Alexander J. Cowell

The Cost-Effectiveness of Criminal Justice Diversion Programs for People with Serious Mental Illness Co-Occurring with Substance Abuse Four Case Studies

Many cities, counties, and states have criminal justice diversion or jail diversion programs, in which those committing low-level offenses and who have mental illness or substance abuse are diverted from the criminal justice system into treatment. However, there is little existing evidence on the cost and cost-effectiveness of such programs. This article presents the first such estimates for four sites. Estimates of the impact of diversion on both costs and effectiveness varied across the sites. This variation likely reflects heterogeneity in the structure and implementation of the programs across the sites. Directions for future research are suggested.

A systematic review and meta-analysis of health care utilization outcomes in alcohol screening and brief intervention trials

Objective:This systematic review and meta-analysis examines the effect of screening and brief intervention (SBI) on outpatient, emergency department (ED), and inpatient health care utilization outcomes. Much of the current literature speculates that SBI provides cost savings through reduced health care utilization, but no systematic review or meta-analysis examines this assertion. Method:Publications were abstracted from online journal collections and targeted Web searches. The systematic review included any publications that examined the association between SBI and health care utilization. Each publication was rated independently by 2 study authors and assigned a consensus methodological score. The meta-analysis focused on those studies examined in the systematic review, but it excluded publications that had incomplete data, low methodological quality, or a cluster-randomized design. Results:Systematic review results suggest that SBI has little to no effect on inpatient or outpatient health care utilization, but it may have a small, negative effect on ED utilization. A random effects meta-analysis using the Hedges method confirms the ED result for SBI delivered across settings (standardized mean difference = −0.06, I2 = 13.9%) but does not achieve statistical significance (confidence interval: −0.15, 0.03). Conclusions:SBI may reduce overall health care costs, but more studies are needed. Current evidence is inconclusive for SBI delivered in ED and non-ED hospital settings. Future studies of SBI and health care utilization should report the estimated effects and variance, regardless of the effect size or statistical significance.

Assessing the impact of the national ‘truth’ antismoking campaign on beliefs, attitudes, and intent to smoke by race/ethnicity

Objective. To examine racial/ethnic differences in the association between exposure to the ‘truth’ antismoking campaign and youths beliefs and attitudes about cigarette companies and their intent to smoke. Design. The data are for 31,758 youth aged 12–17 from seven waves of the Legacy Media Tracking Survey (LMTS), conducted in the USA between December 1999 and July 2003. LMTS was designed to include sufficient proportions of African Americans (n=4631), Hispanics (n=6311), and Asians (n=2469) to assess tobacco countermarketing campaign associations in individual racial/ethnic groups. Separate belief and attitude indices were created. An indicator for the respondent not intending to smoke during the next year was created for non-smokers only, and models were estimated separately by ever-/never-smoking status. Results. Exposure to the truth campaign was positively associated with increased antitobacco beliefs and attitudes among youth overall. When analyzed by race/ethnicity, this association was statistically significant for white and African American youth. An examination of the individual belief and attitude items that composed the measurement indices suggests that different messages appealed to youth based on their race/ethnicity. Among never smokers, those exposed to the truth campaign had significantly higher odds of not intending to smoke. When analyzed separately by race/ethnicity, the estimates for African American youth were statistically significant and the estimates for white and Hispanic youth approached significance. Among ever smokers and across all racial/ethnic groups, those exposed to the truth campaign had significantly higher odds of not intending to smoke, and every racial/ethnic group had an odds ratio greater than one that was also statistically significant. Conclusions. The findings suggest that the individual items comprising the indices may be less meaningful for some non-white groups of youth. Analyses of intention to smoke indicated that, among those who had never smoked, there were greater odds of not intending to smoke when examining all youth together without stratifying by race/ethnicity; however, a statistically significant effect was found only for the African American group when examining the effect by race/ethnicity. Among those who had ever smoked, a statistically significant effect was found for most racial/ethnic groups. This is a rich area for further research and is potentially critical to the success of future efforts to reach youth through behavior change messages.

Incapacitated Sexual Violence Involving Alcohol Among College Women: The Impact of a Brief Drinking Intervention

This study assessed the impact of a motiv ational interv iewing (MI) brief alcohol interv ention and prior v ictimization on alcohol-inv olv ed sexual v ictimization experiences. First-year female college students (N = 229) were randomly assigned to an interv ention condition: MI, MI with feedback (MIFB), feedback (FB), and assessment only (AO). Findings indicate reduced alcohol use for all conditions and v iolence for MIFB, with interactions for prior v ictimization. The mechanism of change for reduced v ictimization was not reductions in alcohol use and mechanisms for this effectiv eness remain somewhat conv oluted. Tailoring of brief interv entions addressing alcohol use and sexual v iolence, particularly for women with prior v ictimization, is critical.

