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1.
Contemp Clin Trials Commun ; 16: 100468, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31701042

RESUMO

Many people with HIV (PWH) experience chronic pain that limits daily function and quality of life. PWH with chronic pain have commonly been prescribed opioids, sometimes for many years, and it is unclear if and how the management of these legacy patients should change in light of the current US opioid epidemic. Guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain (CDCG), provide recommendations for the management of such patients but have yet to be translated into easily implementable interventions; there is also a lack of strong evidence that adhering to these recommendations improves patient outcomes such as amount of opioid use and pain levels. Herein we describe the development and preliminary testing of a theory-based intervention, called TOWER (TOWard SafER Opioid Prescribing), designed to support HIV primary care providers in CDCG-adherent opioid prescribing practices with PWH who are already prescribed opioids for chronic pain. TOWER incorporates the content of the CDCG into the theoretical and operational framework of the Information Motivation and Behavioral Skills (IMB) model of health-related behavior. The development process included elicitation research and incorporation of feedback from providers and PWH; testing is being conducted via an adaptive feasibility clinical trial. The results of this process will form the basis of a large, well-powered clinical trial to test the effectiveness of TOWER in promoting CDCG-adherent opioid prescribing practices and improving outcomes for PWH with chronic pain.

2.
Open Forum Infect Dis ; 6(10): ofz411, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31660369

RESUMO

Background: HIV prevalence is 3 times greater for those in the criminal justice system than the general population, with an assumed increase in sexual risk behaviors (SRBs) postrelease. HIV viral suppression impacts HIV transmission; however, studies of SRBs among persons with HIV leaving the criminal justice system are limited, and no studies have examined viral suppression in relation to SRBs in persons leaving the criminal justice system. Methods: Data were examined from 2 double-blind placebo-controlled trials of extended-release naltrexone among persons with HIV and alcohol use or opioid use disorder. Participants self-reported sexual activity, including number of sexual partners, sex type, and condom use. HIV viral suppression was evaluated prerelease and at 6 months. Results: Thirty days before incarceration, 60% reported having sex compared with 41% and 46%, respectively, at months 1 and 6 postrelease. The number of sex partners and sexual intercourse events decreased from pre-incarceration to months 1 and 6 postrelease. Condom use increased but was not statistically significant. Of the 11 (9.7%) who reported having sex without a condom 1 month postrelease, only 2 did not have viral suppression (VS; HIV VL <200 copies/mL), whereas the 7 (6.5%) who reported SRBs at 6 months all had VS. Conclusions: After release, SRBs decreased, and among those who reported SRBs, most were virally suppressed, and thus risk of transmitting HIV was low.

3.
J Telemed Telecare ; 25(6): 353-364, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29754561

RESUMO

INTRODUCTION: In this paper the economic costs associated with a growing, multi-state telepsychiatry intervention serving rural American Indian/Alaska Native populations were compared to costs of travelling to provide/receive in-person treatment. METHODS: Telepsychiatry costs were calculated using administrative, information-technology, equipment and technology components, and were compared to travel cost models. Both a patient travel and a psychiatrist travel model were estimated utilising ArcGIS software and unit costs gathered from literature and government sources. Cost structure and sensitivity analysis was also calculated by varying modeling parameters and assumptions. RESULTS AND DISCUSSION: It is estimated that per-session costs were $93.90, $183.34, and $268.23 for telemedicine, provider-travel, and patient-travel, respectively. Restricting the analysis to satellite locations with a larger number of visits reduced telemedicine per-patient encounter costs (50 or more visits: $83.52; 100 or more visits: $80.41; and 150 or more visits: $76.25). The estimated cost efficiencies of telemedicine were more evident for highly rural communities. Finally, we found that a multi-state centre was cheaper than each state operating independently. CONCLUSIONS: Consistent with previous research, this study provides additional evidence of the economic efficiency associated with telemedicine interventions for rural American Indian/Alaska Native populations. Our results suggest that there are economies of scale in providing behavioural telemedicine and that bigger, multi-state telemedicine centres have lower overall costs compared to smaller, state-level centres. Additionally, results suggest that telemedicine structures with a higher number of per-satellite patient encounters have lower costs, and telemedicine centres delivering care to highly rural populations produce greater economic benefits.


