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INTRODUCTION: The purpose of this analysis was to rapidly evaluate the potential costs, cost-effectiveness, and long-term effects of efforts by multisector community partnerships (MCPs) to improve chronic disease outcomes and advance health equity by addressing social determinants of health (SDOH). METHODS: In 2022, the evaluators partnered with 13 MCPs to collect data on start-up and ongoing costs for implementing SDOH interventions and on intervention reach and timing. In 2023, the team used the Prevention Impacts Simulation Model to estimate the longer-term impact of MCPs' efforts over 5-, 10-, and 20-year periods. The team also analyzed costs and cumulative 10- and 20-year cost-effectiveness of the MCPs' SDOH interventions. RESULTS: Over 20 years, SDOH interventions implemented by the 13 MCPs can potentially prevent 970 premature deaths and avert $105 million in medical costs and $408 million in productivity losses. The 20-year cumulative results show potential net costs of $38,300 per quality-adjusted life-year gained from the healthcare sector perspective and indicate potentially reduced costs and improved health outcomes from the societal perspective. CONCLUSIONS: These findings can help inform and provide support for future investments in SDOH interventions. With a better understanding of costs needed to start up and implement SDOH interventions, funders, and MCPs can prepare for the resources required to do this work. Findings also suggest promising long-term impacts and potential cost-effectiveness for most MCP-implemented SDOH interventions.
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BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.
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Naloxona , Antagonistas de Entorpecentes , Transtornos Relacionados ao Uso de Opioides , Humanos , Naloxona/uso terapêutico , Estados Unidos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Antagonistas de Entorpecentes/uso terapêutico , Masculino , Feminino , Overdose de Drogas/prevenção & controle , Overdose de Drogas/tratamento farmacológico , Adulto , Inquéritos e Questionários , Pessoa de Meia-Idade , Acessibilidade aos Serviços de Saúde , Educação em Saúde/métodosRESUMO
PURPOSE: To develop a set of social determinants of health (SDOH) measurements. PROBLEM: Despite burgeoning interest in addressing both SDOH and health-related social needs, the evidence on what works is limited due in part to the lack of standardized measures for evaluation. METHODS: In 2020, the Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) identified 5 SDOH domains related to chronic disease for future programmatic work. These included built environment, community connections to clinical care, tobacco-free policies, social connectedness, and food and nutrition security. Subsequently, NCCDPHP launched an effort to develop a set of SDOH measures for evaluating funded programs in these domains. The approach involved a literature scan and a rating process based on 5 criteria relevant to NCCDPHP's SDOH priorities. A complementary community review by 13 multisector community partnerships (MCPs) applied a real-world public health practice lens to measure development. MCPs' ratings were analyzed to create summary scores for each measure, and open-ended feedback was synthesized using rapid qualitative analysis. RESULTS: The internal workgroup identified 59 measures from the initial 200 measures. Feedback from the MCPs identified issues of relevancy and burden of measures. Their high scores narrowed the 59 measures to 22 covering all 5 domains. In response, CDC is honing the original measures review criteria to include community perspectives. CONCLUSION: Public health measures development is often an academic pursuit. Engaging MCPs lends real-world credibility to the development of common SDOH measures.
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BACKGROUND: The U.S. opioid overdose crisis persists. Outpatient behavioral health services (BHS) are essential components of a comprehensive response to opioid use disorder and overdose fatalities. The Helping to End Addiction Long-Term® (HEALing) Communities Study developed the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths in 67 communities in Kentucky, Ohio, New York, and Massachusetts through the implementation of evidence-based practices (EBPs), including BHS. This paper compares the rate of individuals receiving outpatient BHS in Wave 1 intervention communities (n = 34) to waitlisted Wave 2 communities (n = 33). METHODS: Medicaid data included individuals ≥18 years of age receiving any of five BHS categories: intensive outpatient, outpatient, case management, peer support, and case management or peer support. Negative binomial regression models estimated the rate of receiving each BHS for Wave 1 and Wave 2. Effect modification analyses evaluated changes in the effect of the CTH intervention between Wave 1 and Wave 2 by research site, rurality, age, sex, and race/ethnicity. RESULTS: No significant differences were detected between intervention and waitlisted communities in the rate of individuals receiving any of the five BHS categories. None of the interaction effects used to test the effect modification were significant. CONCLUSIONS: Several factors should be considered when interpreting results-no significant intervention effects were observed through Medicaid claims data, the best available data source but limited in terms of capturing individuals reached by the intervention. Also, the 12-month evaluation window may have been too brief to see improved outcomes considering the time required to stand-up BHS. TRIAL REGISTRATION: Clinical Trials.gov http://www. CLINICALTRIALS: gov: Identifier: NCT04111939.