National Estimates of Behavioral Health Conditions and Their Treatment Among Adults Newly Insured Under the ACA

OBJECTIVE Approximately 25 million individuals are projected to gain insurance as a result of the Affordable Care Act (ACA). This study estimated the prevalence of behavioral health conditions and their treatment among individuals likely to gain coverage. METHODS Pooled 2008-2011 National Survey on Drug Use and Health data for adults (ages 18-64) were used. Estimates were created for all adults, current Medicaid beneficiaries, and uninsured adults with incomes that might make them eligible for the Medicaid expansion or tax credits for use in the health insurance marketplace. RESULTS Individuals who may gain insurance under the ACA had lower rates of serious mental illnesses (5.4%, Medicaid expansion; 4.7%, marketplace) compared with current Medicaid beneficiaries (9.6%). They had higher rates of substance use disorders (13.6%, Medicaid expansion; 14.3%, marketplace) compared with Medicaid recipients (11.9%). CONCLUSIONS There is significant need for behavioral health treatment among individuals who may gain insurance under the ACA.

Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy

ISSUES Many policy review articles have concluded that alcohol screening and brief intervention (SBI) is both cost-effective and cost-beneficial. Yet a recent cost-effectiveness review for the United Kingdoms National Institute for Health and Clinical Excellence suggests that these conclusions may be premature. APPROACH This article offers a brief synopsis of the various types of economic analyses that may be applied to SBI, including cost analysis, cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis and other types of economic evaluation. A brief overview of methodological issues is provided, and examples from the SBI evaluation literature are provided. KEY FINDINGS, IMPLICATIONS AND CONCLUSIONS The current evidence base is insufficient to draw firm conclusions about the cost, cost-effectiveness or cost-benefit of SBI and about the impact of SBI on health-care utilisation.[Cowell AJ, Bray JW, Mills MJ, Hinde JM. Conducting economic evaluations of screening and brief intervention for hazardous drinking: Methods and evidence to date for informing policy.

Deriving Service Costs for a Clubhouse Psychosocial Rehabilitation Program

This article (a) discusses “function cost,” a concept to estimate costs where consumers are involved both in delivery and receipt of services; (b) develops a methodology for costing service units for psychosocial rehabilitation clubhouses; and (c) presents a case study of a clubhouse program. Using function cost to estimate the value of member time leads to costs being on average about 10% higher than when using opportunity cost. Because the case-study clubhouse is typical in key dimensions, the methods used here appear generalizable to other programs and should have utility for other rehabilitation-based services for individuals with mental illness.

Medication Costs to Private Insurers of Diversion of Medications for Attention-Deficit Hyperactivity Disorder

AbstractBackground: The diversion of prescription stimulants for misuse, particularly those used in the treatment of attention-deficit hyperactivity disorder (ADHD), is potentially a significant problem for public health and for healthcare funding and delivery. Most prior research on the diversion of prescription stimulants for misuse, particularly those used in the treatment of ADHD, has focused on the ‘end users’ of diverted medications rather than the suppliers. Furthermore, little is known about the direct costs of diversion for third-party insurance payers in the US. Objectives: The objectives of this study were to estimate the prevalence in the US of people whose private insurance paid costs for ADHD prescriptions that they gave or sold to another person (diversion), and to estimate medication costs of diversion to private insurers. Methods: Estimates are from a cross-sectional survey of respondents from two Internet survey panels targeting individuals aged 18–49 years in the civilian, noninstitutionalized US population, principally for those who filled prescriptions for ADHD medications in the past 30 days that were covered by private health insurance. Analysis weights were post-stratified to control totals from the Current Population Survey and National Health Interview Survey. Weighted prevalence rates and standard errors for diversion are reported, as are the costs of diverted pills using drug prices reported in the 2008 Thomson Reuters RED BOOK™. Sensitivity analyses were conducted that varied the cost assumptions for medications. Results: Among individuals aged 18–49 years whose private insurance paid some costs for ADHD medications in the past 30 days, 16.6% diverted medications from these prescriptions. Men aged 18–49 years for whom private insurance paid some costs of ADHD drugs in the past 30 days were more than twice as likely as their female counterparts to divert medications from these prescriptions (22.5% vs 9.1%; p= 0.03). After a pro-rated co-payment share was subtracted, the estimated value of diverted medications in a 30-day period was

The effect of alternative staff time data collection methods on drug treatment service cost estimates

US8.0 million. Lower- and upper-bound estimates were

Cost to conduct screening, brief intervention, and referral to treatment (SBIRT) in healthcare settings

US6.9 million to