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Homayra F, Enns B, Min JE, Kurz M, Bach P, Bruneau J, Greenland S, Gustafson P, Karim ME, Korthuis PT, Loughin T, MacLure M, McCandless L, Platt RW, Schnepel K, Shigeoka H, Siebert U, Socias E, Wood E, Nosyk B. Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder. Epidemiology 2024; 35:218-231. [PMID: 38290142 PMCID: PMC10833049 DOI: 10.1097/ede.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). METHODS Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber's preference IV in analyzing the treatment assignment-treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. RESULTS The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in provider-level prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. CONCLUSIONS Our results suggest that prescriber's preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD.
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Affiliation(s)
- Fahmida Homayra
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Sander Greenland
- Department of Epidemiology, University of California, Los Angeles, California, USA
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammad Ehsanul Karim
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - P Todd Korthuis
- Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas Loughin
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm MacLure
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lawrence McCandless
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Robert William Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kevin Schnepel
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Hitoshi Shigeoka
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Uwe Siebert
- Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Zang X, Piske M, Humphrey L, Enns B, Sui Y, Marshall BDL, Goedel WC, Feaster DJ, Metsch LR, Sullivan PS, Tookes HE, Nosyk B. Estimating the epidemiological impact of reaching the objectives of the Florida integrated HIV prevention and care plan in Miami-Dade County. Lancet Reg Health Am 2023; 27:100623. [PMID: 37928440 PMCID: PMC10624567 DOI: 10.1016/j.lana.2023.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
Background The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly. Methods We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target. Findings The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively. Interpretation Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic. Funding This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747.
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Affiliation(s)
- Xiao Zang
- Division of Health Policy and Management, School of Public Health, University of Minnesota, A302 Mayo Building, MMC 729, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z1Y6, Canada
| | - Lia Humphrey
- Centre for Health Evaluation and Outcome Sciences, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z1Y6, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z1Y6, Canada
| | - Yi Sui
- Centre for Health Evaluation and Outcome Sciences, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z1Y6, Canada
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
| | - William C Goedel
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 919, Miami, FL, 33136, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA
| | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE Atlanta, GA, 30322, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
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Abrams MP, Weiner J, Piske M, Enns B, Krebs E, Zang X, Nosyk B, Meisel ZF. Translating and disseminating a localised economic model to support implementation of the 'Ending the HIV Epidemic' initiative to public health policymakers. Evid Policy 2023; 19:554-571. [PMID: 38313044 PMCID: PMC10836837 DOI: 10.1332/174426421x16875142087569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Background Despite significant progress in HIV treatment and prevention, the US remains far from its goal of 'Ending the HIV Epidemic' by 2030. Economic models using local data can synthesise the evidence to help policymakers allocate HIV resources efficiently, but persistent research-to-practice gaps remain. Little is known about how to facilitate the use of economic modelling data among local public health policymakers in real-world settings. Aims and objectives To explore the dissemination of results from a locally-calibrated economic model for HIV prevention and treatment and identify the factors influencing potential uptake of the model for public health decision making at the local level. Methods Four virtual focus groups with 26 local health department policymakers in Baltimore, Miami, Seattle, and New York City were held between July 2020 and May 2021. Qualitative content analysis of transcripts identified key themes around using the localised economic model in policy decisions. Results Participants were interested in using local data in their decisions to allocate resources for HIV prevention/treatment. Six themes emerged: 1) importance of understanding local policy context; 2) health equity considerations; 3) using evidence to support current priorities; 4) difficulty of changing strategies, even incrementally; 5) bang for the incremental buck (efficiency) vs. previous impact; and 6) community values. Conclusion and relevance To optimise acceptance and use of results from economic models, researchers should engage with local community members and public health decision makers early to understand budgetary and community priorities. Participants prioritised evidence that supports their existing strategies, considers budgets and funding streams, and improves health equity; however, real-world budget constraints and conflicting interests serve as barriers to implementing model recommendations and reaching national goals.
