Implementation costs of the appraise alcohol brief intervention (ABI) for male remand prisoners: A micro-costing protocol and preliminary findings.

OBJECTIVE: This paper documents the methods used to assess the implementation costs of the APPRAISE alcohol brief intervention (ABI) delivered to male remand prisoners across two study sites in Scotland and North East England. METHOD: We first developed a comprehensive taxonomy of the activities constituting the APPRIASE ABI. Next, data were collected for each activity about the study staff and the subject time spent, in addition to the other resources used and unit costs. RESULTS: From the pilot data collection it was possible to construct a narrative, for both study sites, for how the intervention was delivered and the time required for each activity. The ABI was delivered by Change Grow Live and Humankind intervention staff and staff salaries were obtained from both organizations to calculate the staff delivery costs for each site. Other costs, such as the printing of materials, were estimated based on APPRAISE study records. Due to the ongoing Covid-19 restrictions and limited access to prison resources and staff, there were significant deviations from the initial study protocols. As a result, we document the costs of implementing the ABI as delivered rather than as planned. CONCLUSIONS: This paper provides the first estimates of the implementation costs of an ABI delivered in criminal justice setting in the UK. Although these costs are from a pilot implementation that was heavily impacted by the Covid-19 pandemic, this paper nonetheless provides useful, policy-relevant information on the potential costs of providing ABI to remand prisoners. It also serves as a methodological template, guidance, and proof of concept for future micro-costing studies of ABIs in criminal justice settings.

Health Utility of Drinkers' Family Members: A Secondary Analysis of a US Population Data Set.

Background. Problematic alcohol use is known to harm individuals surrounding the drinker. This study described the health utility of people who reported having a family member(s) whom they perceived as a "problem drinker."Methods. We conducted a secondary analysis of the US National Epidemiologic Survey of Alcohol and Related Conditions Wave 3 (NESARC-III, 2012-13) data to estimate the independent associations of a family member's problem drinking on the respondent's health utility, also known as health-related quality of life, assessed via the SF-6D. Participants included 29,159 noninstitutionalized adults, of whom 21,808 reported perceiving a family member or members as having a drinking problem at any point in that person's life. Respondent drinking was assessed via self-report and diagnostic interview. We used population-weighted multivariate regression to estimate disutility. Results. After adjusting for the respondent's own alcohol consumption, alcohol use disorder (AUD), family structure, and sociodemographic characteristics, the mean decrement in SF-6D score associated with perceiving a family member as a problem drinker ranged from 0.033 (P < 0.001) for a spouse/partner to 0.023 (P < 0.001) for a grandparent, sibling, aunt, or uncle. The mean decrement in SF-6D score from having AUD oneself was 0.039 (P < 0.001). Conclusions. Perceived problem drinking within one's family is associated with statistically significant losses in health utility, the magnitude of which is dependent on relationship type. The adverse consequences associated with problem drinking in the family may rival having AUD oneself. Implications. Family-oriented approaches to AUD interventions may confer outsize benefits, especially if focused on the spouse or partner. Economic evaluation of alcohol misuse could be made more accurate through the inclusion of family spillover effects. Highlights: Spillover effects from problem drinking in the family vary by relationship type.One's perception of their spouse or child as having a drinking problem is associated with a utility decrement of equal magnitude to having alcohol use disorder oneself.Medical decision makers should consider the outsize effects of family spillovers in treatment decisions in the context of alcohol consumption, particularly among spouses and children of problem drinkers.Economic evaluation should consider how to incorporate family spillover effects from problem drinking in alcohol-related models.

Association of opioid utilization management with prescribing and overdose.

OBJECTIVES: Deaths from prescription opioids have reached epidemic levels in the United States, yet little is known about how insurers' coverage policies may affect rates of fatal and nonfatal overdose among individuals filling an opioid prescription. STUDY DESIGN: Retrospective cohort study using 2010-2016 Medicare claims data for beneficiaries with 1 or more filled prescriptions for a Schedule II opioid. METHODS: Outcomes were opioid volume dispensed in morphine milligram equivalents (MME), number of days supplied, and number of pills dispensed on each prescription and emergency department or inpatient stay associated with an opioid overdose during a prescription or within 7 days of the end of the prescription. RESULTS: A total of 7.03 million prescriptions for Schedule II opioids were dispensed over 1.87 million Part D beneficiary-years. The 7.03 million opioid prescriptions were associated with 8.5 opioid overdoses per 10,000 prescriptions. Prior authorization was associated with larger opioid volumes per prescription (103.6 MME; 95% CI, 36.2-171.0). Step therapy was associated with a greater number of days supplied (0.62 days; 95% CI, 0.10-1.13) and more pills dispensed (6.12 pills; 95% CI, 2.17-10.1). Quantity limits were associated with smaller opioid volumes (24.3 MME; 95% CI, 12.3-36.3) and fewer pills dispensed (2.35 pills; 95% CI, 1.77-2.93). In adjusted models, beneficiaries filling an opioid requiring prior authorization experienced 3.3 fewer overdoses per 10,000 prescriptions (95% CI, 0.41-6.2). CONCLUSIONS: Opioid utilization management among these beneficiaries was associated with mixed effects on opioid prescribing, and prior authorization was associated with a decreased likelihood of subsequent overdose. Further work exploring the impact of utilization management and insurer policies is needed.

SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs.

OBJECTIVE: We analyzed the association of Screening, Brief Intervention, and Referral to Treatment (SBIRT) with hospitalizations, emergency department (ED) visits, and related costs, when administered to inpatients with substance misuse or disordered use by professional mental health counselors. METHODS: Our study used retrospective program and health records data and a difference-in-differences design with propensity score covariates. The study population consisted of hospital inpatients admitted to integrated care services staffed by physicians, nurses, and mental health counselors. The intervention group consisted of patients selected for intervention based on substance use history and receiving SBIRT (n = 1577). Patients selected for intervention but discharged before SBIRT administration (n = 618) formed the comparison group. The outcome variables were hospitalization and ED visits costs and counts. Costs of hospitalizations and ED visits were combined to allow sufficient data for analysis, with counts treated similarly. Patient-level variables were substance use type and substance use severity. A cluster variable was inpatient clinical service. Zero-censored and two-part logistic and generalized linear models with robust standard errors tested the association of SBIRT interventions with the outcomes. RESULTS: For the full study population of patients using alcohol, illicit drugs, or both, SBIRT administered by mental health counselors was not associated with changes in hospitalizations and ED visits. For patients with alcohol misuse or disordered use, SBIRT by mental health counselors was associated an odds ratio of 0.32 (p < .001) of having subsequent hospitalizations or ED visits. For patients with alcohol use who did return as hospital inpatients or to the ED, SBIRT by counselors was associated with a reduction in costs of $2547 per patient (p < .001) and with an incidence rate ratio of 0.57 for counts (p = .003). CONCLUSION: Our results suggest that professional mental health counselors on inpatient integrated care teams may provide SBIRT effectively for patients with misuse and disordered use of alcohol, reducing the likelihood of future healthcare utilization and costs.

Return on Investment of Workplace Wellness: Evidence From a Long-Term Care Company.

BACKGROUND: Workplace wellness programs (WWPs) are increasingly promoted by businesses and governments as an important strategy to improve workers' overall health and well-being and to reduce health care and other organizational costs. Few studies have evaluated WWPs in small businesses to provide evidence on the potential return-on-investment (ROI) that WWPs might yield. This study aimed to fill this gap by presenting a quasi-experimental, ROI analysis of a WWP in a small company. METHODS: This observational quasi-experimental study evaluated economic outcomes of a multicomponent WWP implemented by a small long-term care company. The company provided approximately 2 years of de-identified, individualized data on its employees for 2013-2015. There were 116 WWP participants and 323 nonparticipants. Difference-in-differences models were used to evaluate the program using organizational costs and ROI estimates. FINDINGS: The estimated program cost was $132.692 (95% confidence interval [CI]: [$112.957, $156.101]) per participant and the estimated organizational costs savings were $210.342 (95% CI: [-4354.095, 2002.890]). The WWP achieved an ROI of $0.585 (95% CI: [-$35.095, $14.103]) per participant. Although not statistically significant, the results suggest that the WWP saved $1.585 for every $1 invested. CONCLUSIONS/APPLICATION TO PRACTICE: These results suggest that the evaluated WWP yielded a positive, although nonsignificant, ROI estimate. While ROI is still one of the most common evaluation metrics used in workplace wellness, few studies present ROI estimates of WWPs in small companies. Given policy efforts to promote WWPs in small businesses, there is a need to conduct high-quality ROI analyses for WWPs in smaller companies.

Implementation science on the margins: How do we demonstrate the value of implementation strategies?

Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Caring for the elderly at work and home: Can a randomized organizational intervention improve psychological health?

