ABSTRACT
BACKGROUND: Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility. METHODS: This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states-Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars. RESULTS: State-level average and median start-up cost (representing 8-10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost. CONCLUSION: We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.
Subject(s)
Opiate Overdose , Humans , Delivery of Health Care , Massachusetts , Evidence-Based PracticeABSTRACT
INTRODUCTION: Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS: KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION: The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER: NCT05657106.
Subject(s)
Drug Overdose , HIV Infections , Hepatitis C , Humans , Kentucky , Cost-Benefit Analysis , Harm Reduction , Rural Population , Hepatitis C/prevention & control , Hepacivirus , Drug Overdose/prevention & control , Appalachian Region , HIV Infections/prevention & controlABSTRACT
OBJECTIVES: Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions. METHODS: We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs. RESULTS: We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC. CONCLUSIONS: OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.
Subject(s)
Cost-Benefit Analysis , Opiate Overdose , Humans , Opiate Overdose/economics , Opiate Overdose/prevention & control , North America , Quality-Adjusted Life Years , CanadaABSTRACT
The Addiction Health Services Research (AHSR) Conference has been held since 2002. This Conference brings together researchers, graduate students, policymakers, and treatment providers to focus improving the organization, distribution, and financing of healthcare resources for prevention/care of SUD. The AHSR 2023 Conference took place in New York City, October 18-20th, and was hosted by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH; cherishresearch.org). Attended by more than 300 participants, the Conference comprised several themes relating to the latest research on addiction health services delivery, financing, and impact. The agenda also included pre-conference workshops, distinguished plenary speakers, a multitude of networking opportunities, and career support for early-stage and minority investigators. AHSR 2023 featured 3 plenary sessions, 120 oral presentations, and 143 poster presentations from academics throughout the world. Overall, AHSR 2023 provided numerous opportunities to advance the field of addiction health services research. The state-of-the-art techniques and insights gained by attending scholars will position them to be change-agents in the addiction field going forward.
Subject(s)
Behavior, Addictive , Malus , Substance-Related Disorders , Humans , Health Services Research , Minority GroupsABSTRACT
INTRODUCTION: The economic burden of substance use disorder (SUD) is significant, comprising costs of health care and social services, criminal justice resources, loss of productivity, and premature mortality. This study assembles and synthesizes two decades of evidence describing the benefits of SUD treatment across five main outcome domains; 1) health care utilization; 2) self-reported criminal activity by offense type; 3) criminal justice involvement collected from administrative records or self-reported; 4) productivity assessed through working hours or wages earned; and 5) social services (e.g., a day spent in transitional housing). METHODS: This review included studies if they reported the monetary value of the intervention outcomes, most commonly through a cost-benefit or cost-effectiveness framework. The search included studies from 2003 to the present day as of this writing (up to October 15, 2021). Summary cost estimates were adjusted using the US Consumer Price Index (CPI) to reflect the 12-month benefits per client in USD 2021. We followed the PRISMA methodology for study selection and assessed quality using the Checklist for Health Economic Evaluation Reporting Standards (CHEERS). RESULTS: The databases yielded 729 studies after removing duplicates, and we ultimately selected 12 for review. Studies varied widely regarding analytical approaches, time horizons, outcome domains, and other methodological factors. Among the ten studies that found positive economic benefits, reductions in criminal activity or criminal justice costs represented the largest or second largest component of these benefits (range $621 to $193,440 per client). CONCLUSIONS: Consistent with previous findings, a reduction in criminal activity costs is driven by the relatively high societal cost per criminal offense, notably for violent crimes, such as aggravated assault and rape/sexual assault. Accepting the economic rationale for increased investment in SUD interventions will require recognizing that more benefits accrue to individuals by avoiding being victims of a crime than to governments through budget offsets resulting from savings in non-SUD program expenses. Future studies should explore individually tailored interventions to optimize care management, which may yield unexpected economic benefits to services utilization, and criminal activity data to estimate economic benefits across a broad range of interventions.
