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Presentatie 2e Ronde Africa Do. 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
    • Process evaluation
    • Outcome evaluation
    • Client satisfaction
    • Economic evaluation
  • Basic assumptions
    • 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
    • being imposed
    • threat
    • 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
    • Inadequate resources
    • 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.
  • Measuring Costs
    • 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.
    • Data
    • Different orientation
    • Different context
    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)
    • Step 1
    • 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)
    • Step 2
    • 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
    • Step 3
    • Conversion of selected indices into monetary units
    • the main goal in this stage is to translate every unit in monetary value
            • Economic expenditures
            • Health efforts
            • Days of abstinence
            • Days of employment
            • Decrease of crime activities
    Methodology (economization)
  • Methodology (analogistic phase)
    • Step 4
    • 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
          • Crime reduction
          • 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
        • Personnel
        • Supplies and materials
        • Contracted services
        • 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 )
    • Composite scores
    • automatically based on questions about the present that are subject to change
    • Severity ratings
    • 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
    • Measurement unit
    • 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 )