THE PRACTICE OF EMERGENCY MEDICINE/ORIGINAL RESEARCH

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Unmet Substance Abuse Treatment Need, Health ServicesUtilization, and Cost: A Population-Based Emergency

Department Study

Ian R. H. Rockett, PhD, MPH

Sandra L. Putnam, PhD

Haomiao Jia, PhD

Cyril F. Chang, PhD

Gordon S. Smith, MD, MPH

From the Department of Community Medicine, Center for Rural Emergency Medicine, WestVirginia University School of Medicine (Rockett), Morgantown, WV; Population HealthResearchCenter, Pacific Institute for Research andEvaluation (Putnam),Morgantown,WV;Department of Community Medicine, Mercer University School of Medicine (Jia), Macon,GA; Fogelman College of Business and Economics, University of Memphis (Chang),Memphis, TN; and the Liberty Mutual Research Institute for Safety (Smith), Hopkinton,MA.

Study objective: There is a high prevalence of unmet substance abuse treatment need among adulthospital emergency department (ED) patients. We examine the association between this unmetneed and excess utilization of health services and estimate costs.

Methods: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee generalhospital EDs from June 1996 to January 1997. Toxicologic screening augmented in-personinterviews. Main outcome measures were ED case disposition; frequency of physician office visits,ED visits, and hospitalizations in the past 12 months; and costs of excess service utilization.Covariates in the multivariate model were substance abuse treatment need status, age, sex, mainreason for ED visit, perceived previous health status, history of tobacco use, and health carecoverage. Unmet substance abuse treatment need was assessed using 13 overlapping criteria thatincorporated use, dependence, denial, and treatment history. Target substances included ethanoland selected illegal and prescription drugs but not nicotine.

Results: Compared with patients without substance abuse treatment need (n=1,073), patients withunmet need (n=415) were 81% more likely to be admitted to the hospital during their current EDvisit (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.27 to 2.64) and 46% more likely to havereported making at least 1 ED visit in the previous 12 months (OR 1.46; 95% CI 1.12 to 1.84). Theirutilization patterns accounted for an estimated US$777.2 million in extra hospital charges forTennessee in 2000 dollars, representing an additional US$1,568 per ED patient with unmetsubstance abuse treatment need.

Conclusion: ED patients with unmet substance abuse treatment need generated much higherhospital and ED charges than patients without such need. Given potential savings from avoidablehealth care costs, the future burden of substance-associated ED visits and hospitalizations may bereduced through programs that screen and, as appropriate, provide brief interventions or treatmentoptions to these patients. [Ann Emerg Med. 2005;--:---.]

0196-0644/$-see front matterCopyright ª 2005 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2004.08.003

INTRODUCTIONBackground

Personal risk of disease, injury, and disability is elevated byabuse of alcohol and other substances.1-6 According to losses inproductivity and the economic impact on the criminal justice,social welfare, and health care systems, substance abuse cost theUnited States an estimated US$277 billion in 1995.7 However,the cost of the health care component may be grosslyunderestimated because of a paucity of economic data on

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patients with undetected need for substance abuse treatment,namely, those patients whose utilization of health services couldhave been avoided had they been identified as substance abusersand given appropriate and effective treatment.

ImportanceA statewide hospital emergency department (ED) study

revealed a high prevalence of undetected substance abusetreatment need.8 Although 1% of adult ED patients received

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Editor’s Capsule Summary

What is already known on this topic

The potential impact of identifying emergencydepartment (ED) patients with chronic substance abusefor intervention and referral is unknown.

What question this study addressed

The utilization of health care services (outpatient, ED,and inpatient) and the associated costs for patients seenin the ED with unmet treatment needs for chronicsubstance abuse were assessed.

What this study adds to our knowledge

In Tennessee, these patients had more ED visits andincreased health care costs compared with other patients.They were almost twice as likely to need admission to thehospital and had 46% excess utilization of ED services.

