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Benefits and costs associated with mutual-help community-based recovery homes: the Oxford House model |
Lo Sasso AT, Byro E, Jason LA, Ferrari JR, Olson B |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study evaluated the costs and benefits of a self-run, self-supporting recovery home; the Oxford House, for people who abused alcohol, drugs, or both. The authors concluded that from a societal net benefit view, Oxford House compared favourably with usual care. The study was well reported, but the type of social care intervention created uncertainty in the outcomes. Significant cost assumptions had to be made, given insufficient data from the Oxford House trial, but these were generally conservative. Type of economic evaluation Cost-effectiveness analysis Study objective This study evaluated the costs and benefits of a self-run, self-supporting recovery home; the Oxford House, for people who abused alcohol, drugs, or both. Interventions The Oxford House was compared with usual care. The Oxford House was a democratic, moderately sized, single-gender, family home that provided a social network to support abstinence from alcohol and drugs. Residents were expected to pay rent, abstain from drugs and alcohol, and avoid disruptive behaviour. The house was self-policing; anyone who violated the rules was evicted. Residents were free to seek treatment as they desired, while receiving the support of their peers. Methods Analytical approach:The economic evaluation was conducted using data from a randomised controlled trial of 129 people (see Other Publications of Related Interest). The study and follow-up assessments occurred between 2002 and 2005. Participants were interviewed every six months for two years. The authors stated that a societal perspective was taken. Effectiveness data:The participants were adults who had received substance abuse treatment and were randomly assigned to the house or usual care. Effectiveness was measured by patient-completed questionnaire, and confirmed by someone in each patient's support network. The primary measures of effectiveness were self-reported treatment enrolment, substance abuse, employment, involvement in illegal activity, and incarceration at two-year follow-up. Treatment enrolment was measured by the number of 12-step meetings, in-patient or residential treatment programmes, and out-patient treatment programmes that the participant had been enrolled in for the six months up to the follow-up. Employment was assessed at the time of follow-up, along with the net income from legal employment in the 30 days before follow-up. Illegal activity was measured by the number of days in the 30 days before follow-up. Incarceration was assessed at the two-year follow-up. Missing values were imputed using predictive mean matching. Regression was used to calculate the mean using values from patients with similar characteristics to the patient with a missing value. Over 90% of participants completed the questionnaires. Monetary benefit and utility valuations:Not relevant. Measure of benefit:The measures of benefit were self-reported treatment enrolment, substance abuse, employment, involvement in illegal activity, and incarceration at two-year follow-up. Cost data:The cost items were the cost per resident in the Oxford House, the cost of the treatment programmes, lost wages while attending treatment programmes, the costs to the patient from drug and alcohol consumption, the costs to society from illegal activities, and the costs of incarceration. These were based on the trial, published studies, or from Illinois hospitals or reports. Complete cost data were not available from the trial, so it was assumed that patients attended 20 days of in-patient and out-patient treatment, the hourly wage was the Illinois minimum wage, each session lasted eight hours, and illegal activities occurred once a day. The cost of lost wages was used for the 12-step meetings. All costs were in US $. Analysis of uncertainty:Confidence intervals for the costs and benefits were estimated by running 1,000 bootstrap simulations, for the primary analysis and sensitivity analyses. The results were presented with Student's t test statistics for the differences between groups. The sensitivity analyses assumed half the incarceration costs, half the lost wages for in-patient and out-patient treatment, and half the criminal activity costs. Results Oxford House residents tended to use fewer in-patient services and more out-patient services, and enrolled in 12-step programmes to a greater extent. They tended to have higher rates of employment, fewer days of illegal activity, and lower drug and alcohol consumption. After enrolment, earnings for Oxford House residents were consistently about twice those of usual care participants over the two years. The authors reported the mean cost per person for the programmes (including Oxford House) as costs, and the mean savings per person from participant income, minus illegal activity, alcohol and drug use, and incarceration costs as benefits. The costs for the Oxford House group