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Affiliation(s)
| | | | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Canada
| | - Emanuel Krebs
- Centre for Health Evaluation and Outcome Sciences, Canada
| | | | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences and Simon Fraser University, Canada
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Rioux W, Enns B, Ghosh SM. Virtual overdose monitoring services/mobile overdose response services: estimated number of potentially averted drug poisoning fatality events by various telephone and digital-based overdose prevention/harm reduction services in North America. Front Public Health 2023; 11:1242795. [PMID: 37927877 PMCID: PMC10622778 DOI: 10.3389/fpubh.2023.1242795] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023] Open
Abstract
Background Virtual overdose monitoring services or Mobile Overdose Response Services (MORS) are novel virtual harm reduction tools which have gained popularity as an adjunct public health intervention especially for those who cannot access harm reduction resources through traditional means. At this time, relatively little is known about their ability to reach their goals of reducing overdose mortality. Our study aims to summarize the potential effectiveness of various MORS collectively to avoid potential mortality from a drug poisoning event/drug overdose. Methods Utilizing publicly available data from various MORS alongside some usage data provided by these services for this study, we model the impact of these services on fatal drug poisoning/overdose. In order to calculate the number of deaths averted, a Monte Carlo simulation was used to calculate point estimates with 95% confidence for fatal drug poisonings/drug overdose potentially averted through the utilization of various MORS. Results From the earliest mention of MORS in current literature (2019), a total of 299 drug poisoning/overdose events occurred across these services. Noting the broad range of mortality statistics available in current literature, these technologies have potentially prevented between 33 to 243 deaths. Our Monte Carlo estimates 135 potentially fatal drug poisonings/overdose were overall averted by the various MORS. Conclusions While there is yet to be a robust data set proving the effectiveness of these services, conservative estimates show that MORS can reduce mortality associated with substance use and therefore should be considered as a viable harm-reduction strategy but as an adjunct to more established harm reduction services such as supervised consumption sites and supervised injection facilities. While more research is needed, clinicians and practitioners should consider the suggestion of these tools for patients who use drugs.
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Affiliation(s)
- William Rioux
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Benjamin Enns
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - S. Monty Ghosh
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Department of Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Rioux W, Enns B, Jackson J, Quereshi H, Irvine M, Ghosh SM. A cost benefit analysis of a virtual overdose monitoring service/mobile overdose response service: the national overdose response service. Subst Abuse Treat Prev Policy 2023; 18:57. [PMID: 37794482 PMCID: PMC10548617 DOI: 10.1186/s13011-023-00565-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/25/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND The overdose crisis continues across Canada which calls for novel harm reduction strategies. Previous research indicates that a majority of eHealth solutions are cost-effective however current literature on the cost-benefit of eHealth for harm reduction is sparse. The National Overdose Response Service (NORS) is a Canada-wide telephone-based harm reduction service. Service users can call the phone number and connect to a peer who can virtually monitor the substance use session and dispatch appropriate interventions in the case of overdose. OBJECTIVES OF THE RESEARCH/PROJECT We aim to assess the cost-benefit of NORS by comparing the estimated cost-savings from prevented overdose mortality to the operating costs of the program, alongside healthcare costs associated with its operation. METHODS Data around systems costs and operational costs were gathered for our calculations. Our primary outcome was cost-benefit ratios, derived from estimates and models of mortality rates in current literature and value of life lost. We presented our main results across a range of values for costs and the probability of death following an unwitnessed overdose. These values were utilized to calculate cost-benefit ratios and value per dollar spent on service provision by NORS over the length of the program's operation (December 2020-2022). RESULTS Over the total funded lifespan of the program, and using a Monte Carlo estimate, the benefit-to-cost ratio of the NORS program was 8.59 (1.53-15.28) per dollar spent, depending on estimated mortality rates following unwitnessed overdose and program operation costs. Further, we conservatively estimate that early community-based naloxone intervention results in healthcare system savings of $4470.82 per overdose response. CONCLUSIONS We found the NORS program to have a positive benefit-to-cost ratio when the probability of death following an unwitnessed overdose was greater than 5%. NORS and potentially other virtual overdose monitoring services have the potential to be cost-effective solutions for managing the drug poisoning crisis.
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Affiliation(s)
- William Rioux
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | | | - Hena Quereshi
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Mike Irvine
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - S Monty Ghosh
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada.
- Department of Internal Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada.
