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ABSTRACT: BACKGROUND:: Guidelines recommend antiretroviral treatment (ART) initiation at CD4 <350/µL for HIV-infected individuals in resource-limited settings. However, funding for treatment expansion remains uncertain. We forecast the mortality impact of ART expansion alternatives in Haiti. METHODS:: We used data from Haiti to develop a country-specific model of HIV disease. The model projects the mortality, total number of HIV-infected individuals, and number and coverage (% of those eligible) on ART by simulating cohorts of HIV-infected individuals over 10 years. We assessed 5 ART expansion scenarios, ranging from fully expanded ART (best case) to no new ART (worst case). RESULTS:: By 2010, the model predicts 103,500 individuals living with HIV in Haiti, of whom 27,300 were estimated to receive ART. Continuing ART initiation at current rates requires increasing the number on ART to 43,300 by 2020 (56% coverage), with 89,700 deaths estimated between 2010 and 2020. The number on ART could increase by 7,400 (+17.1%, best case) or decrease by 25,600 (-59.1%, worst case), resulting in 19,500 deaths averted and 9,900 fewer in care awaiting ART (best versus worst case). Results are sensitive to untreated disease progression and pre-ART loss from care. Increased HIV testing, linkage to care, and retention in care can avert additional deaths and achieve nearly 80% ART coverage with optimal policy improvements. CONCLUSIONS:: In resource-limited settings, continued improvements in HIV treatment access will save lives. Efforts to efficiently expand ART access should remain a global priority.
JAIDS Journal of Acquired Immune Deficiency Syndromes 03/2013; · 4.43 Impact Factor
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ABSTRACT: The U.S. Preventive Services Task Force (USPSTF) recently released a draft statement assigning a grade A recommendation to screening for human immunodeficiency virus (HIV) in the general population 15 to 65 years of age. The proposed guidelines cite an updated systematic evidence review of the benefits and potential harms of HIV screening. Since the previous evidence review was published in 2005, new studies have shown that antiretroviral therapy can reduce transmission by HIV-infected persons and that earlier initiation of such therapy can reduce morbidity and mortality and improve quality of life.(1),(2) When the USPSTF considered clinical guidelines for HIV . . .
New England Journal of Medicine 03/2013; 368(10):884-6. · 53.30 Impact Factor
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ABSTRACT: Chinese translation
U.S. HIV treatment guidelines recommend branded once-daily, 1-pill efavirenz-emtricitabine-tenofovir as first-line antiretroviral therapy (ART). With the anticipated approval of generic efavirenz in the United States, a once-daily, 3-pill alternative (generic efavirenz, generic lamivudine, and tenofovir) will decrease cost but may reduce adherence and virologic suppression.
To assess the clinical effect, costs, and cost-effectiveness of a 3-pill, generic-based regimen compared with a branded, coformulated regimen and to project the potential national savings in the first year of a switch to generic-based ART.
Mathematical simulation of HIV disease.
United States.
HIV-infected persons.
No ART (for comparison); 3-pill, generic-based ART; and branded ART.
Quality-adjusted life expectancy, costs, and incremental cost-effectiveness ratios (ICERs) in dollars per quality-adjusted life-year (QALY).
Compared with no ART, generic-based ART has an ICER of $21 100/QALY. Compared with generic-based ART, branded ART increases lifetime costs by $42 500 and per-person survival gains by 0.37 QALYs for an ICER of $114 800/QALY. Estimated first-year savings, if all eligible U.S. patients start or switch to generic-based ART, are $920 million. Most plausible assumptions about generic-based ART efficacy and costs lead to branded ART ICERs greater than $100 000/QALY.
The efficacy and price reduction associated with generic drugs are unknown, and estimates are intended to be conservative.
Compared with a slightly less effective generic-based regimen, the cost-effectiveness of first-line branded ART exceeds $100 000/QALY. Generic-based ART in the United States could yield substantial budgetary savings to HIV programs.
National Institute of Allergy and Infectious Diseases.
