Cost-Effectiveness of Housing First With Assertive Community Treatment: Results From the Canadian At Home/Chez Soi Trial
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Participants
Sample Recruitment and Randomization
Interventions
Data Collection
Choice of Outcome Measure
Perspective of the Economic Analysis
Calculation of Costs per Individual
Discounting
Statistical Analysis
Sensitivity analyses
Results
Housing First (N=469) | Treatment as usual (N=481) | |||
---|---|---|---|---|
Characteristic | N | % | N | % |
Age group | ||||
<30 | 110 | 24 | 109 | 23 |
30–49 | 280 | 60 | 275 | 57 |
≥50 | 79 | 17 | 97 | 20 |
Sex | ||||
Female | 143 | 31 | 148 | 31 |
Male | 320 | 68 | 329 | 68 |
Other | 6 | 1 | 4 | 1 |
Substance abuse or dependence | ||||
Alcohol | 213 | 45 | 223 | 46 |
Drug | 286 | 61 | 280 | 58 |
Alcohol or drug | 333 | 71 | 359 | 75 |
Hospitalization historya | 238 | 51 | 261 | 54 |
Arrest historyb | 201 | 43 | 203 | 42 |
Homelessness | ||||
Longest period (M±SD months) | 35.1±53.6 | 32.6±46.7 | ||
Median period (interquartile range) | 16 (6, 36) | 13 (6, 36) | ||
MCASc | ||||
Score (M±SD) | 54.5±7.4 | 54.4±7.2 | ||
Median (interquartile range) | 55.0 (50.0–60.0) | 55.0 (50.0–60.0) | ||
Study site | ||||
Moncton | 101 | 22 | 100 | 21 |
Montreal | 81 | 17 | 82 | 17 |
Toronto | 97 | 21 | 100 | 21 |
Winnipeg | 100 | 21 | 99 | 21 |
Vancouver | 90 | 19 | 100 | 21 |
Treatment as usual (N=454) | Housing First (N=463) | Difference (Housing First– treatment as usual) | ||||
---|---|---|---|---|---|---|
Cost category and time | M | 95% CI | M | 95% CI | M | 95% CI |
Shelters | ||||||
Baseline | 6,412 | 5,518, 7,287 | 6,245 | 5,347, 7,037 | –168 | –1,363, 980 |
First year | 4,363 | 3,751, 5,091 | 1,840 | 1,502, 2,247 | –2,523 | –3,373, –1,821 |
Second year | 2,280 | 1,819, 2,748 | 917 | 664, 1,205 | –1,364 | –1,891, –853 |
Mean of first and second years | 3,322 | 2,836, 3,853 | 1,379 | 1,125, 1,669 | –1,943 | –2,554, –1,431 |
Substance use treatment | ||||||
Baseline | 1,171 | 644, 1,822 | 1,476 | 828, 2,169 | 305 | –659, 1,139 |
First year | 1,794 | 1,134, 2,681 | 604 | 347, 896 | –1,190 | –2,085, –416 |
Second year | 1,325 | 843, 1,813 | 921 | 530, 1,346 | –404 | –1,061, 222 |
Mean of first and second years | 1,559 | 1,108, 2,109 | 762 | 505, 1,018 | –797 | –1,463, –256 |
Supportive housingb | ||||||
Baseline | 2,146 | 1,536, 2,916 | 1,506 | 992, 2,207 | –640 | –1,494, 224 |
First year | 2,576 | 1,977, 3,287 | 608 | 412, 830 | –1,968 | –2,690, –1,370 |
Second year | 2,367 | 1,814, 3,007 | 750 | 497, 1,054 | –1,617 | –2,288, –955 |
Mean of first and second years | 2,472 | 1,956, 3,053 | 679 | 497, 893 | –1,793 | –2,437, –1,249 |
Ambulatory visits | ||||||
Baseline | 14,755 | 12,499, 17,150 | 18,585 | 15,438, 21,618 | 3,830 | 52, 7,725 |
First year | 11,480 | 9,591, 13,683 | 5,145 | 4,460, 5,881 | –6,335 | –8,714, –4,212 |
Second year | 8,081 | 6,726, 9,847 | 4,898 | 4,053, 5,993 | –3,182 | –5,092, –1,358 |
Mean of first and second years | 9,780 | 8,437, 11,488 | 5,021 | 4,400, 5,649 | –4,759 | –6,495, –3,233 |
ED visits | ||||||
Baseline | 2,834 | 2,418, 3,275 | 3,423 | 2,729, 4,126 | 590 | –220, 1,378 |
First year | 1,850 | 1,535, 2,298 | 1,915 | 1,467, 2,340 | 65 | –581, 578 |