Although job stress models suggest that changing the work social environment to increase job resources improves psychological health, many intervention studies have weak designs and overlook influences of family caregiving demands. We tested the effects of an organizational intervention designed to increase supervisor social support for work and nonwork roles, and job control in a results-oriented work environment on the stress and psychological distress of health care employees who care for the elderly, while simultaneously considering their own family caregiving responsibilities. Using a group-randomized organizational field trial with an intent-to-treat design, 420 caregivers in 15 intervention extended-care nursing facilities were compared with 511 caregivers in 15 control facilities at 4 measurement times: preintervention and 6, 12, and 18 months. There were no main intervention effects showing improvements in stress and psychological distress when comparing intervention with control sites. Moderation analyses indicate that the intervention was more effective in reducing stress and psychological distress for caregivers who were also caring for other family members off the job (those with elders and those "sandwiched" with both child and elder caregiving responsibilities) compared with employees without caregiving demands. These findings extend previous studies by showing that the effect of organizational interventions designed to increase job resources to improve psychological health varies according to differences in nonwork caregiving demands. This research suggests that caregivers, especially those with "double-duty" elder caregiving at home and work and "triple-duty" responsibilities, including child care, may benefit from interventions designed to increase work-nonwork social support and job control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol use and the wage returns to education and work experience.

Despite a widely held belief that alcohol use should negatively impact wages, much of the literature on the topic suggests a positive relationship between nonproblematic alcohol use and wages. Studies on the effect of alcohol use on educational attainment have also failed to find a consistent, negative effect of alcohol use on years of education. Thus, the connections between alcohol use, human capital, and wages remain a topic of debate in the literature. In this study, we use the 1997 cohort of the National Longitudinal Survey of Youth to estimate a theoretical model of wage determination that links alcohol use to wages via human capital. We find that nonbinge drinking is associated with lower wage returns to education whereas binge drinking is associated with increased wage returns to both education and work experience. We interpret these counterintuitive results as evidence that alcohol use affects wages through both the allocative and productive efficiency of human capital formation and that these effects operate in offsetting directions. We suggest that alcohol control policies should be more nuanced to target alcohol consumption in the contexts within which it causes harm.

Cost and Return on Investment of a Work-Family Intervention in the Extended Care Industry: Evidence From the Work, Family, and Health Network.

OBJECTIVE: To estimate the cost and return on investment (ROI) of an intervention targeting work-family conflict (WFC) in the extended care industry. METHODS: Costs to deliver the intervention during a group-randomized controlled trial were estimated, and data on organizational costs-presenteeism, health care costs, voluntary termination, and sick time-were collected from interviews and administrative data. Generalized linear models were used to estimate the intervention's impact on organizational costs. Combined, these results produced ROI estimates. A cluster-robust confidence interval (CI) was estimated around the ROI estimate. RESULTS: The per-participant cost of the intervention was $767. The ROI was -1.54 (95% CI: -4.31 to 2.18). The intervention was associated with a $668 reduction in health care costs (P < 0.05). CONCLUSIONS: This paper builds upon and expands prior ROI estimation methods to a new setting.

Joint Utility Estimators in Substance Use Disorders.

BACKGROUND: Although co-occurring conditions are common with substance use disorders (SUDs), estimation methods for joint health state utilities have not yet been tested in this context. OBJECTIVES: To compare joint health state utility estimators in SUD to inform economic evaluation. METHODS: We conducted two Internet-based surveys of US adults to collect community perspective standard gamble utilities for SUD and common co-occurring conditions. We evaluated six conditions as they occur individually and four combinations of these as they occur in tandem. We applied joint utility estimators using the six individual conditions' utilities to compare their performance relative to the observed combination states' utilities. We assessed performance with bias (estimated utility minus observed utility) and root mean square error (RMSE). RESULTS: Using 3892 utilities from 1502 respondents, the minimum estimator was statistically unbiased (i.e., the 95% confidence interval included 0) for all combination states that we measured. The maximum estimator was unbiased for two states and the linear index and adjusted decrement estimators were unbiased for one state. The maximum estimator had the smallest RMSE for two combination states (back pain and prescription opioid misuse [0.0004] and injection crack and injection opioid use [0.0007]); the linear index and minimum estimators had the smallest RMSE for one combination state each. The additive and multiplicative estimators had the largest RMSE for all states. CONCLUSIONS: Our results demonstrate the usefulness of the minimum estimator in this context, and confirm the inadequacy of the additive and multiplicative estimators. Further research is needed to extend these results to other SUD states.

Sustaining SBIRT in the wild: simulating revenues and costs for Screening, Brief Intervention and Referral to Treatment programs.

