1. www.alcoholandhealth.org1 Journal Club Alcohol, Other Drugs, and Health: Current Evidence May–June 2009

2. www.alcoholandhealth.org2 Featured Article Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems Larimer ME, et al. JAMA. 2009;301(13):1349–1357.

3. www.alcoholandhealth.org3 Study Objective To evaluate the association between… –participation in a “Housing First” intervention for chronically homeless individuals in Seattle, WA with severe alcohol problems, and –health care use and costs.

4. www.alcoholandhealth.org4 Study Design A quasi-experimental design comparing outcomes in 95 Housing First participants (with drinking permitted) and 39 wait-list control participants. Main outcome measures were use and cost of services at 6 months.

5. www.alcoholandhealth.org5 Study Design (cont’d) Secondary outcome measures were: –length of time in housing as a predictor of outcomes for all participants. –changes in alcohol use for treated participants.

6. www.alcoholandhealth.org6 Users’ Guide for Economic Analysis of Clinical Practice Are the results of the study valid? What are the results? Will the results help me in caring for my patients?

7. www.alcoholandhealth.org7 Are the Results of the Study Valid? Did the analysis provide a full economic comparison of health care strategies? Were the costs and outcomes properly measured and valued? Was appropriate allowance made for uncertainties in the analysis? Are estimates of costs and outcomes related to the baseline risk in the treatment population?

8. www.alcoholandhealth.org8 Did the analysis provide a full economic comparison of health care strategies? Yes. –both costs (societal perspective) and outcomes (alcohol use) were compared. –The costs of 7 services frequently used by the study population (e.g., shelter use, Medicaid-funded services) were factored in along with housing costs.

9. www.alcoholandhealth.org9 Were the costs and outcomes properly measured and valued? Analyses were based on itemized cost data obtained from all agencies that provided services to participants during the 6-month study period. Data were collected on: Alcohol use was based on validated self-report measures. – jail bookings – days incarcerated – shelter and sobering center use – Medicaid-funded services – publicly funded alcohol/drug detoxification and treatment – emergency medical services – hospital-based medical services

10. www.alcoholandhealth.org10 Was appropriate allowance made for uncertainties in the analysis? Due to the lack of random assignment, propensity scores were used to balance treatment groups on important covariables in analyses.

11. www.alcoholandhealth.org11 Are estimates of costs and outcomes related to the baseline risk in the treatment population? Participants were chronically homeless individuals who –incurred the highest total costs in 2004 for use of alcohol-related hospital-emergency visits, sobering, and jail services, or –were referred by community providers familiar with the population. Housing was offered to participants on a “first found, first assigned” basis.

12. www.alcoholandhealth.org12 What Are the Results?  What were the incremental costs and outcomes of each strategy?  Do incremental costs and outcomes differ between subgroups?  How much does allowance for uncertainty change the results?

13. 13 What were the incremental costs and outcomes of each strategy? Median Use and Cost Data Per Person/Per Month 1 year prior to housing 6 months post- intervention 12 months post- intervention housedwait-listhousedwait-listhoused 1 Incidents, no. Jail days0.50.60.00.40.0 Jail bookings0.2 0.00.20.0 Shelter use0.50.40.00.10.0 Hospital use0.90.7 0.3 EMS use0.4 0.50.30.2 Sobering center use6.14.00.02.10.0 Costs, $ Medicaid 2 612345204107122 Hospital use139743000 EMS use505553512438219 Total costs 2 4066331814921932958 1 Because intervention participants were recruited first, data for wait-list participants were only available to 6 months. 2 Significantly different at baseline for the 2 groups.

14. www.alcoholandhealth.org14 Do incremental costs and outcomes differ between subgroups? Yes. –There was a significant difference in costs between the 2 groups, with housed participants accruing 53% less in total costs compared with wait-list participants at 6 months. –Housing First participants cost $2449 less per month than did wait list participants. –At 12 months, the 95 housed individuals had reduced their total costs by more than $4.0 million compared with the year prior to enrollment.

15. www.alcoholandhealth.org15 Do incremental costs and outcomes differ between subgroups? (cont’d) –Housed participants reported substantial declines in drinking despite no requirement to abstain from or reduce drinking to remain in housing. –Median number of drinks per day dropped from 15.7 per day prior to housing to 14.0, 12.5, and 10.6 per day at 6, 9, and 12 months in housing, respectively. Poisson GEE with a linear time covariate showed a similar trend to the medians, with an approximate 2% decrease per month in daily drinking while participants were housed (RR, 0.98; 95% CI, 0.96–0.99).

16. www.alcoholandhealth.org16 How much does allowance for uncertainty change the results? Cost offsets might be attenuated using a less severe sample with less frequent use of publicly funded services. Although propensity scoring controlled for differences in cost of services between groups, and sensitivity analyses using subjects with similar backgrounds and baseline use had similar results, these differences may have impacted outcomes.

17. www.alcoholandhealth.org17 Will the Results Help Me in Caring for My Patients? Are the treatment benefits worth the harms and costs? Could my patients expect similar health outcomes? Could I expect similar costs?

18. www.alcoholandhealth.org18 Are the treatment benefits worth the harms and costs? No harms were noted. Costs were lower with the Housing First intervention. Drinking also declined more in the Housing First group.

19. www.alcoholandhealth.org19 Could my patients expect similar health outcomes? Participants were drawn from a select group of patients with very high baseline costs and service utilization. –All were homeless individuals with high use and costs related to emergency services, a sobering center, and a large urban jail. –Similar savings and benefits might not accrue in less severely affected people.

20. www.alcoholandhealth.org20 Could I expect similar costs? Housing First interventions are not universally available, and capital costs can vary. The cost inputs in the select and high service- utilization group were based on community and social services that are common in large urban locations and, therefore, should be generalizable to these settings.