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Patton T, Boehnke JR, Goyal R, Manca A, Marienfeld C, Martin NK, Nosyk B, Borquez A. Analyzing quality of life among people with opioid use disorder from the National Institute on Drug Abuse Data Share initiative: implications for decision making. Qual Life Res 2024; 33:2783-2796. [PMID: 39115618 PMCID: PMC11452457 DOI: 10.1007/s11136-024-03729-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE We aimed to estimate health state utility values (HSUVs) for the key health states found in opioid use disorder (OUD) cost-effectiveness models in the published literature. METHODS Data obtained from six trials representing 1,777 individuals with OUD. We implemented mapping algorithms to harmonize data from different measures of quality of life (the SF-12 Versions 1 and 2 and the EQ-5D-3 L). We performed a regression analysis to quantify the relationship between HSUVs and the following variables: days of extra-medical opioid use in the past 30 days, injecting behaviors, treatment with medications for OUD, HIV status, and age. A secondary analysis explored the impact of opioid withdrawal symptoms. RESULTS There were statistically significant reductions in HSUVs associated with extra-medical opioid use (-0.002 (95% CI [-0.003,-0.0001]) to -0.003 (95% CI [-0.005,-0.002]) per additional day of heroin or other opiate use, respectively), drug injecting compared to not injecting (-0.043 (95% CI [-0.079,-0.006])), HIV-positive diagnosis compared to no diagnosis (-0.074 (95% CI [-0.143,-0.005])), and age (-0.001 per year (95% CI [-0.003,-0.0002])). Parameters associated with medications for OUD treatment were not statistically significant after controlling for extra-medical opioid use (0.0131 (95% CI [-0.0479,0.0769])), in line with prior studies. The secondary analysis revealed that withdrawal symptoms are a fundamental driver of HSUVs, with predictions of 0.817 (95% CI [0.768, 0.858]), 0.705 (95% CI [0.607, 0.786]), and 0.367 (95% CI [0.180, 0.575]) for moderate, severe, and worst level of symptoms, respectively. CONCLUSION We observed HSUVs for OUD that were higher than those from previous studies that had been conducted without input from people living with the condition.
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Affiliation(s)
- Thomas Patton
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA.
| | - Jan R Boehnke
- School of Health Sciences, University of Dundee, Nethergate, Dundee, DD1 4HN, UK
| | - Ravi Goyal
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
| | - Andrea Manca
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Carla Marienfeld
- UC San Diego Health Psychiatry, 8950 Villa La Jolla Drive, La Jolla, CA, 92037, USA
| | - Natasha K Martin
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Annick Borquez
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
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Tran AD, Grebely J, Chambers M, Degenhardt L, Farrell M, Bajis S, Larance B. Health utility among people who regularly use opioids in Australia. Drug Alcohol Rev 2024. [PMID: 38403293 DOI: 10.1111/dar.13823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Studies of health utilities among people who use opioids have mostly been based on in-treatment populations. We aim to report utility-based quality of life by participants' socio-demographic, drug and treatment characteristics, and to examine the determinants of health utility among people who use opioids regularly. METHODS Cross-sectional study of participants who used opioids regularly, recruited across New South Wales, Victoria and Tasmania in 2018-2019. Differences in European Quality of Life (EQ-5D-5L) heath utility scores between socio-demographic and clinical subgroups were assessed using non-parametric Kruskal-Wallis test by rank. To address the unique distribution of EQ-5D-5L health utility scores in the current sample, a two-part model was applied to assess factors associated with health utility. RESULTS Among 402 participants enrolled in the study, 385 (96%) completed the EQ-5D-5L questionnaire. The mean health utility of the total sample was 0.63 (SD 0.29). Participants who previously received opioid agonist treatment [OAT] (adj marginal effect (ME) -0.11; 95% confidence interval [CI] -0.20 to -0.02) and those currently in OAT (adj ME -0.13; 95% CI -0.22 to -0.06) reported lower health utility than those who had never received OAT. Participants who used both pharmaceutical opioids and benzodiazepines had lower health utility compared to no pharmaceutical opioids and no benzodiazepines use (adj ME -0.17; 95% CI -0.28 to -0.07). DISCUSSION AND CONCLUSIONS Findings provide important health utility data for economic evaluations, useful for guiding allocation of resources for treatment strategies among people who use opioids. Lower health utilities among those using benzodiazepines and pharmaceutical opioids suggests interventions targeting these subgroups may be beneficial.
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Affiliation(s)
- Anh Dam Tran
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | | | - Mark Chambers
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Sahar Bajis
- Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Briony Larance
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute University of Wollongong, Wollongong, Australia
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Brandeau ML. Responding to the US opioid crisis: leveraging analytics to support decision making. Health Care Manag Sci 2023; 26:599-603. [PMID: 37804456 DOI: 10.1007/s10729-023-09657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
The US is experiencing a severe opioid epidemic with more than 80,000 opioid overdose deaths occurring in 2022. Beyond the tragic loss of life, opioid use disorder (OUD) has emerged as a major contributor to morbidity, lost productivity, mounting criminal justice system costs, and significant social disruption. This Current Opinion article highlights opportunities for analytics in supporting policy making for effective response to this crisis. We describe modeling opportunities in the following areas: understanding the opioid epidemic (e.g., the prevalence and incidence of OUD in different geographic regions, demographics of individuals with OUD, rates of overdose and overdose death, patterns of drug use and associated disease outbreaks, and access to and use of treatment for OUD); assessing policies for preventing and treating OUD, including mitigation of social conditions that increase the risk of OUD; and evaluating potential regulatory and criminal justice system reforms.
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Affiliation(s)
- Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
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Maity B, Banerjee S, Senapati A, Chattopadhyay J. Quantifying optimal resource allocation strategies for controlling epidemics. J R Soc Interface 2023; 20:20230036. [PMID: 37194270 PMCID: PMC10189312 DOI: 10.1098/rsif.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023] Open
Abstract
Frequent emergence of communicable diseases is a major concern worldwide. Lack of sufficient resources to mitigate the disease burden makes the situation even more challenging for lower-income countries. Hence, strategy development for disease eradication and optimal management of the social and economic burden has garnered a lot of attention in recent years. In this context, we quantify the optimal fraction of resources that can be allocated to two major intervention measures, namely reduction of disease transmission and improvement of healthcare infrastructure. Our results demonstrate that the effectiveness of each of the interventions has a significant impact on the optimal resource allocation in both long-term disease dynamics and outbreak scenarios. The optimal allocation strategy for long-term dynamics exhibits non-monotonic behaviour with respect to the effectiveness of interventions, which differs from the more intuitive strategy recommended in the case of outbreaks. Further, our results indicate that the relationship between investment in interventions and the corresponding increase in patient recovery rate or decrease in disease transmission rate plays a decisive role in determining optimal strategies. Intervention programmes with decreasing returns promote the necessity for resource sharing. Our study provides fundamental insights into determining the best response strategy when controlling epidemics in resource-constrained situations.
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Affiliation(s)
- Biplab Maity
- Agricultural and Ecological Research Unit, Indian Statistical Institute, 203, B. T. Road, Kolkata 700108, India
| | - Swarnendu Banerjee
- Agricultural and Ecological Research Unit, Indian Statistical Institute, 203, B. T. Road, Kolkata 700108, India
- Copernicus Institute of Sustainable Development, Utrecht University, PO Box 80115, Utrecht 3508 TC, The Netherlands
| | - Abhishek Senapati
- Agricultural and Ecological Research Unit, Indian Statistical Institute, 203, B. T. Road, Kolkata 700108, India
- Center for Advanced Systems Understanding (CASUS), Untermarkt 20, Goerlitz 02826, Germany
| | - Joydev Chattopadhyay
- Agricultural and Ecological Research Unit, Indian Statistical Institute, 203, B. T. Road, Kolkata 700108, India
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Kåberg M, Larsson S, Bergström J, Hammarberg A. Quality-adjusted life years among people who inject drugs in a needle syringe program in Sweden. Qual Life Res 2023; 32:197-207. [PMID: 35996040 PMCID: PMC9829569 DOI: 10.1007/s11136-022-03209-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Needle syringe programs (NSP) significantly reduce risk behavior and HIV and hepatitis transmission in people who inject drugs (PWID). However, PWID are underrepresented in studies on health-related quality of life (HRQoL), representing a barrier to evaluate effects of public health and preventive measures related to injecting drug use. In this study, we investigate how well the two questionnaires EQ-5D-3L and SF-6D measure health in PWID. We also estimate HRQoL in the PWID population. METHOD Data on demographics, injection drug use, HIV, hepatitis status, and self-reported HRQoL were collected from 550 PWID enrolled in the Stockholm NSP at enrollment and at 6-, 12-, and 24-month follow-up. Self-rated HRQoL was measured as QALY, using EQ-5D-3L and the SF-6D. Item response theory (IRT) was used to evaluate which of the two instruments that measure health most accurately in this population. Regression analysis was used to estimate population-specific QALYs. RESULTS The IRT analysis showed that SF-6D was better suited to measure health in PWID. More specifically, SF-6D to a larger extent discriminated between persons regardless of their health status, while EQ-5D was more suitable to detect persons with poorer health. Self-rated HRQoL showed that average QALY was lower among PWID compared to the general Swedish population. However, a general increase in self-reported health was noted over time among participants. CONCLUSION This study increase knowledge of what instruments are most suitable to measure health among PWID. This is of great importance when evaluating effects of public health and preventive measures in the PWID population.
