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Hood JE, Behrends CN, Irwin A, Schackman BR, Chan D, Hartfield K, Hess J, Banta-Green C, Whiteside L, Finegood B, Duchin J. The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. Int J Drug Policy 2019; 67:9-18. [PMID: 30802842 DOI: 10.1016/j.drugpo.2018.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/06/2018] [Accepted: 12/30/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings. METHODS We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates. RESULTS Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater. CONCLUSION This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.
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Affiliation(s)
- J E Hood
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States.
| | - C N Behrends
- Weill Cornell Medical College, 1300 York Ave. Box 65, New York, NY, 10065, United States
| | - A Irwin
- Law Enforcement Action Partnership, Silver Spring, MD, United States
| | - B R Schackman
- Weill Cornell Medical College, 1300 York Ave. Box 65, New York, NY, 10065, United States
| | - D Chan
- King County Department of Community and Health Services, 401 Fifth Avenue, Suite 500, Seattle, WA, United States; University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - K Hartfield
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States
| | - J Hess
- University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - C Banta-Green
- University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - L Whiteside
- University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - B Finegood
- King County Department of Community and Health Services, 401 Fifth Avenue, Suite 500, Seattle, WA, United States
| | - J Duchin
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States; University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States; University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
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2
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Nosyk B, Bray JW, Wittenberg E, Aden B, Eggman AA, Weiss RD, Potter J, Ang A, Y-I H, Ling W, Schackman BR. Short term health-related quality of life improvement during opioid agonist treatment. Drug Alcohol Depend 2015; 157:121-8. [PMID: 26511766 PMCID: PMC4778423 DOI: 10.1016/j.drugalcdep.2015.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Opioid dependence is associated with high levels of morbidity, yet sparse data exists regarding the health-related quality of life (HRQoL) of individuals with opioid dependence, particularly following treatment initiation. To inform cost-effectiveness analyses of treatment modalities, this study investigates short-term changes in HRQoL following enrollment into opioid agonist treatment (OAT), across treatment modalities and patient subgroups. METHODS Data was analyzed from the Starting Treatment with Agonist Replacement Therapies (START) and Prescription Opioid Addiction Treatment Studies (POATS) randomized controlled trials. Participants included individuals dependent on prescription opioids (POs) or heroin, receiving limited-term or time-unlimited treatment. PO- or heroin-users in START received buprenorphine/naloxone (BUP/NX) or methadone (MET) over 24 weeks. PO-users in POATS received psychosocial care and short-term (4-week) taper with BUP/NX, with non-responders offered subsequent extended (12-week) stabilization and taper. HRQoL was assessed using the short-form SF-6D while in and out of OAT, with distinction between MMT and BUP/NX in START. Linear mixed effects regression models were fitted to determine the independent effects of OAT on HRQoL and characterize HRQoL trajectories. RESULTS Treatment had a similar immediate and modest positive association with HRQoL in each patient subgroup. The association of OAT on HRQoL was statistically significant in each model, with effect sizes between 0.039 (heroin-users receiving BUP/NX) and 0.071 (PO-users receiving MET). After initial improvement, HRQoL decreased slightly, or increased at a diminished rate. CONCLUSIONS OAT, whether delivered in time-limited or unlimited form, using BUP/NX or MET, is associated with modest immediate HRQoL improvements, with diminishing benefits thereafter.
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Affiliation(s)
- B Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
| | - JW Bray
- University of North Carolina, Greensboro,Research Triangle International
| | | | - B Aden
- Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - AA Eggman
- Department of Healthcare Policy and Research, Weill Cornell Medical College
| | - RD Weiss
- Harvard Medical School, Boston, MA,McLean Hospital, Belmont, MA
| | - J Potter
- Departments of Psychiatry and Anesthesiology (Pain Medicine), Faculty of Medicine, University of Texas Health Science Center, San Antonio, TX
| | - A Ang
- UCLA Integrated Substance Abuse Programs, Los Angeles CA
| | - Hser Y-I
- UCLA Integrated Substance Abuse Programs, Los Angeles CA
| | - W Ling
- UCLA Integrated Substance Abuse Programs, Los Angeles CA
| | - BR Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College
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Gammal RS, Court MH, Haidar CE, Iwuchukwu OF, Gaur AH, Alvarellos M, Guillemette C, Lennox JL, Whirl-Carrillo M, Brummel SS, Ratain MJ, Klein TE, Schackman BR, Caudle KE, Haas DW. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for UGT1A1 and Atazanavir Prescribing. Clin Pharmacol Ther 2015; 99:363-9. [PMID: 26417955 DOI: 10.1002/cpt.269] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/24/2015] [Indexed: 01/09/2023]
Abstract
The antiretroviral protease inhibitor atazanavir inhibits hepatic uridine diphosphate glucuronosyltransferase (UGT) 1A1, thereby preventing the glucuronidation and elimination of bilirubin. Resultant indirect hyperbilirubinemia with jaundice can cause premature discontinuation of atazanavir. Risk for bilirubin-related discontinuation is highest among individuals who carry two UGT1A1 decreased function alleles (UGT1A1*28 or *37). We summarize published literature that supports this association and provide recommendations for atazanavir prescribing when UGT1A1 genotype is known (updates at www.pharmgkb.org).
