Cost analysis in implementation studies of evidence-based practices for mental health and substance use disorders: a systematic review

Abstract

Background This study is a systematic literature review of cost analyses conducted within implementation studies on behavioral health services. Cost analysis of implementing evidence-based practices (EBP) has become important within implementation science and is critical for bridging the research to practice gap to improve access to quality healthcare services. Costing studies in this area are rare but necessary since cost can be a barrier to implementation and sustainment of EBP. Methods We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and applied the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Key search terms included: (1) economics, (2) implementation, (3) EBP, and (4) behavioral health. Terms were searched within article title and abstracts in: EconLit, SocINDEX, Medline, and PsychINFO. A total of 464 abstracts were screened independently by two authors and reduced to 37 articles using inclusion and exclusion criteria. After a full-text review, 18 articles were included. Results Findings were used to classify costs into direct implementation, direct services, and indirect implementation. While all studies included phases of implementation as part of their design, only five studies examined resources across multiple phases of an implementation framework. Most studies reported direct service costs associated with adopting a new practice, usually summarized as total EBP cost, cost per client, cost per clinician, and/or cost per agency. For studies with detailed analysis, there were eleven direct cost categories represented. For five studies that reported costs per child served, direct implementation costs varied from $886 to $9470 per child, while indirect implementation costs ranged from $897 to $3805 per child. Conclusions This is the first systematic literature review to examine costs of implementing EBP in behavioral healthcare settings. Since 2000, 18 studies were identified that included a cost analysis. Given a wide variation in the study designs and economic methods, comparison across studies was challenging, which is a major limitation in the field, as it becomes difficult to replicate studies or to estimate future costs to inform policy decisions related to budgeting. We recommend future economic implementation studies to consider standard economic costing methods capturing costs across implementation framework phases to support comparisons and replicability.

Implementation science issues in understanding, collecting, and using cost estimates: a multi-stakeholder perspective

“…Developing reporting guides can aid in identifying areas of cooperation and conflict and in applying theories from economics, behavioral economics, and decision sciences, to address economic barriers within and across stakeholder groups. This is consistent with conclusions from a recent systematic review whereby researchers recommended standardized guidelines around costing perspectives, instrumentation, and reporting as critical next steps to advance the field [ 9 ]. At the individual participant level, for example, the priority may be to improve their health outcomes, satisfaction, or quality of life; in contrast, at the organizational level, the priority is often staying within budget.…”

“…There has been a recent surge of publications related to the collection of costs in implementation science [9,14,31,36], and emerging consensus regarding the importance of economic influences on implementation outcomes (see other articles in this collection). This paper contributes to economic evaluation by discussing a range of issues involved in considering implementation costs in the real-world from the perspective of multiple stakeholders to advance both the science and practice of implementation.…”

“…Understanding cost and benefit implications and perceived value from various stakeholder perspectives, from end-users to delivery staff to the larger system/environment, and what implementation cost information is most beneficial for each of these groups is critical in advancing economic analyses in implementation research. Stakeholder engagement across levels is especially critical when organizations face overwhelming competing demands and scarce resources and/or stakeholders experience disproportionate costs related to implementation, such as opportunity costs for frontline staff engaging in implementation efforts in lieu of billable patient care [ 9 ]. Assessing the perspective of different stakeholders has the potential to uncover conflicting priorities on costs and other economic issues.…”

“…In this way, the organizations would know that they either need to hire more nurses or pay overtime to keep the nurses on board with the intervention implementation. Tools to support standardization of multi-level costing approaches and reporting will also aid in building the business case for implementation science; this will facilitate harmonizing data across implementation studies and provide needed empirical evidence for the costs and benefits of implementation efforts for all stakeholders [9]. This illustration above demonstrates some of the complexities involved in data collection and reporting the results of economic analyses in implementation research.…”

“…Costs across these different levels have a notable impact on implementation success and sustainment. A recent systematic review of implementation costing methods by Bowser et al reflects this reality; researchers found a wide range of costing perspectives represented in implementation research, including organizational, facility, provider, and societal perspectives [ 9 ]. Yet, traditional economic evaluation does not always account for costs across these levels.…”