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Nosyk B, Fojo AT, Kasaie P, Enns B, Trigg L, Piske M, Hutchinson AB, DiNenno EA, Zang X, del Rio C. The Testing Imperative: Why the US Ending the Human Immunodeficiency Virus (HIV) Epidemic Program Needs to Renew Efforts to Expand HIV Testing in Clinical and Community-Based Settings. Clin Infect Dis 2023; 76:2206-2208. [PMID: 36815334 PMCID: PMC10273343 DOI: 10.1093/cid/ciad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
Data from several modeling studies demonstrate that large-scale increases in human immunodeficiency virus (HIV) testing across settings with a high burden of HIV may produce the largest incidence reductions to support the US Ending the HIV Epidemic (EHE) initiative's goal of reducing new HIV infections 90% by 2030. Despite US Centers for Disease Control and Prevention's recommendations for routine HIV screening within clinical settings and at least yearly screening for individuals most at risk of acquiring HIV, fewer than half of US adults report ever receiving an HIV test. Furthermore, total domestic funding for HIV prevention has remained unchanged between 2013 and 2019. The authors describe the evidence supporting the value of expanded HIV testing, identify challenges in implementation, and present recommendations to address these barriers through approaches at local and federal levels to reach EHE targets.
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Affiliation(s)
- Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Health Economic Research Unit, Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Anthony Todd Fojo
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Parastu Kasaie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Benjamin Enns
- Health Economic Research Unit, Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura Trigg
- Health Economic Research Unit, Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- School of Health and Related Research, Health Economics and Decision Modelling, Sheffield University, Sheffield, United Kingdom
| | - Micah Piske
- Health Economic Research Unit, Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | | | | | - Xiao Zang
- Department of Epidemiology, Brown University School of Public Health, Providence Rhode Island, USA
| | - Carlos del Rio
- Faculty of Medicine, Emory University, Atlanta, Georgia, USA
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Enns B, Krebs E, Whitehurst DGT, Jutras-Aswad D, Le Foll B, Socias ME, Nosyk B. Cost-effectiveness of flexible take-home buprenorphine-naloxone versus methadone for treatment of prescription-type opioid use disorder. Drug Alcohol Depend 2023; 247:109893. [PMID: 37120920 DOI: 10.1016/j.drugalcdep.2023.109893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/08/2022] [Revised: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Our objective was to examine the cost-effectiveness of flexible take-home buprenorphine-naloxone (BNX) versus methadone alongside the OPTIMA trial in Canada. METHODS The OPTIMA study was a pragmatic, open-label, noninferiority, two-arm randomized controlled trial, to assess the comparative effectiveness of flexible take-home BNX vs. methadone in routine clinical care for individuals with prescription-type opioid use disorder. We evaluated cost-effectiveness using a semi-Markov cohort model. Probabilities of overdose were calibrated, accounting for fentanyl prevalence and other overdose risk factors such as naloxone availability. We considered health sector and societal cost perspectives, including costs (2020 CAD) for treatment, health resource use, criminal activity, and health state-specific preference weights as outcomes to calculate incremental cost-effectiveness ratios. Six-month and lifetime (3% annual discount rate) time-horizons were explored. RESULTS Over a lifetime time horizon, individuals accumulated -0.144 [CI: -0.302, -0.025] incremental quality-adjusted life years (QALYs) in BNX compared with methadone. Incremental costs were -$2047 [CI: -$39,197, $24,250] from a societal perspective, and -$4549 [CI: -$6332, -$3001] from a health sector perspective. Over a six-month time-horizon, individuals accumulated 0.002 [credible interval (CI): -0.011, 0.016] incremental QALYs in BNX compared with methadone. Incremental costs were -$307 [CI: -$10,385, $8466] from a societal perspective and -$1111 [CI: -$1517, -$631] from a health sector perspective. BNX was dominated (costlier, less effective) in 49.7% of simulations when adopting a societal perspective over a lifetime time horizon. CONCLUSIONS Flexible take-home BNX was not cost-effective versus methadone over a lifetime time horizon, resulting from better treatment retention in methadone compared to BNX.
