Cost of specialized addiction treatment of clients with ... - Springer Link

Popova et al. BMC Public Health 2013, 13:570 http://www.biomedcentral.com/1471-2458/13/570

RESEARCH ARTICLE

Open Access

Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada Svetlana Popova1,2,3,4*, Shannon Lange1,2, Larry Burd5, Karen Urbanoski1,2 and Jürgen Rehm1,2,4,6

Abstract Background: Individuals with Fetal Alcohol Spectrum Disorder (FASD) constitute a special population that may be at particularly high risk for substance use. The purpose of the current study was to estimate the utilization of specialized addiction treatment services (SATS) and the associated cost, as a part of the total cost of health care associated with FASD in Canada. Methods: The current study was a modeling study. Data on SATS by lifetime mental disorder status were obtained from the Drug and Alcohol Treatment Information System (DATIS) in Ontario, Canada for 2010/11. The number of clients with FASD who received SATS in Ontario in 2010/11 was estimated, assuming that approximately 37% (confidence interval: 21.6%-54.5%) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that their utilization rate of SATS is the same as those for people with a lifetime mental disorder. The data from DATIS was then extrapolated to the total Canadian population. Results: The cost of SATS for clients with FASD in Canada in 2010/11 ranged from $1.65 million Canadian dollars (CND) to $3.59 million CND, based on 5,526 outpatient visits and 9,529 resident days. When the sensitivity analysis was performed the cost of SATS ranged from $979 thousand CND to $5.34 million CND. Conclusions: Special attention must be paid to at-risk groups of individuals such as those with FASD, in order to reduce the likelihood of the development of co-morbid substance abuse problems, and thus, reducing the overall burden on Canadian society. Keywords: Fetal alcohol syndrome, Fetal alcohol spectrum disorder, Addiction, Specialized treatment, Utilization, Cost, Canada

Background This study is a part of a large economic study on the estimation of the burden and cost associated with Fetal Alcohol Spectrum Disorder (FASD) in Canada [1,2]. FASD is a non-diagnostic term that encompasses four alcohol-related clinical diagnoses, including: Fetal Alcohol Syndrome (FAS), Partial FAS, Alcohol-Related Neurodevelopmental Disorder, and Alcohol-Related Birth Defects. Individuals with FASD have an increased vulnerability to certain risk factors, which put them at a higher risk for substance use/abuse problems, as a result of the damage caused to their central nervous system due to * Correspondence: [email protected] 1 Social and Epidemiological Research Department, Centre for Addiction and Mental Health, 33 Russell St., Toronto, ON M5S 2S1, Canada 2 Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada Full list of author information is available at the end of the article

their exposure to alcohol prenatally. This damage manifests as developmental delays, cognitive impairments, mental disorders, high rates of incarceration and an increased rate of substance abuse [3-5]. The impairments expressed by individuals with FASD typically lead to high-risk behaviours, such as alcohol/ drug abuse or an increased likelihood of being in highrisk situations (increasing the chance of being exposed to alcohol and/or drugs). Currently, there are not many epidemiological studies reporting on the prevalence of substance use/abuse among individuals with FASD. However, the literature does indicate that a disproportionate number of individuals with FASD will have problematic substance use issues at some point in their lives [6]. For instance, Famy et al. [7] reported a prevalence of 55% for alcohol/drug dependence among their sample of individuals with FAS. Additionally, Clark and colleagues

© 2013 Popova et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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[8] and Streissguth and colleagues [9] reported that 22% and 35% of their respective cohorts of individuals with FASD had problems with alcohol/drugs. Lastly, in a study conducted by Grant and colleagues [10], about 68% of women with FASD had reported abusing alcohol and 79% had used illegal drugs in the 10 months prior to being admitted into a community program. There are a few potential explanations for the high prevalence of substance use among individuals with FASD: 1) a biological vulnerability to substance use may exist; 2) individuals with FASD may use substances to self-medicate; and 3) individuals with FASD tend to have difficulties with impulse control, making them susceptible to developing a substance use disorder [11]. Regardless of the reason for such high rates of cooccurring substance use problems and FASD, this population places a greater demand on treatment service providers, given that they suffer from multiple comorbid mental disorders [8,12,13]. Prenatal alcohol use exposes three generations to the harmful effects of alcohol (the mother, the fetus, and the germ line of the fetus). Increased rates of substance abuse increase the risk for additional familial cases of FASD (multiple affected siblings), and increase the risk of generational FASD [3,14]. Therefore, it is also important to address the issue of women of childbearing age with FASD so that the generational effects of FASD can be halted. In Canada, as is common elsewhere, specialized addiction treatment services provide a continuum of care, from assistance with symptoms of withdrawal through to active treatment and continuing care [15]. They vary, however, in their capacity for assisting clients with cooccurring disorders [15,16], which would include complications arising from FASD among others. Prior research suggests that people with co-morbid substance use and mental disorders have a more complicated trajectory of service use, including higher rates of relapse and readmission to addiction treatment [17-22]. Given the high-risk nature of FASD for multiple health and social comorbidities, it is of interest to understand their representation in the specialized addiction treatment system. The purpose of this study was to estimate the use of specialized addiction treatment services and the associated cost, as a part of the total cost of health care associated with FASD in Canada.