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Affiliation(s)
- Martin Kåberg
- grid.4714.60000 0004 1937 0626Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden ,Stockholm Centre for Dependency Disorders, Stockholm Needle Exchange, Stockholm, Sweden
| | - Sofie Larsson
- grid.419734.c0000 0000 9580 3113Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, Stockholm, Sweden
| | - Jakob Bergström
- grid.419734.c0000 0000 9580 3113Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, Stockholm, Sweden
| | - Anders Hammarberg
- grid.4714.60000 0004 1937 0626Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.467087.a0000 0004 0442 1056Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Cerdá M, Jalali MS, Hamilton AD, DiGennaro C, Hyder A, Santaella-Tenorio J, Kaur N, Wang C, Keyes KM. A Systematic Review of Simulation Models to Track and Address the Opioid Crisis. Epidemiol Rev 2022; 43:147-165. [PMID: 34791110 PMCID: PMC9005056 DOI: 10.1093/epirev/mxab013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 10/20/2021] [Accepted: 11/04/2021] [Indexed: 01/04/2023] Open
Abstract
The opioid overdose crisis is driven by an intersecting set of social, structural, and economic forces. Simulation models are a tool to help us understand and address thiscomplex, dynamic, and nonlinear social phenomenon. We conducted a systematic review of the literature on simulation models of opioid use and overdose up to September 2019. We extracted modeling types, target populations, interventions, and findings; created a database of model parameters used for model calibration; and evaluated study transparency and reproducibility. Of the 1,398 articles screened, we identified 88 eligible articles. The most frequent types of models were compartmental (36%), Markov (20%), system dynamics (16%), and agent-based models (16%). Intervention cost-effectiveness was evaluated in 40% of the studies, and 39% focused on services for people with opioid use disorder (OUD). In 61% of the eligible articles, authors discussed calibrating their models to empirical data, and in 31%, validation approaches used in the modeling process were discussed. From the 63 studies that provided model parameters, we extracted the data sources on opioid use, OUD, OUD treatment, cessation or relapse, emergency medical services, and death parameters. From this database, potential model inputs can be identified and models can be compared with prior work. Simulation models should be used to tackle key methodological challenges, including the potential for bias in the choice of parameter inputs, investment in model calibration and validation, and transparency in the assumptions and mechanics of simulation models to facilitate reproducibility.
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Affiliation(s)
- Magdalena Cerdá
- Correspondence to Magdalena Cerdá, Division of Epidemiology, Department of Population Health, New York University School of Medicine, 180 Madison Avenue, Fourth Floor (4-16), New York, NY 10016, USA. (e-mail: )
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Fairley M, Humphreys K, Joyce VR, Bounthavong M, Trafton J, Combs A, Oliva EM, Goldhaber-Fiebert JD, Asch SM, Brandeau ML, Owens DK. Cost-effectiveness of Treatments for Opioid Use Disorder. JAMA Psychiatry 2021; 78:767-777. [PMID: 33787832 PMCID: PMC8014209 DOI: 10.1001/jamapsychiatry.2021.0247] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment. OBJECTIVE To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US. DESIGN AND SETTING This model-based cost-effectiveness analysis included a US population with OUD. INTERVENTIONS Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM). MAIN OUTCOMES AND MEASURES Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs. RESULTS In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings. CONCLUSIONS AND RELEVANCE In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.
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Affiliation(s)
- Michael Fairley
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Keith Humphreys
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Vilija R. Joyce
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Mark Bounthavong
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California,Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Ann Combs
- Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Elizabeth M. Oliva
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jeremy D. Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Medicine, Stanford University, Stanford, California
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Douglas K. Owens
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California,Department of Medicine, Stanford University, Stanford, California
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Cost-Efficacy of Antiretroviral Regimens Recommended in Treatment-Naive HIV-Infected Adults. A Single Center Experience. Processes (Basel) 2021. [DOI: 10.3390/pr9060956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to assess the prescription trends of combined antiretroviral therapy (cART) in one infectious diseases department and the cost-efficacy (C/E) of different regimens used in treatment-naïve patients. The C/E was assessed with a software application developed by a group of researchers in Spain. The efficacy was already calculated in the application. The costs included the local cost of antiretrovirals and other direct costs specific to our institution. In the software application, the C/E reference regimen was ABC/3TC/DTG. In total, 181 HIV-infected patients were diagnosed and initiated cART during 2015–2019. The proportion of patients treated with integrase-strand transfer inhibitor (INSTI)-based regimens increased from 2015–2018 (54%) to the end of 2019 (81%). The relative C/E ranged from 0.90 to 1.28 for the evaluated INSTI-based regimens. Among INSTI-based regimens, ABC/3TC/DTG and TAF/FTC/EVG/c are the regimens with similar efficacy and relative C/E.
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Beaulieu E, DiGennaro C, Stringfellow E, Connolly A, Hamilton A, Hyder A, Cerdá M, Keyes KM, Jalali MS. Economic Evaluation in Opioid Modeling: Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:158-173. [PMID: 33518022 PMCID: PMC7864393 DOI: 10.1016/j.jval.2020.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/29/2020] [Accepted: 07/25/2020] [Indexed: 05/08/2023]
Abstract
OBJECTIVES The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature. METHODS A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study. RESULTS The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs. CONCLUSION The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.
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Affiliation(s)
- Elizabeth Beaulieu
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA
| | - Catherine DiGennaro
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA
| | - Erin Stringfellow
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA
| | - Ava Connolly
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA
| | - Ava Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Mohammad S Jalali
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA; Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA.
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10
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Barbosa C, Dowd WN, Zarkin G. Economic Evaluation of Interventions to Address Opioid Misuse: A Systematic Review of Methods Used in Simulation Modeling Studies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1096-1108. [PMID: 32828223 DOI: 10.1016/j.jval.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Several evidence-based interventions exist for people who misuse opioids, but there is limited guidance on optimal intervention selection. Economic evaluations using simulation modeling can guide the allocation of resources and help tackle the opioid crisis. This study reviews methods employed by economic evaluations using computer simulations to investigate the health and economic effects of interventions meant to address opioid misuse. METHODS We conducted a systematic mapping review of studies that used simulation modeling to support the economic evaluation of interventions targeting prevention, treatment, or management of opioid misuse or its direct consequences (ie, overdose). We searched 6 databases and extracted information on study population, interventions, costs, outcomes, and economic analysis and modeling approaches. RESULTS Eighteen studies met the inclusion criteria. All of the studies considered only one segment of the continuum of care. Of the studies, 13 evaluated medications for opioid use disorder, and 5 evaluated naloxone distribution programs to reduce overdose deaths. Most studies estimated incremental cost per quality-adjusted life-years and used health system and/or societal perspectives. Models were decision trees (n = 4), Markov (n = 10) or semi-Markov models (n = 3), and microsimulations (n = 1). All of the studies assessed parameter uncertainty though deterministic and/or probabilistic sensitivity analysis, 4 conducted formal calibration, only 2 assessed structural uncertainty, and only 1 conducted expected value of information analyses. Only 10 studies conducted validation. CONCLUSIONS Future economic evaluations should consider synergies between interventions and examine combinations of interventions to inform optimal policy response. They should also more consistently conduct model validation and assess the value of further research.
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Affiliation(s)
- Carolina Barbosa
- Behavioral Health Research Division, RTI International, Chicago, IL, USA.
| | - William N Dowd
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
| | - Gary Zarkin
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
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Barbosa C, Fraser H, Hoerger TJ, Leib A, Havens JR, Young A, Kral A, Page K, Evans J, Zibbell J, Hariri S, Vellozzi C, Nerlander L, Ward JW, Vickerman P. Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs. Addiction 2019; 114:2267-2278. [PMID: 31307116 PMCID: PMC7751348 DOI: 10.1111/add.14731] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/19/2018] [Accepted: 06/28/2019] [Indexed: 12/12/2022]
Abstract
AIMS To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States. DESIGN HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective. SETTING Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings. PARTICIPANTS PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies. INTERVENTIONS AND COMPARATOR Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID. MEASUREMENTS Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs). FINDINGS For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis. CONCLUSIONS Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.
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Affiliation(s)
| | | | | | - Alyssa Leib
- Department of Chemistry, University of Colorado, Denver, USA
| | | | - April Young
- University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Alex Kral
- RTI International, Research Triangle Park, NC, USA
| | - Kimberly Page
- University of New Mexico, Health Sciences Center, Albuquerque, NM, USA
| | | | - Jon Zibbell
- RTI International, Research Triangle Park, NC, USA
| | - Susan Hariri
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Lina Nerlander
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John W. Ward
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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12
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Tran BX, Nguyen LH, Turner HC, Nghiem S, Vu GT, Nguyen CT, Latkin CA, Ho CSH, Ho RCM. Economic evaluation studies in the field of HIV/AIDS: bibliometric analysis on research development and scopes (GAP RESEARCH). BMC Health Serv Res 2019; 19:834. [PMID: 31727059 PMCID: PMC6854742 DOI: 10.1186/s12913-019-4613-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/07/2019] [Indexed: 12/31/2022] Open
Abstract
Background The rapid decrease in international funding for HIV/AIDS has been challenging for many nations to effectively mobilize and allocate their limited resources for HIV/AIDS programs. Economic evaluations can help inform decisions and strategic planning. This study aims to examine the trends and patterns in economic evaluation studies in the field of HIV/AIDS and determine their research landscapes. Methods Using the Web of Science databases, we synthesized the number of papers and citations on HIV/AIDS and economic evaluation from 1990 to 2017. Collaborations between authors and countries, networks of keywords and research topics were visualized using frequency of co-occurrence and Jaccards’ similarity index. A Latent Dirichlet Allocation (LDA) analysis to categorize papers into different topics/themes. Results A total of 372 economic evaluation papers were selected, including 351 cost-effectiveness analyses (CEA), 11 cost-utility analyses (CUA), 12 cost-benefit analyses (CBA). The growth of publications, their citations and usages have increased remarkably over the years. Major research topics in economic evaluation studies consisted of antiretroviral therapy (ART) initiation and treatment; drug use prevention interventions and prevention of mother-to-child transmission interventions. Moreover, lack of contextualized evidence was found in specific settings with high burden HIV epidemics, as well as emerging most-at-risk populations such as trans-genders or migrants. Conclusion This study highlights the knowledge and geographical discrepancies in HIV/AIDS economic evaluation literature. Future research directions are also informed for advancing economic evaluation in HIV/AIDS research.
