Alcohol and Other Drug Screening of Hospitalized Trauma Patients
Treatment Improvement Protocol (TIP) Series: 16

Benefits of Brief Interventions

In weighing the costs and benefits of any AOD screening program, the availability of resources to address the problems identified through screening must be considered. Ideally, efforts should be made to match each patient to an appropriate mode of treatment. The efficacy and availability, as well as the costs, of various modes of treatment must therefore be taken into account when costs and benefits are analyzed. For example, in the CALDATA study described above, the cost of treating 150,000 persons in 1992 was $209 million. However, the benefits received during treatment and in the first year afterward were worth approximately $1.5 billion to taxpaying citizens.

Many hospitals face limited funding and resources for AOD abuse treatment. Such limits may play a role in decisions not to implement AOD screening programs among hospitalized trauma patients. However, research has shown that the most effective treatment modalities are not the most expensive options (Holder et al., 1991). Even relatively brief, minimal interventions have been shown to be effective (Bien et al., 1993.) Chapter 4 describes some brief intervention strategies.

Benefits of AOD Screening Among Trauma Patients

As discussed in earlier chapters of this TIP, traumatic injury is very costly to society. The direct and indirect costs approach $110 billion every year, making treatment of traumatic injury more costly than that of any disease. Lifetime costs approach $215 billion. About 2.3 million persons with traumatic injuries are admitted to trauma centers and hospitals each year. Many of these patients recover from their injuries and are reinjured. One of the main objectives of AOD screening among trauma patients is to reduce reinjury and its associated costs, both personal and economic.

Other benefits of AOD screening among injured patients with AOD problems include

• Better medical management of hospitalized patients (see Chapter 3)
• Safer and more effective pain management
• Increased identification by clinicians of the causes of postinjury medical problems, such as wound infections
• Improvements in aftercare planning and treatment
• Enhancement of patient compliance
• • -Increased probability of compliance with physical rehabilitation or other followup care
  • -Increased patient compliance with AOD and other treatment regimens, preventing further hospitalization due to wound infections or other complications
• Prevention of future AOD-related injuries.

It should also be noted that widespread implementation of AOD screening among injured patients will generate important data about the scope of the problem of AOD-related injury and its costs to society. Such data can be used in public education efforts and to pursue increased funding for alcohol and other drug abuse treatment.

Finally, in hospitals where screening programs are implemented and addressing the patients' AOD problems becomes a routine part of care delivery, improved morale of nursing and other staff can be expected, as well as greater patient and family satisfaction with the care provided. Physicians and other healthcare workers, many of whom may be skeptical about the effectiveness of AOD interventions and treatment, may find their attitudes and beliefs changing as they see improvements in the well-being of patients and families.

Laboratory Costs

The costs of laboratory screening for AODs will vary according to volume -- how many patients receive the tests -- and the type of test used. In most areas of the country, testing of a patient's BAC can be done for approximately $44, although in some areas this cost may be much higher (see Exhibit 5-1). Saliva testing for alcohol can usually be done for $10 or less.

A six-drug urine toxicology screen (for opiates, benzodiazepines, barbiturates, amphetamines, cocaine, and marijuana) can generally be done for under $50. The expense of the test varies based on the number of drugs it detects. Factors to be considered in deciding which drugs to screen for include the prevalence of drug use in the local population. Cocaine use, for example, may be prevalent in some major metropolitan areas, whereas use of other drugs may predominate in other areas.

Costs for Other Screening Procedures and Physician Consultation

Chapter 4 of this TIP describes a variety of nonlaboratory methods of AOD screening that provide important information about patterns of AOD use and possible AOD dependence to supplement results of laboratory tests. This screening can be done with minimal expense of time and resources while achieving a high degree of effectiveness (Bush et al., 1987). In general, just a few AOD screening questions can reliably identify AOD problems. As discussed in Chapter 4, the questions themselves, and the concern expressed by the interviewer are effective brief interventions with some patients.

Ideally, an AOD screening interviewer should carry out screening for behavioral risk factors. However, with minimal training, brief screens can be administered by a nurse, a social worker, a certified addictions counselor, or other nonphysician healthcare worker. Some instruments are paper-and-pencil questionnaires that patients can fill out themselves. In most areas of the country, it is estimated that costs for gathering this supplemental screening information would be about $20 per patient. Costs may be higher in some areas. This estimate is based on staff costs associated with interviewing patients. The estimate of $20 per patient is based on two patients interviewed per hour, plus 1 hour of preparation time per day.