Subject(s)
Criminals , Substance-Related Disorders , Humans , Cost-Benefit Analysis , Health Care Costs , Crime , Substance-Related Disorders/therapyABSTRACT
BACKGROUND: Given the personal and public consequences of untreated/undertreated OUD among persons involved in the justice system, an increasing number of jails and prisons are incorporating medication for opioid use disorder (MOUD) into their system. Estimating the costs of implementing and sustaining a particular MOUD program is vital to detention facilities, which typically face modest, fixed health care budgets. We developed a customizable budget impact tool to estimate the implementation and sustainment costs of numerous MOUD delivery models for detention facilities. METHODS: The aim is to describe the tool and present an application of a hypothetical MOUD model. The tool is populated with resources required to implement and sustain various MOUD models in detention facilities. We identified resources via micro-costing techniques alongside randomized clinical trials. The resource-costing method is used to assign values to resources. Resources/costs are categorized as (a) fixed, (b) time-dependent, and (c) variable. Implementation costs include (a), (b), and (c) over a specified timeframe. Sustainment costs include (b) and (c). The MOUD model example entails offering all three FDA-approved medications, with methadone and buprenorphine provided by vendors, and naltrexone by the jail/prison facility. RESULTS: Fixed resources/costs are incurred only once, including accreditation fees and trainings. Time-dependent resources/costs are recurring, but fixed over a given time-period; e.g., medication delivery and staff meetings. Variable resources/costs are those that are a direct function of the number of persons treated, such as the medication provided to each patient. Using nationally representative prices, we estimated fixed/sustainment costs to be $2919/patient, over 1 year. This article estimates annual sustainment costs to be $2885/patient. CONCLUSION: The tool will serve as a valuable asset to jail/prison leadership, policymakers, and other stakeholders interested in identifying/estimating the resources and costs associated with alternative MOUD delivery models, from the planning stages through sustainment.
Subject(s)
Jails , Opioid-Related Disorders , Humans , Prisons , Budgets , Opioid-Related Disorders/drug therapy , Methadone/therapeutic useABSTRACT
BACKGROUND: The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue. METHODS: The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed. DISCUSSION: The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.
Subject(s)
HIV Infections , Hepatitis C , Opioid-Related Disorders , Substance Abuse, Intravenous , Humans , Harm Reduction , Hepacivirus , Hepatitis C/epidemiology , HIV Infections/epidemiology , Opioid-Related Disorders/complications , Randomized Controlled Trials as Topic , Substance Abuse, Intravenous/drug therapy , Multicenter Studies as TopicABSTRACT
The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.
Subject(s)
Behavior, Addictive , Opioid-Related Disorders , Adolescent , Young Adult , Humans , Cost-Benefit Analysis , Opioid-Related Disorders/prevention & control , Opioid-Related Disorders/drug therapy , Analgesics, OpioidABSTRACT
Objetivos: realizar un análisis económico para evaluar los costos de una intervención educativa, utilizando los principios de un modelo de seguridad humana en Bateyes del suroeste de la República Dominicana. Métodos: se consideraron cuatro recursos de intervención, incluyendo la capacitación del personal, los incentivos mensuales, la supervisión de las actividades de campo y el costo total asociado al tratamiento anual de la diarrea aguda. El gasto se comparó entre el programa estándar de atención (Batey Control) y la intervención con el modelo de seguridad humana (Batey Caso). Resultados: el ahorro del costo total anual para el Ministerio de Salud de República Dominicana asociado con la reducción de la incidencia de episodios de diarrea aguda fue de US$252,399. Si se extrapolan a los 300 Bateyes de República Dominicana, se podría ahorrar aproximadamente US$75 millones en prevención de enfermedades infecciosas. Conclusiones: el modelo de seguridad humana luce ser un método eficaz para mejorar el conocimiento sobre la prevención de enfermedades y aumentar el empoderamiento de la comunidad para la movilización de recursos. Aplicada a otros entornos, la intervención podría tener una incidencia beneficiosa en las poblaciones de refugiados e indocumentados bajo el impacto de la violencia estructural.