Assuntos
Serviços de Saúde do Indígena/economia , Índios Norte-Americanos/estatística & dados numéricos , Serviços de Saúde Mental/economia , População Rural/estatística & dados numéricos , Telemedicina/economia , Viagem/economia , Serviços de Saúde Comunitária/economia , Custos de Cuidados de Saúde , Humanos
4.
Am J Drug Alcohol Abuse ; 44(6): 611-618, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30024783

RESUMO

BACKGROUND: The US has the highest incarceration rate in the world and spends $40-$80 billion to house inmates per year. It is well-known that a significant correlation is present between substance use and crime, especially over recent years as opioid use disorder (OUD) has grown exponentially. To mitigate OUD, methadone maintenance treatment (MMT) has demonstrated effectiveness in numerous randomized and quasi-experimental studies. A potentially fruitful environment for MMT is correctional facilities, particularly short-term facilities, such as city and county jails. However, little is known about the economic implications of MMT within correctional facilities. OBJECTIVE: The aim of the present study was to estimate the economic costs of jail-based MMT using data from a novel, established MMT program located within a large urban jail in New Mexico. METHODS: Data were collected using administrative records and by interviewing program administrators using a modified version of the Drug Abuse Treatment Cost Analysis Program (DATCAP). Both sensitivity analysis and cost-structure analysis were conducted to gauge the robustness of the findings. RESULTS: The average (per patient) weekly cost of MMT is $115 and the total treatment cost for an average treatment episode is $689. These costs are generally in-line with non-jail-based MMT programs of similar size. Weekly cost estimates range from $86 to $185 depending on the size of the treatment facility, with larger programs exhibiting lower per-patient costs. CONCLUSION: Results provide a valuable economic benchmark to policy makers, criminal justice officials, and program administrators considering establishing and/or expanding MMT in jail settings.


Assuntos
Analgésicos Opioides/economia , Metadona/economia , Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/economia , Prisões , Analgésicos Opioides/uso terapêutico , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Metadona/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico
5.
J Subst Abuse Treat ; 79: 6-11, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28673528

RESUMO

Screening, brief intervention, and referral to treatment (SBIRT) has been widely implemented as a method to address substance use disorders in general medical settings, and some evidence suggests that its use is associated with decreased societal costs. In this paper, we investigated the economic impact of SBIRT using data from Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), a multisite, randomized controlled trial. Utilizing self-reported information on medical status, health services utilization, employment, and crime, we conduct a benefit-cost analysis. Findings indicate that neither of the SMART-ED interventions resulted in any significant changes to the main economic outcomes, nor had any significant impact on total economic benefit. Thus, while SBIRT interventions for substance abuse in Emergency Departments may be appealing from a clinical perspective, evidence from this economic study suggests resources could be better utilized supporting other health interventions.


Assuntos
Análise Custo-Benefício/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Programas de Rastreamento/métodos , Encaminhamento e Consulta , Transtornos Relacionados ao Uso de Substâncias/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
Popul Health Manag ; 20(5): 362-367, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28574810

RESUMO

A growing literature documents the substantial burden that a small proportion of high-cost, medically complex patients impose on health care systems. However, it is not clear whether high-cost patients remain costly over time. This study looks at the monthly distribution of billed charges for a cohort of high-cost, medically complex patients enrolled in an intensive care management program in a university health care system, and finds that the billing trajectory is heterogeneous and highly nonlinear, characterized by a substantial spike in billed charges prior to identification, followed by a considerable drop prior to enrollment and a sustained drop thereafter. The conclusion is that many high-cost patients experience costly events that resolve without intensive case management. These results also suggest that interventions should target only those high-cost patients with expected continued high cost and that pre-post study designs may overstate the impact of interventions for high-cost, medically complex patients.


Assuntos
Análise Custo-Benefício , Custos de Cuidados de Saúde/estatística & dados numéricos , Administração dos Cuidados ao Paciente/economia , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Estudos de Coortes , Humanos , New Mexico
8.
Popul Health Manag ; 19(6): 398-404, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27031738

RESUMO

High-cost, medically complex patients have been a challenging population to manage in the US health care system, in terms of both improving health outcomes and containing costs. This paper evaluated the economic impact of Care One, an intensive care management program (data analysis, evaluation, empanelment, specialist disease management, nurse case management, and social support) designed to target the most expensive 1% of patients in a university health care system. Data were collected for a cohort of high-cost, medically complex patients (N = 753) who received care management and a control group (N = 794) of similarly complex health system users who did not receive access to the program. A pre-post empirical model estimated the Care One program to be associated with a per-patient reduction in billed charges of $92,227 (95% confidence interval [CI]: $83,988 to $100,466). A difference-in-difference model, which utilized the control group, estimated a per-patient reduction in billing charges of $44,504 (95% CI: $29,195 to $59,813). Results suggest that care management for high-cost, medically complex patients in primary care can reduce costs compared to a control group. In addition, significant reversion to the mean is found, providing support for the use of a difference-in-difference estimator when evaluating health programs for high-cost, medically complex patients.


