Economic Evaluation of Economic Evaluation of Substance Abuse Treatments: Aspects, Substance Abuse Treatments: Aspects, Implications, Challenges Implications, Challenges 1 Gerasimos Papanastasatos Gerasimos Papanastasatos , PhD and Petros , PhD and Petros Triantos MSc Triantos MSc KETHEA KETHEA Research Research D D epartment epartment Therapy Center For Dependent Individuals Therapy Center For Dependent Individuals (KETHEA) (KETHEA) Athens, GREECE Athens, GREECE
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Economic Evaluation of Economic Evaluation of Substance Abuse Treatments: Aspects, Substance Abuse Treatments: Aspects, Implications, ChallengesImplications, Challenges
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Gerasimos PapanastasatosGerasimos Papanastasatos, PhD and Petros , PhD and Petros Triantos MScTriantos MSc
KETHEAKETHEA Research Research D Departmentepartment Therapy Center For Dependent Individuals (KETHEA)Therapy Center For Dependent Individuals (KETHEA)
Athens, GREECEAthens, GREECE
Evaluation: a meaning to define Evaluation: a meaning to define
……systematic data collection in order to provide answers in systematic data collection in order to provide answers in questions referring to a certain program /intervention questions referring to a certain program /intervention witch can be used to assess and to support planningwitch can be used to assess and to support planning
… … an attitude of continually questioning and gaining an attitude of continually questioning and gaining informationinformation
……with only scarce resources for treatment , duplication and with only scarce resources for treatment , duplication and
inefficiency in the delivery of services cannot be toleratedinefficiency in the delivery of services cannot be tolerated
……the systematic collection of information about activities, the systematic collection of information about activities, characteristics and outcomes of program to make characteristics and outcomes of program to make judgments about program, improve program effectiveness judgments about program, improve program effectiveness and impose decisions about future program development and impose decisions about future program development
• Treatment is effective and therapeutic community worksTreatment is effective and therapeutic community works• Resources appears not unlimited Resources appears not unlimited • The world is changing (beliefs, values, priorities)The world is changing (beliefs, values, priorities)• We never will have all we need. Expectation will always exceed We never will have all we need. Expectation will always exceed
capacity ... This service must always be changing, growing and capacity ... This service must always be changing, growing and improving, it must always appear inadequate.improving, it must always appear inadequate.
(Aneurin Bevin, 1948)(Aneurin Bevin, 1948)
Evaluation: Common views
• out of our systemout of our system• being imposedbeing imposed• threatthreat• from which we can’t gain anythingfrom which we can’t gain anything
““Flossing Your teeth” Flossing Your teeth” (You hate to do it but you know it should be done)(You hate to do it but you know it should be done)
““Doing your taxes when you know you won’t get a Doing your taxes when you know you won’t get a refund” refund” (Something to post off until the last possible moment)(Something to post off until the last possible moment)
““Doing a stage performance and having your clothes fall Doing a stage performance and having your clothes fall off” off” (Submitting to the risk of public exposure)(Submitting to the risk of public exposure)
The skepticism even with good intentions • why bother to evaluate?why bother to evaluate? • what’s there for me or my program to what’s there for me or my program to
gain?gain?• in what does consist the threat in in what does consist the threat in
evaluation process?evaluation process?• who can answer better (than us) if what who can answer better (than us) if what
we are doing is well done?we are doing is well done?• why my persuasion, belief or even why my persuasion, belief or even
certainty is not enough? certainty is not enough?
Pragmatist –and maybe distressing – answers
• Increasing number of services leads to a Increasing number of services leads to a need for accurate monitoringneed for accurate monitoring
• Inadequate resourcesInadequate resources • Rationalization in distributionRationalization in distribution• Increase in service qualityIncrease in service quality• Design and planning toolDesign 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)
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The necessity for economic The necessity for economic evaluation evaluation institutional contextinstitutional 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
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The necessity for economic The necessity for economic evaluationevaluationfuctional persuasivenessfuctional persuasiveness
Comparative analysis of alternative ways Comparative analysis of alternative ways of action based on both their costs and of action based on both their costs and impacts impacts
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Drummond et. al, 1987Drummond et. al, 1987
Two big questions remain open Two big questions remain open
• Effective substance abuse treatment investment Effective substance abuse treatment investment with clear focus and with clear focus and
• Rationalization in health care resourcesRationalization in health care resources
Drug Abuse Treatment Drug Abuse Treatment CoreCore Components Components and and ComprehensiveComprehensive Services Services
What does Economic Evaluation What does Economic Evaluation Involve?Involve?
