Release Date:  September 16, 1998

PA NUMBER:  PA-98-104


National Institute on Alcohol Abuse and Alcoholism


The National Institute on Alcohol Abuse and Alcoholism (NIAAA) seeks health
services research grant applications that are aimed at increasing knowledge about
the cost of services for the treatment and prevention of alcoholism and alcohol-
related problems.  This knowledge can be increased through cost analysis studies,
cost effectiveness studies, cost benefit studies, cost offset studies, and cost
modeling studies.  It can also be increased through advances in the methods used
to measure costs of treatment and prevention interventions.  This program
announcement (PA) invites applications to study the costs of services to treat
and prevent alcoholism and alcohol-related problems, either by themselves or in
conjunction with the outcomes of these services.

The research objectives include, but are not limited to, the broad goal of
advancing scientific understanding of treatment and prevention costs and outcomes
as they relate to costs.  Studies of costs and outcomes of specific interventions
are encouraged, as are studies of the costs and outcomes of classes of
interventions (e.g., inpatient versus outpatient).  Studies to improve the
methodologies of estimating costs and comparing costs to outcomes are also


The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2000," a PHS-led national
activity for setting priority areas.  This PA, Cost Research on Alcohol Treatment
and Prevention Services, is related to the priority areas of alcohol abuse
reduction and alcoholism treatment.  Potential applicants may obtain a copy of
"Healthy People 2000" (Full Report:  Stock No. 017-001-00474-0 or Summary Report: 
Stock No.017-001-00473-1) through the Superintendent of Documents, Government
Printing Office, Washington, DC 20402-9325, (Telephone: 202-512-1800).


Applications may be submitted by domestic and foreign, for-profit and non-profit,
public and private organizations, such as universities, colleges, hospitals,
laboratories, units of State and local governments, and eligible agencies of the
Federal government.  Racial/ethnic minority individuals, women, and persons with
disabilities are encouraged to apply as Principal Investigators.


Research support may be obtained through applications for a regular research
project grant (R01) or Small Grant (R03).  Applications are also encouraged for
Exploratory/Developmental Grants (R21), which are limited to up to 2 years for
up to $100,000 for direct costs per year.  Applicants for an
Exploratory/Developmental Grant must cite the program announcement for Secondary
Analysis of Existing Health Services Data Sets PA-97-066 in addition to this
program announcement in their application.  Applicants may also submit
Investigator-Initiated Interactive Research Project Grants (IRPG) under this
program announcement.  IRPGs require the coordinated submission of related
regular research project grant applications from investigators who wish to
collaborate on research.

Potential applicants for an Exploratory/Developmental Grant may obtain copies of
the PA-97-066 from the NIAAA Home Page at or from the
Office of Scientific Affairs, NIAAA, 6000 Executive Boulevard, Suite 409, MSC
7003, Bethesda, MD 20892-7003, telephone: 301-443-4375 or fax 301-443-6077. 
Further information on grant mechanisms and areas of research interest may be
obtained from program staff listed under INQUIRIES.


An important goal of research is to evaluate both the costs and outcomes of
alcoholism treatment and prevention interventions.  The importance of this goal
is established by two considerations.  First, it is prudent to avoid wasting
resources available for the treatment of alcoholism.  The amount of resources
available to treat alcoholism typically falls short of need.  Hence, any dollars
spent for unnecessary or ineffective treatment reduce the amount that could be
used effectively.  Second, effective treatments need to be preserved against the
pressures of cost containment.  In an era that gives close scrutiny to all
medical care costs, cheaper therapies will displace more expensive ones unless
there is evidence that the higher costs of some therapies are justified by better

Economists recognize several varieties of cost research.  All of these are
pertinent to the study of alcohol treatment and prevention.  All of them are
encouraged under the terms of this announcement.

Cost analysis is the most basic.  It concerns the accurate measurement of costs. 
Given that most studies rely on charges for services rather than on true costs,
there is clearly room for improvement in this area.  In addition, the measurement
of cost is least well developed for publicly-funded treatment, despite the
growing importance of the publicly-funded treatment sector.

Cost effectiveness studies compare the costs of  treatments to their outcomes,
using non-monetary units to measure outcomes.  For example, for two treatment
interventions one might want to know the cost of each per treated client and the
proportion of clients who remained abstinent (or alternatively were free of
drinking-related problems) at six months after treatment.  A noteworthy subset
of cost effectiveness studies are those that measure outcomes in terms of quality
adjusted life years (QALYS; Patrick and Erickson 1993; Spilker 1990).  These are
also encouraged under the terms of this announcement.