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Affiliation(s)
- Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - David G T Whitehurst
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montréal, QuébecH2X 0A9, Canada; Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, 2900 boul. Edouard-Montpetit, Montréal, QuébecH3T1J4, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, OntarioM5S 1A8, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 250 College Street, 8th floor, Toronto, OntarioM5T 1R8, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, OntarioM5T 3M7, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), 33 Ursula Franklin Street, Toronto, OntarioM5S 2S1, Canada; Acute Care Program, CAMH, 33 Ursula Franklin Street, Toronto, OntarioM5S 2S1, Canada
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British ColumbiaV6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 1045 Howe Street, Vancouver, British ColumbiaV6Z 2A9, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
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Whitehurst DGT, Mah C, Krebs E, Enns B, Socias ME, Jutras-Aswad D, Le Foll B, Nosyk B. Sensitivity to change of generic preference-based instruments (EQ-5D-3L, EQ-5D-5L, and HUI3) in the context of treatment for people with prescription-type opioid use disorder in Canada. Qual Life Res 2023:10.1007/s11136-023-03381-6. [PMID: 37027087 PMCID: PMC10080515 DOI: 10.1007/s11136-023-03381-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Using data from a randomized controlled trial for treatment of prescription-type opioid use disorder in Canada, this study examines sensitivity to change in three preference-based instruments [EQ-5D-3L, EQ-5D-5L, and the Health Utilities Index Mark 3 (HUI3)] and explores an oft-overlooked consideration when working with contemporaneous responses for similar questions-data quality. METHODS Analyses focused on the relative abilities of three instruments to capture change in health status. Distributional methods were used to categorize individuals as 'improved' or 'not improved' for eight anchors (seven clinical, one generic). Sensitivity to change was assessed using area under the ROC (receiver operating characteristics) curve (AUC) analysis and comparisons of mean change scores for three time periods. A 'strict' data quality criteria, defined a priori, was applied. Analyses were replicated using 'soft' and 'no' criteria. RESULTS Data from 160 individuals were used in the analysis; 30% had at least one data quality violation at baseline. Despite mean index scores being significantly lower for the HUI3 compared with EQ-5D instruments at each time point, the magnitudes of change scores were similar. No instrument demonstrated superior sensitivity to change. While six of the 10 highest AUC estimates were for the HUI3, 'moderate' classifications of discriminative ability were identified in 12 (of 22) analyses for each EQ-5D instrument, compared with eight for the HUI3. CONCLUSION Negligible differences were observed between the EQ-5D-3L, EQ-5D-5L, and HUI3 regarding the ability to measure change. The prevalence of data quality violations-which differed by ethnicity-requires further investigation.
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Affiliation(s)
| | - Cassandra Mah
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - M Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Acute Care Program, CAMH, Toronto, ON, Canada
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
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Enns B, Krebs E, Thomson T, Dale LM, Min JE, Nosyk B. Opioid analgesic prescribing for opioid-naïve individuals prior to identification of opioid use disorder in British Columbia, Canada. Addiction 2021; 116:3422-3432. [PMID: 33861882 DOI: 10.1111/add.15515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/06/2020] [Revised: 10/08/2020] [Accepted: 03/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Prescription opioid analgesics have contributed to the development of opioid use disorder (OUD) in many individuals. We aimed to characterize non-cancer opioid prescribing for opioid-naive individuals prior to OUD identification. DESIGN Population-based retrospective cohort study using six linked health administrative databases. SETTING British Columbia (BC), Canada. PARTICIPANTS People with OUD between 1 January 2001 and 30 September 2018 who initiated opioid analgesic therapy for non-cancer pain prior to OUD identification. MEASUREMENTS Dose (morphine milligram equivalent per day), days prescribed and clinical guideline non-concordance for initial opioid prescriptions (dose ≥ 90 morphine milligram equivalent per day; ≥ 7 days prescribed; concomitant sedative prescription). We estimated the probability of non-concordant initial prescriptions by source (inpatient post-discharge, non-inpatient acute, non-acute) using logistic regression, adjusting for individual characteristics and comorbidities. FINDINGS Among 66 372 individuals identified with OUD from 2001 to 2018, 21 331 (32.1%) received opioid analgesics prior to OUD identification. This proportion increased from 3.0% in 2001 to 41.0% in 2011, before decreasing to 34.2% in 2017. Roughly half of opioid prescriptions were attributed to non-acute care visits, peaking at 56.8% in 2007, while the proportion from inpatient visits increased from 19.7% in 2001 to 28.5% in 2017. The predicted probability of receiving non-guideline concordant prescriptions declined over time-periods across all three measures for inpatient and non-inpatient acute care, while remaining stable for non-acute care. In particular, the predicted probability of receiving ≥ 7-day prescriptions following inpatient visits decreased from 53.3% [95% confidence interval (CI) = 50.9, 55.8%] in 2001-06 to 37.2% (95% CI = 33.9, 40.5%) in 2013-18. CONCLUSIONS Among the 66 372 individuals in British Columbia, Canada diagnosed with opioid use disorder between 2001 and 2018, more than 32% were earlier prescribed non-cancer opioid analgesics. The proportion who had received an opioid analgesic prescription prior to OUD identification peaked at more than 40% in 2011, before stabilizing between 2011 and 2016 and declining thereafter. Guideline concordance improved over time for high-dose and concomitant sedative prescribing.
