No abstract

Context The COMBINE clinical trial recently evaluated the efficacy of medications, behavioral therapies, and their combinations for the outpatient treatment of alcohol dependence. The costs and cost-effectiveness of these combinations are unknown and of interest to clinicians and policy makers. Objective To evaluate the costs and cost-effectiveness of the COMBINE interventions at the end of 16 weeks of treatment. Design, Setting, and Participants A prospective cost and cost-effectiveness study of patients in COMBINE, a randomized controlled clinical trial (RCT) involving 1383 patients with diagnoses of primary alcohol dependence across 11 US clinical sites. Interventions Nine treatment arms, with 4 arms receiving medical management with 16 weeks of naltrexone (100 mg/d) or acamprosate (3 g/d), both, and/or placebo; 4 arms receiving the same options as above but delivered with combined behavioral intervention (CBI); and 1 arm receiving CBI only. Main Outcomes Measures Incremental cost per percentage point increase in percent days abstinent (PDA), incremental cost per patient of avoiding heavy drinking, and incremental cost per patient of achieving a good clinical outcome. Results Based on the mean values of cost and effectiveness, 3 interventions are cost-effective options relative to the other interventions for all three outcomes: medical management (MM) with placebo ($409 cost per patient), MM + naltrexone ($671 cost per patient), and MM + naltrexone + acamprosate ($1003 cost per patient). Conclusions This is only the second prospective RCT-designed cost-effectiveness study that has been performed for the treatment of alcohol dependence. Focusing just on effectiveness, MM + naltrexone + acamprosate is not significantly better than MM + naltrexone. However, looking at cost and effectiveness, MM + naltrexone + acamprosate may be a cost-effective choice, depending on whether the cost of the incremental increase in effectiveness is worth it to the decision maker.

ABSTRACT. Objective: This article summarizes the literature on the implementation costs of alcohol screening and brief intervention (SBI) in medical settings. Method: Electronic databases were searched using SBI-and cost-related terms. Methodological approaches and cost estimates were abstracted from each study and categorized based on the cost methodology. Costs were updated to 2009 U.S. dollars. To determine a summary cost measure, we excluded outliers and computed the median of the remaining cost estimates. Results: Seventeen studies with cost estimates were identifi ed for further study. Costs ranged from $0.51 to $601.50 per screen and from $3.41 to $243.01 per brief intervention (BI). Cost estimates were lower when an activity-based cost methodology was used, in primary care settings, and when the provider was not a doctor. The median summary cost of a screen is approximately $4, and the median summary cost of a BI is approximately $48. Conclusions: Screening cost estimates had more variation than BI cost estimates. Provider type and service delivery time drive the cost variation. Interpretation of cost differences was limited by insuffi cient reporting of the cost methodology. Cost estimates presented here are similar in size to the Healthcare Common Procedure Coding System and Current Procedural Terminology reimbursement amounts, suggesting that insurance-based service reimbursement may be suffi cient to sustain alcohol SBI in practice. (J. Stud. Alcohol Drugs, 73, 911-919, 2012)

QM, a novel gene that was originally identified as a putative tumor suppressor gene, has since been cloned from species encompassing members of the plant, animal, and fungal kingdoms. Sequence comparison indicates that QM has been highly conserved throughout eukaryotic evolution. QM is a member of a multigene family in both mouse and man, is expressed in a broad range of tissues, and is downregulated during adipocyte differentiation. Jif‐1, a chicken homolog of QM, has been reported to interact with the protooncogene c‐Jun, and to inhibit transactivation of AP‐1 regulated promoters in vitro. Furthermore, disruption of the yeast QM homolog is lethal. Although these studies suggest that the QM gene product plays an important role within the normal cell, the precise role of QM has remained elusive. In this study, a thorough analysis of the pattern of QM expression during mouse development was undertaken, using the techniques of whole mount in situ hybridization and whole mount immunohistochemistry, in combination with conventional immunohistochemical analysis of tissue sections. QM is expressed in numerous embryonic tissues, and is differentially expressed throughout the embryo. The cytoplasmic localization of QM is consistent with its reported association with ribosomes, and inconsistent with its previously hypothesized function as a direct modulator of the nuclear protooncogene c‐Jun. QM is expressed in the developing epidermis, and is particularly strong within developing limbs. Analysis of embryos of various stages of gestation indicate that QM is downregulated in the surface ectoderm of the embryo as development proceeds. QM protein is not detectable within either nucleated or enucleated red blood cell precursors. QM is strongly expressed within chondrocytes within the transition zone of developing limb cartilage, as well as within differentiated keratinocytes of the suprabasal regions of the epidermis. Furthermore, within both cartilage and skin, there is an inverse relationship between QM expression and proliferative capacity. This pattern of QM expression suggests that this novel gene product may be involved in processes such as posttranslational protein processing which are essential for differentiation of specific tissues during embryogenesis.