Objectives: To conduct an economic analysis to evaluate the costs of an educational intervention, using the human security model, and potential sources of economic benefits, in Southwestern Bateyes in the Dominican Republic. Methods: Four intervention resources were considered, including staff training, monthly incentives, supervision of field activities, and total cost associated with annual treatment for acute diarrhea. The expenditure was compared between the standard program of care and the intervention using the human security model. Results: The total annual cost saving to the Dominican Republic Ministry of Health, associated with reducing the incidence of acute diarrhea episodes, was US$252,399. If this is extrapolated to the 300 Bateyes of the Dominican Republic, the Ministry of Health could save approximately US$75 million in infectious disease prevention by implementing this intervention model in these isolated rural communities. Conclusions: The educational intervention, which incorporated a human security approach, appeared to be an effective method to enhance knowledge about disease prevention and to increase empathy among community members for resource mobilization and local empowerment. Applied to other settings, the intervention could have a beneficial impact on refugee and undocumented populations under the
Subject(s)
Communicable Disease Control , Public Health , Cross-Sectional Studies , Diarrhea , Dominican Republic , Economic FactorsABSTRACT
BACKGROUND: Syringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care. METHODS: We conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars. RESULTS: A total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost. DISCUSSION/CONCLUSION: Implementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost-benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.
Subject(s)
HIV Infections , Substance Abuse, Intravenous , Academic Medical Centers , HIV Infections/prevention & control , Humans , Needle-Exchange Programs , Retrospective Studies , SyringesABSTRACT
OBJECTIVE: The crisis of opioid use puts a strain on resources in the United States and worldwide. There are 3 US Food and Drug Administration-approved medications for treatment of opioid use disorder: methadone, buprenorphine, and injectable extended-release naltrexone (XR-NTX). The comparative effectiveness and cost vary considerably among these 3 medications. Economic evaluations provide evidence that help stakeholders efficiently allocate scarce resources. Our objective was to summarize recent health economic evidence of pharmacologic treatment of opioid use disorder interventions. METHODS: We searched PubMed for peer-reviewed studies in English from August 2015 through December 2019 as an update to a 2015 review. We used the Drummond checklist to evaluate and categorize economic evaluation study quality. We summarized results by economic evaluation methodology and pharmacologic treatment modality. RESULTS: We identified 105 articles as potentially relevant and included 21 (4 cost-offset studies and 17 cost-effectiveness/cost-benefit studies). We found strengthened evidence on buprenorphine and methadone, indicating that these treatments are economically advantageous compared with no pharmacotherapy, but found limited evidence on XR-NTX. Only half of the cost-effectiveness studies used a generic preference-based measure of effectiveness, limiting broad comparison across diseases/disorders. The disease/disorder-specific cost-effectiveness measures vary widely, suggesting a lack of consensus on the value of substance use disorder treatment. CONCLUSION: We found studies that provide new evidence supporting the cost-effectiveness of buprenorphine compared with no pharmacotherapy. We found a lack of evidence supporting superior economic value for buprenorphine versus methadone, suggesting that both are attractive alternatives. Further economic research is needed on XR-NTX, as well as other emerging pharmacotherapies, treatment modalities, and dosage forms.