How this might change clinical practice

This study provides a background for further research intowhether providing preliminary drug counseling andreferral has the potential to decrease excess ED visits andhealth care costs for patients with chronic substance abuse.

a clinical diagnosis of a substance abuse disorder, between 4%and 27% were determined to need treatment, depending onwhether need was assessed through strict Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition (DSM-IV )9 criteria or through more comprehensive criteria whosedomain included self-reported addiction and denial. There wasa high prevalence of denial among the ED patients. Thirty-threepercent of patients denied use in the previous 30 days of at least1 substance for which they tested positive. Denial of use waslowest for alcohol, at 10%. Patient denial was much higher forother substances, ranging from 57% for marijuana to 100% forhallucinogens, and likely reflects personal concerns about illicituse and stigma. The 2001 National Household Survey on DrugAbuse estimated that 4.5 million Americans were in denial oftheir substance abuse and needed treatment.10

Irrespective of whether the strict or comprehensive casedefinition was applied, less than 10% of the ED patientsneeding substance abuse treatment in the statewide studyreported that they were currently receiving any. This percentageapproximated the prevalence reported in a study of themedically uninsured that analyzed data from the 1998 NationalHousehold Survey on Drug Abuse.11 We found no population-based studies that examined the association between substanceabuse treatment need and general health services utilization butfound 2 that examined substance use and utilization.12,13

Neither study integrated alcohol use with other substance use inan assessment of treatment need, used toxicologic screening,considered denial of substance use, addressed utilization ofinpatient services, or estimated costs of excess service utilization.

2 Annals of Emergency Medicine

Goals of This InvestigationUsing a comprehensive case definition that incorporates

toxicologic screening to augment self-histories and factor indenial of substance use, we evaluate whether adult ED patientswith unmet alcohol and other substance abuse treatment needmade more physician office visits and ED visits and used moreinpatient services than patients without treatment need. Wethen estimate service-specific costs of excess utilization associ-ated with unmet need.

METHODSStudy Design

The study design was a cross-sectional survey conducted in 7hospitals in Tennessee between June 1996 and January 1997.The protocol was approved by the institutional review boards ofthe participating hospitals and the University of Tennessee. Weobtained a Federal Certificate of Confidentiality for addedprotection of human subjects.

Setting and Selection of ParticipantsSubjects (n=1,502) were a probability sample of patients

seeking emergency treatment in any of the registered acute care,civilian, nonpsychiatric, nonpediatric, and nonrehabilitationhospitals in Tennessee, with a minimum annual volume of10,000 ED patient visits. To be eligible, ED patients must havebeen state residents, 18 years and older, not in police custody,possessing intact cognition, and able to give informed consent.Patients were informed that the survey would examine healthstatus, medical care access, and alcohol and other drug issuesand treatment need. No financial inducements were offered forparticipation in the study.

Sampling was 2-stage. All 81 eligible hospitals in thesampling frame were stratified using the 7 health care regionsdesignated by the Tennessee Department of Health’s Bureau ofAlcohol and Drug Services. One hospital was selected from eachof the regions through probability proportional to sizesampling,14 and patients were then prospectively sampled fromthe ED logs of the 7 hospitals. Patient eligibility was determinedpreliminarily from the logs and then finalized after contact withpotential subjects. Trained interviewers sought to enroll the firsteligible patient after the hour, moving sequentially to the ktheligible patient as necessitated by patients leaving the ED beforebeing seen, refusing participation, or being too ill or injured tobe interviewed according to the judgment of medical personnel.When eligible patients were admitted, the interviewers soughttheir participation in the wards within similar constraints.Admissions were determined from the logs. Additional detailson the sampling method were published previously.8

Data Collection and ProcessingIn-person interviews were the principal data source. Seventy-

nine percent of the 1,890 eligible subjects completed theinterviews, with 16% refusing and 5% granting partial inter-views. Of the partial interviews, 33% were attributable to refusal

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to continue, 28% to early ED discharge, 26% to severity ofpatient condition, and 13% to administration of medical care.

Rapid assay saliva and urine screens supplemented theinterviews in our assessment of unmet substance abusetreatment need. We used a saliva test, QED A350 (OraSureTechnologies, Bethlehem, PA), to determine ethanol levels, andAbuSign DOA 4 (Princeton Bio-Meditech Corporation,Princeton, NJ), an immunochromatographic test, to detect inurine the presence of cocaine, marijuana, amphetamines,methamphetamine, benzodiazepines, barbiturates, phencycli-dine, and opioids or their metabolites. Twenty percent ofpatients completing interviews refused urine testing, with nodifferentiation by age, sex, or race. Nine percent refused salivaalcohol testing, with no differentiation by sex or race. Patients65 years and older were 2.3 times more likely to refuse the salivatest than patients aged 18 to 24 years. For saliva and urine, 10%of patients were unable to tender a specimen because ofa medical or other limitation.

