"Deaths of despair" over the business cycle: New estimates from a shift-share instrumental variables approach.

This study presents new evidence of the effects of short-term economic fluctuations on suicide, fatal drug overdose, and alcohol-related mortality among working-age adults in the United States from 2003-2017. Using a shift-share instrumental variables approach, I find that a one percentage point increase in the aggregate employment rate decreases current-year non-drug suicides by 1.7 percent. These protective effects are concentrated among working-age men and likely reflect a combination of individual labor market experiences as well as the indirect effects of local economic growth. I find no consistent evidence that short-term business cycle changes affect drug or alcohol-related mortality. While the estimated protective effects are small relative to secular increases in suicide in recent decades, these findings are suggestive of important, short-term economic factors affecting specific causes of death and should be considered alongside the longer-term and multifaceted social, economic, and cultural determinants of America's "despair" epidemic.

The phenotype of recovery VI: The association between life-history strategies, delay discounting, and maladaptive health and financial behaviors among individuals in recovery from alcohol use disorders.

BACKGROUND: The life-history theory is a well-established framework that predicts behaviors and explains how and why organisms allocate effort and resources to different life goals. Delay discounting (DD) is associated with risky behaviors and has been suggested as a candidate behavioral marker of addiction. Thus, we investigated the relationship between DD, life-history strategies, and engagement in risky behaviors among individuals in recovery from alcohol use disorder (AUD). METHODS: Data from 110 individuals in recovery from addiction from The International Quit & Recovery Registry, an ongoing online registry designed to understand recovery phenotype, were included in the analysis. The association between life-history strategies, DD, engagement in risky behaviors, and remission status were assessed. RESULTS: Life-history strategy scores were significantly associated with DD rates and finance, health, and personal development behaviors after controlling for age, sex, race, ethnicity, years of education, marital status, smoking status, and history of other substance use. Remission status was significantly associated with life-history strategy, DD, drug use, fitness, health, and safe driving after controlling for age, sex, race, years of education, marital status, and smoking status. In addition, a mediation analysis using Hayes' methods revealed that the discounting rates partially mediated the association between remission status and life-history strategy scores. CONCLUSIONS: Life-history strategies and remission status are both significantly associated with DD and various health and finance behaviors among individuals in recovery from AUD. This finding supports the characterizations of DD as a candidate behavioral marker of addiction that could help differentiate subgroups needing special attention or specific interventions to improve the outcomes of their recovery. Future longitudinal studies are warranted to understand the relationships between changes in life-history strategies, DD, maladaptive health behaviors, and remission status over time.

COVID-19 impacts on drinking and mental health in emerging adults: Longitudinal changes and moderation by economic disruption and sex.

BACKGROUND: There are significant concerns that the COVID-19 pandemic may have negative effects on substance use and mental health, but most studies to date are cross-sectional. In a sample of emerging adults, over a two-week period during the pandemic, the current study examined: (1) changes in drinking-related outcomes, depression, anxiety, and posttraumatic stress disorder and (2) differences in changes by sex and income loss. The intra-pandemic measures were compared to pre-pandemic measures. METHODS: Participants were 473 emerging adults (Mage  = 23.84; 41.7% male) in an existing longitudinal study on alcohol misuse who were assessed from June 17 to July 1, 2020, during acute public health restrictions in Ontario, Canada. These intra-pandemic data were matched to participant pre-pandemic reports, collected an average of 5 months earlier. Assessments included validated measures of drinking, alcohol-related consequences, and mental health indicators. RESULTS: Longitudinal analyses revealed significant decreases in heavy drinking and adverse alcohol consequences, with no moderation by sex or income loss, but with substantial heterogeneity in changes. Significant increases in continuous measures of depression and anxiety were present, both of which were moderated by sex. Females reported significantly larger increases in depression and anxiety. Income loss >50% was significantly associated with increases in depression. CONCLUSIONS: During the initial phase of the pandemic, reductions in heavy drinking and alcohol consequences were present in this sample of emerging adults, perhaps due to restrictions on socializing. In contrast, there was an increase in internalizing symptoms , especially in females, highlighting disparities in the mental health impacts of the pandemic.

A pilot economic evaluation of computerized cognitive behavioral therapy for alcohol use disorder as an addition and alternative to traditional therapy.