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Affiliation(s)
- Bach Xuan Tran
- Department of Health Economics, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. .,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Long Hoang Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam
| | - Hugo C Turner
- Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam
| | - Son Nghiem
- Centre for Applied Health Economics, Griffith University, Brisbane, Australia
| | - Giang Thu Vu
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, National University Hospital, Singapore, Singapore
| | - Roger C M Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam.,Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore.,Biomedical Global Institute of Healthcare Research & Technology (BIGHEART), National University of Singapore, Singapore, 117599, Singapore
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13
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Zhang L, Zou X, Xu Y, Medland N, Deng L, Liu Y, Su S, Ling L. The Decade-Long Chinese Methadone Maintenance Therapy Yields Large Population and Economic Benefits for Drug Users in Reducing Harm, HIV and HCV Disease Burden. Front Public Health 2019; 7:327. [PMID: 31781529 PMCID: PMC6861367 DOI: 10.3389/fpubh.2019.00327] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
Objectives: We aimed to conduct a comprehensive evaluation of the population impact of methadone maintenance treatment (MMT) for its future program planning. Methods: We conducted a literature review of the effects of MMT in China on HIV and HCV disease burden, injecting, and sexual behaviors and drug-related harm during 2004–2015. Data synthesis and analysis were conducted to obtain the pooled estimates of parameters for a mathematical model which was constructed to evaluate the effectiveness and cost-effectiveness of the program. Results: Based on a review of 134 articles, this study demonstrated that MMT is highly effective in reducing crime-related, high risk sexual, and injecting behaviors. The model estimated US$1,037 m which was invested in MMT from 2004 to 2015 has prevented 29,463 (15,325–43,600) new HIV infections, 130,563 (91,580–169,546) new HCV infections, 10,783 (10,380–11,187) deaths related to HIV, HCV and drug-related harm, and 338,920.0 (334,596.2–343,243.7) disability-adjusted life years (DALYs). The costs for each prevented HIV infection, HCV infection, death, and DALY were $35,206.8 (33,594.8–36,981.4), $7,944.7 ($7,714.4–8,189.2), $96,193.4 (92,726.0–99,930.2), and $3,060.6 ($3,022.0–3,100.1) respectively. Conclusion: The Chinese MMT program has been effective and cost-effective in reducing injecting, injecting-related risk behaviors and adversities due to HIV/HCV infection and drug-related harm among drug users.
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Affiliation(s)
- Lei Zhang
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China.,China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Xia Zou
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yong Xu
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Nick Medland
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Liwei Deng
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yin Liu
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Shu Su
- China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Li Ling
- Sun Yat-sen Center for Migrant Health Policy, Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
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14
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Ledgerwood DM, Lister JJ, LaLiberte B, Lundahl LH, Greenwald MK. Injection opioid use as a predictor of treatment outcomes among methadone-maintained opioid-dependent patients. Addict Behav 2019; 90:191-195. [PMID: 30412910 DOI: 10.1016/j.addbeh.2018.10.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Injection opioid use is associated with more severe health and psychosocial consequences relative to non-injection use, but few studies have examined whether injection use is associated with methadone maintenance treatment outcomes. The present study examined differential MMT outcomes among opioid injectors and non-injectors. METHODS Data were extracted from the clinic charts of opioid-dependent MMT patients (N = 290; n = 115 injectors) enrolled in a university-affiliated, urban MMT clinic. Injection status was examined as a predictor of short- (3-month opioid, cocaine, benzodiazepine and cannabis urine drug screens) and long- (days retained in treatment) term MMT outcomes. RESULTS Bivariate analyses revealed injection users were less likely to be African American and to have completed high school, were more likely to have started heroin use before age 21, to report having hepatitis C, to report a baseline cocaine use disorder, and had higher methadone doses at 3-months into treatment. Injection status significantly predicted a greater proportion of cocaine-positive urine drug screens in the first 3 months of treatment, but did not significantly predict opioid, benzodiazepine or cannabis drug screens, or length of treatment retention. CONCLUSION This is one of a handful of studies to examine injection status as a predictor of MMT outcomes. Injection status is associated with cocaine use early in treatment, which has implications for the focus of treatment.
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Affiliation(s)
- David M Ledgerwood
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA.
| | - Jamey J Lister
- School of Social Work, Wayne State University, Detroit, MI 48201, USA
| | - Benjamin LaLiberte
- Department of Psychology, Wayne State University, Detroit, MI 48201, USA
| | - Leslie H Lundahl
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA; Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA
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15
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Gallucci A, Lucena PH, Martens G, Thibaut A, Fregni F. Transcranial direct current stimulation to prevent and treat surgery-induced opioid dependence: a systematic review. Pain Manag 2018; 9:93-106. [PMID: 30516441 DOI: 10.2217/pmt-2018-0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Opioid misuse leading to dependence is a major health issue. Recent studies explored valid alternatives to treat pain in postsurgical settings. This systematic review aims to discuss the role of transcranial direct current stimulation (tDCS) in preventing and treating postoperative pain and opioid dependence. PubMed and Embase databases were screened, considering studies testing tDCS effects on pain and opioid consumption in surgical settings and opioid addiction. Eight studies met our inclusion criteria. Results showed a reduction of postoperative pain, opioid consumption and cue-induced craving following cortical stimulation. Despite the limited number of studies, this review shows preliminary encouraging evidence regarding the analgesic role of tDCS. However, future studies are needed to further investigate the application of tDCS in postsurgical settings.
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Affiliation(s)
- Alessia Gallucci
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, 02129, USA.,Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Pedro H Lucena
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, 02129, USA.,Department of Medice, Bahiana School of Medicine & Public Health, Salvador, BA, Brazil
| | - Géraldine Martens
- Coma Science Group, GIGA Research & Neurology Department, University & University Hospital of Liege, Liege, Belgium
| | - Aurore Thibaut
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, 02129, USA.,Coma Science Group, GIGA Research & Neurology Department, University & University Hospital of Liege, Liege, Belgium
| | - Felipe Fregni
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, 02129, USA
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16
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Pitt AL, Humphreys K, Brandeau ML. Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. Am J Public Health 2018; 108:1394-1400. [PMID: 30138057 PMCID: PMC6137764 DOI: 10.2105/ajph.2018.304590] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To estimate health outcomes of policies to mitigate the opioid epidemic. METHODS We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic. RESULTS Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. CONCLUSIONS Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.
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Affiliation(s)
- Allison L Pitt
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Keith Humphreys
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Margaret L Brandeau
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
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17
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Bansback N, Guh D, Oviedo-Joekes E, Brissette S, Harrison S, Janmohamed A, Krausz M, MacDonald S, Marsh DC, Schechter MT, Anis AH. Cost-effectiveness of hydromorphone for severe opioid use disorder: findings from the SALOME randomized clinical trial. Addiction 2018; 113:1264-1273. [PMID: 29589873 DOI: 10.1111/add.14171] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Previous research has found diacetylmorphine, delivered under supervision, to be cost-effective in the treatment of severe opioid use disorder, but diacetylmorphine is not available in many settings. The Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME) randomized controlled trial provided evidence that injectable hydromorphone is non-inferior to diacetylmorphine. The current study aimed to compare the cost-effectiveness of hydromorphone directly with diacetylmorphine and indirectly with methadone maintenance treatment. DESIGN A within-trial analysis was conducted using the patient level data from the 6-month, double-blind, non-inferiority SALOME trial. A life-time analysis extrapolated costs and outcomes using a decision analytical cohort model. The model incorporated data from a previous trial to include an indirect comparison to methadone maintenance. SETTING A supervised clinic in Vancouver, British Columbia, Canada. PARTICIPANTS A total of 202 long-term street opioid injectors who had at least two attempts at treatment, including one with methadone (or other substitution), were randomized to hydromorphone (n = 100) or diacetylmorphine (n = 102). MEASUREMENTS We measured the utilization of drugs, visits to health professionals, hospitalizations, criminal activity, mortality and quality of life. This enabled us to estimate incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness ratios from a societal perspective. Sensitivity analyses considered different sources of evidence, assumptions and perspectives. FINDINGS The within-trial analysis found hydromorphone provided similar QALYs to diacetylmorphine [0.377, 95% confidence interval (CI) = 0.361-0.393 versus 0.375, 95% CI = 0.357-0.391], but accumulated marginally greater costs [$49 830 ($28 401-73 637) versus $34 320 ($21 780-55 998)]. The life-time analysis suggested that both diacetylmorphine and hydromorphone provide more benefits than methadone [8.4 (7.4-9.5) and 8.3 (7.2-9.5) versus 7.4 (6.5-8.3) QALYs] at lower cost [$1.01 million ($0.6-1.59 million) and $1.02 million ($0.72-1.51 million) versus $1.15 million ($0.71-1.84 million)]. CONCLUSIONS In patients with severe opioid use disorder enrolled into the SALOME trial, injectable hydromorphone provided similar outcomes to injectable diacetylmorphine. Modelling outcomes during a patient's life-time suggested that injectable hydromorphone might provide greater benefit than methadone alone and may be cost-saving, with drug costs being offset by costs saved from reduced involvement in criminal activity.