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Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Trevor Thomson
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Laura M Dale
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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10
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Nosyk B, Krebs E, Zang X, Piske M, Enns B, Min JE, Behrends CN, Del Rio C, Feaster DJ, Golden M, Marshall BDL, Mehta SH, Meisel ZF, Metsch LR, Pandya A, Schackman BR, Shoptaw S, Strathdee SA. "Ending the Epidemic" Will Not Happen Without Addressing Racial/Ethnic Disparities in the United States Human Immunodeficiency Virus Epidemic. Clin Infect Dis 2021; 71:2968-2971. [PMID: 32424416 DOI: 10.1093/cid/ciaa566] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 03/02/2020] [Accepted: 05/15/2020] [Indexed: 11/14/2022] Open
Abstract
We estimated human immunodeficiency virus incidence and incidence rate ratios (IRRs) for black and Hispanic vs white populations in 6 cities in the United States (2020-2030). Large reductions in incidence are possible, but without elimination of disparities in healthcare access, we found that wide disparities persisted for black compared with white populations in particular (lowest IRR, 1.69 [95% credible interval, 1.19-2.30]).
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Micah Piske
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong E Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Carlos Del Rio
- Rollins School of Public Health and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Matthew Golden
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington, USA
| | | | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zachary F Meisel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Steven Shoptaw
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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11
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Krebs E, Zang X, Enns B, Min JE, Behrends CN, Del Rio C, Dombrowski JC, Feaster DJ, Gebo KA, Marshall BDL, Mehta SH, Metsch LR, Pandya A, Schackman BR, Strathdee SA, Nosyk B. Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities. J Infect Dis 2021; 222:S301-S311. [PMID: 32877548 DOI: 10.1093/infdis/jiaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities. METHODS Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US). RESULTS Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale. CONCLUSIONS Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.
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Affiliation(s)
- Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong E Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA
| | - Carlos Del Rio
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Julia C Dombrowski
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kelly A Gebo
- School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA
| | | | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
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12
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Zang X, Jalal H, Krebs E, Pandya A, Zhou H, Enns B, Nosyk B. Prioritizing Additional Data Collection to Reduce Decision Uncertainty in the HIV/AIDS Response in 6 US Cities: A Value of Information Analysis. Value Health 2020; 23:1534-1542. [PMID: 33248508 PMCID: PMC7705607 DOI: 10.1016/j.jval.2020.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 12/04/2019] [Revised: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The ambitious goals of the US Ending the HIV Epidemic initiative will require a targeted, context-specific public health response. Model-based economic evaluation provides useful guidance for decision making while characterizing decision uncertainty. We aim to quantify the value of eliminating uncertainty about different parameters in selecting combination implementation strategies to reduce the public health burden of HIV/AIDS in 6 US cities and identify future data collection priorities. METHODS We used a dynamic compartmental HIV transmission model developed for 6 US cities to evaluate the cost-effectiveness of a range of combination implementation strategies. Using a metamodeling approach with nonparametric and deep learning methods, we calculated the expected value of perfect information, representing the maximum value of further research to eliminate decision uncertainty, and the expected value of partial perfect information for key groups of parameters that would be collected together in practice. RESULTS The population expected value of perfect information ranged from $59 683 (Miami) to $54 108 679 (Los Angeles). The rank ordering of expected value of partial perfect information on key groups of parameters were largely consistent across cities and highest for parameters pertaining to HIV risk behaviors, probability of HIV transmission, health service engagement, HIV-related mortality, health utility weights, and healthcare costs. Los Angeles was an exception, where parameters on retention in pre-exposure prophylaxis ranked highest in contributing to decision uncertainty. CONCLUSIONS Funding additional data collection on HIV/AIDS may be warranted in Baltimore, Los Angeles, and New York City. Value of information analysis should be embedded into decision-making processes on funding future research and public health intervention.