AIMS: To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments. DESIGN: A mathematical model was used to estimate the number of patients needed for revenues to exceed costs. SETTING: Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists. PARTICIPANTS: Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA). MEASUREMENTS: Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature. FINDINGS: SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients. CONCLUSIONS: Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits).

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice.

AIMS: This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA). METHODS: Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings. FINDINGS: SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1 million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges. CONCLUSIONS: The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.

The Relationship Between End-of-Treatment Alcohol Use and Subsequent Healthcare Costs: Do Heavy Drinking Days Predict Higher Healthcare Costs?

BACKGROUND: A challenge for evaluating alcohol treatment efficacy is determining what constitutes a "good" outcome or meaningful improvement. Abstinence at the end of treatment is an unambiguously good outcome; however, a focus on abstinence ignores the potential benefits of patients reducing their drinking to less problematic levels. Patients may be drinking at low-risk levels at the end of treatment but may be high-functioning and impose few social costs. In this study, we estimate the relationship between drinking at the end of COMBINE treatment and subsequent healthcare costs with an emphasis on heavy and nonheavy drinking levels. METHODS: Indicators of heavy drinking days (HDDs; 5+ drinks for men, 4+ for women) and nonheavy drinking days (non-HDDs) during the last 30 days of COMBINE treatment were constructed for 748 patients enrolled in the COMBINE Economic Study. Generalized linear models were used to model total costs following COMBINE treatment as a function of drinking indicators. Different model specifications analyzed alternative counts of HDDs (e.g., 1 HDD and 2 to 30 HDDs), and groups having Both non-HDDs and HDDs. RESULTS: Patients with HDDs had 66.4% (p < 0.01) higher healthcare costs than those who were abstinent. Having more than 2 HDDs was associated with the highest costs (75.9%, p < 0.01). Patients with non-HDDs had costs that were not significantly different than abstainers, even if they also had HDDs. However, those with HDDs only had costs 91.7% higher than abstainers (p < 0.01). CONCLUSIONS: Having HDDs at the end of treatment is associated with higher costs. Patients who had Only HDDs at the end of treatment had worse subsequent outcomes than those who had Both non-HDDs and HDDs. These findings offer new context for evaluating treatment outcomes and provide new information on the association of drinking with consequences.

Measuring benefits of opioid misuse treatment for economic evaluation: health-related quality of life of opioid-dependent individuals and their spouses as assessed by a sample of the US population.

AIMS: To understand how the general public views the quality of life effects of opioid misuse and opioid use disorder on an individual and his/her spouse, measured in terms used in economic evaluations. DESIGN: Cross-sectional internet survey of a US population-representative respondent panel conducted December 2013-January 2014. SETTING: United States. PARTICIPANTS: A total of 2054 randomly selected adults; 51.1% male (before weighting). MEASUREMENTS: Mean (95% confidence interval) and median health 'utility' for six opioid misuse and treatment outcomes: active injection misuse; active prescription misuse; methadone maintenance therapy at initiation and when stabilized in treatment; and buprenorphine therapy at initiation and when stabilized. Utility is a numerical representation of health-related quality of life used in economic evaluations to 'adjust' estimated survival to include peoples' preferences for health states. Utilities are determined by surveying the general population to estimate the value they assign to particular health states on a scale where 0 = the value of being dead and 1.0 = the value of being in perfect health. Spouse spillover utility is assigned to a spouse of an individual who is in a particular health state. FINDINGS: Mean individual utility ranged from 0.574 [95% confidence interval (CI) = 0.538, 0.611] for active injection opioid misuse to 0.766 for stabilized buprenorphine therapy (95% CI = 0.738, 0.795), with other states in between. Female respondents assigned higher utility to the active prescription misuse and buprenorphine therapy at initiation states than did males (P < 0.05); all other states did not differ by respondent gender. Mean spousal utilities were significantly lower than 1.0 but mostly higher than individual utility, and were similar between male and female respondents. CONCLUSIONS: In the opinion of the US public, injection opioid misuse results in worse health-related quality of life than prescription misuse, and methadone therapy results in worse health-related quality of life than buprenorphine therapy. Spouses are negatively affected by their partner's opioid misuse and early treatment.

Cost of Screening, Brief Intervention, and Referral to Treatment in Health Care Settings.