We based our analysis on the behavioral model of healthservices utilization that was formulated by Andersen15 andPhillips et al.16 Our multivariate model for predictingutilization comprised substance abuse treatment need status(unmet need/no need) and 6 other covariates selected a priori:patient age and sex, main reason for ED visit (injury/illness),perceived previous health status (poor or fair/good, very good orexcellent), type of health care coverage (Medicare/TennCare[Medicaid]/private insurance/no insurance), and history oftobacco use (lifetime dependence or current use/neither). Weincluded health care coverage because of its salience in hospitalsettings and to access to services. This variable also served asa proxy for education, income, and employment status, allpotential covariates with which it was moderately collinear.Tobacco use was incorporated into the model as a controlbecause of the strong etiologic links between nicotine and illhealth17-19 and thus implications for excess utilization of healthservices.20,21

Methods of MeasurementAssessment of unmet alcohol and other substance abuse

treatment need closely adhered to the methodology used in theSubstance Abuse and Need for Treatment Among AdultArrestees studies.22 Patients were determined to have unmetneed if they reported that they were not in treatment and metany of 13 potentially overlapping criteria: they (1) wantedtreatment; (2) qualified as currently dependent under DSM-IV;(3) self-reported current substance dependence; (4) reportedpast treatment and current substance use (use in the 30 daysbefore survey); (5) reported past treatment and tested positivefor substance use through saliva alcohol or urine drug screening;(6) reported past treatment and verbally refused eithertoxicologic test; (7) qualified as DSM-IV lifetime dependent andreported current substance use; (8) qualified as DSM-IV lifetimedependent and tested positive; (9) qualified as DSM-IV lifetimedependent and verbally refused either toxicologic test; (10) self-reported lifetime dependence and reported current substance

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use; (11) self-reported lifetime dependence and tested positive;(12) self-reported lifetime dependence and verbally refusedeither toxicologic test; or (13) denied current use and testedpositive.

Self-reported current use of prescription drugs was notintegrated into need for substance abuse treatment criteriaunless patients reported abusing them. Abuse was operational-ized as use of prescription drugs for nonmedical purposes within1 year of the survey. Also eliminated from treatment needcriteria were positive bioassays for amphetamines, benzodiaze-pines, barbiturates, and opioids consistent with appropriate useof prescription drugs by patients, as indicated by self-reportedtherapeutic contact with the health care system within the pastyear. Therapeutic contact covered physician office visits, EDvisits, and hospitalizations.

We excluded from the analyses the 14 patients in the samplewho reported that they were in treatment. Treatmentencompassed a range of modalities from self-help or 12-stepgroup participation to seeing a counselor, receiving medication(such as disulfiram [Antabuse] or methadone), detoxification,residential or inpatient rehabilitation, or a stay in a halfwayhouse. Patients with unmet substance abuse treatment needwere compared with patients without such treatment need.

Outcome MeasuresWe examined 4 measures of health services utilization: case

disposition (admitted yes/no) and self-reported frequencies ofphysician office visits, ED visits, and hospitalizations in the past12 months. Bivariate analysis was performed on each of the 3self-report variables using the nonparametric Wilcoxon-Mann-Whitney test. Because of their asymmetric distributions, thesevariables were dichotomized for multivariate analysis as follows:4 or more versus less than 4 for physician office visits and 1 ormore versus none for ED visits and hospitalizations. Cutoffchoices rested on median frequency.

Costs of excess service utilization were estimated using theformula Total Excess Costs (EC)=T�P�(RR�1), where T is thetotal charges for patients aged 18 years and older for the type ofservice under review, P is the proportion of patients with unmetsubstance abuse treatment need, and RR is the rate ratio for therelative likelihood that patients with unmet need versus thosewith no substance abuse treatment need will utilize a givenservice. We obtained cost data for 2000 from the TennesseeDepartment of Health.23

Primary Data AnalysisWe used Software for Survey Data Analysis (version 7.5,

Research Triangle Institute, Research Triangle Park, NC) toimplement the analyses because of its capacity to accommodatethe complex sampling design. Separate logistic regression analyseswere conducted on the 4 outcome measures commencing withthe 7 potential predictors composing our utilization model.Actual predictors were selected through backwards elimination,with a set at 0.05. In each analysis, our model was validated withthe Hosmer-Lemeshow goodness-of-fit test.24

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RESULTSCharacteristics of Study Subjects

EDpatients with unmet needwere younger than those withoutsubstance abuse treatment need, and higher proportions weremen, uninsured, and enrolled in TennCare, Tennessee’sMedicaid-waiver managed-care program (Table 1).25

Twenty-seven percent of the ED patients manifested unmetsubstance abuse treatment need (Table 2). Of the 13 over-lapping criteria generating this estimate of unmet need, thehighest criterion-specific prevalences were recorded for DSM–lifetime dependence and current use (47%), self-diagnosedlifetime dependence and current use (36%), and denial ofcurrent use and test positivity (32%). Twenty-one percent of thepatients who we determined had unmet substance abusetreatment need did so through meeting the denial criterionalone. Among this set of patients, 61 (15%) qualified throughdenying marijuana use and another 3 (0.7%) through denyingalcohol use.