were $25,158.89 and the benefits were $9,149.41. The benefits were subtracted from costs, leaving a total of $16,009.47. The costs for usual care participants were $21,949.64 and the benefits were -$23,081.83, leaving a total cost of $45,031.47. On average, the Oxford House intervention was $29,022.00 (95% CI 12,292 to 45,752) less expensive. The sensitivity analyses indicated that the results were not sensitive to halving the incarceration costs, and to halving lost wages. Cutting the cost of illegal activity reduced the total cost difference, between the two programmes, to $18,616 (95% CI 7,170 to 30,062) over two years. Authors' conclusions The authors concluded that from a societal net benefit view, Oxford House compared favourably with usual care. CRD commentary Interventions:The Oxford House intervention was well described, and appears to have been appropriate. The details of usual care were not given, which makes an assessment of the similarity of usual care, to that provided in other locations, impossible; the results may not generalise beyond the US setting. Effectiveness/benefits:As acknowledged by the authors, the study depended on responses from the participants for their rates of drug use and criminal activity. This could have led to under-reporting from Oxford House residents, to avoid eviction, which would bias the results. Incarceration was only measured at 24 months. It is possible that participants were incarcerated during the study, but not at 24 months. It was not clear what effect this might have had, and why the data were not collected at other time points. It was not clear why the patient data were not linked to the criminal justice system for incarcerations, which would have provided accurate qualitative data on the type of offence, as well as identifying any illegal activities. Costs:The costs were generally well reported with justifications and acknowledgements of the limitations. The authors acknowledged that the costs were based on activity reported by the participants, with potential for bias. They were not from the original trial, but were from external sources, with a few assumptions. They were also from different years, and there was no indication that they were adjusted to the same year. An assumption was made that there was just one illegal activity per day; this cost was varied in the sensitivity analysis. Not all costs relevant to a societal perspective were measured. Any costs to government aid programmes and charitable organisations were omitted. Analysis and results:The results were generally clearly reported. Appropriate methods were used to impute missing values, and different methods of handling missing data were discussed. The Student's t test was used to assess differences, rather than statistical significance or probabilities. The analyses of uncertainty were clearly presented. The authors indicated that their assumption of one criminal activity per day was conservative; illegal activity costs were halved in the sensitivity analysis. Some estimates were considered to be conservative for the Oxford House intervention, so the sensitivity analyses made less conservative assumptions. The analysis was concerned only with the costs; the measures of benefit were those resource use categories identified by the authors. The authors conducted a bootstrapping exercise on these costs to generate 95% confidence intervals. They appropriately acknowledged the limitations of their data, including the small sample in the trial. Concluding remarks:The study was well reported. The nature of the social care intervention resulted in uncertainty in the outcomes. Significant cost assumptions had to be made, given insufficient data from the Oxford House trial, but these were generally conservative. Funding Supported by the National Institute on Alcohol Abuse and Alcoholism; the National Institute on Drug Abuse; and the National Center on Minority Health and Health Disparities, USA. Bibliographic details Lo Sasso AT, Byro E, Jason LA, Ferrari JR, Olson B. Benefits and costs associated with mutual-help community-based recovery homes: the Oxford House model. Evaluation and Program Planning 2012; 35(1): 47-53 Other publications of related interest Jason LA, Olson BD, Ferrari JR, Majer JM, Alvarez J, Stout J. An examination of main and interactive effects of substance abuse recovery. Addiction 2007; 102: 1114-1121. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Community Health Services /organization & Confidence Intervals; Continuity of Patient Care /economics /organization & Cost Savings; Cost-Benefit Analysis; Female; Group Homes /economics /organization & Humans; Length of Stay /economics; Sensitivity and Specificity; Social Environment; Substance Abuse Treatment Centers /economics /organization & Substance-Related Disorders /economics /therapy; Surveys and Questionnaires; United States; Young Adult; administration; administration; administration; administration AccessionNumber 22012010137 Date bibliographic record published 12/06/2012 Date abstract record published 05/09/2013 |
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