Annals of internal medicine 01/2013; 158(2):84-92. · 16.73 Impact Factor
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New England Journal of Medicine 12/2012; 367(26):2467-9. · 53.30 Impact Factor
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ABSTRACT: BACKGROUND: Homozygosity for UGT1A1*28/*28 (Gilbert's variant) has been reported to be associated with atazanavir-associated hyperbilirubinemia and premature atazanavir discontinuation. We assessed the potential cost-effectiveness of UGT1A1 testing to inform choice of an initial protease inhibitor-containing regimen in antiretroviral therapy (ART)-naïve individuals. METHODS: We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model to project quality-adjusted life years (QALYs) and lifetime costs (2009 US dollars) for atazanavir-based ART with or without UGT1A1 testing, using darunavir rather than atazanavir when indicated. We assumed UGT1A1-associated atazanavir discontinuation rates reported in the Swiss HIV Cohort Study, a *28/*28 frequency of 14.9%, equal efficacy and cost of atazanavir and darunavir, and genetic assay cost of $107. Sensitivity analyses varied these parameters and hyperbilirubinemia impact on quality of life and loss to follow-up (LTFU). Costs and QALYs were discounted at 3% annually. RESULTS: Initiating atazanavir-based ART at CD4 <500/µl without UGT1A1 testing had an average discounted life expectancy of 16.02 QALYs and $475,800 discounted lifetime cost. Testing for UGT1A1 increased QALYs by 0.49 per 10,000 patients tested, and was not cost-effective (>$100,000/QALY). Testing for UGT1A1 was cost-effective (<$100,000/QALY) if assay cost decreased to $10, or if avoiding hyperbilirubinemia by UGT1A1 testing reduced LTFU by 5%. If atazanavir and darunavir differed in cost or efficacy, testing for UGT1A1 was not cost-effective under any scenario. CONCLUSIONS: Testing for UGT1A1 may be cost-effective if assay cost is low and if testing improves retention in care, but only if the comparator ART regimens have the same drug cost and efficacy.
Antiviral therapy 12/2012; · 3.16 Impact Factor
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Bruce R Schackman,
Lisa R Metsch,
Grant N Colfax,
Jared A Leff,
Angela Wong,
Callie A Scott,
Daniel J Feaster,
Lauren Gooden,
Tim Matheson,
Louise F Haynes,
A David Paltiel,
Rochelle P Walensky
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ABSTRACT: BACKGROUND: The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral. METHODS: We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. RESULTS: Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit. CONCLUSIONS: A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.
Drug and alcohol dependence 09/2012; · 3.60 Impact Factor
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ABSTRACT: The Patient Protection and Affordable Care Act, more commonly known as health reform, is designed to expand health coverage to 32 million uninsured Americans by 2019 and makes significant changes to public and private health insurance systems that will affect providers of HIV care. We review the major features of the legislation and when they will be implemented, discuss the ways in which it will affect HIV care for different patient populations, and outline implementation challenges that are relevant for HIV care. We conclude with ways in which HIV providers can get involved to learn more about the law and help their patients take advantage of the new opportunities for health coverage.
JAIDS Journal of Acquired Immune Deficiency Syndromes 05/2012; 60(1):72-6. · 4.43 Impact Factor
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Lisa R Metsch,
Daniel J Feaster,
Lauren Gooden,
Tim Matheson,
Raul N Mandler,
Louise Haynes,
Susan Tross,
Tiffany Kyle,
Dianne Gallup,
Andrzej S Kosinski, [......],
Moupali Das,
Robert Lindblad,
Sarah Erickson,
P Todd Korthuis,
Steve Martino,
James L Sorensen,
José Szapocznik,
Rochelle Walensky,
Bernard Branson,
Grant N Colfax
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ABSTRACT: We examined the effectiveness of risk reduction counseling and the role of on-site HIV testing in drug treatment.
Between January and May 2009, we randomized 1281 HIV-negative (or status unknown) adults who reported no past-year HIV testing to (1) referral for off-site HIV testing, (2) HIV risk-reduction counseling with on-site rapid HIV testing, or (3) verbal information about testing only with on-site rapid HIV testing.