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Terapia Comportamental , Transtornos Relacionados ao Uso de Opioides , Humanos , Feminino , Masculino , Adulto , Transtornos Relacionados ao Uso de Opioides/terapia , Pessoa de Meia-Idade , Terapia Comportamental/métodos , Listas de Espera , Estados Unidos/epidemiologia , Medicaid , Adulto JovemRESUMO
Background: Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS). Methods: We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm). Findings: Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18). Interpretation: The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally. Funding: US National Institute on Drug Abuse.
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Importance: Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined. Objective: To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing. Design, Setting, and Participants: This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022. Intervention: Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity. Main Outcomes and Measures: The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100â¯000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed. Results: A total of 8â¯166â¯963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10). Conclusions and Relevance: In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder. Trial Registration: ClinicalTrials.gov Identifier: NCT04111939.
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Buprenorfina , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Adulto , Humanos , Buprenorfina/uso terapêutico , Análise de Dados , Escolaridade , Intenção , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adolescente , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Public health plays a key role in addressing social determinants of health (SDOH) through multisector community partnerships (MCPs), which contribute to community changes that promote healthy living; however, little is known about the longer-term impact of MCP-driven interventions. We used the Prevention Impacts Simulation Model (PRISM) in a rapid evaluation to better understand the implementation and potential impact of MCPs' SDOH initiatives. Results suggest that, if sustained, initiatives implemented by the 27 included MCPs may prevent 880 premature deaths and avert $125.7 million in medical costs over 20 years. As a validated model that estimates impact by using available implementation data, PRISM is a useful tool for evaluating SDOH initiatives.
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Saúde Pública , Determinantes Sociais da Saúde , Humanos , Saúde Pública/métodos , Simulação por Computador , Mortalidade PrematuraRESUMO
PURPOSE: To better understand and inform how multisector community partnerships (MCPs) perform meaningful work to prevent chronic disease and advance health equity by addressing social determinants of health (SDOH). METHODS: We conducted a rapid retrospective evaluation of SDOH initiatives implemented within the past three years by 42 established MCPs across the United States. The mixed methods evaluation included document review and coding of available outcomes data, virtual discussions, and Prevention Impacts Simulation Model (PRISM) analysis. RESULTS: All 42 MCPs built community capacity for addressing SDOH through new or strengthened data systems, leveraged resources, or engaged residents, for example. Most MCPs (N = 38, 90%) reported contributions to community changes that promote healthy living. More than half of the MCPs (N = 22) reported health outcomes data for their SDOH initiatives, including improved health behaviors and clinical outcomes. Based on reach data provided by 27 MCPs, PRISM analysis results suggest that sustained initiatives could save over $633 million in productivity and medical costs cumulatively through 20 years. CONCLUSIONS: With sufficient technical assistance and funding resources, MCPs are a key component of the public health strategy to address SDOH.
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Saúde Pública , Determinantes Sociais da Saúde , Humanos , Estados Unidos , Estudos Retrospectivos , Avaliação de Programas e Projetos de SaúdeRESUMO
Diabetes is a significant population health threat. Evidence-based interventions, such as the Centers for Disease Control and Prevention's National Diabetes Prevention Program and diabetes self-management education and support programs, can help prevent, delay, or manage the disease. However, participation is suboptimal, especially among populations who are at an increased risk of developing diabetes. Evaluations of programs reaching populations who are medically underserved or people with lower incomes can help elucidate how best to tailor evidence-based interventions, but it is also important for evaluations to account for cultural and contextual factors. Culturally responsive evaluation (CRE) is a framework for centering an evaluation in the culture of the programs being evaluated. We integrated CRE with implementation and outcome constructs from the Adapted Consolidated Framework for Implementation Research (CFIR) to ensure that the evaluation produced useful evidence for putting evidence-based diabetes interventions to use in real-world settings, reaching populations who are at an increased risk of developing diabetes. The paper provides an overview of how we integrated CRE and CFIR approaches to conduct mixed-methods evaluations of evidence-based diabetes interventions.
