, 2001). Despite the proven benefits of continuing care programs for substance abuse disorders and other chronic conditions, many patients either do not attend any continuing care, or stop attending after a few sessions (Donovan, 1998, Hawkins and Catalano, 1985, McKay, 2007, McKay, 2009, McLellan et al., 2000, O’Brien and McLellan, 1996). Telephone-based continuing care (TEL) is a promising alternative to traditional face-to-face counseling sessions. TEL may be more flexible, less burdensome, and less embarrassing for the patient, and more easily structured by the provider than traditional modalities. All these advantages could improve treatment adherence and health outcomes. By reducing patient travel expenses and time and facility overhead, TEL should also reduce costs.
The telephone has proven to be a viable therapeutic tool in the treatment of several chronic disorders including alcoholism (Connors et al., 1992, Foote and Erfurt, 1991, McKay et al., 2010), panic disorder (Swinson et al., 1995), obsessive-compulsive disorder (Baer et al., 1993), depression (Baer et al., 1995) and congestive heart failure (Jerant et al., 2001). It has also been found to improve outcomes in smoking cessation (Lichtenstein et al., 1996, Stoffelmeyr et al., 2003) and cardiac rehabilitation (Bambauer et al., 2005), and reduces costs for patients in fair or poor overall health (Wasson et al., 1992).
To our knowledge, this report provides one of the first economic evaluations of telephone counseling in substance abuse treatment. It builds on the results from a randomized trial of telephone-based continuing care for alcohol and other drugs (AOD; McKay et al., 2004, McKay et al., 2005a, McKay et al., 2005b). That trial found that telephone-based counseling is an effective form of continuing care for patients with AOD who are progressing reasonably through their initial phases of care, compared to standard continuing care (STD) or in-person relapse prevention (RP). However, the effect of this modality on health care costs is a key factor in its adoption. Because the public sector funded an estimated 83% of substance abuse treatment in 2014 (Levit et al., 2008), if TEL proves inexpensive, it could become an important tool towards controlling health costs.
Section snippets
Overview
This economic analysis of TEL entails four steps. First, the costs of each continuing care intervention are calculated, with and without the inclusion of societal costs for patients’ time and travel expenses. Second, cost-effectiveness analyses (CEAs) are presented in which TEL and RP are compared to STD. Third, benefit-cost analyses are presented in which the three continuing care interventions are compared on costs related to the consequences of substance use, investment costs, and income
Effectiveness and costs by arm
Table 1 section (c) shows average values of costs and effectiveness by arm. TEL produced higher abstinence rates overall during the 24-month follow-up than STD (p < 0.05) and were somewhat higher in TEL than in RP, although not significantly so (McKay et al., 2004, McKay et al., 2005a, McKay et al., 2005b). The moderator analysis found that TEL was more effective for clients who met the majority of the initial goals of their IOP (80% of the sample). However, STD, with its greater group support,
Discussion
The strengths of this study are design features that address many of the limitations of previous research and meet recently recommended standards for economic evaluation of continuing care (Popovici et al., 2008). The use of random assignment protects against selection bias. The long-term (24-month) follow-up period is suitable for a continuing care intervention. Program costs and benefits were assessed with validated instruments (Flynn et al., 2009, Shepard et al., 2012). Treatment sites and
Conflict of interest statement
The authors have no conflicts of interest to declare.
Contributors
DSS and JM came up with the concept of the paper. MD, MN, and APB performed the statistical analysis. MN wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
References (50)
- et al.
The effectiveness of web-based interventions designed to reduce alcohol consumption - a systematic review
Prev. Med.
(2008) - et al.
Achieving and maintaining gains among problem drinkers: process and outcome results
Behav. Ther.
(1992) - et al.
Treatment cost analysis tool (TCAT) for estimating costs of outpatient treatment services
Drug Alcohol Depend.
(2009) - et al.
Alcohol consumption patterns and health care costs in an HMO
Drug Alcohol Depend.
(2001) Continuing care research: what we have learned and where we are going
J. Subst. Abuse Treat.
(2009)- et al.
Myths about the treatment of addiction
Lancet
(1996) - et al.
Five-year trajectories of health care utilization and cost in a drug and alcohol treatment sample
Drug Alcohol Depend.
(2005) - et al.
Efficacy of telephone-administered behavioral therapy for panic disorder with agoraphobia
Behav. Res. Ther.
(1995) - et al.
The substance abuse services cost analysis program (SASCAP): a new method for estimating drug treatment services costs
Eval. Prog. Plan.
(2004) Patient Placement Criteria for the Treatment of Substance-Related Disorders
(2001)
Computer assisted telephone administration of a structured interview for obsessive-compulsive disorder
Am. J. Psychiatry
Automated telephone screening survey for depression
JAMA
The effect of a telephone counseling intervention on self-rated health of cardiac patients
Psychosom. Med.
Organizational and client determinants of cost in outpatient substance abuse treatment
J. Ment. Health Policy Econ.
The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act
Health Aff. (Millwood)
Relapse prevention as a psychosocial treatment: a review of controlled studies
Exp. Clin. Psychopharmacol.
Recovery from DSM-IV alcohol dependence: United States, 2001–2002
Addiction
Managing addiction as a chronic condition
Addict. Sci. Clin. Pract.
Substance abuse and other substantive matters
Health Aff. (Millwood)
Continuing care: promoting the maintenance of change
A systematic approach to containing health care spending
N. Engl. J. Med.
Effects of EAP follow-up on prevention of relapse among substance abuse clients
J. Stud. Alcohol
Benefit-cost analysis of residential and outpatient addiction treatment in the state of Washington
Eval. Rev.
Economic evaluation of alcohol treatment services
Benefit-cost analysis of addiction treatment: methodological guidelines and empirical application using the DATCAP and ASI
Health Serv. Res.
Cited by (11)
Telehealth interventions to reduce alcohol use in men with HIV who have sex with men: Protocol for a factorial randomized controlled trial
2019, Contemporary Clinical Trials CommunicationsCitation Excerpt :Third, this study will examine the duration of intervention needed to produce optimal effects. Outside of studies that have tested telephone-based continuing care for patients receiving addictions treatment [84–89], few behavioral alcohol interventions have based the number of sessions and the duration of the intervention on empirical data, relying instead on clinical judgement, precedent, or pilot testing to set these intervention parameters. The present study is novel in its inclusion of intervention quantity/duration as an experimental factor in an alcohol intervention among people with HIV.
Capacity of primary care to deliver telehealth in the United States
2021, Journal of the American Board of Family MedicineImpact of continuing care on recovery from substance use disorder
2021, Alcohol Research: Current ReviewsTelephone- and Text Message–Based Continuing Care After Residential Treatment for Alcohol Use Disorder: A Randomized Clinical Multicenter Study
2021, Alcoholism: Clinical and Experimental ResearchEconomic impact of faith-based residential addiction recovery for the homeless
2020, Public Health Nursing