Second year | 1,529 | 1,230, 1,920 | 1,789 | 1,421, 2,163 | 260 | –273, 712 |
Mean of first and second years | 1,689 | 1,402, 2,105 | 1,852 | 1,466, 2,249 | 162 | –419, 600 |
Hospitalizations (physical) | ||||||
Baseline | 1,518 | 474, 2,842 | 2,300 | 875, 4,071 | 782 | –1,374, 2,838 |
First year | 2,498 | 1,403, 3,881 | 2,292 | 1,200, 3,667 | –205 | –2,081, 1,815 |
Second year | 4,268 | 2,701, 6,269 | 3,175 | 1,969, 4,557 | –1,093 | –3,535, 1,038 |
Mean of first and second years | 3,383 | 2,228, 4,657 | 2,734 | 1,960, 3,841 | –649 | –2,109, 950 |
Hospitalizations (psychiatric) | ||||||
Baseline | 21,491 | 16,241, 27,280 | 25,209 | 19,442, 31,378 | 3,718 | –4,218, 11,669 |
First year | 13,153 | 9,270, 16,984 | 11,096 | 7,929, 14,175 | –2,057 | –7,028, 3,366 |
Second year | 11,798 | 8,353, 15,417 | 7,689 | 5,173, 10,586 | –4,109 | –8,762, 360 |
Mean of first and second years | 12,476 | 8,982, 16,226 | 9,393 | 7,086, 11,811 | –3,083 | –7,216, 1,275 |
Other (e.g., help lines, day centers) | ||||||
Baseline | 3,370 | 2,937, 3,864 | 3,198 | 2,681, 3,691 | –172 | –846, 471 |
First year | 1,593 | 1,412, 1,808 | 1,390 | 1,170, 1,610 | –203 | –483, 85 |
Second year | 1,066 | 909, 1,242 | 999 | 813, 1,178 | –67 | –313, 174 |
Mean of first and second years | 1,329 | 1,185, 1,483 | 1,194 | 1,009, 1,359 | –135 | –350, 89 |
Police | ||||||
Baseline | 12,811 | 10,920, 15,123 | 11,077 | 9,220, 13,032 | –1,734 | –4,834, 1,246 |
First year | 9,003 | 7,372, 10,938 | 7,968 | 6,530, 9,409 | –1,035 | –3,561, 1,245 |
Second year | 6,779 | 5,638, 8,119 | 6,534 | 5,301, 7,937 | –245 | –1,976, 1,566 |
Mean of first and second years | 7,891 | 6,667, 9,201 | 7,251 | 6,096, 8,478 | –640 | –2,411, 1,117 |
Incarcerations | ||||||
Baseline | 3,737 | 2,641, 5,021 | 3,422 | 2,305, 4,499 | –315 | –1,954, 1,349 |
First year | 4,256 | 3,105, 5,390 | 2,948 | 1,971, 3,942 | –1,308 | –3,001, 257 |
Second year | 4,747 | 3,487, 6,123 | 3,084 | 2,185, 4,085 | –1,663 | –3,309, –28 |
Mean of first and second years | 4,501 | 3,423, 5,555 | 3,016 | 2,125, 3,851 | –1,485 | –3,001, –73 |
Welfare and disability benefits | ||||||
Baseline | 2,651 | 2,505, 2,826 | 2,931 | 2,766, 3,106 | 279 | 36, 531 |
First year | 8,244 | 7,908, 8,625 | 8,954 | 8,574, 9,321 | 711 | 159, 1,235 |
Second year | 9,023 | 8,688, 9,369 | 9,652 | 9,281, 10,026 | 629 | 117, 1,110 |
Mean of first and second years | 8,633 | 8,325, 8,965 | 9,303 | 8,948, 9,641 | 670 | 190, 1,119 |
Income earned | ||||||
Baseline | 280 | 178, 385 | 121 | 76, 180 | –159 | –278, –34 |
First year | 903 | 613, 1,266 | 428 | 306, 584 | –474 | –858, –159 |
Second year | 1,001 | 732, 1,322 | 682 | 455, 913 | –319 | –716, 36 |
Mean of first and second years | 952 | 677, 1,277 | 555 | 400–733 | –397 | –776, –105 |
Total excluding intervention cost | ||||||
Baseline | 71,738 | 65,179, 78,101 | 78,144 | 71,198, 85,620 | 6,406 | –2,831, 16,234 |
First year | 59,906 | 54,486, 65,263 | 44,332 | 40,338, 47,822 | –15,575 | –21,716, –9,225 |
Second year | 52,262 | 47,354, 57,285 | 39,725 | 35,903, 43,701 | –12,537 | –18,849, –6,396 |
Mean of first and second years | 56,084 | 51,501, 60,828 | 42,028 | 38,750, 45,141 | –14,056 | –19,823, –8,991 |
Total including intervention cost | ||||||