Cost benefit studies measure both costs and outcomes in monetary units. This is
achieved by estimating monetary values for mortality, morbidity, and such outcome
variables as improved productivity and reduced criminality.

Cost offset analyses are, in fact, partial cost benefit analyses in which future
medical care costs are the only outcomes measured.  Historically, cost offset
research has formed the largest part of the cost research undertaken in the
alcohol field (Holder and Blose 1986, 1992; Holder and Shachtman 1987; Jones and
Vischi 1979).

Cost modeling analyses develop and test formal models of the relationship between
treatment inputs and outcomes, with attention to prices and costs.

It is not expected than any one study will provide a full answer to the question
of which treatments provide the best outcomes for the costs incurred.  Answering
this question is a general goal that will be approached through the accretion of
many studies over time.  These individual studies will most likely take one of
two approaches.  Some studies will focus on particular treatment interventions
of interest, conducting cost studies (cost effectiveness, cost offset, cost
benefit, etc.) of those specific programs.  Usually the intent is to establish
that the interventions analyzed provide a good enough balance between outcomes
and costs that their more widespread application would be justified. 
Accordingly, future work should be directed at:

Analyses of the costs, cost effectiveness, cost benefits, and cost offsets of
specific, interventions.

Other studies draw conclusions about a class of interventions or about a
dimension of the treatment process.  A familiar example is the comparison of
inpatient to outpatient treatment.  Results have generally shown that outpatient
treatment achieves comparable outcomes for lower costs (Institute of Medicine
1990; Miller and Hester 1986; Office of Technology Assessment 1983; Note,
however, that for some types of patients, inpatient treatment is still more
appropriate.).  In part because of such findings, various forms of outpatient
treatment have been replacing inpatient treatment.  Current need is shifting to
questions about the relative costs and outcomes of other dimensions of patient
care.  An example of this type of cost study would be the following:

Comparisons of more intensive versus less intensive versions of outpatient
treatment, longer versus shorter treatment interventions, stronger versus weaker
links to an aftercare system, and other critical variables in the treatment
process, focusing on their outcomes and their costs.

Studies of both types are encouraged under the terms of this announcement.

As the case of inpatient care for the most severely dependent alcoholics
indicates, the balance between costs and outcomes will vary by patient
characteristics.  Studies of these variations are also encouraged such as:

Assessments of how the balance between outcomes and costs varies for different
population subgroups and by patient characteristics.

The advance of scientific understanding in this area can be enhanced
significantly by improvements in methodology.  For example, two general
methodological developments in cost research have unfolded over recent years, but
neither has been applied specifically to the study of alcoholism treatment. 
Hence the field could benefit from studies that address:

Cost effectiveness analyses conducted by applying the guidelines of the Public
Health Service Panel on Cost Effectiveness in Health and Medicine (Gold et al.

Such a study could provide important information by showing how these guidelines
can be applied to the study of alcohol treatment and could identify areas where
the recommended methods for measuring costs and/or outcomes are problematic in
this particular application.  Also encouraged are studies that utilize:

Applications of the Drug Abuse Treatment Cost Analysis Program (French 1995;
French et al. 1997), or similar "user friendly" systems for monitoring treatment
costs to the provision of alcohol treatment services.

Additional methodological developments are also sought such as:

Development and testing of alternative approaches to case mix adjustment.  This
would facilitate comparisons between interventions that have differing client

Improved methods of gathering data on health care utilization and cost records. 
This would facilitate the study of pools of subjects who may change health plans
or insurers several times over the period of study and who may furthermore
combine plan-financed with out-of-plan services use in unknown proportions.

Improvements in techniques for using administrative data sets for research

Development and use of improved techniques for estimating the true costs of
treatment services as distinct from the charges for those services.

Two additional topics, aimed at substantive rather than methodological goals,
also stand out as specific research priorities at this time.  They are:

Development and improvement of estimates of the cost of providing parity between
insurance coverage for substance abuse treatment and the coverage of other health

While a very thorough study of this issue has recently been released by the
Center for Substance Abuse Treatment (Sing et al. 1997), that analysis is based
only on the experience of States that had adopted parity at the time of the study
and represents only one of several possible methodological approaches to the
subject.  A compelling but neglected question within this area of research is
whether the phenomenon of "moral hazard" can be asserted for a disease typified
by denial of the need for treatment.