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Affiliation(s)
- Nick Bansback
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Daphne Guh
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Suzanne Brissette
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Scott Harrison
- Providence Crosstown Clinic, Providence Health Care, Vancouver, British Columbia, Canada
| | - Amin Janmohamed
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Michael Krausz
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Scott MacDonald
- Providence Crosstown Clinic, Providence Health Care, Vancouver, British Columbia, Canada
| | - David C Marsh
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Martin T Schechter
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Aslam H Anis
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, British Columbia, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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18
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Kidorf M, Brooner RK, Leoutsakos JM, Peirce J. Treatment initiation strategies for syringe exchange referrals to methadone maintenance: A randomized clinical trial. Drug Alcohol Depend 2018; 187:343-350. [PMID: 29709732 DOI: 10.1016/j.drugalcdep.2018.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/26/2022]
Abstract
This randomized clinical trial evaluated the efficacy of three treatment initiation strategies for improving retention to methadone maintenance for opioid-dependent individuals referred from a syringe exchange program (SEP). New admissions (n = 212) were randomly assigned to one of three 3-month initiation strategies: 1) Low Threshold (LTI), 2) Voucher Reinforcement (VRI), or 3) Standard Care (SCI). LTI was modeled on interim methadone maintenance to transition SEP admissions to the structure of medication-assisted treatment while maximizing exposure to methadone pharmacotherapy. VRI used monetary incentives to reinforce adherence to pharmacotherapy and adaptive counseling. SCI participants received standard methadone dosing and adaptive counseling. All participants were stabilized on methadone pharmacotherapy with a target dose of 80 mg. Following the initiation phase, participants in each condition received standard adaptive counseling from months 4-6. Results showed that most participants failed to achieve the target methadone dose. While no condition differences were observed in retention rates over the 3-month and 6-month observation periods, participants across conditions exhibited reductions in objective and self-report measures of drug use. Results support the benefits of referring syringe exchangers to methadone maintenance, and demonstrate the challenge of retaining these individuals in treatment.
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Affiliation(s)
- Michael Kidorf
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States.
| | - Robert K Brooner
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jeannie-Marie Leoutsakos
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jessica Peirce
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
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19
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Cost-effectiveness of alternative strategies for provision of HIV preexposure prophylaxis for people who inject drugs. AIDS 2018; 32:663-672. [PMID: 29334549 DOI: 10.1097/qad.0000000000001747] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Oral HIV preexposure prophylaxis (PrEP) has been recommended as a means of HIV prevention among people who inject drugs (PWIDs) but, at current prices, is unlikely to be cost-effective for all PWID. OBJECTIVE To determine the cost-effectiveness of alternative strategies for enrolling PWID in PrEP. DESIGN Dynamic network model that captures HIV transmission and progression among PWID in a representative US urban center. OUTCOME MEASURES HIV infections averted, discounted costs and quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. INTERVENTION We assume 25% PrEP coverage and investigate four strategies: first, random PWID are enrolled (Unselected Enrollment); second, individuals are randomly selected and enrolled together with their partners (Enroll Partners); third, individuals with the highest number of sexual and needle-sharing partnerships are enrolled (Most Partners); fourth, individuals with the greatest number of infected partners are enrolled (Most Positive Partners). RESULTS PrEP can achieve significant health benefits: compared with the status quo of no PrEP, the strategies gain 1114 QALYs (Unselected Enrollment), 2194 QALYs (Enroll Partners), 2481 QALYs (Most Partners), and 3046 QALYs (Most Positive Partners) over 20 years in a population of approximately 8500 people. The incremental cost-effectiveness ratio of each strategy compared with the status quo (cost per QALY gained) is $272 000 (Unselected Enrollment), $158 000 (Enroll Partners), $124 000 (Most Partners), and $101 000 (Most Positive Partners). All strategies except Unselected Enrollment are cost-effective according to WHO criteria. CONCLUSION Selection of high-risk PWID for PrEP can improve the cost-effectiveness of PrEP for PWID.
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20
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Nosyk B, Min JE, Krebs E, Zang X, Compton M, Gustafson R, Barrios R, Montaner JSG. The Cost-Effectiveness of Human Immunodeficiency Virus Testing and Treatment Engagement Initiatives in British Columbia, Canada: 2011-2013. Clin Infect Dis 2018; 66:765-777. [PMID: 29028964 PMCID: PMC5850008 DOI: 10.1093/cid/cix832] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/22/2017] [Indexed: 01/03/2023] Open
Abstract
Background Recognition of the secondary preventive benefits of antiretroviral therapy (ART) has mobilized global efforts to "seek, test, treat, and retain" people living with human immunodeficiency virus [HIV]/AIDS (PLHIV) in HIV care. We aimed to determine the cost-effectiveness of a set of HIV testing and treatment engagement interventions initiated in British Columbia, Canada, in 2011-2013. Methods Using a previously validated dynamic HIV transmission model, linked individual-level health administrative data for PLHIV, and aggregate-level HIV testing data, we estimated the cost-effectiveness of primary care testing (hospital, emergency department [ED], outpatient), ART initiation, and ART retention initiatives vs a counterfactual scenario that approximated the status quo. HIV incidence, mortality, costs (in 2015$CDN), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios were estimated. Analyses were executed over 5- to 25-year time horizons from a government-payer perspective. Results ED testing was the best value at $30216 per QALY gained and had the greatest impact on incidence and mortality among PLHIV, while ART initiation provided the greatest QALY gains. The ART retention initiative was not cost-effective. Delivered in combination at the observed scale and sustained throughout the study period, we estimated a 12.8% reduction in cumulative HIV incidence and a 4.7% reduction in deaths among PLHIV at $55258 per QALY gained. Results were most sensitive to uncertainty in the number of undiagnosed PLHIV. Conclusions HIV testing and ART initiation interventions were cost-effective, while the ART retention intervention was not. Developing strategies to reengage PLHIV lost to care is a priority moving forward.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | | | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver
| | - Miranda Compton
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Reka Gustafson
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Vancouver Coastal Health Authority, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, Vancouver
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Gilchrist G, Swan D, Shaw A, Keding A, Towers S, Craine N, Munro A, Hughes E, Parrott S, Mdege N, Strang J, Taylor A, Watson J. Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial. Health Technol Assess 2017; 21:1-312. [PMID: 29208190 PMCID: PMC5733383 DOI: 10.3310/hta21720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment. OBJECTIVES To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control. DESIGN A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London. SETTING NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016. PARTICIPANTS Current PWID, aged ≥ 18 years. INTERVENTIONS A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control). MAIN OUTCOME MEASURES Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability. RESULTS A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported. CONCLUSIONS As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs. FUTURE WORK The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female. LIMITATIONS Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results. TRIAL REGISTRATION Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gail Gilchrist
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Davina Swan
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - April Shaw
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Sarah Towers
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Noel Craine
- Public Health Wales, Microbiology, Bangor, UK
| | - Alison Munro
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Elizabeth Hughes
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Noreen Mdege
- Department of Health Sciences, University of York, York, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Avril Taylor
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Judith Watson
- Department of Health Sciences, University of York, York, UK
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Kenworthy J, Yi Y, Wright A, Brown J, Maria Madrigal A, Dunlop WCN. Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study. J Med Econ 2017; 20:740-748. [PMID: 28489467 DOI: 10.1080/13696998.2017.1325744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year. METHODS Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. RESULTS Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use. LIMITATIONS The model's 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured. CONCLUSIONS OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK's willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.
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Krebs E, Min JE, Evans E, Li L, Liu L, Huang D, Urada D, Kerr T, Hser YI, Nosyk B. Estimating State Transitions for Opioid Use Disorders. Med Decis Making 2017; 37:483-497. [PMID: 28027027 PMCID: PMC5536954 DOI: 10.1177/0272989x16683928] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM The aim was to estimate transitions between periods in and out of treatment, incarceration, and legal supervision, for prescription opioid (PO) and heroin users. METHODS We captured all individuals admitted for the first time for publicly funded treatment for opioid use disorder (OUD) in California (2006 to 2010) with linked mortality and criminal justice data. We used Cox proportional hazards and competing risks models to assess the effect of primary PO use (v. heroin) on the hazard of transitioning among 5 states: (1) opioid detoxification treatment; (2) opioid agonist treatment (OAT); (3) legal supervision (probation or parole); (4) incarceration (jail or prison); and (5) out-of-treatment. Transitions were conditional on survival, and death was modeled as an absorbing state. RESULTS Both primary PO (n = 11,733) and heroin (n = 19,926) users spent most of their median 2.3 y of observation out of treatment. Primary PO users were significantly younger (median age 30 v. 34 y), and a higher percentage were female (43.1% v. 31.5%; P < 0.001), white (74.6% v. 63.1%; P < 0.001), and had completed high school (31.8% v. 18.9%; P < 0.001). When compared to primary heroin users, PO users had a higher hazard of transitioning from detoxification to OAT (Hazard Ratio (HR), 1.65; 95% CI, 1.54 to 1.77), and had a lower hazard of transitioning from out-of-treatment to either detoxification (0.75 [0.70, 0.81]) or OAT (0.90 [0.85, 0.96]). CONCLUSION Our findings can be applied directly in state transition modeling to improve the validity of health economic evaluations. Although PO users tended to remain in treatment for longer durations than heroin users, they also tended to remain out of treatment for longer after transitioning to an out-of-treatment state. Despite the proven effectiveness of time-unlimited treatment, individuals with OUD spend most of their time out of treatment.
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Affiliation(s)
| | - Jeong E. Min
- British Columbia Centre for Excellence in HIV/AIDS
| | | | - Libo Li
- UCLA Integrated Substance Abuse Programs
| | - Lei Liu
- Northwestern University Feinberg School of Medicine
| | | | | | - Thomas Kerr
- UCLA Integrated Substance Abuse Programs
- Division of AIDS, Faculty of Medicine, University of British Columbia
| | | | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS
- Faculty of Health Sciences, Simon Fraser University
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Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS Med 2017; 14:e1002312. [PMID: 28542184 PMCID: PMC5443477 DOI: 10.1371/journal.pmed.1002312] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 04/28/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP). METHODS AND FINDINGS We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities. CONCLUSIONS We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.