Assuntos
Cuidados Críticos/economia , Custos de Cuidados de Saúde , Idoso , Estudos de Coortes , Controle de Custos/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New Mexico , Avaliação de Programas e Projetos de Saúde
9.
J Telemed Telecare ; 22(1): 47-55, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26026190

RESUMO

OBJECTIVE: The purpose of this study was to model the cost of delivering behavioural health services to rural Native American populations using telecommunications and compare these costs with the travel costs associated with providing equivalent care. METHODS: Behavioural telehealth costs were modelled using equipment, transmission, administrative and IT costs from an established telecommunications centre. Two types of travel models were estimated: a patient travel model and a physician travel model. These costs were modelled using the New Mexico resource geographic information system program (RGIS) and ArcGIS software and unit costs (e.g. fuel prices, vehicle depreciation, lodging, physician wages, and patient wages) that were obtained from the literature and US government agencies. RESULTS: The average per-patient cost of providing behavioural healthcare via telehealth was US$138.34, and the average per-patient travel cost was US$169.76 for physicians and US$333.52 for patients. Sensitivity analysis found these results to be rather robust to changes in imputed parameters and preliminary evidence of economies of scale was found. CONCLUSION: Besides the obvious benefits of increased access to healthcare and reduced health disparities, providing behavioural telehealth for rural Native American populations was estimated to be less costly than modelled equivalent care provided by travelling. Additionally, as administrative and coordination costs are a major component of telehealth costs, as programmes grow to serve more patients, the relative costs of these initial infrastructure as well as overall per-patient costs should decrease.


Assuntos
Custos de Cuidados de Saúde , Serviços de Saúde do Indígena/economia , Índios Norte-Americanos , Serviços de Saúde Mental/economia , Telemedicina/economia , Viagem/economia , Serviços de Saúde Comunitária/economia , Serviços de Saúde do Indígena/organização & administração , Humanos , Serviços de Saúde Mental/organização & administração , Modelos Econômicos , New Mexico , População Rural/estatística & dados numéricos , Telemedicina/organização & administração
10.
Health Psychol ; 32(9): 1003-12, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24001251

RESUMO

OBJECTIVE: The purpose of this study was to economically evaluate Project MARS (Motivating Adolescents to Reduce Sexual Risk; T. J. Callahan, E. A. Montanaro, R. E. Magnan, & A. D. Bryan, 2013, "Project MARS: Design of a multi-behavior intervention trial for justice-involved youth," Translational Behavioral Medicine, Vol. 3, pp. 122-130), an ongoing, randomized, sexual-risk-reduction intervention for justice-involved youth. We consider the effect of including viral STIs in the economic analysis, and explore the impact of the MARS intervention on the perceived cost of acquiring STIs to justice-involved youth. METHOD: 206 participants, ages 14 to 18, participated in a sexual-risk-reduction intervention that included screening and treatment for chlamydia and gonorrhea. A Bernoulli probability model was used to estimate averted STIs attributable to the MARS intervention. The economic benefit of averted STIs was monetized using the direct medical cost of treatment. In addition, we used a contingent valuation (willingness-to-pay) model to investigate the impact of the Project MARS on participants' perceived cost of acquiring an STI. RESULTS: Using the standard outcome domains typically used to evaluate STI interventions, Project MARS resulted in a reduction of $2.08 in direct medical costs for every $1 spent. When viral STIs were added to the economic model, a considerable increase in averted direct medical costs ($2.68 for every $1 spent) was found. Preliminary contingent valuation estimates suggest that participants' willingness-to-pay for averted STIs significantly increased after receiving the MARS intervention. CONCLUSION: From an economic perspective, Project MARS is a worthwhile program to adopt. Future attention should be given to the impact of behavioral interventions on viral infections.


Assuntos
Comportamento do Adolescente/psicologia , Motivação , Comportamento de Redução do Risco , Comportamento Sexual/psicologia , Doenças Sexualmente Transmissíveis/prevenção & controle , Adolescente , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Delinquência Juvenil , Masculino , Modelos Econômicos , Avaliação de Programas e Projetos de Saúde , Doenças Sexualmente Transmissíveis/economia
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