BACKGROUND: Computer-based delivery of cognitive behavioral therapy (CBT) may be a less costly approach to increase dissemination and implementation of evidence-based treatments for alcohol use disorder (AUD). However, comprehensive evaluations of costs, cost-effectiveness, and cost-benefit of computer-delivered interventions are rare. METHODS: This study used data from a completed randomized clinical trial to evaluate the cost-effectiveness and cost-benefit of a computer-based version of CBT (CBT4CBT) for AUD. Sixty-three participants were randomized to receive one of the following treatments at an outpatient treatment facility and attended at least one session: (1) treatment as usual (TAU), (2) CBT4CBT plus treatment as usual (CBT4CBT+TAU), or (3) CBT4CBT plus brief monitoring. RESULTS: Median protocol treatment costs per participant differed significantly between conditions, Kruskal-Wallis H(2) = 8.40, p = 0.02, such that CBT4CBT+TAU and CBT4CBT+monitoring each cost significantly more per participant than TAU. However, when nonprotocol treatment costs were included, total treatment costs per participant did not differ significantly between conditions. Median incremental cost-effective ratios (ICERs) revealed that CBT4CBT+TAU was more costly and more effective than TAU. It cost $35.08 to add CBT4CBT to TAU to produce a reduction of one additional drinking day per month between baseline and the end of the 8-week treatment protocol: CBT4CBT+monitoring cost $33.70 less to produce a reduction of one additional drinking day per month because CBT4CBT+monitoring was less costly than TAU and more effective at treatment termination, though not significantly so. Net benefit analyses suggested that costs of treatment, regardless of condition, did not offset monthly costs related to healthcare utilization, criminal justice involvement, and employment disruption between baseline and 6-month follow-up. Benefit-cost ratios were similar for each condition. CONCLUSIONS: Results of this pilot economic evaluation suggest that an 8-week course of CBT4CBT may be a cost-effective addition and potential alternative to standard outpatient treatment for AUD. Additional research is needed to generate conclusions about the cost-benefit of providing CBT4CBT to treatment-seeking individuals participating in standard outpatient treatment.

Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship.

AIMS: We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012. METHODS: Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings. RESULTS: A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings. CONCLUSIONS: The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Do the Costs of AUD-Related Health and Social Care Services Vary Across Patient Profiles?

OBJECTIVE: Alcohol use disorders (AUDs) are associated with high social and health care costs. We compare the direct social and health care costs of patients with AUDs, according to four service use profiles: (a) AUD treatment, (b) mental health (MH) treatment, (c) AUD + MH treatment, (d) no treatment. A separate analysis of the costliest 10% is included. Furthermore, the association between the service user profile and the risk of death is examined. METHOD: Direct unit service costs were retrieved from the electronic health record system and supplemented with patient grouping-based costs for primary and secondary care services, to examine the yearly mean cost per patient in the AUD cohort (N = 5,136; 71.1% male). We used data collected in the North Karelia region of Finland between 2014 and 2018. RESULTS: Total costs of care for the cohort during the 5-year follow-up were 126 million Euros, and the percentage of the costliest 10% (n = 521) was 51.7% (65 million Euros). Total costs were 12,778 Euros lower if the person received AUD treatment only, compared with those not in treatment. For those receiving MH treatment only, the total costs were 1,819 Euros higher, and costs were 1,523 Euros higher for those receiving AUD + MH treatment. Receiving any treatment was associated with a diminished risk of death (AUD: odds ratio [OR] = 0.56; MH: OR = 0.63; AUD + MH: OR = 0.41). CONCLUSIONS: Receiving only AUD treatment was associated with the lowest cost of care. Our results support the early identification of AUDs and provision of treatment in specialized addiction services to lower the costs of care and improve care outcomes.

Group Versus Standard Behavioral Couples' Therapy for Alcohol Use Disorder Patients: Cost-Effectiveness.