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Pourkhajoei S, Barouni M, Noroozi A, Hajebi A, Amini S, Karamouzian M, Sharifi H. Cost-effectiveness of Methadone Maintenance Treatment Centers in Prevention of Human Immunodeficiency Virus Infection. ADDICTION & HEALTH 2017; 9:81-87. [PMID: 29299210 PMCID: PMC5742414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Acquired immune deficiency syndrome (AIDS) is one of the greatest social health problems in many communities in the twenty-first century. Methadone maintenance treatment (MMT) could decrease HIV infection among injection drug users (IDU). The main aim of this paper was to determine the cost-effectiveness of the governmental MMT program to prevent human immunodeficiency virus (HIV) infection among IDU. METHODS This analytical study was performed through a before-after assessment during a one-year period. Using census sampling, 251 IDU referred to the public MMT program of Kerman, Iran, were selected. The expenditures of MMT centers were calculated in the view of government (public sector). The cost-effectiveness was calculated using TreeAge software. FINDINGS MMT centers averted 86 new cases of HIV infection. The total cost of centers was US$471 per client in the year. The share of IDU from current expenditures was 35% and from capital expenditures was 32%. Also, methadone per capita for each person who injected drug was US$514. Per capita expenditure of HIV drug treatment was estimated US$8535 per year. Incremental cost effectiveness ratio (ICER) was US$2856 per year, which means governmental MMT program is cost-effective according to the World Health Organization (WHO) criteria. CONCLUSION MMT centers are cost-effective in preventing HIV infection and the access to this program should be facilitated for IDU.
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Affiliation(s)
- Sirus Pourkhajoei
- Department of Health Services Management and Health Policy and Health Economics, School of Health Management and Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohsen Barouni
- Associate Professor, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran,Correspondence to: Mohsen Barouni PhD,
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies AND Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Hajebi
- Associate Professor, Research Center for Addiction and Risky Behaviors, Department of Psychiatry, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Amini
- PhD Student, Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Karamouzian
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran AND School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Hamid Sharifi
- Associate Professor, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Chetty M, Kenworthy JJ, Langham S, Walker A, Dunlop WCN. A systematic review of health economic models of opioid agonist therapies in maintenance treatment of non-prescription opioid dependence. Addict Sci Clin Pract 2017; 12:6. [PMID: 28235415 PMCID: PMC5324212 DOI: 10.1186/s13722-017-0071-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/06/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioid dependence is a chronic condition with substantial health, economic and social costs. The study objective was to conduct a systematic review of published health-economic models of opioid agonist therapy for non-prescription opioid dependence, to review the different modelling approaches identified, and to inform future modelling studies. METHODS Literature searches were conducted in March 2015 in eight electronic databases, supplemented by hand-searching reference lists and searches on six National Health Technology Assessment Agency websites. Studies were included if they: investigated populations that were dependent on non-prescription opioids and were receiving opioid agonist or maintenance therapy; compared any pharmacological maintenance intervention with any other maintenance regimen (including placebo or no treatment); and were health-economic models of any type. RESULTS A total of 18 unique models were included. These used a range of modelling approaches, including Markov models (n = 4), decision tree with Monte Carlo simulations (n = 3), decision analysis (n = 3), dynamic transmission models (n = 3), decision tree (n = 1), cohort simulation (n = 1), Bayesian (n = 1), and Monte Carlo simulations (n = 2). Time horizons ranged from 6 months to lifetime. The most common evaluation was cost-utility analysis reporting cost per quality-adjusted life-year (n = 11), followed by cost-effectiveness analysis (n = 4), budget-impact analysis/cost comparison (n = 2) and cost-benefit analysis (n = 1). Most studies took the healthcare provider's perspective. Only a few models included some wider societal costs, such as productivity loss or costs of drug-related crime, disorder and antisocial behaviour. Costs to individuals and impacts on family and social networks were not included in any model. CONCLUSION A relatively small number of studies of varying quality were found. Strengths and weaknesses relating to model structure, inputs and approach were identified across all the studies. There was no indication of a single standard emerging as a preferred approach. Most studies omitted societal costs, an important issue since the implications of drug abuse extend widely beyond healthcare services. Nevertheless, elements from previous models could together form a framework for future economic evaluations in opioid agonist therapy including all relevant costs and outcomes. This could more adequately support decision-making and policy development for treatment of non-prescription opioid dependence.
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Affiliation(s)
| | - James J. Kenworthy
- Mundipharma International Ltd, Cambridge Science Park, Milton Road, Cambridge, CB4 0GW UK
| | | | | | - William C. N. Dunlop
- Mundipharma International Ltd, Cambridge Science Park, Milton Road, Cambridge, CB4 0GW UK
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Hall W, Strang J. Value for money in reducing opioid-related deaths. LANCET PUBLIC HEALTH 2017; 2:e124-e125. [PMID: 29253382 DOI: 10.1016/s2468-2667(17)30027-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Wayne Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Herston, QLD 4029, Australia; National Addiction Centre, King's College London, London, UK.
| | - John Strang
- Centre for Youth Substance Abuse Research, University of Queensland, Herston, QLD 4029, Australia; National Addiction Centre, King's College London, London, UK
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Uyei J, Fiellin DA, Buchelli M, Rodriguez-Santana R, Braithwaite RS. Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling study. LANCET PUBLIC HEALTH 2017; 2:e133-e140. [PMID: 29253386 DOI: 10.1016/s2468-2667(17)30006-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/23/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the USA, an epidemic of opioid overdose deaths is occurring, many of which are from heroin. Combining naloxone distribution with linkage to addiction treatment or pre-exposure prophylaxis (PrEP) for HIV prevention through syringe service programmes has the potential to save lives and be cost-effective. We estimated the outcomes and cost-effectiveness of five alternative strategies: no additional intervention, naloxone distribution, naloxone distribution plus linkage to addiction treatment, naloxone distribution plus PrEP, and naloxone distribution plus linkage to addiction treatment and PrEP. METHODS We developed a decision analytical Markov model to simulate opioid overdose, HIV incidence, overdose-related deaths, and HIV-related deaths in people who inject drugs in Connecticut, USA. Model input parameters were derived from published sources. We compared each strategy with no intervention, as well as simultaneously considering all strategies. Sensitivity analysis was done for all variables. Linkage to addiction treatment was referral to an opioid treatment programme for methadone. Endpoints were survival, life expectancy, quality-adjusted life-years (QALYs), number and percentage of overdose deaths averted, number of HIV-related deaths averted, total costs (in 2015 US$) associated with each strategy, and incremental cost per QALY gained. FINDINGS In the base-case analysis, compared with no additional intervention, the naloxone distribution strategy yielded an incremental cost-effectiveness ratio (ICER) of $323 per QALY, and naloxone distribution plus linkage to addiction treatment was cost saving compared with no additional intervention (greater effectiveness and less expensive). The most efficient strategies (ie, those conferring the greatest health benefit for a particular budget) were naloxone distribution combined with linkage to addiction treatment (cost saving), and naloxone distribution combined with PrEP and linkage to addiction treatment (ICER $95 337 per QALY) at a willingness-to-pay threshold of $100 000. In probabilistic sensitivity analysis, the combination of naloxone distribution, PrEP, and linkage to addiction treatment was the optimal strategy in 37% of iterations and the combination of naloxone distribution and linkage to addiction treatment was the optimal strategy in 34% of iterations. INTERPRETATION Naloxone distribution through syringe service programmes is cost-effective compared with syringe distribution alone, but when combined with linkage to addiction treatment is cost saving compared with no additional services. A strategy that combines naloxone distribution, PrEP, and linkage to addiction treatment results in greater health benefits in people who inject drugs and is also cost-effective. FUNDING State of Connecticut Department of Public Health and the National Institute of Mental Health.
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Affiliation(s)
- Jennifer Uyei
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | | | | | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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Andrews C, Grogan CM, Brennan M, Pollack HA. Lessons From Medicaid's Divergent Paths On Mental Health And Addiction Services. Health Aff (Millwood) 2016; 34:1131-8. [PMID: 26153307 DOI: 10.1377/hlthaff.2015.0151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaid's role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental health's experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.
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Affiliation(s)
- Christina Andrews
- Christina Andrews is an assistant professor in the College of Social Work, University of South Carolina, in Columbia
| | - Colleen M Grogan
- Colleen M. Grogan is a professor in the School of Social Service Administration, University of Chicago, in Illinois
| | - Marianne Brennan
- Marianne Brennan is a doctoral student in the School of Social Service Administration, University of Chicago
| | - Harold A Pollack
- Harold A. Pollack is a professor in the School of Social Service Administration, University of Chicago
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Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/0022042616679829] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.
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Affiliation(s)
- Amos Irwin
- Criminal Justice Policy Foundation, Silver Spring, MD, USA
- Law Enforcement Against Prohibition, Medford, MA, USA
| | - Ehsan Jozaghi
- BC Centre for Disease Control, University of British Columbia, Vancouver, Canada
| | | | - Alex H. Kral
- Research Triangle Institute, San Francisco, CA, USA
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Zang X, Tang H, Min JE, Gu D, Montaner JSG, Wu Z, Nosyk B. Cost-Effectiveness of the 'One4All' HIV Linkage Intervention in Guangxi Zhuang Autonomous Region, China. PLoS One 2016; 11:e0167308. [PMID: 27893864 PMCID: PMC5125690 DOI: 10.1371/journal.pone.0167308] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/13/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In Guangxi Zhuang Autonomous Region, China, an estimated 80% of newly-identified antiretroviral therapy (ART)-eligible patients are not engaged in ART. Delayed ART uptake ultimately translates into high rates of HIV morbidity, mortality, and transmission. To enhance HIV testing receipt and subsequent treatment uptake in Guangxi, the Chinese Center for Disease Control and Prevention (CDC) executed a cluster-randomized trial to assess the effectiveness and cost-effectiveness of a streamlined HIV testing algorithm (the One4All intervention) in 12 county-level hospitals. OBJECTIVE To determine the incremental cost-effectiveness of the One4All intervention delivered at county hospitals in Guangxi, China, compared to the current standard of care (SOC). PERSPECTIVE Health System. TIME HORIZON 1-, 5-and 25-years. METHODS We adapted a dynamic, compartmental HIV transmission model to simulate HIV transmission and progression in Guangxi, China and identify the economic impact and health benefits of implementing the One4All intervention in all Guangxi hospitals. The One4All intervention algorithm entails rapid point-of-care HIV screening, CD4 and viral load testing of individuals presenting for HIV screening, with same-day results and linkage to counselling. We populated the model with data from the One4All trial (CTN-0056), China CDC HIV registry and published reports. Model outcomes were HIV incidence, mortality, costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of the One4All intervention compared to SOC. RESULTS The One4All testing intervention was more costly than SOC (CNY 2,182 vs. CNY 846), but facilitated earlier ART access, resulting in delayed disease progression and mortality. Over a 25-year time horizon, we estimated that introducing One4All in Guangxi would result in 802 averted HIV cases and 1629 averted deaths at an ICER of CNY 11,678 per QALY gained. Sensitivity analysis revealed that One4All remained cost-effective at even minimal levels of effectiveness. Results were robust to changes to a range of parameters characterizing the HIV epidemic over time. CONCLUSIONS The One4All HIV testing strategy was highly cost-effective by WHO standards, and should be prioritized for widespread implementation in Guangxi, China. Integrating the intervention within a broader combination prevention strategy would enhance the public health response to HIV/AIDS in Guangxi.