First year | 59,906 | 54,486, 65,263 | 65,988 | 61,727, 69,968 | 6,081 | –592, 12,710 |
Second year | 52,262 | 47,354, 57,285 | 58,802 | 54,073, 63,415 | 6,540 | –467, 12,904 |
Mean of first and second years | 56,084 | 51,501, 60,828 | 62,395 | 58,843, 65,897 | 6,311 | 309, 12,350 |
Treatment as usual (N=454) | Housing First (N=453) | Difference (Housing First– treatment as usual) | ||||
---|---|---|---|---|---|---|
Cost category and time | M | 95% CI | M | 95% CI | M | 95% CI |
Cost of ACT teamb | — | — | ||||
Moncton | 7,205 | 5,954, 8,797 | ||||
Montreal | — | — | 16,261 | 13,739, 19,241 | — | — |
Toronto | — | — | 13,066 | 10,581, 15,417 | — | — |
Winnipeg | — | — | 12,620 | 9,592, 15,886 | — | — |
Vancouver | — | — | 15,613 | 13,506, 18,375 | — | — |
Cost of housing team and rent supplements | — | — | ||||
Moncton | 9,603 | 9,149, 10,111 | ||||
Montreal | — | — | 5,565 | 4,839, 6,196 | — | — |
Toronto | — | — | 8,475 | 7,712, 9,221 | — | — |
Winnipeg | — | — | 4,937 | 4,355, 5,446 | — | — |
Vancouver | — | — | 9,274 | 8,571, 9,890 | — | — |
Total cost without intervention | ||||||
Moncton | 29,566 | 24,993, 34,258 | 27,573 | 21,184, 35,632 | –1,993 | –10,572, 7,107 |
Montreal | 70,258 | 59,501, 80,567 | 49,857 | 43,625, 56,715 | –20,401 | –32,669, –7,594 |
Toronto | 76,960 | 64,376, 91,223 | 51,034 | 43,040, 58,835 | –25,926 | –41,936, –11,896 |
Winnipeg | 47,947 | 40,769, 54,586 | 40,210 | 35,215, 45,329 | –7,737 | –16,761, 1,154 |
Vancouver | 59,272 | 48,895, 70,416 | 43,738 | 37,065, 51,032 | –15,534 | –28,201, –3,463 |
Total cost including | ||||||
intervention | ||||||
Moncton | 29,566 | 25,117, 34,371 | 44,381 | 37,542, 51,165 | 14,815 | 6,577, 23,074 |
Montreal | 70,258 | 60,757, 80,724 | 71,682 | 65,488, 77,855 | 1,424 | –10,509, 13,195 |
Toronto | 76,960 | 65,404, 90,379 | 72,574 | 63,420, 82,072 | –4,386 | –22,357, 9,243 |
Winnipeg | 47,947 | 41,003, 57,103 | 57,766 | 51,512, 65,505 | 9,820 | –460, 20,763 |
Vancouver | 59,272 | 48,814, 69,954 | 68,625 | 61,217, 77,118 | 9,353 | –4,815, 21,993 |
λb=$0 | λb=$20 | λb=$40 | ||||
---|---|---|---|---|---|---|
Variable | M | 95% CI | M | 95% CI | M | 95% CI |
Housing First | –24,882 | –42,142, –7,621 | –21,994 | –39,457, –4,530 | –19,106 | –36,807, –1,404 |
Montrealc | –35,023 | –49,217, –20,828 | –36,087 | –50,444, –21,731 | –37,152 | –51,700, –22,604 |
Torontoc | –38,745 | –53,112, –24,378 | –39,445 | –53,977, –24,913 | –40,145 | –54,870, –25,419 |
Winnipegc | –15,066 | –28,386, –1,745 | –15,894 | –29,352, –2,435 | –16,721 | –30,344, –3,098 |
Vancouverc | –20,034 | –34,090, –5,978 | –21,061 | –35,282, –6,840 | –22,088 | –36,504, –7,672 |
Ages 30–49d | –9,010 | –19,241, 1,221 | –8,911 | –19,254, 1,433 | –8,811 | –19,287, 1,664 |
Ages ≥50d | 3,785 | –9,676, 17,246 | 4,098 | –9,511, 17,707 | 4,411 | –9,372, 18,194 |
Female | –3,278 | –9,851, 3,295 | –2,970 | –9,609, 3,668 | –2,663 | –9,380, 4,054 |
Alcohol or drug abuse or dependencee | –2,913 | –10,123, 4,296 | –2,968 | –10,262, 4,326 | –3,023 | –10,415, 4,370 |
MCAS scoref | 3,313 | –1,354, 7,980 | 3,657 | –1,066, 8,379 | 4,000 | –786, 8,786 |
Hospitalization historyg | –13,840 | –23,075, –4,606 | –13,615 | –22,954, –4,276 | –13,390 | –22,851, –3,929 |