Subject(s)
Cost-Benefit Analysis , Drug Therapy/economics , Opioid-Related Disorders/drug therapy , Adolescent , Adult , Humans , Middle Aged , United States , Young AdultABSTRACT
BACKGROUND AND AIMS: In a US randomized-effectiveness trial comparing extended-release naltrexone (XR-NTX) with buprenorphine-naloxone (BUP-NX) for the prevention of opioid relapse among participants recruited during inpatient detoxification (CTN-0051), the requirement to complete opioid detoxification prior to initiating XR-NTX resulted in lower rates of initiation of XR-NTX (72% XR-NTX versus 94% BUP-NX). DESIGN: This was a retrospective secondary analysis of CTN-0051 trial data, including follow-up data over 24-36 weeks. SETTING: Eight community-based, inpatient-detoxification and follow-up outpatient treatment facilities in the United States. PARTICIPANTS: A total of 283 participants randomized to receive XR-NTX. MEASUREMENTS: Efficiency was estimated using a multivariable generalized structural equation model to explore simultaneous determinants of XR-NTX induction and induction duration (detoxification + residential days). Cost-effectiveness was estimated from the health-care sector perspective and included expected costs and quality-adjusted life-years (QALYs). FINDINGS: Treatment site was the only modifiable factor that simultaneously increased the likelihood of XR-NTX induction and decreased induction duration. Incorporating the higher predicted probability of XR-NTX induction, and fewer predicted days of detoxification and subsequent residential treatment into the cost-effectiveness framework, reduced the incremental average 24-week total cost of XR-NTX treatment from $5317 more than that of BUP-NX (P = 0.01) to a non-statistically-significant difference of $1016 (P = 0.63). QALYs gained remained similar across arms. CONCLUSION: Adopting an efficient model of extended-release naltrexone initiation could result in extended-release naltrexone and buprenorphine-naloxone being of comparable economic value from the health-care sector perspective over 24-36 weeks for patients seeking treatment for opioid use disorder at an inpatient detoxification facility.
Subject(s)
Naltrexone , Opioid-Related Disorders , Cost-Benefit Analysis , Delayed-Action Preparations/therapeutic use , Humans , Injections, Intramuscular , Naltrexone/therapeutic use , Narcotic Antagonists/therapeutic use , Opioid-Related Disorders/drug therapy , Retrospective Studies , United StatesABSTRACT
BACKGROUND: Standardization and harmonization of healthcare resource utilization data can improve evaluations of the economic impact of treating people with substance use disorder (SUD), including reductions in use of expensive hospital and emergency department (ED) services, and can ensure consistency with current cost-effectiveness and cost-benefit analysis guidelines. METHODS: We examined self-reported healthcare and other resource utilization data collected at baseline from three National Institute on Drug Abuse (NIDA)-funded Seek, Test, Treat, and Retain intervention studies of individuals living with/at risk for HIV with SUD. Costs were calculated by multiplying mean healthcare resource utilization measures by monetary conversion factors reflecting cost per unit of care. We normalized baseline recall timeframes to past 30 days and evaluated for missing data. RESULTS: We identified measures that are feasible and appropriate for estimating healthcare sector costs including ED visits, inpatient hospital and residential facility stays, and outpatient encounters. We also identified two self-reported measures to inform societal costs (days experiencing SUD problems, participant spending on substances). Missingness was 8% or less for all study measures and was lower for single questions measuring utilization in a recall period. CONCLUSIONS: We recommend including measures representing units of service with specific recall periods (e.g., 6 months vs. lifetime), and collecting healthcare resource utilization data using single-question measures to reduce missingness.