OBJECTIVE: The purpose of this study was to evaluate the costs and cost-effectiveness of two treatments for 101 alcohol use disorder patients and their intimate partners--group behavioral couples' therapy plus individual-based treatment (G-BCT), or standard behavioral couples' therapy plus individual-based treatment (S-BCT). METHOD: We estimated the per-patient cost of each intervention using a microcosting approach that allowed us to estimate costs of specific components in each intervention as well as the overall total costs. Using simple means analysis and multiple regression models, we estimated the incremental effectiveness of G-BCT relative to S-BCT. Immediately after treatment and 12 months after treatment, we computed incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves for percentage days abstinent, adverse consequences of alcohol and drugs, and overall relationship functioning. RESULTS: The average per-patient cost of delivering G-BCT was $674, significantly less than the cost of S-BCT ($831). However, 12 months after treatment, S-BCT participants performed better on all outcomes compared with those in G-BCT, and the calculated ICER moving from G-BCT to S-BCT ranged from $10 to $12 across these outcomes. The current findings indicated that, except at very low willingness-to-pay values, S-BCT is a cost-effective option relative to G-BCT when considering 12-month posttreatment outcomes. CONCLUSIONS: As expected, G-BCT was delivered at a lower cost per patient than S-BCT; however, S-BCT performed better over time on the clinical outcomes studied. These economic findings indicate that alcohol use disorder treatment providers should seriously consider S-BCT over G-BCT when deciding what format to use in behavioral couples' therapy.

Measuring intangible cost-of-morbidity due to substance dependence: implications of using alternative preference-based instruments.

OBJECTIVE: Drug and/or alcohol dependence (DAD) generates substantial costs to society. One of the main consequences of DAD is its negative impact on health-related quality of life (HRQoL). The main objective of this study is to analyse the impact of using EQ-5D-5L, SF-6DSG (SF-6D using standard-gamble as the preference-eliciting method) and SF-6DPG (SF-6D using a paired-gamble method), to estimate the HRQoL burden, attributable to DAD, within the cost-of-illness framework. METHODS: A convenience sample of 109 patients with a diagnosis of substance use disorder was recruited. SF-6D and EQ-5D-5L were administered and then the utility scores were computed. The impact of employing different instruments to estimate the HRQoL burden was assessed by comparing the utility scores of patients and general population after controlling for sex and age through regression analysis. The analysis was reproduced for two subgroups of severity. RESULTS: All instruments detect that DAD significantly affects the HRQoL. However, the estimated impact changes, according to the instrument used, whose pattern varies by severity group. Nonetheless, regardless of severity, SF-6DPG always estimates a higher or equal DAD burden than the other instruments considered. These results are compatible with the presence of the floor effect in SF-6DSG, the ceiling effect in EQ-ED-5L, and a smaller presence of both biases in SF-6DPG. CONCLUSIONS: The SF-6DPG instrument emerges as a good candidate to avoid under-estimating intangible costs within the cost-of-illness framework. However, further research is needed to assess the validity of our results in the context of other health problems.

Twenty Years Socioeconomic Trajectories in Older Adults with Varying Alcohol Use: A Register-Based Cohort Study.

AIMS: The objective of this paper was to examine 20-year trends of the socioeconomic status (SES) measures income and employment and their association with current alcohol use behaviors in Danish adults aged 60-70. METHODS: Data from The Danish National Health Survey 2013 and the baseline assessment of the Elderly Study (2013-2016) were combined to form four groups from the general population with various drinking patterns, but with no recent treatment for alcohol use disorder (AUD), and one group seeking treatment: Abstinent (n = 691), low- (n = 1978), moderate- (n = 602), and high-risk (HR) drinkers (n = 467), and DSM-5 AUD seeking treatment (n = 262). For all groups, Danish national register data were linked at the individual level obtain find annual information on income and employment during the 20 years prior to interview. Mixed effects models were utilized to model trajectories of income and employment for the five groups. RESULTS: Lower income and employment status was observed from middle-aged adulthood when comparing 12-month abstinence or AUD to individuals with low or moderate alcohol consumption. At the end of the study period, moderate-risk drinkers experienced an increase, and HR drinkers a decrease, in income and rate of employment relative to the low-risk drinkers. CONCLUSIONS: Alcohol use behaviors observed in older adults are related to distinct long-term trajectories regarding income and employment status, which are observable already in middle-aged adulthood.

Current diagnosis-related group-based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives.

BACKGROUND: The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). METHODS: The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. RESULTS: Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. CONCLUSIONS: Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

Relationships between US state alcohol policies and alcohol outcomes: differences by gender and race/ethnicity.

