Presentatie 2e Ronde Africa Do.Presentation Transcript
Economic Evaluation of Substance Abuse Treatments: Aspects, Implications, Challenges Gerasimos Papanastasatos , PhD and Petros Triantos MSc KETHEA Research D epartment Therapy Center For Dependent Individuals (KETHEA) Athens, GREECE
Evaluation: a meaning to define
… systematic data collection in order to provide answers in questions referring to a certain program /intervention witch can be used to assess and to support planning
… an attitude of continually questioning and gaining information
… with only scarce resources for treatment , duplication and inefficiency in the delivery of services cannot be tolerated
… the systematic collection of information about activities, characteristics and outcomes of program to make judgments about program, improve program effectiveness and impose decisions about future program development
( Patton, 1997; WHO, 2000;DHHS, 2005)
Systematic evaluation of substance abuse program includes
Clients needs and characteristics evaluation
Treatment is effective and therapeutic community works
Resources appears not unlimited
The world is changing (beliefs, values, priorities)
We never will have all we need. Expectation will always exceed capacity ... This service must always be changing, growing and improving, it must always appear inadequate.
(Aneurin Bevin, 1948)
Evaluation: Common views
out of our system
from which we can’t gain anything
“ Flossing Your teeth” (You hate to do it but you know it should be done) “ Doing your taxes when you know you won’t get a refund” (Something to post off until the last possible moment) “ Doing a stage performance and having your clothes fall off” (Submitting to the risk of public exposure)
The skepticism even with good intentions
why bother to evaluate?
what’s there for me or my program to gain?
in what does consist the threat in evaluation process?
who can answer better (than us) if what we are doing is well done?
why my persuasion, belief or even certainty is not enough?
Pragmatist –and maybe distressing – answers
Increasing number of services leads to a need for accurate monitoring
Rationalization in distribution
Increase in service quality
Design and planning tool
“ Our aim is to build a government that works and would be able to document and justify citizens’ investment in this work”
VP’s Gore committee on governmental excellence plan (1993)
“ In order to have specific indications on the pros and cons of the ongoing interventions in the EU therapeutic programs, evaluation should be a major and indispensable part of European policy in the drug addiction field . ”
EU Strategic Plan for Drugs 2005-2012
“ Our view is based on the idea that every Public Health System should be organized and consist of accurate management systems and in the best possible management of the resources available. State financing should be rationalized in order to maximize the social investment in drug addiction therapy
Greek Health Ministry Strategic Plan for drugs 2008-2012 (Chapter 4)
The necessity for economic evaluation institutional context
Economic evaluation provides a powerful tool for the continuous quality improvement of drug addiction therapy
It supports objective methods and has been proven to be an important strategic planning tool
Provides accurate data to sponsors which proved to be an essential tool of the New Public Management
It allows comparison between organizations, useful to sponsors and society in order to make strategic decisions
The necessity for economic evaluation fuctional persuasiveness
Defining economic evaluation
Comparative analysis of alternative ways of action based on both their costs and impacts
Drummond et. al, 1987
Two big questions remain open
Effective substance abuse treatment investment with clear focus and
Rationalization in health care resources
Drug Abuse Treatment Core Components and Comprehensive Services Medical Mental Health Vocational Educational Legal AIDS / HIV Risks Financial Housing & Transportation Child Care Family Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 ( PAB ) core treatment Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmaco-therapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment Plans
What does Economic Evaluation Involve?
Health effects, for example, cases found, cases prevented, lives saved.
Economic benefits that can be measured
in direct benefits (savings in health care costs because the programme increases person’s health),
indirect benefits (individuals are able to return to work), and
intangible benefits (monetary value of the reduction in pain and suffering).
Value of the health improvement itself to the patient, family and society, regardless of the economic consequences.
Economic evaluation focus on economic or opportunity cost and not the accounting cost.