Arrest historyh | –4,983 | –11,111, 1,145 | –5,396 | –11,592, 800 | –5,810 | –12,086, 467 |
Longest period homelessi | –108 | –171, –45 | –110 | –174, –46 | –112 | –176, –47 |
Interaction terms | ||||||
Montreal × Housing First | 12,542 | –7,152, 32,236 | 12,084 | –7,823, 31,991 | 11,626 | –8,529, 31,781 |
Toronto × Housing First | 19,223 | –31, 38,477 | 19,343 | –114, 38,800 | 19,463 | –233, 39,159 |
Winnipeg × Housing First | 5,740 | –12,217, 23,698 | 4,744 | –13,409, 22,897 | 3,747 | –14,636, 22,130 |
Vancouver × Housing First | 400 | –18,649, 19,449 | 744 | –18,519, 20,008 | 1,089 | –18,427, 20,605 |
Ages 30–49 × Housing First | 13,160 | –1,136, 27,457 | 13,480 | –976, 27,935 | 13,800 | –843, 28,442 |
Ages ≥50 × Housing First | 3,218 | –15,613, 22,050 | 3,413 | –15,632, 22,458 | 3,607 | –15,687, 22,901 |
Hospitalized × Housing First | 5,855 | –6,938, 18,647 | 6,063 | –6,875, 19,002 | 6,272 | –6,837, 19,381 |
Constant | –32,735 | –64,498, –971 | –31,942 | –64,073, 189 | –31,150 | –63,710, 1,410 |
λb=$60 | λb=$80 | λb=$100 | ||||
M | 95% CI | M | 95% CI | M | 95% CI | |
Housing First intervention | –16,217 | –34,189, 1,754 | –13,329 | –31,603, 4,944 | –10,441 | –29,047, 8,164 |
Montrealc | –38,217 | –52,983, –23,451 | –39,281 | –54,292, –24,271 | –40,346 | –55,626, –25,066 |
Torontoc | –40,845 | –55,791, –25,899 | –41,545 | –56,738, –26,352 | –42,245 | –57,711, –26,780 |
Winnipegc | –17,549 | –31,362, –3,736 | –18,377 | –32,403, –4,350 | –19,204 | –33,468, –4,941 |
Vancouverc | –23,115 | –37,756, –8,475 | –24,142 | –39,036, –9,249 | –25,170 | –40,343, –9,997 |
Ages 30–49d | –8,712 | –19,339, 1,914 | –8,613 | –19,409, 2,183 | –8,513 | –19,497, 2,470 |
Ages ≥50d | 4,724 | –9,257, 18,705 | 5,037 | –9,165, 19,240 | 5,350 | –9,096, 19,796 |
Female | –2,355 | –9,163, 4,452 | –2,048 | –8,958, 4,863 | –1,740 | –8,764, 5,284 |
Alcohol or drug abuse or dependencee | –3,077 | –10,581, 4,427 | –3,132 | –10,759, 4,495 | –3,186 | –10,948, 4,575 |
MCAS scoref | 4,344 | –514, 9,202 | 4,688 | –249, 9,624 | 5,031 | 8, 10,054 |
Hospitalization historyg | –13,165 | –22,765, –3,566 | –12,940 | –22,694, –3,186 | –12,715 | –22,639, –2,791 |
Arrest historyh | –6,223 | –12,591, 145 | –6,637 | –13,107, –166 | –7,050 | –13,634, –467 |
Longest period homelessi | –113 | –179, –48 | –115 | –181, –49 | –117 | –184, –50 |
Interaction terms | ||||||
Montreal × Housing First | 11,168 | –9,271, 31,607 | 10,710 | –10,045, 31,465 | 10,252 | –10,851, 31,355 |
Toronto × Housing First | 19,583 | –386, 39,552 | 19,703 | –574, 39,980 | 19,823 | –793, 40,439 |
Winnipeg × Housing First | 2,750 | –15,897, 21,397 | 1,754 | –17,189, 20,696 | 757 | –18,511, 20,025 |
Vancouver × Housing First | 1,433 | –18,372, 21,239 | 1,778 | –18,351, 21,907 | 2,123 | –18,364, 22,609 |
Ages 30–49 × Housing First | 14,119 | –737, 28,976 | 14,439 | –657, 29,535 | 14,759 | –602, 30,120 |
Ages ≥50 × Housing First | 3,801 | –15,776, 23,378 | 3,995 | –15,898, 23,888 | 4,190 | –16,050, 24,430 |
Hospitalized × Housing First | 6,481 | –6,821, 19,783 | 6,690 | –6,828, 20,208 | 6,899 | –6,856, 20,653 |
Constant | –30,358 | –63,405, 2,690 | –29,566 | –63,157, 4,026 | –28,773 | –62,962, 5,416 |
Discussion
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