We defined 2 primary self-reported outcomes a priori: receipt of HIV test results and unprotected anal or vaginal intercourse episodes at 6-month follow-up. The combined on-site rapid testing participants received more HIV test results than off-site testing referral participants (P<.001; Mantel-Haenszel risk ratio=4.52; 97.5% confidence interval [CI]=3.57, 5.72). At 6 months, there were no significant differences in unprotected intercourse episodes between the combined on-site testing arms and the referral arm (P=.39; incidence rate ratio [IRR]=1.04; 97.5% CI=0.95, 1.14) or the 2 on-site testing arms (P=.81; IRR=1.03; 97.5% CI=0.84, 1.26).
This study demonstrated on-site rapid HIV testing's value in drug treatment centers and found no additional benefit from HIV sexual risk-reduction counseling.
American Journal of Public Health 04/2012; 102(6):1160-7. · 3.93 Impact Factor
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ABSTRACT: We used a Monte Carlo computer simulation to estimate the effectiveness and cost-effectiveness of screening for acute hepatitis C virus (HCV) infection in human immunodeficiency virus (HIV)-infected men who have sex with men.
One-time screening for prevalent HCV infection was performed at the time of enrollment in care, followed by either symptom-based screening, screening with liver function tests (LFTs), HCV antibody (Ab) screening, or HCV RNA screening in various combinations and intervals. We considered both treatment with pegylated interferon and ribavirin (PEG/RBV) alone and with an HCV protease inhibitor. Outcome measures were life expectancy, quality-adjusted life expectancy, direct medical costs, and cost-effectiveness, assuming a societal willingness to pay $100000 per quality-adjusted life-year (QALY) gained.
All strategies increased life expectancy (from 0.49 to 0.94 life-months), quality-adjusted life expectancy (from 0.47 to 1.00 quality-adjusted life-months), and costs (from $1900 to $7600), compared with symptom-based screening. The incremental cost-effectiveness ratio of screening with 6-month LFTs and a 12-month HCV Ab test, compared with symptom-based screening, was $43 700/QALY (for PEG/RBV alone) and $57 800/QALY (for PEG/RBV plus HCV protease inhibitor). The incremental cost-effectiveness ratio of screening with 3-month LFTs, compared with 6-month LFTs plus a 12-month HCV Ab test, was $129 700/QALY (for PEG/RBV alone) and $229 900/QALY (for PEG/RBV plus HCV protease inhibitor). With HCV protease inhibitor-based therapy, screening with 6-month LFTs and a 12-month HCV Ab test was the optimal strategy when the HCV infection incidence was ≤1.25 cases/100 person-years. The 3-month LFT strategy was optimal when the incidence was >1.25 cases/100 person-years.
Screening for acute HCV infection in HIV-infected MSM prolongs life expectancy and is cost-effective. Depending on incidence, regular screening with LFTs, with or without an HCV Ab test, is the optimal strategy.
Clinical Infectious Diseases 04/2012; 55(2):279-90. · 9.15 Impact Factor
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Journal of General Internal Medicine 02/2012; · 2.83 Impact Factor
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ABSTRACT: Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic.
We evaluated the cost-effectiveness of long-term office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment. DESIGN, SUBJECTS, AND INTERVENTION: A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-of-life weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated.
Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually.
In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce quality-of-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction.
Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.
Journal of General Internal Medicine 01/2012; 27(6):669-76. · 2.83 Impact Factor
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Caroline E Sloan,
Karen Champenois,
Philippe Choisy,
Elena Losina,
Rochelle P Walensky, Bruce R Schackman,
Faiza Ajana,
Hugues Melliez,
A D Paltiel,
Kenneth A Freedberg,
Yazdan Yazdanpanah
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ABSTRACT: To determine the component costs of care to optimize treatment with limited resources.
We used the Cost-Effectiveness of Preventing AIDS Complications Model of HIV disease and treatment to project life expectancy and both undiscounted and discounted lifetime costs (2010 €).
We determined medical resource utilization among HIV-infected adults followed from 1998 to 2005 in northern France. Monthly HIV costs were stratified by CD4 cell count. Costs of CD4, HIV RNA and genotype tests and antiretroviral therapy (ART) were derived from published literature. Model inputs from national data included mean age 38 years, mean initial CD4 cell count 372 cells/μl, ART initiation at CD4 cell counts less than 350 cells/μl, and ART regimen costs ranging from €760 to 2570 per month.