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Affiliation(s)
- Xiao Zang
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Haoxuan Zhou
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
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13
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Nosyk B, Weiner J, Krebs E, Zang X, Enns B, Behrends CN, Feaster DJ, Jalal H, Marshall BDL, Pandya A, Schackman BR, Meisel ZF. Dissemination Science to Advance the Use of Simulation Modeling: Our Obligation Moving Forward. Med Decis Making 2020; 40:718-721. [PMID: 32755285 PMCID: PMC7484337 DOI: 10.1177/0272989x20945308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- BC Center for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Janet Weiner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Emanuel Krebs
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- BC Center for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Xiao Zang
- School of Public Health, Brown University, Providence, RI, USA
| | - Benjamin Enns
- BC Center for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, NY, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Hawre Jalal
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Ankur Pandya
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, NY, USA
| | - Zachary F Meisel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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14
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Nosyk B, Zang X, Krebs E, Enns B, Min JE, Behrends CN, Del Rio C, Dombrowski JC, Feaster DJ, Golden M, Marshall BDL, Mehta SH, Metsch LR, Pandya A, Schackman BR, Shoptaw S, Strathdee SA. Ending the HIV epidemic in the USA: an economic modelling study in six cities. Lancet HIV 2020; 7:e491-e503. [PMID: 32145760 PMCID: PMC7338235 DOI: 10.1016/s2352-3018(20)30033-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 09/18/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The HIV epidemic in the USA is a collection of diverse local microepidemics. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach 90% reduction of incidence in 10 years, in six US cities that comprise 24·1% of people living with HIV in the USA. METHODS In this economic modelling study, we used a dynamic HIV transmission model calibrated with the best available evidence on epidemiological and structural conditions for six US cities: Atlanta (GA), Baltimore (MD), Los Angeles (CA), Miami (FL), New York City (NY), and Seattle (WA). We assessed 23 040 combinations of 16 evidence-based interventions (ie, HIV prevention, testing, treatment, engagement, and re-engagement) to identify combination strategies providing the greatest health benefit while remaining cost-effective. Main outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total cost (in 2018 US$), and incremental cost-effectiveness ratio (ICER; from the health-care sector perspective, 3% annual discount rate). Interventions were implemented at previously documented and ideal (90% coverage or adoption) scale-up, and sustained from 2020 to 2030, with outcomes evaluated until 2040. FINDINGS Optimal combination strategies providing health benefit and cost-effectiveness contained between nine (Seattle) and 13 (Miami) individual interventions. If implemented at previously documented scale-up, these strategies could reduce incidence by between 30·7% (95% credible interval 19·1-43·7; Seattle) and 50·1% (41·5-58·0; New York City) by 2030, at ICERs ranging from cost-saving in Atlanta, Baltimore, and Miami, to $95 416 per QALY in Seattle. Incidence reductions reached between 39·5% (26·3-53·8) in Seattle and 83·6% (70·8-87·0) in Baltimore at ideal implementation. Total costs of implementing strategies across the cities at previously documented scale-up reached $559 million per year in 2024; however, costs were offset by long-term reductions in new infections and delayed disease progression, with Atlanta, Baltimore, and Miami projecting cost savings over the 20 year study period. INTERPRETATION Evidence-based interventions can deliver substantial public health and economic value; however, complementary strategies to overcome social and structural barriers to HIV care will be required to reach national targets of the ending the HIV epidemic initiative by 2030. FUNDING National Institutes of Health.