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Affiliation(s)
- Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Houlin Tang
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jeong Eun Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Diane Gu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zunyou Wu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- * E-mail:
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Smith-Rohrberg D, Bruce RD, Altice FL. Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/002204260403400210] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.
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Bernard CL, Brandeau ML, Humphreys K, Bendavid E, Holodniy M, Weyant C, Owens DK, Goldhaber-Fiebert JD. Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States. Ann Intern Med 2016; 165:10-19. [PMID: 27110953 PMCID: PMC5118181 DOI: 10.7326/m15-2634] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear. OBJECTIVE To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID. DESIGN Empirically calibrated dynamic compartmental model. DATA SOURCES Published literature and expert opinion. TARGET POPULATION Adult U.S. PWID. TIME HORIZON 20 years and lifetime. INTERVENTION PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage. OUTCOME MEASURES Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years. RESULTS OF SENSITIVITY ANALYSIS Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence. LIMITATION Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited. CONCLUSION PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Affiliation(s)
- Cora L. Bernard
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Margaret L. Brandeau
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Keith Humphreys
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Eran Bendavid
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Mark Holodniy
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Christopher Weyant
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Douglas K. Owens
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Jeremy D. Goldhaber-Fiebert
- From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Hoang VP, Shanahan M, Shukla N, Perez P, Farrell M, Ritter A. A systematic review of modelling approaches in economic evaluations of health interventions for drug and alcohol problems. BMC Health Serv Res 2016; 16:127. [PMID: 27074871 PMCID: PMC4831174 DOI: 10.1186/s12913-016-1368-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/29/2016] [Indexed: 02/01/2023] Open
Abstract
Background The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame. Methods Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases. Results Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector. Conclusions This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Van Phuong Hoang
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - Marian Shanahan
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, 2031, Australia
| | - Nagesh Shukla
- SMART Infrastructure Facility, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Pascal Perez
- SMART Infrastructure Facility, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, 2031, Australia
| | - Alison Ritter
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, 2031, Australia
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Enns EA, Zaric GS, Strike CJ, Jairam JA, Kolla G, Bayoumi AM. Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada. Addiction 2016; 111:475-89. [PMID: 26616368 DOI: 10.1111/add.13195] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 06/15/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. DESIGN Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. SETTING Toronto and Ottawa, Canada. PARTICIPANTS Simulated population of each city. INTERVENTIONS Zero to five supervised injection facilities. MEASUREMENTS Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. FINDINGS In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. CONCLUSIONS Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.
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Affiliation(s)
- Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Gregory S Zaric
- Ivey Business School, Western University, London, ON, Canada
| | - Carol J Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Center for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Jairam
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Gillian Kolla
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ahmed M Bayoumi
- Centre for Research on Inner City Health, Li KaShing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, St Michael's Hospital, Toronto, ON, Canada
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Maddali MV, Dowdy DW, Gupta A, Shah M. Economic and epidemiological impact of early antiretroviral therapy initiation in India. J Int AIDS Soc 2015; 18:20217. [PMID: 26434780 PMCID: PMC4592848 DOI: 10.7448/ias.18.1.20217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 07/31/2015] [Accepted: 08/25/2015] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. METHODS We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. RESULTS Assuming "idealistic" engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). CONCLUSIONS Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment.
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Affiliation(s)
- Manoj V Maddali
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maunank Shah
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA;
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Shah M, Risher K, Berry SA, Dowdy DW. The Epidemiologic and Economic Impact of Improving HIV Testing, Linkage, and Retention in Care in the United States. Clin Infect Dis 2015; 62:220-229. [PMID: 26362321 DOI: 10.1093/cid/civ801] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 07/02/2015] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Recent guidelines advocate early antiretroviral therapy (ART) to decrease human immunodeficiency virus (HIV) morbidity and prevent transmission, but suboptimal engagement in care may compromise impact. We sought to determine the economic and epidemiologic impact of incomplete engagement in HIV care in the United States. METHODS We constructed a dynamic transmission model of HIV among US adults (aged 15-65 years) and conducted a cost-effectiveness analysis of improvements along the HIV care continuum : We evaluated enhanced HIV testing (annual for high-risk groups), increased 3-month linkage to care (to 90%), and improved retention (50% relative reduction in yearly disengagement and 50% increase in reengagement). Our primary outcomes were HIV incidence, mortality, costs and quality-adjusted life-years (QALYs). RESULTS Despite early ART initiation, a projected 1.39 million (95% uncertainty range [UR], 0.91-2.2 million) new HIV infections will occur at a (discounted) cost of $256 billion ($199-298 billion) over 2 decades at existing levels of HIV care engagement. Enhanced testing with increased linkage has modest epidemiologic benefits and could reduce incident HIV infections by 21% (95% UR, 13%-26%) at a cost of $65 700 per QALY gained ($44 500-111 000). By contrast, comprehensive improvements that couples enhanced testing and linkage with improved retention would reduce HIV incidence by 54% (95% UR, 37%-68%) and mortality rate by 64% (46%-78%), at a cost-effectiveness ratio of $45 300 per QALY gained ($27 800-72 300). CONCLUSIONS Failure to improve engagement in HIV care in the United States leads to excess infections, treatment costs, and deaths. Interventions that improve not just HIV screening but also retention in care are needed to optimize epidemiologic impact and cost-effectiveness.
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Affiliation(s)
| | - Kathryn Risher
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - David W Dowdy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Creating impact with operations research in health: making room for practice in academia. Health Care Manag Sci 2015; 19:305-312. [PMID: 26003321 DOI: 10.1007/s10729-015-9328-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 05/18/2015] [Indexed: 01/02/2023]
Abstract
Operations research (OR)-based analyses have the potential to improve decision making for many important, real-world health care problems. However, junior scholars often avoid working on practical applications in health because promotion and tenure processes tend to value theoretical studies more highly than applied studies. This paper discusses the author's experiences in using OR to inform and influence decisions in health and provides a blueprint for junior researchers who wish to find success by taking a similar path. This involves selecting good problems to study, forming productive collaborations with domain experts, developing appropriate models, identifying the most salient results from an analysis, and effectively disseminating findings to decision makers. The paper then suggests how journals, funding agencies, and senior academics can encourage such work by taking a broader and more informed view of the potential role and contributions of OR to solving health care problems. Making room in academia for the application of OR in health follows in the tradition begun by the founders of operations research: to work on important real-world problems where operations research can contribute to better decision making.
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Abstract
BACKGROUND People who inject drugs (PWID) account for roughly 13% of the prevalent HIV/AIDS population outside of sub-Saharan Africa, and access to opioid substitution treatment (OST) is limited in many settings globally. OST likely facilitates access to HAART, yet sparse evidence is available to support this hypothesis. Our objective was to determine the causal impact of OST exposure on HAART adherence among HIV-positive PWID in a Canadian setting. METHODS We executed a retrospective cohort study using linked population-level data for British Columbia, Canada (January 1996-March 2010). We considered HIV-positive PWID after meeting HAART initiation criteria. A marginal structural model was estimated on a monthly timescale using inverse probability of treatment weights. The primary outcome was 95% HAART adherence, according to pharmacy refill compliance. Exposure to OST was defined as 95% of OST receipt, and we controlled for a range of fixed and time-varying covariates. RESULTS Our study included 1852 (63.3%) HIV-positive PWID with a median follow-up of 5.5 years; 34% were female and 39% had previously accessed OST. The baseline covariate-adjusted odds of HAART adherence following OST exposure was 1.96 (95% confidence interval: 1.72-2.24), although the adjusted odds estimated within the marginal structural model was 1.68 (1.48-1.92). Findings were robust to sensitivity analyses on model specification. CONCLUSION In a setting characterized by universal healthcare and widespread access to both office-based OST and HAART, OST substantially increased the odds of HAART adherence. This underlines the need to address barriers to OST globally to reduce the disease burden of both opioid dependence and HIV/AIDS.