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Affiliation(s)
- R S Gammal
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M H Court
- Individualized Medicine Program, Department of Veterinary Clinical Sciences, Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - C E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - O F Iwuchukwu
- Division of Pharmaceutical Sciences, Fairleigh Dickinson University School of Pharmacy, Florham Park, New Jersey, USA.,Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - A H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M Alvarellos
- Department of Genetics, Stanford University, Stanford, California, USA
| | - C Guillemette
- Laval University CHU de Québec Research Center, Quebec, Quebec, Canada
| | - J L Lennox
- Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Whirl-Carrillo
- Department of Genetics, Stanford University, Stanford, California, USA
| | - S S Brummel
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - M J Ratain
- Center for Personalized Therapeutics, Comprehensive Cancer Center, The University of Chicago, Chicago, Illinois, USA
| | - T E Klein
- Department of Genetics, Stanford University, Stanford, California, USA
| | - B R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - D W Haas
- Departments of Medicine, Pharmacology, Pathology, Microbiology & Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Haynes LF, Korte JE, Holmes BE, Gooden L, Matheson T, Feaster DJ, Leff JA, Wilson L, Metsch LR, Schackman BR. HIV rapid testing in substance abuse treatment: implementation following a clinical trial. Eval Program Plann 2011; 34:399-406. [PMID: 21367457 PMCID: PMC3124222 DOI: 10.1016/j.evalprogplan.2011.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The Substance Abuse Mental Health Services Administration has promoted HIV testing and counseling as an evidence-based practice. Nevertheless, adoption of HIV testing in substance abuse treatment programs has been slow. This article describes the experience of a substance abuse treatment agency where, following participation in a clinical trial, the agency implemented an HIV testing and counseling program. During the trial, a post-trial pilot, and early implementation the agency identified challenges and developed strategies to overcome barriers to adoption of the intervention. Their experience may be instructive for other treatment providers seeking to implement an HIV testing program. Lessons learned encompassed the observed acceptability of testing and counseling to clients, the importance of a "champion" and staff buy-in, the necessity of multiple levels of community and agency support and collaboration, the ability to streamline staff training, the need for a clear chain of command, the need to develop program specific strategies, and the requirement for sufficient funding. An examination of costs indicated that some staff time may not be adequately reimbursed by funding sources for activities such as adapting the intervention, start-up training, ongoing supervision and quality assurance, and overhead costs.
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Affiliation(s)
- LF Haynes
- Medical University of South Carolina, Division of Clinical Neuroscience, 67 President St, Charleston SC 29425
| | - JE Korte
- Medical University of South Carolina, Division of Biostatistics and Epidemiology, 135 Cannon Street, Charleston SC 29425
| | - BE Holmes
- Lexington Richland Alcohol and Drug Abuse Council, 2711 Colonial Dr., Columbia SC 29203
| | - L Gooden
- University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, 1120 Northwest 14 St., Miami Fl 33136
| | - T Matheson
- San Francisco Department of Public Health, 25 Van Ness Ave., San Francisco CA 94102
| | - DJ Feaster
- University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, 1120 Northwest 14 St., Miami Fl 33136
| | - JA Leff
- Weill Cornell Medical College, Department of Public Health, 402 East 67 St., New York, NY 10065
| | - L Wilson
- Lexington Richland Alcohol and Drug Abuse Council, 2711 Colonial Dr., Columbia SC 29203
| | - LR Metsch
- University of Miami Miller School of Medicine, Department of Epidemiology and Public Health, 1120 Northwest 14 St., Miami Fl 33136
| | - BR Schackman
- Weill Cornell Medical College, Department of Public Health, 402 East 67 St., New York, NY 10065
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Linas BP, Wang B, Smurzynski M, Losina E, Bosch RJ, Schackman BR, Rong J, Sax PE, Walensky RP, Schouten J, Freedberg KA. The impact of HIV/HCV co-infection on health care utilization and disability: results of the ACTG Longitudinal Linked Randomized Trials (ALLRT) Cohort. J Viral Hepat 2011; 18:506-12. [PMID: 20546501 PMCID: PMC3347883 DOI: 10.1111/j.1365-2893.2010.01325.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
HIV/hepatitis C virus (HCV) co-infection places a growing burden on the HIV/AIDS care delivery system. Evidence-based estimates of health services utilization among HIV/HCV co-infected patients can inform efficient planning. We analyzed data from the ACTG Longitudinal Linked Randomized Trials (ALLRT) cohort to estimate resource utilization and disability among HIV/HCV co-infected patients and compare them to rates seen in HIV mono-infected patients. The analysis included HIV-infected subjects enrolled in the ALLRT cohort between 2000 and 2007 who had at least one CD4 count measured and completed at least one resource utilization data collection form (N = 3143). Primary outcomes included the relative risk of hospital nights, emergency department (ED) visits, and disability days for HIV/HCV co-infected vs HIV mono-infected subjects. When controlling for age, sex, race, history of AIDS-defining events, current CD4 count and current HIV RNA, the relative risk of hospitalization, ED visits, and disability days for subjects with HIV/HCV co-infection compared to those with HIV mono-infection were 1.8 (95% CI: 1.3-2.5), 1.7 (95% CI: 1.4-2.1), and 1.6 (95% CI: 1.3-1.9) respectively. Programs serving HIV/HCV co-infected patients can expect approximately 70% higher rates of utilization than expected from a similar cohort of HIV mono-infected patients.