Subject(s)
Substance-Related Disorders , Cost-Benefit Analysis , Emergency Service, Hospital , Health Care Costs , Humans , Substance-Related Disorders/therapyABSTRACT
BACKGROUND: This study is a systematic literature review of cost analyses conducted within implementation studies on behavioral health services. Cost analysis of implementing evidence-based practices (EBP) has become important within implementation science and is critical for bridging the research to practice gap to improve access to quality healthcare services. Costing studies in this area are rare but necessary since cost can be a barrier to implementation and sustainment of EBP. METHODS: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and applied the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Key search terms included: (1) economics, (2) implementation, (3) EBP, and (4) behavioral health. Terms were searched within article title and abstracts in: EconLit, SocINDEX, Medline, and PsychINFO. A total of 464 abstracts were screened independently by two authors and reduced to 37 articles using inclusion and exclusion criteria. After a full-text review, 18 articles were included. RESULTS: Findings were used to classify costs into direct implementation, direct services, and indirect implementation. While all studies included phases of implementation as part of their design, only five studies examined resources across multiple phases of an implementation framework. Most studies reported direct service costs associated with adopting a new practice, usually summarized as total EBP cost, cost per client, cost per clinician, and/or cost per agency. For studies with detailed analysis, there were eleven direct cost categories represented. For five studies that reported costs per child served, direct implementation costs varied from $886 to $9470 per child, while indirect implementation costs ranged from $897 to $3805 per child. CONCLUSIONS: This is the first systematic literature review to examine costs of implementing EBP in behavioral healthcare settings. Since 2000, 18 studies were identified that included a cost analysis. Given a wide variation in the study designs and economic methods, comparison across studies was challenging, which is a major limitation in the field, as it becomes difficult to replicate studies or to estimate future costs to inform policy decisions related to budgeting. We recommend future economic implementation studies to consider standard economic costing methods capturing costs across implementation framework phases to support comparisons and replicability.
Subject(s)
Mental Health , Substance-Related Disorders , Child , Cost-Benefit Analysis , Delivery of Health Care , Evidence-Based Practice , Humans , Substance-Related Disorders/therapyABSTRACT
BACKGROUND: In 2016, at least 20% of people with opioid use disorder (OUD) were involved in the criminal justice system, with the majority of individuals cycling through jails. Opioid overdose is the leading cause of death and a common cause of morbidity after release from incarceration. Medications for OUD (MOUD) are effective at reducing overdoses, but few interventions have successfully engaged and retained individuals after release from incarceration in treatment. OBJECTIVE: To assess whether follow-up care in the Transitions Clinic Network (TCN), which provides OUD treatment and enhanced primary care for people released from incarceration, improves key measures in the opioid treatment cascade after release from jail. In TCN programs, primary care teams include a community health worker with a history of incarceration, and they attend to social needs, such as housing, food insecurity, and criminal legal system contact, along with patients' medical needs. METHODS AND ANALYSIS: We will bring together six correctional systems and community health centers with TCN programs to conduct a hybrid type-1 effectiveness/implementation study among individuals who were released from jail on MOUD. We will randomize 800 individuals on MOUD released from seven local jails (Bridgeport, CT; Niantic, CT; Bronx, NY; Caguas, PR; Durham, NC; Minneapolis, MN; Ontario County, NY) to compare the effectiveness of a TCN intervention versus referral to standard primary care to improve measures within the opioid treatment cascade. We will also determine what social determinants of health are mediating any observed associations between assignment to the TCN program and opioid treatment cascade measures. Last, we will study the cost effectiveness of the approach, as well as individual, organizational, and policy-level barriers and facilitators to successfully transitioning individuals on MOUD from jail to the TCN. ETHICS AND DISSEMINATION: Investigation Review Board the University of North Carolina (IRB Study # 19-1713), the Office of Human Research Protections, and the NIDA JCOIN Data Safety Monitoring Board approved the study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. We will disseminate study data through a web-based platform designed to share data with TCN PATHS participants and other TCN stakeholders. Clinical trials.gov registration: NCT04309565.
Subject(s)
Jails , Opioid-Related Disorders , Ambulatory Care Facilities , Delivery of Health Care , Humans , Opioid-Related Disorders/drug therapy , Primary Health Care , Social Support , Treatment OutcomeABSTRACT
The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.
