An economic evaluation of contingency management for completion of hepatitis B vaccination in those on treatment for opiate dependence

Cost-Benefit Analysis of Vaccination Strategies to Prevent Mother-to-Child Transmission of the Hepatitis B Virus Using a Markov Model Decision Tree

Objectives

Currently, in China, several strategies exist to prevent mother-to-child transmission (MTCT) of the hepatitis B virus (HBV). These include providing Hepatitis B vaccination and hepatitis B immunoglobulin (HBIG) injection with different types of administration and dosages. The aim of this study is threefold: first, to evaluate the economic viability of current hepatitis B vaccination strategies for preventing MTCT from a public health policy perspective; second, to optimize the current immunization strategy for preventing perinatal transmission of the HBV; and third, to offer policy options to the National Health Commission in China.

Methods

To simulate the disease outcome for the entire life of newborns infected with HBV, a Markov model with eight possible health states was built by using TreeAge Pro 2011 software. In the present study, the model parameters were probability and cost, which were extracted from literature and calculated using Microsoft Excel 2013. The optimal immunization strategies were identified through cost-benefit analyses. A benefit-cost ratio (BCR) > 1 indicated that the strategy had positive benefits and vice versa. A one-way sensitivity analysis was used to investigate the stability of the results.

Results

From a public health care system perspective, we evaluated the economic viability of 11 strategies in China. For all 11 strategies, the BCR was > 1, which indicated that the benefits of all the strategies were greater than the costs. We recommended strategy number 9 as being optimal. In strategy number 9, babies born to hepatitis B surface antigen (HBsAg)-positive mothers were given an HBIG (200 IU) within 24 h of birth and three injections of hepatitis -B vaccine (20-μg each) at 0, 1, and 6 months, and the strategy had a BCR of 4.61. The one-way sensitivity analysis revealed that the full vaccination coverage and effective rates of protection were two factors that greatly influenced the BCR of the different prevention strategies; other factors had little effect.

Conclusion

The benefits of all strategies were greater than the costs. For decision-making and application, the strategy should be based on local socio-economic conditions so that an appropriate immunization strategy can be selected.

Contingency Management and SARS-CoV-2 Testing Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are especially vulnerable to morbidity and mortality as a result of SARS-CoV-2 infection because of social and physical health vulnerabilities. Routine testing for SARS-CoV-2 is critical to reduce transmission. Contingency management-the provision of tangible rewards to reinforce positive behavior-can promote the use of health services among PWID. Evidence is scarce on the utility of contingency management to promote SARS-CoV-2 testing. The objective of this study was to evaluate the effectiveness of contingency management to increase testing among PWID.

METHODS

SARS-CoV-2 testing was implemented at 9 syringe exchange program sites in partnership with an Oregon-based nonprofit organization for 5 weeks without contingency management and for 6 weeks with contingency management (a $10 financial incentive for testing) from February 1 through mid-April 2021. We measured rates of testing among syringe exchange program clients before and after implementation of contingency management.

RESULTS

Before contingency management, SARS-CoV-2 testing occurred during approximately 131 of 1410 (9.3%) client encounters, and 123 of 997 (12.3%) unique clients were tested. During contingency management, testing occurred during approximately 571 of 1756 (32.5%) client encounters, and 407 of 1151 (35.4%) unique clients were tested. Rates of testing increased from 0.04 (SD, 0.04) before contingency management implementation to 0.25 (SD, 0.15) after implementation (t₈ = -3.88; P = .005; Cohen d = 1.46).

CONCLUSIONS

Contingency management facilitated uptake of SARS-CoV-2 testing among PWID. Contingency management may be an effective strategy for improving communicable disease testing beyond testing for SARS-CoV-2 and for improving vaccine uptake among PWID and warrants additional research.

Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

INTRODUCTION

Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.

DESIGN

Cluster randomised controlled trial.

SETTING AND PARTICIPANTS

552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.

INTERVENTIONS

Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.

MEASUREMENTS

Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12).

SECONDARY OUTCOMES

heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health.

RESULTS

CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use.

CONCLUSIONS

A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.

TRIAL REGISTRATION NUMBER

ISRCTN 01591254.

An economic evaluation of contingency management for completion of hepatitis B vaccination in those on treatment for opiate dependence

AIMS

To determine whether the provision of contingency management using financial incentives to improve hepatitis B vaccine completion in people who inject drugs entering community treatment represents a cost-effective use of health-care resources.

DESIGN

A probabilistic cost-effectiveness analysis was conducted, using a decision-tree to estimate the short-term clinical and health-care cost impact of the vaccination strategies, followed by a Markov process to evaluate the long-term clinical consequences and costs associated with hepatitis B infection.

SETTINGS AND PARTICIPANTS

Data on attendance to vaccination from a UK cluster randomized trial.

INTERVENTION

Two contingency management options were examined in the trial: fixed versus escalating schedule financial incentives.

MEASUREMENT

Life-time health-care costs and quality-adjusted life years discounted at 3.5% annually; incremental cost-effectiveness ratios.

FINDINGS

The resulting estimate for the incremental life-time health-care cost of the contingency management strategy versus usual care was £21.86 [95% confidence interval (CI) = -£12.20 to 39.86] per person offered the incentive. For 1000 people offered the incentive, the incremental reduction in numbers of hepatitis B infections avoided over their lifetime was estimated at 19 (95% CI = 8-30). The probabilistic incremental cost per quality adjusted life-year gained of the contingency management programme was estimated to be £6738 (95% CI = £6297-7172), with an 89% probability of being considered cost-effective at a threshold of £20 000 per quality-adjusted life years gained (97.60% at £30 000).

CONCLUSIONS

Using financial incentives to increase hepatitis B vaccination completion in people who inject drugs could be a cost-effective use of health-care resources in the UK as long as the incidence remains above 1.2%.