BACKGROUND AND AIMS: Alcohol taxation and availability restrictions are among the most effective methods for reducing alcohol use and problems, yet may affect demographic subgroups differently. Understanding who responds to specific policies can inform approaches for reducing disparities. We examined how state-level beverage-specific taxes and availability restrictions in the United States are associated with consumption and alcohol-related problems across subgroups defined by gender and race/ethnicity. DESIGN, SETTING AND PARTICIPANTS: Data came from the 2000-15 National Alcohol Surveys (n = 28 251), computer-assisted telephone cross-sectional surveys of United States residents aged 18+. African Americans and Hispanics were oversampled. MEASUREMENTS: Primary outcomes were beverage-specific (beer, wine, spirits and total) volume, DSM-IV alcohol dependence and alcohol-related consequences. Analyses entailed survey-weighted log-log and logistic regressions adjusting for state-level beer tax, spirits tax, government-controlled spirits sales and sales tax; respondent ZIP-code-level density of off-premise beer outlets, off-premise spirits outlets and on-premise bars; respondent individual-level age, marital status, education, employment and income; and fixed effects for wet/moderate/dry US region and year. FINDINGS: Higher beer tax was significantly (P < 0.05) associated with lower odds of any drinking among white women [odds ratio (OR) = 0.98] and lower beer volume (price-elasticity = -0.40), total volume (price-elasticity = -0.50) and odds of alcohol-related consequences (OR = 0.84) among African American women. Higher spirits tax was significantly (P < 0.05) associated with both lower beer and total volume among Hispanic women (price-elasticities = -0.73 and - 1.04, respectively) and men (price-elasticities = -1.19 and - 0.92, respectively) and decreased wine volume among Hispanic women (price-elasticity = -0.62). Apparent protective effects of living in a state with government-controlled spirits sales or a neighborhood with lower bar density was greater among white men than other groups. CONCLUSIONS: The effects of beverage-specific taxes and alcohol availability policies may vary across subgroups, highlighting the importance of considering differential policy impacts in future research and intervention.

Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke.

OBJECTIVE: To determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes. METHODS: All adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS. RESULTS: Of the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p for trend <0.001). Patients with AA were predominantly men (80.2%), white (65.9%), and in the 40- to 59-year (44.6%) and 60- to 79-year (45.6%) age groups. After multivariable adjustment, AIS admissions with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11-1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost (p < 0.001). CONCLUSION: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Estimating Long-Term Drinking Patterns for People with Lifetime Alcohol Use Disorder.

Background. There is a lack of data on alcohol consumption over time. This study characterizes the long-term drinking patterns of people with lifetime alcohol use disorders who have engaged in treatment or informal care. Methods. We developed multinomial logit models using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to estimate short-term transition probabilities (TPs) among the 4 World Health Organization drinking risk levels (low, medium, high, and very high risk) and abstinence by age, sex, and race/ethnicity. We applied an optimization algorithm to convert 3-year TPs from NESARC to 1-year TPs, then used simulated annealing to calibrate TPs to a propensity-scored matched set of participants derived from a separate 16-year study of alcohol consumption. We validated the resulting long-term TPs using NESARC-III, a cross-sectional study conducted on a different cohort. Results. Across 24 demographic groups, the 1-year probability of remaining in the same state averaged 0.93, 0.81, 0.49, 0.51, and 0.63 for abstinent, low, medium, high, and very high-risk states, respectively. After calibration to the 16-year study data (N = 420), resulting TPs produced state distributions that hit the calibration target. We find that the abstinent or low-risk states are very stable, and the annual probability of leaving the very high-risk state increases by about 20 percentage points beyond 8 years. Limitations. TPs for some demographic groups had small cell sizes. The data used to calibrate long-term TPs are based on a geographically narrow study. Conclusions. This study is the first to characterize long-term drinking patterns by combining short-term representative data with long-term data on drinking behaviors. Current research is using these patterns to estimate the long-term cost effectiveness of alcohol treatment.

Production Losses Associated with Alcohol-Attributable Mortality in the European Union.