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The Helping End Addictions Long Term (HEALing) Communities Study (HCS) seeks to significantly reduce overdose deaths in 67 highly impacted communities in Kentucky (KY), Massachusetts (MA), New York (NY), and Ohio (OH) by implementing evidence-based practices (EBPs) to reduce overdose deaths. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA) organizes EBP strategies under three menus: Overdose Education and Naloxone Distribution (OEND), Medication Treatment for Opioid Use Disorder (MOUD), and Safer Prescribing and Dispensing Practices (SPDP). The ORCCA sets requirements for strategy selection but allows flexibility to address community needs. This paper describes and compiles strategy selection and examines two hypotheses: 1) OEND selections will differ significantly between communities with higher versus lower opioid-involved overdose deaths; 2) MOUD selections will differ significantly between urban versus rural settings. METHODS: Wave 1 communities (n = 33) provided data on EBP strategy selections. Selections were recorded as a combination of EBP menu, sector (behavioral health, criminal justice, and healthcare), and venue (e.g., jail, drug court, etc.); target medication(s) were recorded for MOUD strategies. Strategy counts and proportions were calculated overall and by site (KY, MA, NY, OH), setting (rural/urban), and opioid-involved overdose deaths (high/low). RESULTS: Strategy selection exceeded ORCCA requirements across all 33 communities, with OEND strategies accounting for more (40.8%) than MOUD (35.1%), or SPDP (24.1%) strategies. Site-adjusted differences were not significant for either hypothesis related to OEND or MOUD strategy selection. CONCLUSIONS: HCS communities selected strategies from the ORCCA menu well beyond minimum requirements using a flexible approach to address unique needs.
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Overdose de Drogas , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/uso terapêutico , Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Overdose de Opiáceos/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Overdose de Drogas/tratamento farmacológicoRESUMO
Multisector community partnerships (MCPs) are key component of the public health strategy for addressing social determinants of health (SDOH) and promoting health equity. Governmental public health agencies are often members or leaders of MCPs, but few studies have examined the role of health departments in supporting MCPs' SDOH initiatives. We engaged 42 established MCPs in a rapid retrospective evaluation to better understand how MCPs' SDOH initiatives contribute to community changes that promote healthy living and improved health outcomes. As part of this work, we gained insights into how health departments support MCPs' SDOH initiatives, as well as opportunities for enhanced collaboration. Results indicate that health departments can support MCPs' SDOH initiatives through the provision of funding and technical assistance, data sharing, and connecting community organizations with shared missions, for example. Findings can be used to inform the development of funding opportunities and technical assistance for MCPs and health department partners.
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Equidade em Saúde , Determinantes Sociais da Saúde , Humanos , Estudos Retrospectivos , Órgãos Governamentais , Disseminação de InformaçãoRESUMO
INTRODUCTION: Opioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally. METHODS AND ANALYSIS: The CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation. ETHICS AND DISSEMINATION: The HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders. TRIAL REGISTRATION NUMBER: NCT04111939.
