Brief interventions to address substance use among patients presenting to emergency departments in resource poor settings: a cost-effectiveness analysis

Abstract

BackgroundThere are limited data describing the cost-effectiveness of brief interventions for substance use in resource-poor settings. Using a patient and provider perspective, this study investigates the cost-effectiveness of a brief motivational interviewing (MI) intervention versus a combined intervention of MI and problem solving therapy (MI-PST) for reducing substance use among patients presenting to emergency departments, in comparison to a control group.MethodsEffectiveness data were extracted from Project STRIVE (Substance use and Trauma InterVention) conducted in South Africa. Patients were randomised to either receive 1 session of MI (n = 113) or MI in addition to four sessions of PST (n = 109) or no intervention [control (n = 110)]. Costs included the direct health care costs associated with the interventions. Patient costs included out of pocket payments incurred accessing the MI-PST intervention. Outcome measures were patients’ scores on the Alcohol, Smoking and Substance Use Involvement Screening Test (ASSIST) and the Centre for Epidemiological Studies Depression Scale (CES-D).ResultsCost per patient was low in all three groups; US$16, US$33 and US$11, and for MI, MI-PST and control respectively. Outcomes were 0.92 (MI), 1.06 (MI-PST) and 0.88 (control) for ASSIST scores; and 0.74 (MI), 1.27 (MI-PST) and 0.53 (control) for CES-D scores. In comparison to the control group, the MI intervention costs an additional US$119 per unit reduction in ASSIST score, (US$20 for CES-D); MI-PST in comparison to MI costs US$131 or US$33 per unit reduction in ASSIST or CES-D scores respectively. The sensitivity analyses showed that increasing the number of patients who screened positive and thus received the intervention could improve the effectiveness and cost-effectiveness of the interventions.ConclusionMI or MI-PST interventions delivered by lay counsellors have the potential to be cost-effective strategies for the reduction of substance use disorder and depressive symptoms among patients presenting at emergency departments in resource poor settings. Given the high economic, social and health care cost of substance use disorders in South Africa, these results suggest that these interventions should be carefully considered for future implementation.Trial registration This study is part of a trial registered with the Pan African Clinical Trial Registry (PACTR201308000591418)

Patient outcomes and experience of a task-shared screening and brief intervention service for problem substance use in South African emergency centres: a mixed methods study

“…The terms community health workers and facility-based counsellors are often used to describe a certain cadre of non-professional healthcare worker who does not have any health qualification but is trained to deliver a specific low-intensity service. This cost-saving approach is particularly attractive in LMIC settings, such as South Africa, for tackling widespread public health issues [ 21 ]. While SBIRT programmes using a task-sharing approach employing nurses or social workers have been found to be effective and acceptable to patients in healthcare settings, few studies have explored patient experiences and the acceptability of community health worker or facility-based counsellor-delivered SBIRT [ 22 – 25 ].…”

Assessment of substance use among injured persons seeking emergency care in Nairobi, Kenya

“…This observed burden in the injured population suggests that the EC venue may be an impactful environment to access and provide care for substance use disorders in Kenya and other similar settings. Furthermore as the EC treatment period has been documented as a setting in which health promotion and readiness to change is present, interventions for substance use may be both feasible and efficacious [33] , [34] , [35] . However, there is an urgent need for research into how to best develop and implement substance use assistance interventions in the EC setting in sub-Saharan Africa.…”

Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review

“…Frequency of treatment over the intervention period ranged from weekly (Chang et al, 2018;Hamdani et al, 2020;Lund et al, 2020) to fortnightly (Patel et al, 2003;Nadkarni et al, 2017;Adewuya et al, 2019;Gureje et al, 2019a). Duration of treatment ranged from a minimum of 4 weeks (brief treatments for AUDs) (Nadkarni et al, 2016;Dwommoh et al, 2018) up to a maximum of 12 months (perinatal depression) (Fuhr et al, 2019). Three studies provided booster sessions, two as part of the treatment programme (Sava et al, 2009;Adewuya et al, 2019) and the other where the booster sessions were modelled in a separate study (Siskind et al, 2008).…”

“…A provider perspective was exclusively applied in 3 of the 18 studies that stated the perspective (Araya et al, 2006;Hamdani et al, 2020;Nakimuli-Mpungu et al, 2020). Nine of the 18 studies that stated the perspective reported both provider and societal perspectives (Nadkarni et al, 2016;Patel et al, 2017;Weobong et al, 2017;Dwommoh et al, 2018;Fuhr et al, 2019;Sikander et al, 2019;Sun et al, 2021). Six studies adopted a societal perspective exclusively (6/18) (Moraes et al, 2010;McBain et al, 2016;Gal á rraga et al, 2017;Chang et al, 2018;Lund et al, 2020;Blackburn et al, 2021) including the two studies reporting CBA results.…”

“…Productivity costs capturing the opportunity costs of an 'individual's time not spent in productive work activity' (Culyer, 2014) were reported across a wide spectrum ranging from the opportunity costs of a patient's time, sometimes including caregiver and guardians' time costs, to the full suite of costs including income and job losses. Of the studies that reported including productivity costs (20/26) (Patel et al, 2003;Sava et al, 2009;Moraes et al, 2010;Buttorff et al, 2012;McBain et al, 2016;Nadkarni et al, 2016;Gal á rraga et al, 2017;Weobong et al, 2017;Chang et al, 2018;Dwommoh et al, 2018;Fuhr et al, 2019;Sikander et al, 2019;Gureje et al, 2019b;Hamdani et al, 2020;Lund et al, 2020;Blackburn et al, 2021;Sun et al, 2021), four reported adopting the Human Capital Approach (Weisbrod, 1961;Johannesson, 1996) to value a patient's time (Weobong et al, 2017;Chang et al, 2018;Fuhr et al, 2019;Sikander et al, 2019). Different daily wage rates based on participants' skill categories were detailed in 5 of the 20 studies (Nadkarni et al, 2016;Weobong et al, 2017;Chang et al, 2018;Fuhr et al, 2019;Sikander et al, 2019), whilst 2 studies allocated the unskilled minimum wage rate to the unemployed in their patient sample (Buttorff et al, 2012;Gal á rraga et al, 2017) (Table S3).…”