Main ResultsThe bivariate analysis showed that patients with unmet

substance abuse treatment need reported more ED visits andfewer physician office visits in the past 12 months than patientswithout this treatment need (Tables 3A and 3B). No predictorinfluenced all utilization outcomes in the multivariate analysis(Table 4). Age was positively associated with the likelihood ofcurrent hospital admission, and patients aged 25 to 44 yearsreported excess physician office visits relative to the youngestpatients. Injured patients reported excess previous physicianoffice and ED visits relative to ill patients. Perceived fair or poorprevious health status was associated with excess previousphysician office visits, ED visits, and hospitalizations. Com-pared with privately insured patients, uninsured patientsreported fewer previous physician office visits and hospital-izations, and TennCare and Medicare patients reported more.TennCare patients also reported more ED visits.

Tennessee Department of Health data showed that adultsmade 1,567,129 outpatient ED visits in 2000, with each visitincurring US$572 in average billable charges for hospitalservices.23 These visits resulted in 243,590 inpatient admissions,with the mean hospitalization charges being US$13,460 peradmission. Patients with unmet substance treatment need were1.8 times more likely to be admitted during the current ED visitthan patients without need and were 1.5 times more likely toreport previous ED visits. These higher probabilities implysubstantial extra resource utilization and health care costs thatare potentially avoidable. The utilization patterns of the 27% ofED patients whom we assessed as having unmet substance abusetreatment need accounted for an estimated US$777 million inextra ED and hospitalization charges for Tennessee, or anadditional US$1,568 per ED patient with unmet need (Table 5).The ED component comprised 30% of the aggregate. Weestimated the range for excess utilization costs to be US$708million to US$846 million, through application of the 95%confidence limits around the point prevalence of unmet need.

4 Annals of Emergency Medicine

LIMITATIONSOur sampling plan precluded examination of the effects of

seasonality and rural-urban residence on the utilization of healthservices, and we lacked sufficient cases to separate patientswhose unmet treatment need implicated alcohol only. The largetreatment gap, that is, the discrepancy between the respectivepercentages of patients needing and receiving treatment, meantthat we had too few subjects currently in treatment for them toform a second comparison group. Small numbers also precludedmore refined utilization analyses of the unmet treatment needgroup. In all statistical analyses, we used Software for SurveyData Analysis to adjust for the stratified sampling, that is, toadjust for sampling correlation within hospitals. Because raceand the regionally sampled hospitals were highly correlated, itwas invalid to examine the impact of race on health careutilization.

Table 1. Sociodemographic characteristics of the TennesseeED patient sample by substance abuse treatment needstatus, 1996 to 1997.*

Characteristic

Unmet

Treatment

Need %

No

Treatment

Need %

Total 415 1,073% (standard error) 27.0 (1.2) 73.0 (1.2)Age, y 414 1,06718–24 23.4 16.625–44 56.6 43.845–64 16.5 23.4R65 3.6 17.1Male sex, % 415 55.9 1,073 39.1Race 411 1,062White 69.0 72.7Black 30.0 25.3Other 0.99 2.0Education 415 1,068Less than high school 39.9 35.3High school 37.0 34.8Some college 16.6 19.7College degree 5.1 7.1Postgraduate 1.5 3.0Work 411 1,066Full-time 49.6 49.4Part-time 10.5 7.3Not employed 40.0 43.3Health care coverage 401 1,056Private 33.9 43.6TennCare 40.0 31.4Medicare 7.1 13.6Uninsured 19.0 11.4Annual household

income, US$

396 1,012

\15,000 52.4 51.415,000–34,999 30.7 29.1R35,000 16.9 19.5

*Percentages are based on the sample weighted for the unequal probability of

hospital selection.