It is helpful for both the effectiveness and the credibility of the screening program to have a physician liaison to the screening/assessment team who has specialized training in addiction medicine. The physician acts as a resource to the team, creating liaisons with hospital medical staff. The physician may consult with the primary physician about managing the patient's addiction or withdrawal, discuss the patient's AOD use with the patient, or assist the treatment team in planning for aftercare to address AOD problems. The cost of a physician liaison to the team for 2 to 4 hours per week would range from $200 to $400. Separate physician consultations for individual patients may add an extra $100 to $200 per patient.

Training Costs

In addition to the costs of performing the laboratory tests and supplemental screening interviews, costs relating to education and training of healthcare personnel must also be taken into account when calculating the costs of implementing an AOD screening program for trauma patients. Many emergency department personnel encounter persons with chronic, long-term AOD problems. Many of these patients either have not received AOD treatment or have had ineffective treatment. Repeated experiences with this patient group often shape staff members' attitudes about persons with AOD use disorders and the effectiveness of AOD treatment.

Education is needed to raise the awareness and change the attitudes of nursing and other hospital staff, including emergency department staff, regarding the link between abuse of AODs (particularly alcohol) and traumatic injuries. It should be noted that a feedback process frequently occurs once an AOD screening and assessment program is implemented in a facility. Attitudes of hospital personnel often change when they note the benefits to individual patients and their families.

Hospital personnel also need education about how the medical management of trauma patients is affected by AOD use and dependence. The effects of AOD use and dependence on patient management in the acute, subacute, and rehabilitation phases of care are described in Chapter 3. Providing this inservice medical training to a wide range of hospital personnel will also raise costs. However, as discussed above, significant benefits in terms of improved care, patient and family satisfaction, and staff morale may offset costs for training.

Costs of Assessment

As described in Chapter 4, comprehensive AOD assessments of patients with positive screens may be necessary as clinical circumstances warrant. The use of extensive assessment instruments is best delayed until the patient chooses to receive help for an AOD problem and consents to a more comprehensive assessment.

Assessment must be performed by a clinician with training in assessment and treatment of substance use disorders. As indicated in Exhibit 5-1, costs per hour for nonphysician AOD clinicians range from $9 to $30; rates for physicians are much higher.

The need for a full-time AOD clinician to perform assessments and recommend treatment will be determined on the basis of the institution's particular needs, the volume of trauma patients handled, and the incidence of AOD abuse in the surrounding population. Such AOD clinicians may see as many as 4,000 to 5,000 patients per year in some institutions (New York State Office of Alcoholism and Substance Abuse, 1993).

Many institutions do not have the resources to employ full-time AOD clinicians. One of the purposes of this TIP is to show that AOD clinicians play an important role in providing appropriate medical care and that funds should be allocated for these positions. In 1987 and 1989, Soderstrom and colleagues conducted a national survey of trauma centers to assess clinical practices involving alcohol (Soderstrom and Cowley, 1987; Soderstrom et al., 1994a). In the earlier survey of 154 centers in 43 States and the District of Columbia, it was found that fewer than a third of the centers employed an alcoholism counselor/clinician. The updated survey, which involved 316 respondents, found a significant increase (59 percent) in the number of centers employing a full-time counselor/clinician with specific training in substance abuse. Many hospitals have come to recognize the need for an AOD clinician, especially in the trauma setting.

Other Costs

Mutual-help or support group contacts. Contacts from self-help or support groups are important adjuncts to an AOD screening program. To fulfill its intended role, AOD screening should be designed to lead into available treatment resources and adjunct resources such as mutual-help and support groups. The costs of developing and maintaining these

contacts for the ongoing recovery of patients identified with AOD abuse problems must be factored into the overall costs of screening.

Recordkeeping. A care provider offering AOD abuse services is subject to Federal regulations governing the confidentiality of patients' records. As discussed in Chapter 6, some information in the records of trauma patients who undergo assessment by an AOD clinician is protected under Federal regulations, which restrict how it is to be used and what can be done with it. Special procedures for handling protected records will affect costs, although these procedures can be simplified (see Chapter 7).