Assessments of the impact of interventions to prevent alcohol-related problems
on subsequent demand for health services.

While most of the text in this section addresses the need for cost studies of
alcoholism treatment, there is a parallel need to begin work on cost studies of
prevention.  This need was identified as a priority for future research by the
Subcommittee on Health Services Research, National Advisory Council on Alcohol
Abuse and Alcoholism (1997), but has not yet captured the attention of the
research community.


It is the policy of the NIH that women and members of minority groups and their
subpopulations must be included in all NIH supported biomedical and behavioral
research projects involving human subjects, unless a clear and compelling
rationale and justification is provided that inclusion is inappropriate with
respect to the health of the subjects or the purpose of the research.  This
policy results from the NIH Revitalization Act of 1993 (Section 492B of Public
Law 103-43)

All investigators proposing research involving human subjects should read the
"NIH Guidelines For Inclusion of Women and Minorities as Subjects in Clinical
Research," which have been published in the Federal Register of March 28, 1994
(FR 59 14508-14513) and in the NIH Guide for Grants and Contracts, Vol. 23, No.
11, March 18, 1994.

Investigators also may obtain copies of the policy from the program staff listed
under INQUIRIES.  Program staff may also provide additional relevant information
concerning the policy.


It is the policy of NIH that children (e.g., individuals under the age of 21)
must be included in all human subjects research, conducted or supported by the
NIH, unless there are scientific and ethical reasons not to include them.  This
policy applies to all initial (Type 1) applications submitted for receipt dates
after October 1, 1998.

All investigators proposing research involving human subjects should read the
"NIH Policy and Guidelines on the Inclusion of Children as Participants in
Research Involving Human Subjects" that was published in the NIH Guide for Grants
and Contracts, March 6, 1998, and is available a the following URL address:


Applications are to be submitted on the grant application form PHS 398 (rev.
5/95) and will be accepted at the standard application deadlines as indicated in
the application kit.  Application kits are available at most institutional
offices of sponsored research and may be obtained from the Division of Extramural
Outreach and Information Resources, National Institutes of Health, 6701 Rockledge
Drive, MSC 7710, Bethesda, MD 20892-7910, telephone 301-710-0267, email,  The title and number of the program announcement must be
typed in section 2 on the face page of the application.

The completed original application and five legible copies must be sent or
delivered to:

6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817-7710 (for express/courier service)


Applications that are complete will be evaluated for scientific and technical
merit by an appropriate peer review group convened in accordance with the
standard NIH peer review procedures.  As part of the initial merit review, all
applications will receive a written critique and undergo a process in which only
those applications deemed to have the highest scientific merit, generally the top
half of the applications under review, will be discussed, assigned a priority
score, and receive a second level review by the appropriate national advisory

Review Criteria

The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health.  The
reviewers will comment on the following aspects of the application in their
written critiques in order to judge the likelihood that the proposed research
will have a substantial impact on the pursuit of these goals.  Each of these
criteria will be addressed and considered by the reviewers in assigning the
overall score weighting them as appropriate for each application.  Note that the
application does not need to be strong in all categories to be judged likely to
have a major scientific impact and thus deserve a high priority score.  For
example, an investigator may propose to carry out important work that by its
nature is not innovative but is essential to move a field forward.

Significance:  Does this study address an important problem?  If the aims of the
application are achieved, how will scientific knowledge be advanced?  What will
be the effect of these studies on the concepts or methods that drive this field?

Approach:  Are the conceptual framework, design, methods, and analyses adequately
developed, well-integrated, and appropriate to the aims of the project?  Does the
applicant acknowledge potential problem areas and consider alternative tactics?

Innovation:  Does the project employ novel concepts, approaches or methods?  Are
the aims original and innovative?  Does the project challenge existing paradigms
or develop new methodologies or technologies?

Investigator:  Is the investigator appropriately trained and well-suited to carry
out this work?  Is the work proposed appropriate to the experience level of the
principal investigator and other researchers (if any)?

Environment:  Does the scientific environment in which the work will be done
contribute to the probability of success?  Do the proposed experiments take
advantage of unique features of the scientific environment or employ useful
collaborative arrangements?  Is there evidence of institutional support?

Budget:  Is the requested budget and estimation of time to completion of the
project appropriate for the proposed research?