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Our inability to access pharmacy charges, physician andother professional fees, and the costs of follow-up medical caredownwardly biases the estimated costs of excess serviceutilization. One estimate is that professional fees account for anadditional 25% in inpatient charges.26 This inflation factor wasapplied to hospital base charges in a 1-year follow-up study oftraumatic injury patients.27 The authors estimated that in-corporation of the postdischarge costs of care would furtherexpand charges by 23%. Thus, even with pharmacy chargesomitted, true excess costs of hospitalization and ED visitsattributable to patients with unmet substance abuse treatmentneed could surpass our estimate by up to 37%.

Our prevalence of unmet substance abuse treatment needamong Tennessee adult ED patients may be underestimated,and hence total cost estimates of excess service utilization aswell, because our toxicologic tests were restricted in the range ofsubstances they could detect, false negatives likely outweighedfalse positives,28,29 and our measurement of prescription drugabuse was conservative. We probably also underestimated thepresence of episodic or sporadic binge drinkers in the EDpopulation,30 and chronic alcohol abusers were likely over-

Table 2. Prevalence of unmet substance abuse treatmentneed by coding criteria, Tennessee ED patients, 1996 to1997.*

Coding Criteria No. % (95% CI)

Treatment need status

No need 1,073 73.0 (67.6–78.4)Unmet need 415 27.0 (21.6–32.3)Criteria for unmet treatment need 415 100.0y

Want treatment 29 8.0 (4.2–11.6)DSM-IV current dependence 52 14.7 (9.6–17.9)Self-diagnosed current dependence 74 19.9 (12.7–25.9)Past treatment/current use 78 18.0 (12.6–23.5)Past treatment/test positivez 48 11.2 (8.2–14.2)Past treatment/test refusal 28 6.3 (1.9–10.7)DSM-IV lifetime dependence/currentuse

194 47.4 (41.0–53.7)

DSM-IV lifetime dependence/testpositivez

120 27.4 (22.9–31.8)

DSM-IV lifetime dependence/testrefusal

63 16.0 (11.0–21.0)

Self-diagnosed lifetime dependence/current use

148 36.1 (31.6–40.5)

Self-diagnosed lifetime dependence/test positivez

101 23.4 (20.2–26.6)

Self-diagnosed lifetime dependence/test refusal

55 13.1 (10.6–15.5)

Deny current use/test positivez 131 32.0 (28.3–35.7)

CI, Confidence interval.

*Percentages are based on the sample weighted for the unequal probability of

hospital selection.yPercentages and numbers corresponding to reasons patients are coded as

needing treatment reflect qualification through multiple criteria and exclude 14

patients who reported that they were currently receiving substance abuse

treatment. Thus, summed percentages well exceed 100% of patients (415)

determined to have unmet treatment need.zPositive alcohol in saliva or other psychoactive drugs in urine (except when

indicating appropriate use of prescription drugs).

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represented among the ED patients too severely injured toparticipate in our study.31 Moreover, nonparticipants in generaland participants who refused toxicologic screening may havebeen more selective of substance abusers than their counterparts.On the other hand, misclassification of casual substance users asabusers would upwardly bias the prevalence of unmet substanceabuse treatment need. However, such misclassification wouldtend to depress the magnitude of utilization gaps between thestudy and comparison groups.

Excess costs associated with previous ED visits would beunderestimated if the study group were prone to underreporttheir use of health services relative to the comparison group.Although the 2 variables are not equivalent, some suggestion ofselective underreporting can be gleaned from comparing thehospitalization history that we elicited from self-reports with theED case disposition that we determined from hospital records.Whereas treatment need status did not predict the retrospectivehospitalizations, patients with unmet need had an 81% greaterlikelihood of being admitted during their current ED visit thanpatients without substance abuse treatment need.

We assumed equal duration of hospital stay across treatmentneed status. This assumption would upwardly bias our excesshospitalization cost estimates if the mean length of stay wereshorter for ED patients with unmet treatment need thanpatients without substance abuse treatment need. We lacked thedata to investigate this possibility. Also, we did not screen forpsychiatric disease and treatment need. Because psychiatricdisease is likely to be collinear with substance abuse treatmentneed,32-34 this may upwardly bias our estimates of excessutilization and costs among ED patients. Other limitations arethat we could not differentiate costs attributable to injury andillness and were unable to estimate costs attributable to patientstoo ill or injured to participate in the study. Nevertheless, webelieve that the net effect of all stated biases would be to makeour upper limit for the overall estimated cost of excess serviceutilization a closer approximation of the true cost than ourlower limit.

