Med Policy: The Problem with Otis

Remember, Otis, the friendly drunk who would sleep it off overnight in Andy's jail. Well, now imagine thousands of Otis's throughout San Diego repeatedly getting arrested and utilizing medical resources. An April 2006 study in the Annals of Emergency Medicine talked about how offering placement in a halfway house as an alternative to 3 days in jail can result in fewer trips to the ED and the doctor.

This study documents the extraordinary consumption of EMS, ED, and inpatient resources by one city’s population of homeless chronic alcoholics. Assuming an average observation period of 4.5 hours (Dunford, unpublished data) these patients consumed nearly 15,000 hours of ED staff time at 2 of San Diego’s major regional hospitals, which equates to a 34% chance that a Serial Inebriate Program client was occupying an ED bed at one of these facilities at any moment during the 4-year study. These data provide evidence that a relatively small number of individuals can have a large impact on a community’s safety net.

There was a 50% decline in the use of ED, inpatient, and EMS resources for the 156 individuals who accepted a 6-month outpatient treatment program in lieu of custody. Conversely, there was no change in resource consumption by the 112 individuals who elected not to enter treatment. The Serial Inebriate Program’s success derived primarily from its impact on the most recidivist individuals. Those accepting treatment were typically older men who had been transported by EMS and treated in ED twice as often as nonacceptors.

The median number of ED visits declined from 15 to 9 (P<.01), median ED costs declined from $4,124 to $2,195 (P<.01), median inpatient costs declined from $8,330 to $2,786 (P<.01), and alcohol use was reduced by 25% (P=.05). The authors concluded that each dollar invested yielded a $1.44 savings.

That means that the biggest leaches on health services were more likely to accept the program and ultimately end up using less emergency medical services (presumably because they were doing better). This is a great example of how social welfare programs can help people avoid prison, result in improved personal outcomes, and less cost to society. Additionally, it also seems to demonstrate how locking people up for substance abuse may be both ineffective and counterproductive.