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Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Prática Clínica Baseada em Evidências , Humanos , Kentucky , Massachusetts , Naloxona/uso terapêutico , New York , Ohio , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática MédicaAssuntos
Participação da Comunidade/estatística & dados numéricos , Equidade em Saúde/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Pesquisa Participativa Baseada na Comunidade , Política de Saúde , Humanos , Determinantes Sociais da Saúde , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Estados UnidosRESUMO
BACKGROUND: In response to the U.S. opioid epidemic, the HEALing (Helping to End Addiction Long-termSM) Communities Study (HCS) is a multisite, wait-listed, community-level cluster-randomized trial that aims to test the novel Communities That HEAL (CTH) intervention, in 67 communities. CTH will expand an integrated set of evidence-based practices (EBPs) across health care, behavioral health, justice, and other community-based settings to reduce opioid overdose deaths. We present the rationale for and adaptation of the RE-AIM/PRISM framework and methodological approach used to capture the CTH implementation context and to evaluate implementation fidelity. METHODS: HCS measures key domains of the internal and external CTH implementation context with repeated annual surveys and qualitative interviews with community coalition members and key stakeholders. Core constructs of fidelity include dosage, adherence, quality, and program differentiation-the adaptation of the CTH intervention to fit each community's needs. Fidelity measures include a monthly CTH checklist, collation of artifacts produced during CTH activities, coalition and workgroup attendance, and coalition meeting minutes. Training and technical assistance delivered by the research sites to the communities are tracked monthly. DISCUSSION: To help attenuate the nation's opioid epidemic, the adoption of EBPs must be increased in communities. The HCS represents one of the largest and most complex implementation research experiments yet conducted. Our systematic examination of implementation context and fidelity will significantly advance understanding of how to best evaluate community-level implementation of EBPs and assess relations among implementation context, fidelity, and intervention impact.
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Overdose de Opiáceos/prevenção & controle , Analgésicos Opioides , Comportamento Aditivo , Lista de Checagem , Ensaios Clínicos como Assunto , Atenção à Saúde , Prática Clínica Baseada em Evidências , HumanosRESUMO
BACKGROUND: The implementation of evidence-based practices to reduce opioid overdose deaths within communities remains suboptimal. Community engagement can improve the uptake and sustainability of evidence-based practices. The HEALing Communities Study (HCS) aims to reduce opioid overdose deaths through the Communities That HEAL (CTH) intervention, a community-engaged, data-driven planning process that will be implemented in 67 communities across four states. METHODS: An iterative process was used in the development of the community engagement component of the CTH. The resulting community engagement process uses phased planning steeped in the principles of community based participatory research. Phases include: 0) Preparation, 1) Getting Started, 2) Getting Organized, 3) Community Profiles and Data Dashboards, 4) Community Action Planning, 5) Implementation and Monitoring, and 6) Sustainability Planning. DISCUSSION: The CTH protocol provides a common structure across the four states for the community-engaged intervention and allows for tailored approaches that meet the unique needs or sociocultural context of each community. Challenges inherent to community engagement work emerged early in the process are discussed. CONCLUSION: HCS will show how community engagement can support the implementation of evidence-based practices for addressing the opioid crisis in highly impacted communities. Findings from this study have the potential to provide communities across the country with an evidence-based approach to address their local opioid crisis; advance community engaged research; and contribute to the implementation, sustainability, and adoption of evidence-based practices. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04111939).
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Participação da Comunidade , Prática Clínica Baseada em Evidências/métodos , Overdose de Opiáceos/prevenção & controle , Ensaios Clínicos como Assunto , HumanosAssuntos
Centers for Medicare and Medicaid Services, U.S./organização & administração , Atenção à Saúde/organização & administração , Avaliação de Programas e Projetos de Saúde/métodos , Continuidade da Assistência ao Paciente/organização & administração , Humanos , Informática Médica/organização & administração , Desenvolvimento de Programas , Melhoria de Qualidade/organização & administração , Desenvolvimento de Pessoal/organização & administração , Estados Unidos , Engajamento no TrabalhoRESUMO
The outcome indicator framework helps tobacco prevention and control programs (TCPs) plan and implement theory-driven evaluations of their efforts to reduce and prevent tobacco use. Tobacco use is the single-most preventable cause of morbidity and mortality in the United States. The implementation of public health best practices by comprehensive state TCPs has been shown to prevent the initiation of tobacco use, reduce tobacco use prevalence, and decrease tobacco-related health care expenditures. Achieving and sustaining program goals require TCPs to evaluate the effectiveness and impact of their programs. To guide evaluation efforts by TCPs, the Centers for Disease Control and Prevention's Office on Smoking and Health developed an outcome indicator framework that includes a high-level logic model and evidence-based outcome indicators for each tobacco prevention and control goal area. In this article, we describe how TCPs and other community organizations can use the outcome indicator framework in their evaluation efforts. We also discuss how the framework is used at the national level to unify tobacco prevention and control efforts across varying state contexts, identify promising practices, and expand the public health evidence base.