The economic aspects of alcohol misuse are attracting increasing attention from policy makers and researchers but the evidence on the economic burden of this substance is hardly comparable internationally. This study aims to overcome this problem by estimating production losses (indirect costs) associated with alcohol-attributable mortality in 28 European Union (EU) countries in the year 2016. This study applies the prevalence-based top-down approach, societal perspective and human capital method to sex- and age-specific data on alcohol-related mortality at working age. The alcohol-attributable mortality data was taken from estimates based on the Global Burden of Disease Study 2016. Uniform data on labor and economic measures from the Eurostat database was used. The total production losses associated with alcohol-related deaths in the EU in 2016 were €32.1 billion. The per capita costs (share of costs in gross domestic product (GDP)) were €62.88 (0.215%) for the whole EU and ranged from €17.29 (0.062%) in Malta to €192.93 (0.875%) in Lithuania. On average, 81% of the losses were associated with male deaths and mortality among those aged 50-54 years generated the highest burden. Because alcohol is a major avoidable factor for mortality, public health community actions aimed at limiting this substance misuse might not only decrease the health burden but also contribute to the economic welfare of European societies.

The economic cost of preventable disease in Australia: a systematic review of estimates and methods.

OBJECTIVE: The aim of this literature review was to establish the economic burden of preventable disease in Australia in terms of attributable health care costs, other costs to government and reduced productivity. METHODS: A systematic review was conducted to establish the economic cost of preventable disease in Australia and ascertain the methods used to derive these estimates. Nine databases and the grey literature were searched, limited to the past 10 years, and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed to identify, screen and report on eligible studies. RESULTS: Eighteen studies were included. There were at least three studies examining the attributable costs and economic impact for each risk factor. The greatest costs were related to the productivity impacts of preventable risk factors. Estimates of the annual productivity loss that could be attributed to individual risk factors were between $840 million and $14.9 billion for obesity; up to $10.5 billion due to tobacco; between $1.1 billion and $6.8 billion for excess alcohol consumption; up to $15.6 billion due to physical inactivity and $561 million for individual dietary risk factors. Productivity impacts were included in 15 studies and the human capital approach was the method most often employed (14 studies) to calculate this. CONCLUSIONS: Substantial economic burden is caused by lifestyle-related risk factors. Implications for public health: The significant economic burden associated with preventable disease provides an economic rationale for action to reduce the prevalence of lifestyle-related risk factors. New analysis of the economic burden of multiple risk factors concurrently is needed.

Social Inequalities in Harmful Drinking and Alcohol-Related Problems Among Swedish Adolescents.

AIMS: The study aims to examine how socio-economic status (SES) among youth is related to binge-drinking and alcohol-related problems using three SES indicators: (i) SES of origin (parental education level), (ii) SES of the school environment (average parental education level at student's school) and (iii) SES of destination (academic orientation). METHODS: Cross-sectional data on upper secondary students (n= 4448) in Sweden. Multilevel logistic and negative binomial regression were used to estimate the relationship between each SES indicator and binge-drinking and alcohol-related problems, respectively. RESULTS: Only SES of destination was significantly associated with binge-drinking, with higher odds for students in vocational programmes (OR= 1.42, 95% CI= 1.13-1.80). For the second outcome, SES of destination (rr=1.25; 95%CI=1.08-1.45) and SES of the school environment (rr=1.19, 95% CI=1.02-1.39) indicated more alcohol-related problems in vocational programmes and in schools with lower-educated parents. After adjustment for drinking patterns, the relationship remained for SES of the school environment, but became non-significant for SES of destination. CONCLUSION: Our results suggest that the SES gradient among youth is stronger for alcohol-related problems than for harmful drinking. By only focusing on SES differences in harmful alcohol use, researchers may underestimate the social inequalities in adverse alcohol-related outcomes among young people. Our findings also support the notion that the environment young people find themselves in matters for social inequalities in alcohol-related harm.

The Prescription of Anticraving Medication and its Economic Consequences.

