Cost-Effectiveness of the START Hospital Addiction Consultation Service for Opioid Use Disorder Treatment

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.