Evaluation and Comparative Cost Analysis of the San Francisco Sobering Center as an Alternative to the Emergency Department for Individuals with Acute Alcohol Intoxication
- Author(s): Smith-Bernardin, Shannon Marie
- Advisor(s): Chapman, Susan
- et al.
Purpose: The purpose of this study was to investigate the San Francisco Sobering Center, provides short-term (4-12 hour) monitoring and nursing support for adults with acute alcohol intoxication. This study evaluated the programmatic outcomes, costs, and the population of individuals utilizing services.
Background: Sobering centers have emerged as an alternative care site to emergency department and jail for those with acute intoxication. There are approximately 20 sobering programs nationally and more internationally; yet there has been limited formal evaluation of sobering center-based care compared to the emergency department for intoxicated individuals.
Methods: Two distinct studies were completed within this collective study. The first analysis included users of the Sobering Center from July 2014 to June 2015. Continuous variables included age, length of homelessness, healthcare service utilization, and related costs. Categorical included ethnicity, housing status, homeless history, language, and gender. Lifetime health diagnoses were dichotomized as Yes/No utilizing the Elixhauser Comorbidity Index. We analyzed the data via analysis of variance, chi-square, and t-tests. The second analysis included a cross-sectional study examining the outcomes and costs of treating acute alcohol intoxication in a sobering center compared to the emergency department of a public hospital in San Francisco, California. All sobering center encounters from July 2010 to June 2014 were included for analysis. Subjects included from the San Francisco General Emergency Department from the same time period had: 1) a primary ICD-9 code related to acute alcohol intoxication adults; 2) visits lasting under 24 hours; 3) been discharged without admission or transfer to another healthcare facility; and 4) were aged 18 or older.
Results: The population analysis investigated the 1,271 unduplicated clients utilizing services in a single year for total 3,452 encounters. The population was primarily male (82%) and ethnically diverse. Unduplicated clients were distributed into two groups: low users (n=1013, 1-2 visits) and high users (n=258, 3+ visits). As compared to low users, high users were older (49.6 vs. 43.1 years, p<0.001), had a 100% a history of homelessness (vs. 72%, p<0.001); was more likely to be homeless during the last year (99 vs. 65%, p<0.001); and spent more time homelessness (9.1 vs. 5.7 years; p=0.000). High users had significantly higher rates of hypertension (41 vs. 19%), depression (64 vs. 33%), psychoses (46 vs. 21%), and drug abuse (63 vs. 33%) as compared to low users (p<0.001). In addition to sobering visits, utilization of ambulance (p=0.016) and ED (p<0.001) was significantly greater for the high users compared to low users. During the four-year period of analysis comparing the emergency department, there were 4,471 unduplicated clients who had 17,296 encounters at the Sobering Center, and 2,731 unduplicated clients accounting for 4,618 primary alcohol intoxication-related encounters in the ED. In evaluating the Sobering Center outcomes, we found a vast majority of encounters were able to sober safely and discharge either to self or to another program. Less than 4% of Sobering Center visits resulted in a discharge via ambulance to a medical or psychiatric emergency department, while less than 1% required police intervention. Our cost analysis compared direct actual costs of the ED to the per-encounter costs for the Sobering Center and found the Sobering Center was significantly less costly ($274.00, SE 0.06; p<0.001) than the ED ($517.85, SE 6.83) for care of acute intoxication.
Conclusions: Our analysis provides the first comprehensive look at the both the characteristics of the population using a sobering center and provided a comparative analysis to the emergency department. Our findings indicate the overall population, though heterogeneous, has substantial rates of homelessness, co-occurring diagnoses, and rates of system-wide utilization. High users as compared to low users had significantly greater prevalence of chronic disorders and homelessness. Sobering programs may be an important hub in which to connect with a medically and socially complex population. Our data suggest that a sobering center may be an appropriate, lower cost alternative to the emergency department in the care of the acutely intoxicated. Identifying funding sources for sobering programs, as an alternative to the emergency department, would be likely to save healthcare dollars.