Is Alcohol Screening, Brief Intervention, and Referral to Treatment More Cost-Effective in the Emergency Department than Primary Care?

Although there are concerns about effective implementation, alcohol screening, brief intervention, and referral to treatment (SBIRT) is recommended in the US by a number of national organizations, including the Substance Abuse and Mental Health Services Administration (SAMHSA). Researchers used data from 9835 participants with positive alcohol screens in the SAMHSA programs to model the cost-effectiveness of alcohol SBIRT delivered in the emergency department (ED) versus primary care (PC). The researchers constructed a decision analytic tree model and used standard methods and a variety of data sources to estimate costs and effectiveness.

• For the ED setting, per patient, SBIRT cost $12.81, decreased social costs by $544.55, and increased utility by 0.013.
• For the PC setting, per patient, SBIRT cost $21.44, decreased social costs by $239.39, and increased utility by 0.008.
• In probabilistic sensitivity analyses, ED was the more cost-effective setting for SBIRT except when the payer is not willing to pay more than $1500 per full utility gained. 

Comments:

This analysis suggests that social costs decrease and health utility increases with SBIRT in both ED and PC settings. However, I am not sure how to interpret the findings of the ED versus PC comparison in regards to clinical and resource allocation decision-making. Although many patients with unhealthy alcohol use are seen in both ED and PC settings, many others are seen in only one or the other over long time frames. From a resource allocation perspective, a more useful analysis would have been to compare alcohol SBIRT to usual care (no SBIRT), separately, in the 2 clinical settings. In addition, the findings assume efficacy of SBIRT in both settings but systematic reviews find consistent evidence for efficacy in PC (at least for hazardous use), but mixed evidence for the ED.

Kevin L. Kraemer, MD, MSc

Reference:

Barbosa C, Cowell A, Bray J, Aldridge A. The cost-effectiveness of alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency and outpatient medical settings. J Subst Abuse Treat. 2015;53:1–8.