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Song DL, Altice FL, Copenhaver MM, Long EF. Cost-effectiveness analysis of brief and expanded evidence-based risk reduction interventions for HIV-infected people who inject drugs in the United States. PLoS One 2015; 10:e0116694. [PMID: 25658949 PMCID: PMC4320073 DOI: 10.1371/journal.pone.0116694] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/14/2014] [Indexed: 02/05/2023] Open
Abstract
AIMS Two behavioral HIV prevention interventions for people who inject drugs (PWID) infected with HIV include the Holistic Health Recovery Program for HIV+ (HHRP+), a comprehensive evidence-based CDC-supported program, and an abbreviated Holistic Health for HIV (3H+) Program, an adapted HHRP+ version in treatment settings. We compared the projected health benefits and cost-effectiveness of both programs, in addition to opioid substitution therapy (OST), to the status quo in the U.S. METHODS A dynamic HIV transmission model calibrated to epidemic data of current US populations was created. Projected outcomes include future HIV incidence, HIV prevalence, and quality-adjusted life years (QALYs) gained under alternative strategies. Total medical costs were estimated to compare the cost-effectiveness of each strategy. RESULTS Over 10 years, expanding HHRP+ access to 80% of PWID could avert up to 29,000 HIV infections, or 6% of the projected total, at a cost of $7,777/QALY gained. Alternatively, 3H+ could avert 19,000 infections, but is slightly more cost-effective ($7,707/QALY), and remains so under widely varying effectiveness and cost assumptions. Nearly two-thirds of infections averted with either program are among non-PWIDs, due to reduced sexual transmission from PWID to their partners. Expanding these programs with broader OST coverage could avert up to 74,000 HIV infections over 10 years and reduce HIV prevalence from 16.5% to 14.1%, but is substantially more expensive than HHRP+ or 3H+ alone. CONCLUSIONS Both behavioral interventions were effective and cost-effective at reducing HIV incidence among both PWID and the general adult population; however, 3H+, the economical HHRP+ version, was slightly more cost-effective than HHRP+.
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Affiliation(s)
- Dahye L. Song
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts, United States of America
| | - Frederick L. Altice
- AIDS Program, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Michael M. Copenhaver
- Division of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, United States of America
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut, United States of America
| | - Elisa F. Long
- UCLA Anderson School of Management, Los Angeles, California, United States of America
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Friedman SR, Perlman DC, Ompad DC. The Flawed Reliance on Randomized Controlled Trials in Studies of HIV Behavioral Prevention Interventions for People Who Inject Drugs and Other Populations. Subst Use Misuse 2015; 50. [PMID: 26222900 PMCID: PMC4568155 DOI: 10.3109/10826084.2015.1007677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This article discusses ways in which randomized controlled trials do not accurately measure the impact of HIV behavioral interventions. This is because: 1. Such trials measure the wrong outcomes. Behavior change may have little to do with changes in HIV incidence since behavior change in events between HIV-concordant people have no impact on incidence. Even more important, the comparison of HIV incidence rates between study arms of individual-level RCTs does not measure the true outcome of interest-whether or not the intervention reduces HIV transmission at the community level. This is because this comparison cannot measure the extent to which the intervention stops transmission by HIV-infected people in the study to those outside it. (And this is made even worse if HIV-infected are excluded from the evaluation of the intervention.) 2. There are potential harms implicit in most cognitively oriented behavioral interventions that are not measured in current practice and may not be measurable using RCTs. Intervention trials often reinforce norms and values of individual self-protection. They rarely if ever measure whether doing this reduces community trust, solidarity, cohesion, organization, or activism in ways that might facilitate HIV transmission. 3. Many interventions are not best conceived of as interventions with individuals but rather with networks, cultures of risks, or communities. As such, randomizing individuals leads to effective interventions that diffuse protection through a community; but these are evaluated as ineffective because the changes diffuse to the control arm, which leads to systematic and erroneous reductions in the evaluated effectiveness as RCTs measure it. The paper ends by discussing research designs that are superior to individual-level RCTs at measuring whether an intervention reduces or increases new HIV transmission.
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Affiliation(s)
- Samuel R Friedman
- a National Development and Research Institutes, Inc. , New York , USA
| | - David C Perlman
- a National Development and Research Institutes, Inc. , New York , USA
| | - Danielle C Ompad
- a National Development and Research Institutes, Inc. , New York , USA
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Gastfriend DR. A pharmaceutical industry perspective on the economics of treatments for alcohol and opioid use disorders. Ann N Y Acad Sci 2014; 1327:112-30. [PMID: 25236185 PMCID: PMC4206699 DOI: 10.1111/nyas.12538] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Individuals with alcohol and/or drug use disorders often fail to receive care, or evidence-based care, yet the literature shows health economic benefits. Comparative effectiveness research is emerging that examines approved approaches in terms of real, total healthcare cost/utilization. Comprehensive retrospective insurance claims analyses are few but tend to be nationally distributed and large. The emerging pattern is that, while treatment in general is cost effective, specific therapeutics can yield different health economic outcomes. Cost/utilization data consistently show greater savings with pharmacotherapies (despite their costs) versus psychosocial treatment alone. All FDA-approved addiction pharmacotherapies (oral naltrexone, extended-release naltrexone, acamprosate, disulfiram, buprenorphine, buprenorphine/naloxone, and methadone) are intended for use in conjunction with psychosocial management, not as stand-alone therapeutics; hence, pharmacotherapy costs must offer benefits in addition to abstinence alone or psychological therapy. Patient persistence is problematic, and (despite its cost) extended-release pharmacotherapy may be associated with lower or no greater total healthcare cost, mostly due to reduced hospitalization. The reviewed studies use rigorous case-mix adjustment to balance treatment cohorts but lack the randomization that clinical trials use to protect against confounding. Unlike trials, however, these studies can offer generalizability to diverse populations, providers, and payment models--and are of particular salience to payers.
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Nosyk B, Li L, Evans E, Urada D, Huang D, Wood E, Rawson R, Hser YI. Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991-2012. Drug Alcohol Depend 2014; 143:149-57. [PMID: 25110333 PMCID: PMC4484858 DOI: 10.1016/j.drugalcdep.2014.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 06/30/2014] [Accepted: 07/15/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND California treats the largest population of opioid dependent individuals in the USA and is among a small group of states that applies regulations for opioid treatment that are more stringent than existing federal regulations. We aim to characterize changes in patient characteristics and treatment utilization over time, and identify determinants of successful completion of detoxification and MMT retention in repeated attempts. METHODS State-wide administrative data was obtained from California Outcome Measurement System during the period: January 1st, 1991-March 31st, 2012. Short-term detoxification treatment and long-term maintenance treatment, primarily with methadone, was available to study participants. Mixed effects regression models were used to define determinants of successful completion of the detoxification treatment protocol (as classified by treatment staff) and duration of maintenance treatment. RESULTS The study sample consisted of 237,709 unique individuals and 885,971 treatment episodes; 837% were detoxification treatment episodes in 1994, dropping to 40.5% in 2010. Among individuals accessing only detoxification, the adjusted odds of success declined with each successive attempt (vs. 1st attempt: 2nd: OR: 0.679; 95% CI (0.610, 0.755); 3rd: 0.557 (0.484, 0.641); 4th: 0.526 (0.445, 0.622); 5th: 0.407 (0.334, 0.497); ≥6th: 0.339 (0.288, 0.399). For those ever accessing maintenance treatment, later subsequent attempts were longer in duration, and those with two or more prior attempts at detoxification had marginally longer subsequent maintenance episodes (hazard ratio: 0.97; 95% CI: 0.95, 0.99). Finally, only 10.9% of all detoxification episodes were followed by admission into maintenance treatment within 14 days. CONCLUSIONS This study has revealed high rates of detoxification treatment for opioid dependence in California throughout the study period, and decreasing odds of success in repeated attempts at detoxification.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, 613-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; Faculty of Health Sciences, Simon Fraser University, Canada; UCLA Integrated Substance Abuse Programs, USA.
| | - Libo Li
- UCLA Integrated Substance Abuse Programs, USA
| | | | | | - David Huang
- UCLA Integrated Substance Abuse Programs, USA
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, 613-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
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Nosyk B, Li L, Evans E, Huang D, Min J, Kerr T, Brecht ML, Hser YI. Characterizing longitudinal health state transitions among heroin, cocaine, and methamphetamine users. Drug Alcohol Depend 2014; 140:69-77. [PMID: 24837584 PMCID: PMC4072125 DOI: 10.1016/j.drugalcdep.2014.03.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 03/20/2014] [Accepted: 03/27/2014] [Indexed: 10/25/2022]
Abstract
AIMS Characterize longitudinal patterns of drug use careers and identify determinants of drug use frequency across cohorts of primary heroin, methamphetamine (MA) and cocaine users. DESIGN Pooled analysis of prospective cohort studies. SETTINGS Illicit drug users recruited from community, criminal justice and drug treatment settings in California, USA. PARTICIPANTS We used longitudinal data on from five observational cohort studies featuring primary users of heroin (N=629), cocaine (N=694) and methamphetamine (N=474). The mean duration of follow-up was 20.9 years. MEASUREMENTS Monthly longitudinal data was arranged according to five health states (incarceration, drug treatment, abstinence, non-daily and daily use). We fitted proportional hazards (PH) frailty models to determine independent differences in successive episode durations. We then executed multi-state Markov (MSM) models to estimate probabilities of transitioning between health states, and the determinants of these transitions. FINDINGS Across primary drug use types, PH frailty models demonstrated durations of daily use diminished in successive episodes over time. MSM models revealed primary stimulant users had more erratic longitudinal patterns of drug use, transitioning more rapidly between periods of treatment, abstinence, non-daily and daily use. MA users exhibited relatively longer durations of high-frequency use. Criminal engagement had a destabilizing effect on health state durations across drug types. Longer incarceration histories were associated with delayed transitions toward cessation. CONCLUSIONS PH frailty and MSM modeling techniques provided complementary information on longitudinal patterns of drug abuse. This information can inform clinical practice and policy, and otherwise be used in health economic simulation models, designed to inform resource allocation decisions.