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Affiliation(s)
- Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
| | - Xiao Zang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Emanuel Krebs
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Benjamin Enns
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jeong E Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Carlos Del Rio
- Rollins School of Public Health and Emory School of Medicine, Emory University, Atlanta, GA, USA
| | - Julia C Dombrowski
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA
| | - Daniel J Feaster
- Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Matthew Golden
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA
| | | | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Steven Shoptaw
- School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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15
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Enns B, Min JE, Panagiotoglou D, Montaner JSG, Nosyk B. Geographic variation in the costs of medical care for people living with HIV in British Columbia, Canada. BMC Health Serv Res 2019; 19:626. [PMID: 31481056 PMCID: PMC6724338 DOI: 10.1186/s12913-019-4391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/01/2019] [Indexed: 12/04/2022] Open
Abstract
Background Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix. Methods We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals’ Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities. Results Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively. Conclusions We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province. Electronic supplementary material The online version of this article (10.1186/s12913-019-4391-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Dimitra Panagiotoglou
- Faculty of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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16
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Krebs E, Enns B, Wang L, Zang X, Panagiotoglou D, Del Rio C, Dombrowski J, Feaster DJ, Golden M, Granich R, Marshall B, Mehta SH, Metsch L, Schackman BR, Strathdee SA, Nosyk B. Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis. PLoS One 2019; 14:e0217559. [PMID: 31145752 PMCID: PMC6542533 DOI: 10.1371/journal.pone.0217559] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dynamic HIV transmission models can provide evidence-based guidance on optimal combination implementation strategies to treat and prevent HIV/AIDS. However, these models can be extremely data intensive, and the availability of good-quality data characterizing regional microepidemics varies substantially within and across countries. We aim to provide a comprehensive and transparent description of an evidence synthesis process and reporting framework employed to populate and calibrate a dynamic, compartmental HIV transmission model for six US cities. METHODS We executed a mixed-method evidence synthesis strategy to populate model parameters in six categories: (i) initial HIV-negative and HIV-infected populations; (ii) parameters used to calculate the probability of HIV transmission; (iii) screening, diagnosis, treatment and HIV disease progression; (iv) HIV prevention programs; (v) the costs of medical care; and (vi) health utility weights for each stage of HIV disease progression. We identified parameters that required city-specific data and stratification by gender, risk group and race/ethnicity a priori and sought out databases for primary analysis to augment our evidence synthesis. We ranked the quality of each parameter using context- and domain-specific criteria and verified sources and assumptions with our scientific advisory committee. FINDINGS To inform the 1,667 parameters needed to populate our model, we synthesized evidence from 59 peer-reviewed publications and 24 public health and surveillance reports and executed primary analyses using 11 data sets. Of these 1,667 parameters, 1,517 (91%) were city-specific and 150 (9%) were common for all cities. Notably, 1,074 (64%), 201 (12%) and 312 (19%) parameters corresponded to categories (i), (ii) and (iii), respectively. Parameters ranked as best- to moderate-quality evidence comprised 39% of the common parameters and ranged from 56%-60% across cities for the city-specific parameters. We identified variation in parameter values across cities as well as within cities across risk and race/ethnic groups. CONCLUSIONS Better integration of modelling in decision making can be achieved by systematically reporting on the evidence synthesis process that is used to populate models, and by explicitly assessing the quality of data entered into the model. The effective communication of this process can help prioritize data collection of the most informative components of local HIV prevention and care services in order to reduce decision uncertainty and strengthen model conclusions.
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Affiliation(s)
- Emanuel Krebs
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Benjamin Enns
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Linwei Wang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Xiao Zang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Dimitra Panagiotoglou
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Carlos Del Rio
- Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Julia Dombrowski
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel J. Feaster
- Center for Family Studies, Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Matthew Golden
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, United States of America
| | - Brandon Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States of America
| | - Shruti H. Mehta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Steffanie A. Strathdee
- School of Medicine, University of California San Diego, La Jolla, CA, United States of America
| | - Bohdan Nosyk
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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17