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Affiliation(s)
- B. P. Linas
- Divisions of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA,General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - B. Wang
- The Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
| | - M. Smurzynski
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - E. Losina
- The Harvard University Center for AIDS Research (CFAR), Boston, MA, USA,Department of Orthopedic Surgery Brigham and Women’s Hospital, Boston, MA, USA,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - R. J. Bosch
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - B. R. Schackman
- Department of Public Health, Weill Cornell Medical College, New York, NY, USA
| | - J. Rong
- Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - P. E. Sax
- The Harvard University Center for AIDS Research (CFAR), Boston, MA, USA,Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA, USA
| | - R. P. Walensky
- Divisions of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA,The Harvard University Center for AIDS Research (CFAR), Boston, MA, USA,Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA, USA
| | - J. Schouten
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - K. A. Freedberg
- Divisions of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA,General Medicine, Massachusetts General Hospital, Boston, MA, USA,The Harvard University Center for AIDS Research (CFAR), Boston, MA, USA,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Schackman BR, Finkelstein R, Neukermans CP, Lewis L, Eldred L. The cost of HIV medication adherence support interventions: Results of a cross-site evaluation. AIDS Care 2007; 17:927-37. [PMID: 16265786 DOI: 10.1080/09540120500100635] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this study was to determine the direct cost of HIV adherence support programmes participating in a cross-site evaluation in the US. Data on the frequency, type, and setting of adherence encounters; providers' professions; and adherence tools provided were collected for 1,122 patients enrolled in 13 interventions at 9 sites. The site staff estimated the average duration of each type of encounter and national wage rates were used for labour costs. The median (range) adherence encounters/year among interventions was 16.5 (4.3-104.6) per patient; encounters lasted 24.6 (8.9-40.9) minutes. Intervention direct cost was correlated with the average frequency of encounters (r = 0.57), but not with encounter duration or providers' professions. The median direct cost/month was 35 dollars(5 dollars-58 dollars) per patient, and included direct provider costs (66%); incentives (17%); reminders and other tools (8%); and direct administrative time, provider transportation, training, and home delivery (9%). The median direct cost/month from a societal perspective, which includes patient time and travel costs, was 47 dollars(24 dollars-114 dollars) per patient. Adherence interventions with moderate efficacy costing < or =100 dollars/month have been estimated to meet a cost-effectiveness threshold that is generally accepted in the US. Payers should consider enhanced reimbursement for adherence support services.
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Affiliation(s)
- B R Schackman
- Weill Medical College of Cornell University, New York, USA.
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Schackman BR, Goldie SJ, Weinstein MC, Losina E, Zhang H, Freedberg KA. Cost-effectiveness of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults. Am J Public Health 2001; 91:1456-63. [PMID: 11527782 PMCID: PMC1446805 DOI: 10.2105/ajph.91.9.1456] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study was designed to examine the societal cost-effectiveness and the impact on government payers of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults. METHODS A state-transition simulation model of HIV disease was used. Data were derived from the Multicenter AIDS Cohort Study, published randomized trials, and medical care cost estimates for all government payers and for Massachusetts, NewYork, and Florida. RESULTS Quality-adjusted life expectancy increased from 7.64 years with therapy initiated at 200 CD4 cells/microL to 8.21 years with therapy initiated at 500 CD4 cells/microL. Initiating therapy at 500 CD4/microL was a more efficient use of resources than initiating therapy at 200 CD4/microL and had an incremental cost-effectiveness ratio of $17,300 per quality-adjusted life-year gained, compared with no therapy. Costs to state payers in the first 5 years ranged from $5,500 to $24,900 because of differences among the states in the availability of federal funds forAIDS drug assistance programs. CONCLUSIONS Antiretroviral therapy initiated at 500 CD4 cells/microL is cost-effective from a societal: perspective compared with therapy initiated later. States should consider Medicaid waivers to expand access to early therapy.
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Affiliation(s)
- B R Schackman
- Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass, USA.
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