Depot buprenorphine as an opioid agonist therapy in New South Wales correctional centres: a costing model.

BACKGROUND: In 2019 daily liquid methadone and sublingual buprenorphine-naloxone were primary opioid agonist treatments for correctional centres in New South Wales, Australia. However, both had significant potential for diversion to other patients, and their daily administration was resource intensive. An alternative treatment in the form of subcutaneous depot buprenorphine became a viable option following a safety trial in 2020 - the UNLOC-T study. Depot preparation demonstrated advantages over current treatments as more difficult to divert and requiring fewer administrations. This paper reports the results of economic modelling of staffing costs in medication administration comparing depot buprenorphine, methadone, and sublingual buprenorphine provision in UNLOC-T trial facilities. METHODS: The costing study adopted a micro-costing approach involving the synthesis of cost data from the UNLOC-T clinical trial as well as data collected from Justice Health and Forensic Mental Health Network records. Labour and materials data were collected during site observations and interviews. Costs were calculated from two payer perspectives: a) the New South Wales (state) government which funds custodial and health services; and b) the Australian Commonwealth government, which pays for medications. The analysis compared the monthly-per-patient cost for each of the three medications in trial-site facilities during July 2019. This was followed by simulation of depot buprenorphine implementation across the study population. Costs associated with medical assessment and reviews were excluded. RESULTS: The monthly-per-patient New South Wales government service costs of depot buprenorphine, methadone and sublingual buprenorphine were: $151, $379 and $1,529 respectively while Commonwealth government medication costs were $434, $80 and $525. The implementation simulation found that service costs of depot buprenorphine declined as patients transitioned from weekly to monthly administration. Costs of treatment using the other medications increased as patient numbers decreased alongside fixed costs. At 12 months, monthly-per-patient service costs for depot buprenorphine, methadone and sublingual buprenorphine-which would be completely phased out by month 13-were $92, $530 and $2,162 respectively. CONCLUSIONS: Depot buprenorphine was consistently the least costly of the treatment options. Future modelling could allow for dynamic patient populations and downstream impacts for participants and the state health system. TRIAL REGISTRATION: ACTRN12618000942257 . Registered 4 June 2018.

The Medical Emergency Team: 21st century critical care.

In-hospital cardiac arrests, intensive care unit (ICU) admissions and unexpected deaths are commonly preceded by warning signs up to 24 hours prior to the event. As a result, some of these critical events are potentially preventable. Critical care physicians are increasingly familiar with patient care systems; trauma systems have become well established in most health services, and the chain of survival provides a system response to out of hospital cardiac arrests. We now need to build on experience with systems to extend critical care services to all hospital patients at risk, whatever their location and on a continuous basis to prevent these critical events from occurring. In fact, if critical care medicine is to take up the challenge and move forward into the 21st century, we need to engage in a re-orientation from individual to system thinking. We know that the majority of in-hospital cardiac arrests occurring on the general wards represent failures in the system. These events are not the fault of one or two individual practitioners that failed to provide adequate care, but a consequence of organisational factors that result in failures in recognition and response involving more than one department, professional group or area of the hospital. There is also potential to reduce morbidity. Morbidity caused by failure to adequately treat hypoxemia and hypovolemia on the wards, results in preventable cases of renal and respiratory failure, requiring prolonged, uncomfortable and expensive admissions to intensive care, along with the invasive therapy that ICU admission entails. The Medical Emergency Team (MET) system provides a potential solution.

The medical emergency team: does it really make a difference?

Hospital systems are failing the critically ill. This has been well documented in many countries around the world, with detailed reports of suboptimal care prior to intensive care and high rates of serious adverse events, including death. These events are potentially preventable, but insufficient attention has been directed towards developing solutions to these important problems to date. The medical emergency team (MET) is a system approach that promotes early and appropriate intervention in the care of critically ill hospital patients. The benefits of the MET in terms of absolute in-patient mortality and cardiac arrest rates are not yet well-defined, although preliminary studies are promising. The MET does provide a potentially beneficial impact on many other aspects of patient care. These benefits include: (i) facilitating an integrated and coordinated approach to patient care across the hospital, (ii) increasing awareness of at-risk patients, (iii) encouraging early referral of seriously ill patients to clinicians with expertise in critical care and (iv) providing a foundation for quality initiatives for hospital-wide care of the seriously ill. The MET also empowers nursing staff and junior medical staff to call for immediate assistance in cases where they are seriously concerned about a patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately.

Drug related admissions to intensive care: the role of illicit drugs and self poisoning.

OBJECTIVE: Drug related problems are a major consumer of healthcare, although little is known about the impact of self-poisoning and illicit drug use on the provision of intensive care. We wished to quantify the number of admissions to our intensive care unit that were attributable to self-poisoning and illicit drug use, and to identify issues related to recognition, follow-up, prevention and cost. METHODS: A retrospective review of all admissions to Liverpool hospital intensive care unit for the year 2000. All admissions with non-alcohol drug-related causes or associations were reviewed and data relating to demographics, reason for admission, drugs taken, length of intensive care unit stay, interventions by Drug and Alcohol and Psychiatry services, follow-up and outcome were obtained. RESULTS: Of the 1790 patients admitted to the intensive care unit during the study period, 108 (6%) were non-alcohol drug-related. These admissions accounted for 407 intensive care unit bed days (5% of total intensive care unit bed days) and approximated to 10% of the intensive care unit budget for the year 2000. The majority of patients were male (66%), with a mean age of 33 years. Drug overdose was the most common reason for admission (80%), followed by drug related traumatic injury (16%). The most common drug classes involved were the benzodiazepines, followed by the opiates and tricyclic antidepressants. The majority of patients (65%) had used more than one drug. Thirty-two patients (30%) did not return to their previous functioning level by the time of their discharge from hospital, and 13 of these (12% overall) required full-time nursing care. There were two deaths (2%) as a direct result of illicit drug use or self-poisoning. The hospital Drug and Alcohol or Psychiatry services reviewed 78 patients (72%) as inpatients, and 3 patients (3%) after discharge. Self-discharge or patient refusal to be reviewed by these services occurred in 13 (12%) cases. Twelve patients (11%) were not assessed by these services and were either reviewed by the admitting team or returned to the care of their family practitioner. CONCLUSIONS: Drug related problems account for a significant number of preventable admissions to intensive care unit every year. The mortality is low, but the cost to the community is high, as represented by the high level of morbidity and dependence on medical care.