The initial review group will also examine the provisions for the protection of
human and animal subjects and the safety of the research environment as well as
the adequacy of plans to include both genders, minorities and their subgroups,
and children as appropriate for the scientific goals of the research.  Plans for
the recruitment and retention of subjects will also be evaluated.


Applications will be considered for funding on the basis of the overall
scientific and technical merit of the application as determined by peer review,
programmatic needs and balance, and the availability of funds.


Inquiries concerning this program announcement are encouraged.  The opportunity
to clarify any issues or questions from potential applicants is welcome.

Inquiries regarding programmatic issues may be directed to:

Mike Hilton, Ph.D.
Division of Clinical and Prevention Research
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard MSC 7003
Bethesda, MD  20892-7003
Telephone:  (301) 443-8753
FAX:  (301) 443-8774

Direct inquiries regarding fiscal matters to:

Edward Ellis
Grants Management Branch
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard MSC 7003
Bethesda, MD  20892-7003
Telephone:  (301) 443-4706
FAX:  (301) 443-3891


This program is described in the Catalog of Federal Domestic Assistance, No.
93.273.  Awards are made under the authorization of the Public Health Service
Act, Sections 301 and 464H, and administered under the PHS policies and Federal
Regulations at Title 42 CFR Part 52 and 45 CFR Part 74 or 45 CFR Part 95, as
applicable.  This program is not subject to the intergovernmental review
requirements of Executive Order 12372 or Health Systems Agency Review.

The PHS strongly encourages all grant recipients to provide a smoke-free
workplace and promote the non-use of all tobacco products.  In addition, Public
Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain
facilities (or in some cases, any portion of a facility) in which regular or
routine education, library, day care, health care or early childhood development
services are provided to children. This is consistent with the PHS mission to
protect and advance the physical and mental health of the American people.


French MT. "Economic evaluation of drug abuse treatment programs:  Methodology
and findings." American Journal of Drug and Alcohol Abuse 21:111-135, 1995.

French MT, Dunlap LJ, Zarkin GA, McGeary KA, and McLellan AT. "A structured
instrument for estimating the economic cost of drug abuse treatment:  The Drug
Abuse Treatment Cost Analysis Program (DATCAP)." Journal of Substance Abuse
Treatment, 14: 1-11, 1997.

Gold ME, Siegel JE, Russell LB, and Weinstein MC. Cost-Effectiveness in Health
and Medicine. New York: Oxford University Press, 1996.

Holder, HD and Blose, JO. "Alcoholism treatment and total health care utilization
costs:  A four-year longitudinal analysis of Federal employees." Journal of the
American Medical Association, 256: 1456-1460, 1986.

Holder, HD and Blose, JO. "The reduction of health care costs associated with
alcoholism treatment: A 14-year longitudinal study." Journal of Studies on
Alcohol, 53:293-302, 1992.

Holder, HD and Shachtman, RH. "Estimating health care savings associated with
alcoholism treatment." Alcoholism: Clinical and Experimental Research, 11: 66-73,

Institute of Medicine.  Broadening the Base of Treatment for Alcohol Problems.
Washington, D.C.: National Academy Press, 1990.

Jones KR and Vischi TR. "Impact of alcohol, drug abuse and mental health
treatment on medical care utilization:  A review of research literature." Medical
Care, 17: 1-82, 1979.

Miller WR and Hester RK. "The effectiveness of alcoholism treatment methods: 
What research reveals." In: Miller WR and Heather N (eds.). Treating Addictive
Behaviors:  Processes of Change. New York: Plenum Press, 1986, pp. 121-174.

Office of Technology Assessment, U.S. Congress. The Effectiveness and Costs of
Alcoholism Treatment. Washington, D.C.: U.S. Government Printing Office, 1983.

Patrick DL and Erickson P. Health Status and Health Policy:  Quality of Life in
Health Care Evaluation and Resource Evaluation. New York: Oxford University
Press, 1990.

Spilker B. Quality of Life Assessment in Clinical Trials. New York: Raven Press,

Subcommittee on Health Services Research, National Advisory Council on Alcohol
Abuse and Alcoholism.  Improving the Delivery of Alcohol Treatment and Prevention
Services:  A National Plan for Alcohol Health Services Research. Bethesda, MD:
National Institute on Alcohol Abuse and Alcoholism, National Institutes of
Health, Department of Health and Human Services, 1997.

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