Cost-Effectiveness of the START Hospital Addiction Consultation Service for Opioid Use Disorder Treatment
Abstract
Importance People with opioid use disorder (OUD) are often hospitalized for emergent medical problems, but opioid use is seldom addressed during the inpatient stay. In a recent trial, patients randomized to Substance Use Treatment and Recovery Team (START), a hospital-based addiction consultation service, were more likely to initiate medication for opioid use disorder and be linked to OUD-focused follow-up care compared with patients receiving usual OUD care, which was at the discretion of the primary team.
Objective To evaluate the incremental cost-effectiveness of START from the health sector and limited societal perspectives relative to usual care.
Design, Setting, and Participants This economic evaluation was an incremental cost-effectiveness analysis based on the START trial, which was conducted at 3 major academic medical centers. START participants were adults with a probable OUD diagnosis documented during an inpatient hospitalization from November 2021 to September 2023. This economic evaluation used trial participant–level cost and health outcomes data, supplemented with published data.
Exposures Two strategies were compared: (1) START and (2) usual care.
Main Outcomes and Measures Costs, quality-adjusted life year (QALYs), and incremental cost-effectiveness ratios (ICERs). ICERs were estimated using a Markov model over a 12-month horizon, with deterministic and probabilistic sensitivity analyses. ICERs were expressed as cost per QALY gained, with a willingness-to-pay threshold of USD $150 000/QALY.
Results A total of 325 participants were randomized to the START (164 [50.5%]) or usual care (161 [49.5%]); 213 were male (66%) and the median (IQR) age was 41 (32-50) years. START implementation costs were $640 per patient (personnel, $602; training and onboarding, $38). Compared with usual care, START was associated with an incremental cost of $162 (95% UI, −$93 to $179) and a gain in QALYs of 0.0103 (95% UI, 0.0102 to 0.0106) per person from a health sector perspective, leading to an ICER of $15 750 (95% UI, $8742 to $17 034) per QALY gained. The ICER was $20 921 (95% UI, $13 747 to $22 190) per QALY gained from a limited societal perspective. Sensitivity analyses demonstrated that health care expenditures and intervention effectiveness were the strongest drivers of cost-effectiveness.
Conclusions and Relevance In this trial-based economic evaluation, START was a cost-effective approach for addressing opioid use disorder in the inpatient setting by increasing the initiation of medication for OUD and linkage to OUD-focused care after discharge.