IMPORTANCE: According to recent studies, only a small proportion of alcoholics in the system for addiction treatment receive expedited treatment [Rehm et al.: Sucht 2014;60:93-105] and that those who are untreated are at risk of harmful and dependent alcohol consumption. This is associated with significantly negative effects on morbidity, mortality, and quality of life [Kraus et al.: Sucht 2010;56:337-347]. As a result, not only individuals and their environment suffer but there is also a health economic impact. OBJECTIVE: How often do patients with a primary or secondary diagnosis of alcohol dependence who have been discharged from inpatient treatment receive anticraving medication in the follow-up period of 6 months? DESIGN, SETTING, AND PARTICIPANTS: Based on data from a statutory health insurance in Germany, 12,958 patients were investigated regarding alcohol dependence, rates for readmission to hospital, and prescription of anticraving drugs. In addition, outpatient and inpatient treatment costs were calculated. Main Outcomes and Measures: There will be an examination of how often anticraving medications are prescribed and what the economic consequences are. RESULTS: Two hundred and eighty-eight (2.22%) patients received anticraving medication, 98 (0.76%) in the first 6 months after inpatient treatment. Fifty-nine of the 288 patients were monitored with a pre- and postcomparison over a 90-day period. Inpatient treatment fell from 0.83 times (±1.10) during the 3 months afterward to 0.79 (±1.01). On average, the duration of an inpatient stay before anticraving treatment (n = 29) was 17.34 days (±14.37), with an average cost of EUR 4,142.70 (±2,721.28). Among the anticraving treatment group, this fell to 14.03 days (±9.96) with an average cost of EUR 3,685.43 (±2,307.67). Overall, the average outpatient and inpatient treatment costs dropped from EUR 1,533.88 before treatment to EUR 1,462.76 after treatment. If this is extrapolated to the whole group, it leads to between EUR 921,500 and EUR 6.6 million saving for a health insurance company. CONCLUSION: Anticraving medications are hardly ever prescribed. Their routine use could reduce hospital readmission rates and save on health-care costs.

Integrating a brief mental health intervention into primary care services for patients with HIV and diabetes in South Africa: study protocol for a trial-based economic evaluation.

INTRODUCTION: Depression and alcohol use disorders are international public health priorities for which there is a substantial treatment gap. Brief mental health interventions delivered by lay health workers in primary care services may reduce this gap. There is limited economic evidence assessing the cost-effectiveness of such interventions in low-income and middle-income countries. This paper describes the proposed economic evaluation of a health systems intervention testing the effectiveness, cost-effectiveness and cost-utility of two task-sharing approaches to integrating services for common mental disorders with HIV and diabetes primary care services. METHODS AND ANALYSIS: This evaluation will be conducted as part of a three-armed cluster randomised controlled trial of clinical effectiveness. Trial clinical outcome measures will include primary outcomes for risk of depression and alcohol use, and secondary outcomes for risk of chronic disease (HIV and diabetes) treatment failure. The cost-effectiveness analysis will evaluate cost per unit change in Alcohol Use Disorder Identification Test and Centre for Epidemiological Studies scale on Depression scores as well as cost per unit change in HIV RNA viral load and haemoglobin A1c, producing results of provider and patient cost per patient year for each study arm and chronic disease. The cost utility analyses will provide results of cost per quality-adjusted life year gained. Additional analyses relevant for implementation including budget impact analyses will be conducted to inform the development of a business case for scaling up the country's investment in mental health services. ETHICS AND DISSEMINATION: The Western Cape Department of Health (WCDoH) (WC2016_RP6_9), the South African Medical Research Council (EC 004-2/2015), the University of Cape Town (089/2015) and Oxford University (OxTREC 2-17) provided ethical approval for this study. Results dissemination will include policy briefs, social media, peer-reviewed papers, a policy dialogue workshop and press briefings. TRIAL REGISTRATION NUMBER: PACTR201610001825405.

Patient predictors of individual cost of integrated treatment program for alcohol problems at community hospitals in southern Thailand.

OBJECTIVES: To estimate the average cost of an integrated alcohol intervention program at community hospitals of Thailand and identify patient predictors and sources of variation of the program cost. METHODS: Activity-based costing was conducted under a societal perspective among 113 outpatient alcohol users (29 low-risk, 43 high-risk and 41 dependent drinkers), aged 15 years and older, at four community hospitals in southern Thailand. Multivariate regression models were performed to identify individual-level determinants of cost components. RESULTS: The average cost per low-risk, high-risk, and dependent drinkers were 516 (16 USD), 2,961 (94 USD), and 5,325 baht (168 USD), respectively, of which labor and patient costs were the major components. Regardless of drinking risk level, past-year functional disturbance lasting more than 20 days (ß = 0.215, p = 0.035) and increasing number of previous treatment episodes (ß = 0.035, p = 0.046) independently increased overall program cost. Variation in the program cost was mainly caused by length of hospital stay followed by staff time for screening and delivering interventions. CONCLUSION: The study underlines the important role of pretreatment alcohol-related problems and human resources in alcohol intervention programs. Efforts should be focused on adequacy of treatment for the very first episode of alcohol problems to reduce the high healthcare costs.