The national cost of suicides and suicide attempts in the United States in 2013 was $58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under‐reporting increased the total cost to $93.5 billion or $298 per capita, 2.1–2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit–cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.

BackgroundPay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs).MethodsBuilding on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes.ResultsAt trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191–$16,171).ConclusionThis study provides experimental evidence supporting P4P as a cost-effective implementation strategy.Trial registrationNCT01016704.

Aims To estimate the incremental cost, cost-effectiveness, and benefit-cost ratio of incorporating a significant other (SO) into motivational intervention for alcohol misuse. Design We obtained economic data from the one year with the intervention in full operation for patients in a recent randomized trial. Setting The underlying trial took place at a major urban hospital in the USA. Participants The trial randomized 406 (68.7% male) eligible hazardous drinkers (196 during the economic study) admitted to the emergency department or trauma unit. Intervention The motivational interview condition consisted of one in-person session featuring personalized normative feedback. The significant other motivational interview condition comprised one joint session with the participant and SO in which the SO’s perspective and support were elicited. Measurements We ascertained activities across 445 representative time segments through work sampling (including staff idle time), calculated the incremental cost in per patient of incorporating an SO, expressed the results in 2014 U.S. dollars, incorporated quality and mortality effects from a closely related trial, and derived the cost per quality-adjusted life year (QALY) gained. Findings From a health system perspective, the incremental cost per patient of adding an SO was $341 [95% confidence interval (CI): $244 to $438]. The incremental cost per year per hazardous drinker averted was $3,623 (CI: $1,777 to $22,709), the cost per QALY gained $32,200 (CI: $15,800 to $201,700), and the benefit-cost ratio was 4.73 (95% CI: 0.75 to 9.66). If adding an SO into the intervention strategy were concentrated during the hours with highest risk or in the trauma unit, it would become even more cost-beneficial. Conclusions Using criteria established by the World Health Organization (cost-effectiveness below the country’s GDP per capita), incorporating a significant other into a patient’s motivational intervention for alcohol misuse is highly cost effective.

Although several costing instruments have been previously developed, few have been validated or applied systematically to the delivery of evidence-based practices (EBPs). Using data collected from 26 organizations implementing the same EBP, this paper examined the reliability, validity, and applicability of the brief Treatment Cost Analysis Tool (TCAT-Lite). The TCAT-Lite demonstrated good reliability—correlations between replications averaged 0.61. Validity also was high, with correlation of treated episodes per $100,000 between the TCAT-Lite and independent data of 0.57. In terms of applicability, cost calculations found that if all organizations had operated at optimal scale (124 client episodes per year), existing funds could have supported 64% more clients.

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