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Journal Club
Alcohol, Other Drugs, and Health: Current Evidence
May–June 2009
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Featured Article
Health Care and Public Service Use andCosts Before and After Provision ofHousing for Chronically HomelessPersons With Severe Alcohol Problems
Larimer ME, et al. JAMA. 2009;301(13):1349–1357.
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Study Objective
To evaluate the association between…
–participation in a “Housing First” interventionfor chronically homeless individuals in Seattle,WA with severe alcohol problems, and
–health care use and costs.
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Study Design
•A quasi-experimental design comparingoutcomes in 95 Housing First participants (withdrinking permitted) and 39 wait-list controlparticipants.
•Main outcome measures were use and cost ofservices at 6 months.
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Study Design (cont’d)
•Secondary outcome measures were:
–length of time in housing as a predictor of outcomesfor all participants.
–changes in alcohol use for treated participants.
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Users’ Guide for Economic Analysis ofClinical Practice
•Are the results of the study valid?
•What are the results?
•Will the results help me in caring for mypatients?
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Are the Results of the Study Valid?
•Did the analysis provide a full economiccomparison of health care strategies?
•Were the costs and outcomes properly measuredand valued?
•Was appropriate allowance made foruncertainties in the analysis?
•Are estimates of costs and outcomes related tothe baseline risk in the treatment population?
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Did the analysis provide a full economiccomparison of health care strategies?
•Yes.
–both costs (societal perspective) and outcomes(alcohol use) were compared.
–The costs of 7 services frequently used by the studypopulation (e.g., shelter use, Medicaid-fundedservices) were factored in along with housing costs.
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Were the costs and outcomesproperly measured and valued?
•Analyses were based on itemized cost dataobtained from all agencies that provided servicesto participants during the 6-month study period.
•Data were collected on:
•Alcohol use was based on validated self-reportmeasures.
– jail bookings
– days incarcerated
– shelter and sobering
center use
– Medicaid-funded services
– publicly funded alcohol/drug
detoxification and treatment
– emergency medical services
– hospital-based medical services
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Was appropriate allowance made foruncertainties in the analysis?
•Due to the lack of random assignment,propensity scores were used to balancetreatment groups on important covariablesin analyses.
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Are estimates of costs and outcomesrelated to the baseline risk in thetreatment population?
•Participants were chronically homelessindividuals who
–incurred the highest total costs in 2004 for use ofalcohol-related hospital-emergency visits, sobering,and jail services, or
–were referred by community providers familiar withthe population.
•Housing was offered to participants on a “firstfound, first assigned” basis.
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What Are the Results?
What were the incremental costs andoutcomes of each strategy?
Do incremental costs and outcomes differbetween subgroups?
How much does allowance for uncertaintychange the results?
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What were the incremental costsand outcomes of each strategy?
Median Use and Cost Data Per Person/Per Month
1 year prior tohousing
6 months post-intervention
12 months post-intervention
housed
wait-list
housed
wait-list
housed1
Incidents, no.
Jail days
0.5
0.6
0.0
0.4
0.0
Jail bookings
0.2
0.2
0.0
0.2
0.0
Shelter use
0.5
0.4
0.0
0.1
0.0
Hospital use
0.9
0.7
0.7
0.3
0.3
EMS use
0.4
0.4
0.5
0.3
0.2
Sobering center use
6.1
4.0
0.0
2.1
0.0
Costs, $
Medicaid2
612
345
204
107
122
Hospital use
139
743
0
0
0
EMS use
505
553
512
438
219
Total costs2
4066
3318
1492
1932
958
1Because intervention participants were recruited first, data for wait-list participants were onlyavailable to 6 months. 2Significantly different at baseline for the 2 groups.
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Do incremental costs and outcomesdiffer between subgroups?
•Yes.
–There was a significant difference in costs between the2 groups, with housed participants accruing 53% lessin total costs compared with wait-list participants at 6months.
–Housing First participants cost $2449 less per monththan did wait list participants.
–At 12 months, the 95 housed individuals had reducedtheir total costs by more than $4.0 million comparedwith the year prior to enrollment.
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Do incremental costs and outcomesdiffer between subgroups? (cont’d)
–Housed participants reported substantial declines indrinking despite no requirement to abstain from orreduce drinking to remain in housing.
–Median number of drinks per day dropped from 15.7per day prior to housing to 14.0, 12.5, and 10.6 perday at 6, 9, and 12 months in housing, respectively.Poisson GEE with a linear time covariate showed asimilar trend to the medians, with an approximate 2%decrease per month in daily drinking while participantswere housed (RR, 0.98; 95% CI, 0.96–0.99).
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How much does allowance foruncertainty change the results?
•Cost offsets might be attenuated using a lesssevere sample with less frequent use of publiclyfunded services.
•Although propensity scoring controlled fordifferences in cost of services between groups,and sensitivity analyses using subjects withsimilar backgrounds and baseline use had similarresults, these differences may have impactedoutcomes.
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Will the Results Help Me inCaring for My Patients?
•Are the treatment benefits worth the harmsand costs?
•Could my patients expect similar healthoutcomes?
•Could I expect similar costs?
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Are the treatment benefits worth theharms and costs?
•No harms were noted.
•Costs were lower with the Housing Firstintervention.
•Drinking also declined more in the HousingFirst group.
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Could my patients expect similarhealth outcomes?
•Participants were drawn from a select group ofpatients with very high baseline costs and serviceutilization.
–All were homeless individuals with high use and costsrelated to emergency services, a sobering center, anda large urban jail.
–Similar savings and benefits might not accrue in lessseverely affected people.
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Could I expect similar costs?
•Housing First interventions are not universallyavailable, and capital costs can vary.
•The cost inputs in the select and high service-utilization group were based on communityand social services that are common in largeurban locations and, therefore, should begeneralizable to these settings.