specialized addiction treatment services in Canada, several important assumptions were used and sensitivity analyses were conducted, as described step-by-step below.

Methods Since there is great uncertainty regarding the true prevalence of people with FASD in the general population, and the prevalence of people with FASD who abuse or are addicted to substances, specifically, in combination with the lack of FASD-specific data pertaining to

Study population

Source of data

Data were obtained from the Drug and Alcohol Treatment Information System (DATIS; www.datis.ca), which monitors the use of specialized addiction treatment services by people in Ontario, Canada. Started in 1992, DATIS collects data on the numbers and types of clients entering publicly funded specialized addiction treatment across the province. This system includes approximately 200 treatment programs, administered by 170 agencies [23,24]. The types of services provided by each agency can vary; some agencies provide a specific type of service (e.g., assessment and referral, withdrawal management, individual counseling), while others provide a comprehensive mix of services. Regardless of the type of service, all services are delivered free-of-charge to Ontario residents (i.e., they are covered by the province’s universal health insurance plan). Agency-level participation has been over 95% since 2000. The DATIS database is structured by admissions to treatment programs, such that a new admission is triggered when a client enters a new treatment program or transitions between two different types of services. Since 2002, data entry has been supported by a web-based user platform accessible by all frontline clinicians working in the designated programs across the province. Data entry fields correspond to 66 data elements that are mandatory for all admissions. Sociodemographic characteristics, information on substance use, and other treatment-related factors (e.g., referral source, current and past diagnoses of mental disorders, and treatment mandates) are entered by the service provider at admission, typically following the first face-to-face encounter with the client. Unique identifiers for individual clients and agencies are generated automatically by the software, as is a variable documenting the type of treatment program or service (i.e., outpatient, residential or residential withdrawal management). Details on service use, including the number of outpatient visits and days or residential care, are entered by service providers at discharge. Data are stored on a central server located at the Centre for Addiction and Mental Health in Toronto, Canada.

All admissions corresponding to services received during the 2010/11 fiscal year (April 1, 2010 to March 31, 2011; N=91,333) were extracted for analysis. This included all admissions occurring during the fiscal year, as well as those where treatment had started prior to April 1,


2010, but that had continued into the study period. As noted above, an admission corresponds to a particular type of service, with movement between types of services (e.g., from a residential service to an outpatient program) counted as separate admissions. Multiple admissions per individual client were included. This was done to ensure that the most complete estimates of the volume and costs of services delivered during the study period were obtained. Therefore, it is important to note that each admission does not necessarily represent a separate individual, as one individual can have multiple admissions. Data elements

In order to determine whether or not a client has had a “lifetime mental disorder” (i.e., a diagnosed mental disorder at any point within their lifetime; response: yes versus no), the question “Have you ever been diagnosed by a qualified mental health professional with a mental disorder within the last 12 months or within your lifetime?” was asked to each client at the beginning of treatment. Age groups, divided into 5-year intervals from 14 years of age and younger to 70 years of age and older, were generated from the clients’ date of birth. All variables (lifetime mental disorder, date of birth, and sex) were self-reported by the clients during their initial clinical encounter. Service type (i.e., outpatient, residential treatment, or residential withdrawal management, automatically generated in DATIS) was abstracted, as were the number of visits for outpatient treatment and days in residential treatment and residential withdrawal management. The numbers of visits and days of care, entered by service providers based on client charts, provide estimates of the volume of services received. For admissions that began prior to or ended after the 2010/11 fiscal year, only those visits/days that occurred within the study period were counted. To comply with Personal Health Information Protection Act (2004), cells with values less than 6 were redacted and replaced with "