DISCUSSIONMerging toxicologic screening with patient self-histories, we

used a comprehensive case definition to better identify adult EDpatients in Tennessee with untreated chronic substance abuseproblems. Compared with patients without substance abusetreatment need, patients with unmet need exhibited excess useof hospital outpatient and inpatient services. They had analmost twofold risk of being admitted during their current EDvisit. That unmet substance treatment need status did notdifferentiate case disposition in the bivariate analysis (Table 3)underscores the importance of adjusting for probable con-founders, particularly age, in the multivariate analysis (Table 4).The multivariate analysis further showed that patients withunmet need reported 46% excess utilization of ED services.This finding was consistent with the 30% excess utilization thatwas estimated from the 1994 National Household Survey onDrug Abuse in a comparison of chronic drug users with casual

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Table 3A. Self-reported utilization of health services in the past 12 months by substance abuse treatment need status:Tennessee ED patients, 1996 to 1997.*

Frequency, %

Type of Past

Service Utilization/Treatment Need Status No. 0 1 2 3 4C Total % P Valuey

Physician office visits

Unmet need 415 21.2 16.2 13.5 11.8 37.3 100No need 1,068 16.7 17.3 12.6 9.5 43.9 100 .03ED visits

Unmet need 414 47.6 19.9 10.7 7.7 14.1 100No need 1,070 54.4 17.9 11.9 6.1 9.7 100 .01Hospital admissions

Unmet need 415 74.4 16.3 4.2 1.7 3.5 100No need 1,069 75.4 16.0 4.8 1.5 2.3 100 .66

*Percentages are based on the sample weighted for the unequal probability of hospital selection.yWilcoxon-Mann-Whitney test was used to assess rank differences according to substance abuse treatment need status.

Table 3B. Case disposition in the past 12 months by substance abuse treatment need status: Tennessee ED patients,1996 to 1997.*

Case Disposition,

% Current Hospital Admission

Treatment Need Status No. Yes No Total % P Valuey

Unmet need 384 16.1 83.9 100No need 990 15.2 84.8 100 .68

*Percentages are based on the sample weighted for the unequal probability of hospital selection.yc2 Test was used to assess difference according to substance abuse treatment need status.

users and nonusers.12 Using 2000 as the index year, ED patientswith unmet substance abuse treatment need generate anestimated US$777 million, or US$1,568 per patient, in extraED and hospitalization charges annually.

One of the United States Healthy People 2010 objectives is‘‘to increase the proportion of persons who are referred forfollow-up care for alcohol problems, drug problems, or suicideattempts after diagnosis or treatment for one of these conditionsin a hospital emergency department.’’35 Achievement of thisobjective has the committed support of the emergency medicinecommunity. However, adoption of screening, intervention, andreferral regimens in EDs is impeded by scarce resources,conflicting priorities, and clinical inertia.30,36 A related barrier isthe real and perceived likelihood that insurers will refuse toreimburse hospitals in cases in which patients have testedpositive for alcohol or other substances.37-39 In addition, thefunding environment for substance abuse treatment haschanged and become more complex.40-42 A national trendanalysis determined that individuals with the greatest need forsubstance abuse treatment, especially inpatient treatment,experienced reduced insurance coverage during 1987 to 1996,whereas those with less intensive treatment gained coverage.43

Exemplified by diagnoses of alcohol intoxication and drugoverdose, another impediment to screening and intervention

6 Annals of Emergency Medicine

might be a tendency among emergency physicians to regardsubstance abuse disorders as acute rather than chronicproblems.30 Alternatively, they may deliberately overlook thechronic dimension because their hospitals lack appropriateresources to initiate follow-up, including such key auxiliarystaff as social workers or substance abuse counselors. They arealso likely cognizant that substance abuse screening in EDsneeds the support of primary care providers for referraland treatment and that continuity of care is problematicin a fragmented health care system such as that ofTennessee.

Emergency physicians are more prone to ‘‘blame thevictim’’ when patients have substance abuse disorders thanwhen they have diabetes, asthma, or hypertension.44 Yet all 4conditions share implications for lifelong management andetiologic similarities and uncertainties about potential genetic,behavioral, and environmental determinants. One reviewfound that 40% to 60% of adult patients treated for substancedependence remained continuously abstinent after 12 monthsof follow-up, an observation period that is standard inevaluating treatment effectiveness.45 By comparison, adultpatients being treated for type 2 diabetes showed corre-sponding therapeutic compliance less than 60%, and forasthma or hypertension patients it was less than 40%.