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Affiliation(s)
- B Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada, Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, V5A 1S6, Canada
| | - L Li
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada
| | - E Evans
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada
| | - D Huang
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada
| | - J Min
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, V5A 1S6, Canada
| | - T Kerr
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, V5A 1S6, Canada, Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, V5Z 1M9, Canada
| | - ML Brecht
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada
| | - YI Hser
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, V6Z 2C7, Canada
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Alistar SS, Long EF, Brandeau ML, Beck EJ. HIV epidemic control-a model for optimal allocation of prevention and treatment resources. Health Care Manag Sci 2014; 17:162-81. [PMID: 23793895 PMCID: PMC3839258 DOI: 10.1007/s10729-013-9240-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
With 33 million people living with human immunodeficiency virus (HIV) worldwide and 2.7 million new infections occurring annually, additional HIV prevention and treatment efforts are urgently needed. However, available resources for HIV control are limited and must be used efficiently to minimize the future spread of the epidemic. We develop a model to determine the appropriate resource allocation between expanded HIV prevention and treatment services. We create an epidemic model that incorporates multiple key populations with different transmission modes, as well as production functions that relate investment in prevention and treatment programs to changes in transmission and treatment rates. The goal is to allocate resources to minimize R 0, the reproductive rate of infection. We first develop a single-population model and determine the optimal resource allocation between HIV prevention and treatment. We extend the analysis to multiple independent populations, with resource allocation among interventions and populations. We then include the effects of HIV transmission between key populations. We apply our model to examine HIV epidemic control in two different settings, Uganda and Russia. As part of these applications, we develop a novel approach for estimating empirical HIV program production functions. Our study provides insights into the important question of resource allocation for a country's optimal response to its HIV epidemic and provides a practical approach for decision makers. Better decisions about allocating limited HIV resources can improve response to the epidemic and increase access to HIV prevention and treatment services for millions of people worldwide.
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Affiliation(s)
- Sabina S. Alistar
- Department of Management Science and Engineering, Stanford University, Stanford, California,
| | - Elisa F. Long
- School of Management, Yale University, New Haven, Connecticut,
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, California,
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Nosyk B, Anglin MD, Brissette S, Kerr T, Marsh DC, Schackman BR, Wood E, Montaner JSG. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff (Millwood) 2014; 32:1462-9. [PMID: 23918492 DOI: 10.1377/hlthaff.2012.0846] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite decades of experience treating heroin or prescription opioid dependence with methadone or buprenorphine--two forms of opioid substitution therapy--gaps remain between current practices and evidence-based standards in both Canada and the United States. This is largely because of regulatory constraints and pervasive suboptimal clinical practices. Fewer than 10 percent of all people dependent on opioids in the United States are receiving substitution treatment, although the proportion may increase with expanded health insurance coverage as a result of the Affordable Care Act. In light of the accumulated evidence, we recommend eliminating restrictions on office-based methadone prescribing in the United States; reducing financial barriers to treatment, such as varying levels of copayment in Canada and the United States; reducing reliance on less effective and potentially unsafe opioid detoxification; and evaluating and creating mechanisms to integrate emerging treatments. Taking these steps can greatly reduce the harms of opioid dependence by maximizing the individual and public health benefits of treatment.
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Affiliation(s)
- Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia.
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Expanded HIV testing in low-prevalence, high-income countries: a cost-effectiveness analysis for the United Kingdom. PLoS One 2014; 9:e95735. [PMID: 24763373 PMCID: PMC3998955 DOI: 10.1371/journal.pone.0095735] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/30/2014] [Indexed: 02/07/2023] Open
Abstract
Objective In many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed. Design We developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries. Methods We estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness. Results Annual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000–£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4–15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained. Conclusions Annual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries.
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Javanbakht M, Mirahmadizadeh A, Mashayekhi A. The long-term effectiveness of methadone maintenance treatment in prevention of hepatitis C virus among illicit drug users: a modeling study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13484. [PMID: 24719731 PMCID: PMC3965864 DOI: 10.5812/ircmj.13484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/06/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022]
Abstract
Background: Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem. Illicit injection drug use is an important risk factor for the rising hepatitis C virus (HCV) prevalence in IR Iran. Objectives: The objective of this study was to determine the long-term effectiveness (total quality adjusted life years (QALYs) gained) of methadone maintenance treatment (MMT program) in prevention of HCV infection among injecting drug users (IDUs). Materials and Methods: A number of Markov models were developed to model morbidity and mortality among IDUs. The input data used in modeling were collected by a self-reported method from 259 IDUs before registration and one year after MMT and also from previous studies. One way and probabilistic sensitivity analyses were done to show the effects of uncertainty in parameters on number of life years and QALYs saved. The expected consequences were estimated using a life-time time horizon for the two strategies including implementation and not implementation of the MMT program. Results: Our model estimated that total number of discounted life years lived per IDU with and without the MMT program would be 5.15 (5.05 - 5.25) and 4.63 (4.42 - 4.81), respectively. The model also estimated that total number of discounted QALYs lived per IDU with and without the MMT program would be 4.11 (3.86 - 4.41) and 2.45 (2.17 - 2.84). Simulation results indicated that all differences in life years and QALYs lived between the two strategies were statistically significant (p < 0.001). Based on our model, total discounted life years and QALYs saved in a cohort of 1000 IDUs were 1790 (1520 - 2090) and 1590 (1090- 2090), respectively. Conclusions: Considering the high prevalence of illicit injecting drug use in Iran and MMT effectiveness in prevention of HCV infection, it is necessary to develop MMT centers at regional and national levels.
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Affiliation(s)
- Mehdi Javanbakht
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, IR Iran
| | | | - Atefeh Mashayekhi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Atefeh Mashayekhi, Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2144017935, Fax: +98-2144017935, E-mail:
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Alistar SS, Owens DK, Brandeau ML. Effectiveness and cost effectiveness of oral pre-exposure prophylaxis in a portfolio of prevention programs for injection drug users in mixed HIV epidemics. PLoS One 2014; 9:e86584. [PMID: 24489747 PMCID: PMC3904940 DOI: 10.1371/journal.pone.0086584] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 12/15/2013] [Indexed: 01/22/2023] Open
Abstract
Background Pre-exposure prophylaxis with oral antiretroviral treatment (oral PrEP) for HIV-uninfected injection drug users (IDUs) is potentially useful in controlling HIV epidemics with a significant injection drug use component. We estimated the effectiveness and cost effectiveness of strategies for using oral PrEP in various combinations with methadone maintenance treatment (MMT) and antiretroviral treatment (ART) in Ukraine, a representative case for mixed HIV epidemics. Methods and Findings We developed a dynamic compartmental model of the HIV epidemic in a population of non-IDUs, IDUs who inject opiates, and IDUs in MMT, adding an oral PrEP program (tenofovir/emtricitabine, 49% susceptibility reduction) for uninfected IDUs. We analyzed intervention portfolios consisting of oral PrEP (25% or 50% of uninfected IDUs), MMT (25% of IDUs), and ART (80% of all eligible patients). We measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, HIV infections averted, and incremental cost effectiveness. A combination of PrEP for 50% of IDUs and MMT lowered HIV prevalence the most in both IDUs and the general population. ART combined with MMT and PrEP (50% access) averted the most infections (14,267). For a PrEP cost of $950, the most cost-effective strategy was MMT, at $520/QALY gained versus no intervention. The next most cost-effective strategy consisted of MMT and ART, costing $1,000/QALY gained compared to MMT alone. Further adding PrEP (25% access) was also cost effective by World Health Organization standards, at $1,700/QALY gained. PrEP alone became as cost effective as MMT at a cost of $650, and cost saving at $370 or less. Conclusions Oral PrEP for IDUs can be part of an effective and cost-effective strategy to control HIV in regions where injection drug use is a significant driver of the epidemic. Where budgets are limited, focusing on MMT and ART access should be the priority, unless PrEP has low cost.
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Affiliation(s)
- Sabina S. Alistar
- Department of Management Science and Engineering, Stanford University, Stanford, California, United States of America
- * E-mail:
| | - Douglas K. Owens
- Veterans Affairs Palo Healthcare System, Palo Alto, California, United States of America
- Center for Health Policy/Program on Clinical Outcomes Research, Stanford University, Stanford, California, United States of America
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, California, United States of America
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Keshtkaran A, Mirahmadizadeh A, Heidari A, Javanbakht M. Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e7801. [PMID: 24719714 PMCID: PMC3964432 DOI: 10.5812/ircmj.7801] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/20/2013] [Accepted: 11/12/2013] [Indexed: 01/25/2023]
Abstract
Background: The increase in high-risk injections and unsafe sexual behaviors has led to increased HIV infection prevalence among Intravenous Drug Users (IDUs). The high costs of HIV/AIDS care and low financial resources necessitate an economic evaluation to make the best decision for the control of HIV/AIDS. Objectives: This study was conducted to determine the cost-effectiveness of Methadone Maintenance Treatment (MMT) centers in HIV infection prevention among drug users. Materials and Methods: In this interventional study, we included all the seven MMT centers and the drug users registered there (n = 694). We calculated all the costs imposed on the government, i.e. Provider of case. Mathematical models were used to estimate the number of HIV cases averted from high-risk behaviors. Sensitivity analyses were performed to show the effects of uncertainty in parameters on the number of HIV cases averted and also Incremental Cost-Effectiveness Ratio (ICER). Results: Based on the averted models, the selected MMT centers could prevent 128 HIV cases during 1 year. The total cost was $ 547423 and that of HIV/AIDS care in the no intervention scenario was estimated $ 14171816. ICER was $ 106382 per HIV case averted. The results of the sensitivity analysis indicated that MMT intervention was cost-effective even in the worst scenario and ICER varied from $ 39149 to $ 290004 per HIV case averted. Conclusions: With regard to the high prevalence of drug injection among drug users and considering the high effectiveness and cost-effectiveness of MMT centers in preventing HIV infection, establishment of MMT centers in regional and national levels seems reasonable.
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Affiliation(s)
- Ali Keshtkaran
- School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Alireza Mirahmadizadeh
- Shiraz AIDS Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Author: Alireza Mirahmadizadeh, Shiraz AIDS Research Center Central Building of Shiraz University of Medical Sciences, 8th floor, Zand Blvd., Shiraz, IR Iran. Tel: +98-7112122320, E-mail:
| | - Alireza Heidari
- Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, IR Iran
| | - Mehdi Javanbakht
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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