Subject(s)
Analgesics, Opioid , Opioid-Related Disorders , Analgesics, Opioid/therapeutic use , Female , Humans , Jurisprudence , Kentucky , Opioid Epidemic , Opioid-Related Disorders/drug therapyABSTRACT
BACKGROUND: Understanding patterns of multimorbidity in the US older adult population and their relationship with mortality is important for reducing healthcare utilization and improving health. Previous investigations measured multimorbidity as counts of conditions rather than specific combination of conditions. METHODS: This cross-sectional study with longitudinal mortality follow-up employed latent class analysis (LCA) to develop clinically meaningful subgroups of participants aged 50 and older with different combinations of 13 chronic conditions from the National Health Interview Survey 2002-2014. Mortality linkage with National Death Index was performed through December 2015 for 166,126 participants. Survival analyses were conducted to assess the relationships between LCA classes and all-cause mortality and cause specific mortalities. RESULTS: LCA identified five multimorbidity groups with primary characteristics: "healthy" (51.5%), "age-associated chronic conditions" (33.6%), "respiratory conditions" (7.3%), "cognitively impaired" (4.3%) and "complex cardiometabolic" (3.2%). Covariate-adjusted survival analysis indicated "complex cardiometabolic" class had the highest mortality with a Hazard Ratio (HR) of 5.30, 99.5% CI [4.52, 6.22]; followed by "cognitively impaired" class (3.34 [2.93, 3.81]); "respiratory condition" class (2.14 [1.87, 2.46]); and "age-associated chronic conditions" class (1.81 [1.66, 1.98]). Patterns of multimorbidity classes were strongly associated with the primary underlying cause of death. The "cognitively impaired" class reported similar number of conditions compared to the "respiratory condition" class but had significantly higher mortality (3.8 vs 3.7 conditions, HR = 1.56 [1.32, 1.85]). CONCLUSION: We demonstrated that LCA method is effective in classifying clinically meaningful multimorbidity subgroup. Specific combinations of conditions including cognitive impairment and depressive symptoms have a substantial detrimental impact on the mortality of older adults. The numbers of chronic conditions experienced by older adults is not always proportional to mortality risk. Our findings provide valuable information for identifying high risk older adults with multimorbidity to facilitate early intervention to treat chronic conditions and reduce mortality.
Subject(s)
Cardiovascular Diseases/epidemiology , Chronic Disease/epidemiology , Cognitive Dysfunction/epidemiology , Depressive Disorder/epidemiology , Diabetes Mellitus/epidemiology , Aged , Aged, 80 and over , Cardiovascular Diseases/mortality , Chronic Disease/mortality , Cognitive Dysfunction/mortality , Cross-Sectional Studies , Depressive Disorder/mortality , Diabetes Mellitus/mortality , Female , Follow-Up Studies , Humans , Male , Middle Aged , Multimorbidity , Survival Rate , United StatesABSTRACT
A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.
Subject(s)
Buprenorphine , COVID-19 , Opioid-Related Disorders , Analgesics, Opioid/therapeutic use , Buprenorphine/therapeutic use , Humans , Massachusetts , Opiate Substitution Treatment , Opioid-Related Disorders/drug therapy , Pandemics , SARS-CoV-2ABSTRACT
The Justice Community Opioid Innovation Network (JCOIN) will generate real-world evidence to address the unique needs of people with opioid use disorder (OUD) in justice settings. Evidence regarding the economic value of OUD interventions in justice populations is limited. Moreover, the variation in economic study designs is a barrier to defining specific interventions as broadly cost-effective. The JCOIN Health Economics Analytic Team (HEAT) has worked closely with the Measures Committee to incorporate common economic measures and instruments across JCOIN studies, which will: a) ensure rigorous economic evaluations within each trial; b) enhance comparability of findings across studies; and c) allow for cross-study analyses of trials with similar designs/settings (e.g., pre-reentry MOUD), to assess questions beyond the scope of a single study, while controlling for and evaluating the effect of intervention-, organizational-, and population-level characteristics. We describe shared trial characteristics relevant to the economic evaluations, and discuss potential cross-study economic analyses.
Subject(s)
Analgesics, Opioid , Opioid-Related Disorders , Analgesics, Opioid/therapeutic use , Community Networks , Cost-Benefit Analysis , Humans , Jurisprudence , Opioid-Related Disorders/drug therapyABSTRACT
BACKGROUND: The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings. METHODS: The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list-controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention. DISCUSSION: The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.