AIMS: This study analyzed service unit and annual costs of substance abuse screening, brief intervention, and referral to treatment (SBIRT) programs implemented in emergency department (ED), inpatient, and outpatient medical settings in three U.S. states and one tribal organization. METHODS: Unit costs and annual costs were estimated from the perspective of service providers. Data for unit costs came from 26 performance sites, and data for annual costs came from 10 programs. A bottom-up approach was used to derive unit costs and included labor, space, and materials used in each SBIRT activity. Activities included direct SBIRT services and activities that support direct service delivery. Labor time spent in each activity was collected by trained observers using a time-and-motion approach. A top-down approach used cost questionnaires completed by program administrators to calculate annual costs and included labor, space, contracted services, overhead, training, travel, equipment, and supplies and materials. Costs were estimated in 2012 U.S. dollars. RESULTS: Average unit costs for prescreening, screening, brief intervention, brief treatment, and referral to treatment were $0.61, $6.59, $10.48, $22.63, and $12.06 in ED; $0.86, $6.33, $9.07, $27.61, and $8.03 in inpatient; and $0.84, $3.98, $7.81, $27.94, and $9.23 in outpatient settings, respectively; over half of the costs were attributable to support activities. Across all settings, the average cost to provide SBIRT per positive screen, for 1year, was about $400. CONCLUSIONS: Support activities comprise a large proportion of costs. Health administrators can use the results to budget and compare how much sites are reimbursed for SBIRT to how much services actually cost.

Return on Investment of a Work-Family Intervention: Evidence From the Work, Family, and Health Network.

OBJECTIVE: To estimate the return on investment (ROI) of a workplace initiative to reduce work-family conflict in a group-randomized 18-month field experiment in an information technology firm in the United States. METHODS: Intervention resources were micro-costed; benefits included medical costs, productivity (presenteeism), and turnover. Regression models were used to estimate the ROI, and cluster-robust bootstrap was used to calculate its confidence interval. RESULTS: For each participant, model-adjusted costs of the intervention were $690 and company savings were $1850 (2011 prices). The ROI was 1.68 (95% confidence interval, -8.85 to 9.47) and was robust in sensitivity analyses. CONCLUSION: The positive ROI indicates that employers' investment in an intervention to reduce work-family conflict can enhance their business. Although this was the first study to present a confidence interval for the ROI, results are comparable with the literature.

The Impact of a Mandated Trauma Center Alcohol Intervention on Readmission and Cost per Readmission in Arizona.

BACKGROUND: Persons appearing in trauma centers have a higher prevalence of unhealthy alcohol use than the general population. Screening and brief intervention (SBI) is designed to moderate drinking levels and avoid costly future readmissions, but few studies have examined the impact of SBI on hospital readmissions and health care costs in a trauma population. RESEARCH DESIGN: This study uses comparative interrupted time-series and the Arizona State Inpatient Database to estimate the effect of the American College of Surgeons Committee on Trauma SBI mandate on the probability of readmission and cost per readmission in Arizona trauma centers. We compare individuals with and without an alcohol diagnosis code before and after the mandate was implemented. RESULTS: The mandate resulted in a 2.2 percentage point reduction (44%) in the probability of readmission. Total health care and readmission costs were not affected by the mandate. CONCLUSIONS: The estimates are consistent with a differential effect of SBI: SBI reduces readmissions among those who present with a less serious alcohol-related problem. Persons with more serious alcohol problems are less likely to respond to SBI. These higher risk individuals likely have a higher cost, which may explain the lack of change in readmission costs. Our study is a macrolevel intent-to-treat analysis of SBI's impact that corroborates the potential of SBI implied by efficacy studies in trauma centers and other settings. This study provides a framework for future research involving more states and health systems and evaluating other SBI policies.

Program- and service-level costs of seven screening, brief intervention, and referral to treatment programs.

This paper examines the costs of delivering screening, brief intervention, and referral to treatment (SBIRT) services within the first seven demonstration programs funded by the US Substance Abuse and Mental Health Services Administration. Service-level costs were estimated and compared across implementation model (contracted specialist, inhouse specialist, inhouse generalist) and service delivery setting (emergency department, hospital inpatient, outpatient). Program-level costs were estimated and compared across grantee recipient programs. Service-level data were collected through timed observations of SBIRT service delivery. Program-level data were collected during key informant interviews using structured cost interview guides. At the service level, support activities that occur before or after engaging the patient comprise a considerable portion of the cost of delivering SBIRT services, especially short duration services. At the program level, average costs decreased as more patients were screened. Comparing across program and service levels, the average annual operating costs calculated at the program level often exceeded the cost of actual service delivery. Provider time spent in support of service provision may comprise a large share of the costs in some cases because of potentially substantial fixed and quasifixed costs associated with program operation. The cost structure of screening, brief intervention, and referral to treatment is complex and discontinuous of patient flow, causing annual operating costs to exceed the costs of actual service provision for some settings and implementation models.