Elsevier

Drug and Alcohol Dependence

Volume 159, 1 February 2016, Pages 109-116
Drug and Alcohol Dependence

Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial

https://doi.org/10.1016/j.drugalcdep.2015.11.034Get rights and content

Highlights

  • Telephone continuing care achieved greater abstinence than standard groups.

  • Shorter sessions made telephone continuing care less costly than standard groups.

  • Avoiding travel time and expenses, telephone continuing care saved clients money.

  • Telephone continuing care is cost-effective and should be more widely disseminated.

  • Telephone provides support to clients who otherwise might not get continuing care.

Abstract

Purpose

To investigate whether telephone-based continuing care (TEL) is a promising alternative to traditional face-to-face counseling for clients in treatment for substance abuse.

Methods

Patients with alcohol and/or cocaine dependence who had completed a 4-week intensive outpatient program were randomly assigned through urn randomization into one of three 12-week interventions: standard continuing care (STD), in-person relapse prevention (RP), or telephone-based continuing care (TEL). This study performed cost, cost-effectiveness, and cost-benefit analyses of TEL and RP compared to STD, using results from the randomized clinical trial with two years of follow up (359 participants). In addition, the study examined the potential moderating effect of baseline patient costs on economic outcomes.

Results

The study found that TEL was less expensive per client from the societal perspective ($569) than STD ($870) or RP ($1684). TEL also was also significantly more effective, with an abstinence rate of 57.1% compared to 46.7% for STD (p < 0.05). Thus TEL dominated STD, with a highly favorable negative incremental cost-effectiveness ratio (−$1400 per abstinent year). TEL also proved favorable under a benefit-cost perspective.

Conclusions

TEL proved to be a cost-effective and cost-beneficial contributor to long-term recovery over two years. Because TEL dominated STD care interventions, wider adoption should be considered.

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.

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