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Table 4. Predictors of utilization of health services by type: Tennessee ED patients.*

Service Type, OR (95% CI)

Predictor

R4 Physician

Office Visits in Past

12 Months

R1 ED Visits in Past

12 Months

R1 Hospital

Admissions in Past

12 Months Current Hospital Admission

Age, y

18–24 (referent) 1.00 1.0025–44 1.46 (1.04–2.11) 1.95 (1.06–5.19)45–64 1.41 (0.91–2.08) 4.44 (2.49–12.32)R65 1.33 (0.78–2.45) 13.77 (6.93–34.66)Reason for visit

Illness (referent) 1.00 1.00Injury 1.47 (1.10–2.00) 1.48 (1.17–1.89)Health care coverage

Private insurance (referent) 1.00 1.00 1.00TennCare 2.05 (1.53–2.66) 1.66 (1.22–2.15) 1.72 (1.22–2.54)Medicare 1.89 (1.21–3.14) 1.40 (0.87–2.02) 3.66 (2.53–6.04)Uninsured 0.43 (0.24–0.67) 0.79 (0.50–1.09) 0.53 (0.27–0.94)Perceived health status

Excellent/very good/good(referent)

1.00 1.00 1.00

Fair/poor 3.94 (3.00–5.34) 2.74 (2.15–3.39) 2.62 (1.90–3.36)Substance abuse

treatment need

No need (referent) 1.00 1.00Unmet need 1.46 (1.12–1.84) 1.81 (1.27–2.64)

ED, Emergency department; OR, odds ratio.

*The logistic regression analyses are based on the sample weighted for the unequal probability of hospital selection.

Moreover, the compliance of those 3 patient groups tocrucial prescribed dietary or behavioral changes was lessthan 30%.

There exist innovative and inexpensive substance abusescreening, intervention, and referral programs that hospitals couldconsider for adoption. An example is Project ASSERT (improv-ing Alcohol and Substance abuse Services and Educatingproviders to Refer patients to Treatment).46,47 This programassigns community health advocates or community outreachworkers primary responsibility for identifying substance-abusingpatients in the ED and facilitates timely referrals through linkagewith community treatment centers. Rapid linkage induces suchpatients to enter treatment.48

There is no 1-size-fits-all treatment modality,49 and evenbrief interventions by health care providers can be effective.50-54

ED patients who are substance abusers but not dependent aremore likely to comply with brief interventions and treatmentmodalities than dependent patients.46,50,55-60 Their highprevalence in the Tennessee study argues for the importance ofassessing severity when ED patients are screened for substanceabuse problems. To this end, there is a need to design andevaluate brief screening instruments, akin to AUDIT (AlcoholUse Disorders Identification Test), CAGE (Cut down, Annoyed,Guilty, Eye opener), RAPS4 (Rapid Alcohol Problems Screen),and Brief MAST (Michigan Alcohol Screening Test), whichcover other substances besides alcohol. A promising instrumentthat has been tested among ED patients in Mexico City is therapid drug problems screen.61

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A group of ED patients that warrants intensive investigationof screening, utilization of services, intervention, and treatmentneed is marijuana users. The highest prevalence of Tennesseeadult ED patients testing positive on the saliva alcohol or urinedrug screen was for marijuana (15%).8 Of this patient subset,57% denied such use in the previous 30 days. Although useremained constant, a trend analysis of face-to-face survey datashowed that the prevalence of marijuana dependence and abusein the United States increased between 1991 and 1992 and2001 and 2002.62

We recommend that research be conducted on the healthcare utilization and costs attributable to ED patients currentlyreceiving substance abuse treatment. In estimating avoidablehealth care costs attributable to such treatment, cost-offsetstudies have subtracted those added costs incurred through thetreatment itself.63-65 Although ED patients were not the focus,findings from this research suggest that screening, intervention,and treatment for substance abuse can be highly cost-effective.Targeting alcoholics, one study reported 24% lower health carecosts for treated versus untreated patients during a 14-yearfollow-up period.66 Furthermore, for high-intensity drinkerswho are injured, ED visits can represent teachable moments andinduce readiness to change.67 However, randomized controlledtrials will be necessary to address cost-offset specifics within thehospital ED arena across the spectrum of patients with varyingsubstance abuse problems, presenting complaints, and diagnosesand to optimize the identification and matching of compliantpatients to appropriate treatment modalities.

