1. A Meta Analysis of the Impact of SBI on Healthcare Utilization
Presented by
Jesse M. Hinde
RTI International
Presented at
INEBRIA, Gateshead, UK
October 9, 2009
This research was conducted under NIAAA grant no. R01 AA013925

2. Acknowledgements Co-Authors Funding Jeremy Bray, PhD
Alexander Cowell, PhD
Funding
National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health
Grant R01 AA (PI: Jeremy Bray)
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3. Motivation: Broad Policy Support
Ensuring Solutions.org:
“Every dollar spent on SBI saves nearly four dollars in subsequent health care costs.”
United States Preventative Services Task Force:
“B” recommendation for SBI (some evidence that is reduce health care costs)
U.S. Substance Abuse and Mental Health Services Administration (SAMHSA):
SBI is associated with fewer hospital days and fewer ED visits
SBI cost-benefit and cost-effectiveness demonstrates cost-savings
Pending Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation:
All U.S. Hospitals would have to implement SBI
SBI saves hospitals money
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4. Support from the Literature
D’Onofrio et al., 2002:
Strongly recommends SBI to reduce ED/outpatient visits and hospitalizations after 32 article review
Gentilello et al., 2005:
SBI can potentially save $1.82 billion in health care costs annually
Solberg et al., 2008:
“Screening and brief counseling in primary care was cost-saving from the societal perspective and highly cost-effective from the health-system perspective.”
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5. Weaknesses in the Literature
Systematic reviews and meta-analyses often focus on drinking outcomes, not health care utilization
Whitlock et al. 2004: Only 1 of the 5 RCT studies that included health care measures showed reduced health care utilization
Policy statements are only based on a few source projects (TrEAT) or articles (Gentilello 2004)
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6. Systematic Review Methods
Search strategy:
Targeted electronic journals using online databases
EBSCOhost-PsycArticles;
EBSCSO-host-Psychology & Behavioral Sciences Collection;
Springer Online Journals System;
PubMed Central;
JSTOR Arts and Sciences Collections I and II
Supplemented with GoogleScholar queries
Reviewed references from identified articles, focusing on previous SBI systematic reviews and meta-analyses
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7. Systematic Review Methods cont…
Key words
Screening and brief intervention; alcohol brief intervention; SBI
Health care utilization; health care; cost; effectiveness; cost-effectiveness
Basic inclusion criteria
Used SBI, brief interventions, or motivational interviewing
Randomized controlled trial
Presence of health care utilization outcomes
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8. Article Selection Process
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9. Included Primary Care Studies
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10. Included Emergency Department Studies
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11. Studies Included from Other Settings
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12. Preliminary Meta Analysis
For each intervention and control condition, collected a post-baseline measure of the mean effect, standard deviation and sample N
For each study, there are potentially multiple
Follow-up points
Utilization measures
Intervention arms
Stratified data by setting
ED and primary care
Stata v.10 with random effects
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13. Meta Analysis Specifications
Calculated for both outpatient and inpatient measures
Observations stratified by primary care and emergency department settings
Only included observations for 12-month follow-ups.
Excluded “other” settings.
Excluded incomplete records (e.g. without sample N, mean effect, or standard deviation)
5 total articles (5 Outpatient, 4 Inpatient)
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14. Outpatient Measures
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15. Limitations Small sample size and clustering of articles
Excludes several articles both for and against health care utilization reductions (N=11)
2 articles had no health care data
2 articles were excluded on setting (inpatient only setting)
3 articles did not have sufficient data to perform analyses
4 articles did not have a 12-month follow-up
Project TrEAT was excluded due to incomplete data from the source articles
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16. Preliminary Conclusions
Strong evidence of heterogeneity
Large variation that is not random
Outpatient:
Significant negative effect for primary care setting
Rejected null hypothesis for heterogeneity
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17. Preliminary Conclusions (cont’d)
Inpatient:
No significant effect of the standardized mean differences for both settings
Significant evidence of heterogeneity
Across all settings:
No significant effect of the standardized mean differences
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18. Next Steps Review Score articles
Complete review of literature that we have
Search on other databases
Seek out complete data from authors
Score articles
Score articles by qualitative analysis of studies, based on design (e.g. Vasilaki 2006)
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19. Next Steps (cont’d) Heterogeneity Meta Analysis Methodology
Investigate role of
intervention implementation
setting
Meta Analysis Methodology
Methodology to handle clustering
Meta-regression methods
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20. Outpatient Measures – Model 1
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21. Outpatient Measures – Model 2
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22. Inpatient Measures – Model 1
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23. Inpatient Measures – Model 2
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