• Health effects, for example, cases found, Health effects, for example, cases found, cases prevented, lives saved. cases prevented, lives saved.
• Economic benefits that can be measured Economic benefits that can be measured • in directin direct benefits (savings in health care costs because the benefits (savings in health care costs because the
programme programme increases person’sincreases person’s health), health), • indirect benefits (individuals are able to return to work), indirect benefits (individuals are able to return to work),
and and • intangible benefits (monetary value of the reduction in intangible benefits (monetary value of the reduction in
pain and suffering).pain and suffering).
• Value of the health improvement itself to the Value of the health improvement itself to the patient, family and society, regardless of the patient, family and society, regardless of the economic consequences. economic consequences.
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Measuring CostsMeasuring 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
• 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).
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Cost-Effectiveness Mostly used until 1980 in Mostly used until 1980 in medicine. It is based in the medicine. It is based in the comparison between cost and comparison between cost and ONE effectiveness indexONE effectiveness index ((i.e. life years i.e. life years gained as a result of a gained as a result of a treatmenttreatment))
Cost-Utility Similar to Cost-effectiveness Similar to Cost-effectiveness focus is on only one focus is on only one effectiveness index. effectiveness index. Introducing the quality factor Introducing the quality factor ((i.e. quality i.e. quality life years gained /QALY as a life years gained /QALY as a result of a treatment)result of a treatment)
Cost- Benefit Conversion of selected Conversion of selected effectiveness indexes into effectiveness indexes into monetary units and monetary units and comparison to opportunity comparison to opportunity cost for the operation of a cost for the operation of a treatment setting.treatment setting.
Types of economic evaluationTypes of economic evaluation
• Data• Different orientation• Different context
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Research ExperienceResearch Experience(restrains)(restrains)
• Cost-Benefit is the most commonly used method in Cost-Benefit is the most commonly used method in substance abuse treatment programssubstance abuse treatment programs
• Major part of experience steams from the US and Major part of experience steams from the US and the United Kingdomthe United Kingdom
• Relatively new field. Not much literatureRelatively new field. Not much literature• Use of established and fully assessed tools for Use of established and fully assessed tools for
effectiveness measurement (ASI, EuropASI)effectiveness measurement (ASI, EuropASI)• Development of new tools for cost assessmentDevelopment of new tools for cost assessment
((DATCAP)DATCAP)
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Research ExperienceResearch Experience(steps done)(steps done)
Economic Evaluation: literature Economic Evaluation: literature Review in US therapeutic Review in US therapeutic programsprograms
• Major benefit from the decrease of Major benefit from the decrease of criminal behaviorcriminal behavior (50% (50% of aggregate of aggregate benefitbenefit))
• Lower benefit from the reconnection with Lower benefit from the reconnection with employmentemployment (13% (13% of aggregate of aggregate benefitbenefit))
• Even lower benefit from savingEven lower benefit from saving resources resources due to minor usage of health servicesdue to minor usage of health services
Measurement of effectiveness using severity Measurement of effectiveness using severity indexes in specific areas in different time periods. indexes in specific areas in different time periods.
Main goal of this step is to record the benefit Main goal of this step is to record the benefit from the therapeutic intervention.from the therapeutic intervention.
Most commonly used indicesMost commonly used indices::• Absence from criminal activitiesAbsence from criminal activities• Cost of using health servicesCost of using health services• Income from employmentIncome from employment
Step 3Step 3
Conversion of selected indices into monetary unitsConversion of selected indices into monetary units
the main goal in this stage is to translate every unit in the main goal in this stage is to translate every unit in monetary valuemonetary value
• Economic expenditures Economic expenditures • Health efforts Health efforts • Days of abstinenceDays of abstinence• Days of employment Days of employment • Decrease of crime activities Decrease of crime activities
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Methodology(economization)
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Methodology (analogistic phase)Step 4Step 4
Cost/Benefit ratio or/and Net Benefit (Benefit Cost/Benefit ratio or/and Net Benefit (Benefit minus Cost)minus Cost)
The goal in this final phase is to understand The goal in this final phase is to understand how much is gained for each monetary unit how much is gained for each monetary unit invested in each field there are expectationsinvested in each field there are expectations
Crime reduction Crime reduction
National health indexes National health indexes
Police and justice system costs reductions Police and justice system costs reductions
Effectiveness Analysis Tool: ASI Effectiveness Analysis Tool: ASI and EuropASIand 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)(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
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The skepticism continues The skepticism continues Critics on Economic Evaluation Critics on Economic Evaluation MethodologyMethodology