Opportunity cost denotes the payment required to keep the resources in its present use (and not in any other use)
Accounting cost is based on actual expenditures and standard depreciation schedules and may be less representative of the opportunity cost
Measuring Costs: defining opportunity cost
Direct (staff wages),
Indirect (for example, loss of income due to illness),
Capital costs (investments in buildings),
NHS costs (staff, hotel services, drugs),
Patient and family costs (for example, travel),
Costs to the rest of society (for example, health education).
Types of economic evaluation Cost-Effectiveness Mostly used until 1980 in medicine. It is based in the comparison between cost and ONE effectiveness index ( i.e. life years gained as a result of a treatment ) Cost-Utility Similar to Cost-effectiveness focus is on only one effectiveness index. Introducing the quality factor ( i.e. quality life years gained /QALY as a result of a treatment) Cost- Benefit Conversion of selected effectiveness indexes into monetary units and comparison to opportunity cost for the operation of a treatment setting.
Research Experience (restrains)
Cost-Benefit is the most commonly used method in substance abuse treatment programs
Major part of experience steams from the US and the United Kingdom
Relatively new field. Not much literature
Use of established and fully assessed tools for effectiveness measurement (ASI, EuropASI)
Development of new tools for cost assessment ( DATCAP)
Research Experience (steps done)
Economic Evaluation: literature Review in US therapeutic programs
Major benefit from the decrease of criminal behavior (50% of aggregate benefit )
Lower benefit from the reconnection with employment (13% of aggregate benefit )
Even lower benefit from saving resources due to minor usage of health services
(Mc Allister &French, 2002)
Cost analysis using specific tools.
Main goal of this step is to record the Aggregate (Economic/opportunity) and not only the Logistic cost
Why opportunity cost?
Use of standardized tool
Methodology (cost monitoring – logistic phase)
Methodology (effectiveness measurement)
Measurement of effectiveness using severity indexes in specific areas in different time periods.
Main goal of this step is to record the benefit from the therapeutic intervention.
Most commonly used indices :
Absence from criminal activities
Cost of using health services
Income from employment
Conversion of selected indices into monetary units
the main goal in this stage is to translate every unit in monetary value
Days of abstinence
Days of employment
Decrease of crime activities
Methodology (analogistic phase)
Cost/Benefit ratio or/and Net Benefit (Benefit minus Cost)
The goal in this final phase is to understand how much is gained for each monetary unit invested in each field there are expectations
National health indexes
Police and justice system costs reductions
Taxes income increase
Procedures’ stages summary logistic outcome economization analogistic DATCAP ASI / EuropASI Translation in monetary units Conclusions
Cost Analysis Tool: DATCAP
It is an onsite data-collection instrument that estimates the economic cost of treatment services
It is structured along standard categories such as
Supplies and materials
Buildings and facilities
The essence of DATCAP is the concept of economic or opportunity cost.
(French 2001a, 2001b, www.DATCAP.com)
Effectiveness Analysis Tool: ASI and EuropASI
Structured questionnaire investigating 7 problem areas
(General Information, General Health, Employment and Educational Background, Drugs and Alcohol use, Family History, Legal and Mental Health status)
2 summary indices for each area
(Both indices combine quantitative information and client ’ s subjective ratings of the current importance of the problems and the need for treatment )
automatically based on questions about the present that are subject to change
Existence and severity of lifetime problems together with client’s present condition and need for treatment
(McLellan, Kushner, Metzger, et al.1992; McLellan et al.1980)
Vulnerable in methodological constrains ( i.e. male over representation )
Absence of specific and widely accepted terminology ( i.e. therapeutic intervention , effectiveness )
The structure of therapeutic intervention does not allow conversion of some effectiveness indexes into monetary units
The skepticism continues Critics on Economic Evaluation Methodology (Mc Allister &French, 2002)
Common views, definitions, goals
Detailed record of services, procedures, methods
Benefits steamed from recording of services
Definition on beneficiaries
Definition on the sample size and content
Problems in conversion of indices
Subjects for further examination ( Reuter 1999, French, Salome et al. 2000 )