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Table 5. Excess health services–specific costs for ED patients with unmet substance abuse treatment need: Tennessee, 2000.*

Cost Components

R1 ED Visits in

Past 12 Months (A)

Current Hospital

Admission (B) Total Costs (C)=(A)C(B)

Patients with unmet treatmentneed, %

P 27.00 27.00

Excess risk of utilization RR�1y 1.21�1.00=0.21 1.61�1.00=0.61State total hospital charges T $4.18 billion $3.28 billion $7.46 billionTotal excess costs, Tennessee EC=T�P�(RR�1) $237.0 million $540.2 million $777.2 millionEstimated number of ED patientswith unmet treatment needz

N 495,560 495,560

Mean excess per-patient costs EC/N $478 $1,090 $1,568

P, Proportion of patients with unmet substance abuse treatment need; RR, rate ratio; T, the total charges for patientsR18 y for the type of service under review; EC,

excess costs; N, estimated number of ED patients with unmet substance abuse treatment need.

*The data source for patient numbers and hospital charges is the Tennessee Department of Health. Patient data were adjusted to conform to the age cutoff ofR18 y

that was used in this study for subject eligibility.yRate RatioðRRÞ ¼ OR

1þp0 ðOR�1Þ. For example, RR ¼ 1:461þ0:456ð1:46�1Þ ¼ 1:21, where p0 is the probability that ED patients not needing substance abuse treatment need

reported makingR1 previous ED visit in the past 12 months, and OR is the ratio of the respective odds of past service utilization by ED patients with unmet substance

abuse treatment need and no substance abuse treatment need. The p0 and OR estimates derive from Tables 3 and 4, respectively.zThis is the product of the number of Tennessee adult ED patients in 2000 multiplied by the estimated prevalence of unmet substance abuse treatment need in that

population.

For their assistance with the study, we thank James Malia, PhD,Tanya Ergh, PhD, Michelle Blackwell, MS, Fred Stout, MS, andother staff from the Community Health Research Group at TheUniversity of Tennessee, Knoxville; and Kevin Smith, MA, andLinda Lilly, MA.

Author contributions: IRHR and SLP conceived and designedthe study with assistance from GSS and CFC. SLP and IRHRobtained the funding. SLP and IRHR supervised data collec-tion, and SLP and HJ managed the data. IRHR, SLP, and GSSreviewed the literature. IRHR, SLP, HJ, CFC, and GSS analyzedand interpreted the data and drafted the manuscript. IRHR,SLP, and HJ take responsibility for the paper as a whole.

Received for publication April 14, 2004. Revision receivedJuly 16, 2004. Accepted for publication August 6, 2004.

Preliminary results were presented at the annual meetings ofthe Kettil Bruun Society for Social and EpidemiologicalResearch on Alcohol and the International Council on Alcoholand Addictions, Toronto, Canada, May 2001, and theAmerican Public Health Association, Atlanta, GA, October2001.

Supported by the Substance Abuse and Mental HealthServices Administration, Center for Substance Abuse Treat-ment (1H79TI12235-01), and the Tennessee Department ofHealth, Bureau of Alcohol and Drug Abuse Services. Additionalsupport for Dr. Smith was provided by the National Institute ofAlcohol Abuse and Alcoholism (R29AA07700).

Address for reprints: Ian R. H. Rockett, PhD, MPH, De-partment of Community Medicine, West Virginia UniversitySchool of Medicine, Health Sciences Center, PO Box 9190,Morgantown, WV 26506-9190; 304-293-5325, fax 304-293-6685; E-mail irockett@hsc.wvu.edu.

8 Annals of Emergency Medicine

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Short abstract for Rockett et al, YMEMWhat isalready known on this topic. The potential impact ofidentifying emergency department (ED) patientswith chronic substance abuse for intervention andreferral is unknown. What question this studyaddressed. The utilization of health care services(outpatient, ED, and inpatient) and the associatedcosts for patients seen in the ED with unmettreatment needs for chronic substance abuse wereassessed. What this study adds to our knowledge. InTennessee, these patients had more ED visits andincreased health care costs compared with otherpatients. They were almost twice as likely to needadmission to the hospital and had 46% excessutilization of ED services. How this might changeclinical practice. This study provides a background forfurther research into whether providing preliminarydrug counseling and referral has the potential todecrease excess ED visits and health care costs forpatients with chronic substance abuse.

10 Annals of Emergency Medicine

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