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Krebs E, Enns B, Evans E, Urada D, Anglin MD, Rawson RA, Hser YI, Nosyk B. Cost-Effectiveness of Publicly Funded Treatment of Opioid Use Disorder in California. Ann Intern Med 2018; 168:10-19. [PMID: 29159398 DOI: 10.7326/m17-0611] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Only 1 in 5 of the nearly 2.4 million Americans with an opioid use disorder received treatment in 2015. Fewer than half of Californians who received treatment in 2014 received opioid agonist treatment (OAT), and regulations for admission to OAT in California are more stringent than federal regulations. OBJECTIVE To determine the cost-effectiveness of OAT for all treatment recipients compared with the observed standard of care for patients presenting with opioid use disorder to California's publicly funded treatment facilities. DESIGN Model-based cost-effectiveness analysis. DATA SOURCES Linked population-level administrative databases capturing treatment and criminal justice records for California (2006 to 2010); published literature. TARGET POPULATION Persons initially presenting for publicly funded treatment of opioid use disorder. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Immediate access to OAT with methadone for all treatment recipients compared with the observed standard of care (54.3% initiate opioid use disorder treatment with medically managed withdrawal). OUTCOME MEASURES Discounted quality-adjusted life-years (QALYs) and discounted costs. RESULTS OF BASE-CASE ANALYSIS Immediate access to OAT for all treatment recipients costs less (by $78 257), with patients accumulating more QALYs (by 0.42) than with the observed standard of care. In a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, total lifetime savings for this cohort could be as high as $3.8 billion. RESULTS OF SENSITIVITY ANALYSIS 99.6% of the 2000 simulations resulted in lower costs and more QALYs. LIMITATION Nonrandomized delivery of OAT or medically managed withdrawal. CONCLUSION The value of publicly funded treatment of opioid use disorder in California is maximized when OAT is delivered to all patients presenting for treatment, providing greater health benefits and cost savings than the observed standard of care. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Affiliation(s)
- Emanuel Krebs
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Elizabeth Evans
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Darren Urada
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - M Douglas Anglin
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Richard A Rawson
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Yih-Ing Hser
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- From British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; UCLA Integrated Substance Abuse Programs and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts; and Simon Fraser University Faculty of Health Sciences, Vancouver, British Columbia, Canada
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Enns B, Krebs E, DeBeck K, Hayashi K, Milloy MJ, Richardson L, Wood E, Nosyk B. The costs of crime associated with stimulant use in a Canadian setting. Drug Alcohol Depend 2017; 180:304-310. [PMID: 28942287 PMCID: PMC6154799 DOI: 10.1016/j.drugalcdep.2017.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 05/16/2017] [Revised: 08/18/2017] [Accepted: 08/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Costs attributable to criminal activity are a major component of the economic burden of substance use disorders, yet there is a paucity of empirical evidence on this topic. Our aim was to estimate the costs of crime associated with different forms and intensities of stimulant use. METHODS Retrospective cohort study, including individuals from three prospective cohorts in Vancouver, Canada, measured biannually (2011-2015), reporting stimulant use at baseline assessment. Monthly crime costs included policing, court, corrections, and criminal victimization (2016 CAD). We estimated monthly crime costs associated with mutually exclusive categories of crack, cocaine, methamphetamine, and polystimulant use, stratified by daily/non-daily use, relative to stimulant abstinence, as well as the independent effects of treatment (opioid agonist (OAT) and other addiction treatment). We used a two-part model, capturing the probability of criminal activity and costs of crime with generalized linear logistic and gamma regression models, respectively, controlling for age, gender, education, homelessness, mental health issues, employment, prior incarceration, alcohol and opioid use. RESULTS The study sample included 1599 individuals (median age 39, 65.9% male) assessed over 5299 biannual interviews. Estimates of associated monthly crime costs ranged from $5449 [95% C.I.: $2180, $8719] for non-daily polystimulant use, to $8893 [$4196, $13,589] for daily polystimulant use. Cost differences between daily/non-daily use, injection/non-injection, and stimulant type were not statistically significant. Drug treatment was not associated with lower monthly crime costs in our sample. CONCLUSIONS Substantial crime-related costs were associated with stimulant use, emphasizing the urgency for development and implementation of efficacious treatment regimens.
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Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Kora DeBeck
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Policy, Simon Fraser University, Vancouver, BC, Canada
| | - Kanna Hayashi
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - M-J Milloy
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC, Canada
| | - Lindsey Richardson
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada.
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Liu K, Enns B, Evans B, Wang N, Shang X, Sittiwong W, Dussault PH, Guo J. A genetically encoded cyclobutene probe for labelling of live cells. Chem Commun (Camb) 2017; 53:10604-10607. [PMID: 28902227 PMCID: PMC5648060 DOI: 10.1039/c7cc05580c] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 01/06/2023]
Abstract
We have identified an aminoacyl-tRNA synthetase/tRNA pair for the efficient and site-specific incorporation of a cyclobutene-containing amino acid into proteins in response to an amber nonsense codon. Fast and fluorescent labeling of purified proteins and intact proteins in live cells was demonstrated using the inverse electron demand Diels-Alder reaction with a tetrazine.
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Affiliation(s)
- K Liu
- Department of Chemistry, University of Nebraska-Lincoln, Lincoln, Nebraska 68588, USA.
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Jung H, Wu J, Murray A, Enns B, Pelletier G, Hagen N. Development and Early Experience with a New Integrated Palliative Oncology Clinic for Multidisciplinary Management of Patients with Brain Metastases. Int J Radiat Oncol Biol Phys 2011. [DOI: 10.1016/j.ijrobp.2011.06.1926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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