Dual diagnosis patients in community or hospital care: One-year outcomes and health care utilization and costs

Abstract

Background: Services for dual diagnosis patients are strained by reductions in hospital-based inpatient treatment facilities and the lengths of inpatient stays in order to reduce health care costs. Aims: This study evaluated the effectiveness and cost-effectiveness of community- and hospital-based acute residential treatment for dually disordered patients, and whether moderately-ill patients benefitted more from community care, and severely-ill patients from hospital care. Method: Patients (N ¼230) with dual substance use and psychiatric disorders were randomly assigned to community or hospital acute care programs that had the same level of service-intensity. They were followed for 1 year (80%) using the Addiction Severity Index. Patients' health care utilization was assessed from charts, VA databases, and health care diaries; costs were assigned using methods established by the VA Health Economics Resource Center. Results: Patients had better substance use outcomes when they were initially assigned to community rather than to hospital acute care. Patients assigned to hospital care had shorter index stays, but these index stays were more costly than were the longer index stays of patients assigned to community care. Patients assigned to hospital care also had more mental health follow-up outpatient visits, and more costly mental health follow-up stays, over the study year. Conclusions: Cost savings may be achieved without loss of benefit to all but the most decompensated dually disordered patients by shifting the locus of acute treatment from hospital to community care. Declaration of interest: This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. We thank Rudolf Moos for his valuable contributions to this study.