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Moraes E, Campos G.M., Figlie N.B. et al.
European Addiction Research: 2010, 16, p. 69–77.
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In Brazil adding home visits to a three-month alcohol detoxification and treatment programme cost-effectively increased the abstinence rate at the end of treatment.
Summary The featured report is a cost-effectiveness analysis based on a study conducted in the mid-2000s in Brazil comparing outpatient alcohol treatment with versus without additional home visits. In the trial 120 alcoholic patients starting outpatient treatment at a clinic in São Paulo were allocated to a multidisciplinary unit devised for the study. It offered a standard three-month treatment programme of detoxification plus 20 group therapy sessions based on relapse prevention techniques and motivational interviewing. A randomly selected half of the patients were also offered four home visits beginning at the start of the treatment and then weekly, during which therapists used motivational interviewing principles and techniques to enhance the patient's and family's adherence to treatment.
The main criterion of successful treatment – abstinence during what was intended to be the last month of treatment – was achieved by 43% of patients not offered home visits and 58% offered these visits, a substantial but not statistically significant difference, so one subject to considerable uncertainty. Taking in to account the treatment itself, other medical costs, and productivity losses, the costs associated with outpatient treatment amounted to 602 Brazilian Real per patient; with home visits, costs increased to 819 Brazilian Real per patient. However, home visits led to more patients achieving abstinence. Per extra abstinent patient, the extra cost associated with home visits was 4260 Brazilian Real or 1852 US dollars, though this figure varied considerably when different assumptions were made about the success rates of the treatments.
According to the yardstick adopted by the World Health Organization, the extra abstinence rate gained by home visits means these count as a cost-effective health intervention, and the extra costs are highly likely to be outweighed by social cost savings.
commentary The structured nature, explicitly motivational approach, and clear objectives of the home visits in this study may have been critical to their achieving a greater abstinence rate. In one British study (details below), how visits were done made the difference between practically no patients controlling their drinking 12 months later versus a substantial minority.
A British study has suggested that what happens during home visits has a major impact on sustained success after detoxification. In this study half the patients were randomly allocated to standard home detoxification consisting of five home visits by a community psychiatric nurse who gave medication and advice to help control withdrawal symptoms and reduce discomfort. The other half were allocated to the same procedure over the same time periods conducted by the same staff, except that the advice element was structured via a manual into three phases. The first session adopted a non-confrontational style aimed at building rapport and motivation. The next two aimed to help the patient manage and accept discomfort and to develop and practice specific relapse prevention skills. The last two aimed to engage the patient's friends and family in supporting their recovery and developing new social activities.
Researchers interviewed patients three (92% contacted) and twelve (86% contacted) months after the detoxification and the results were compared with pre-treatment assessments. On every measure of drinking including abstinence and amount overall or per drinking day, patients given structured counselling had made greater reductions. In the three months before the 12-month follow-up, just three out of 40 standard detoxification patients were abstinent or drinking at relatively safe levels compared to 15 out of 38 given structured counselling. The latter also experienced greater reductions in alcohol-related problems and improved social satisfaction and self-esteem. Cost estimates suggest that even accounting for the training required, the home detoxification programme was a ninth the cost of an inpatient detoxification and under half the cost of an outpatient procedure.
Thanks for their comments on this entry in draft to Edilaine Moraes of the Federal University of São Paulo. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 24 January 2012
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