The model projected a mean undiscounted life expectancy of 26.5 years and a lifetime undiscounted cost of €535,000/patient (€320,700 discounted); 73% of costs were ART related. When patients presented to care with mean CD4 cell counts of 510 cells/μl and initiated ART at CD4 cell counts less than 500 cells/μl or HIV RNA more than 100,000 copies/ml, life expectancy was 27.4 years and costs increased 1-2%, to €546,700 (€324,500 discounted). When we assumed introducing generic drugs would result in a 50% decline in first-line ART costs, lifetime costs decreased 4-6%, to €514,200 (€302 ,800 discounted).
As HIV disease is treated earlier with more efficacious drugs, survival and thus costs of care will continue to increase. The availability in high-income countries of widely used antiretroviral drugs in generic form could reduce these costs.
AIDS (London, England) 01/2012; 26(1):45-56. · 4.91 Impact Factor
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Caroline E. Sloan,
Karen Champenois,
Philippe Choisy,
Elena Losina,
Rochelle P. Walensky, Bruce R. Schackman,
Faiza Ajana,
Hugues Melliez,
A.D. Paltiel,
Kenneth A. Freedberg,
Yazdan Yazdanpanah,
for the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) investigators
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ABSTRACT: Objective: To determine the component costs of care to optimize treatment with limited resources.
Design: We used the Cost-Effectiveness of Preventing AIDS Complications Model of HIV disease and treatment to project life expectancy and both undiscounted and discounted lifetime costs (2010 €).
Methods: We determined medical resource utilization among HIV-infected adults followed from 1998 to 2005 in northern France. Monthly HIV costs were stratified by CD4 cell count. Costs of CD4, HIV RNA and genotype tests and antiretroviral therapy (ART) were derived from published literature. Model inputs from national data included mean age 38 years, mean initial CD4 cell count 372 cells/μl, ART initiation at CD4 cell counts less than 350 cells/μl, and ART regimen costs ranging from €760 to 2570 per month.
Results: The model projected a mean undiscounted life expectancy of 26.5 years and a lifetime undiscounted cost of €535 000/patient (€320 700 discounted); 73% of costs were ART related. When patients presented to care with mean CD4 cell counts of 510 cells/μl and initiated ART at CD4 cell counts less than 500 cells/μl or HIV RNA more than 100 000 copies/ml, life expectancy was 27.4 years and costs increased 1–2%, to €546 700 (€324 500 discounted). When we assumed introducing generic drugs would result in a 50% decline in first-line ART costs, lifetime costs decreased 4–6%, to €514 200 (€302 800 discounted).
Conclusion: As HIV disease is treated earlier with more efficacious drugs, survival and thus costs of care will continue to increase. The availability in high-income countries of widely used antiretroviral drugs in generic form could reduce these costs.
AIDS 01/2012; 26(1):45–56. · 6.24 Impact Factor
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ABSTRACT: With substantial morbidity and functional impairment, older patients receiving home health care are especially susceptible to the adverse effects of unsafe or ineffective medications. Home health agencies’ medication review and reconciliation services, however, provide an added mechanism of medication safety that could offset this risk.
To estimate the prevalence of potentially inappropriate medications (PIMs) among current elderly home health patients in the US.
Cross-sectional analysis using data from the 2007 National Home and Hospice Care Survey.
3,124 home health patients 65 years of age or older on at least one medication.
Prevalence and classification of PIM use and the association between PIM use and patient and home health agency characteristics.Key Results In 2007, 38% (95% CI: 36-41) of elderly home health patients were taking at least one PIM. Polypharmacy was associated with an increased risk of PIM use; admission to home health care from a nursing home or other sub-acute facility (compared to admission from the community) and a payment source other than Medicare or Medicaid were associated with a decreased risk of PIM use.
The prevalence of PIM use in older home health patients is high despite potential mechanisms for improved safety. Policies to improve the review and reconciliation processes within home health agencies and to improve physician-home health clinician collaboration are likely needed to lower the prevalence of PIM use in older home health patients.
Journal of General Internal Medicine 10/2011; 27(3):304-10. · 2.83 Impact Factor
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Serena P Koenig,
Heejung Bang,
Patrice Severe,
Marc Antoine Jean Juste,
Alex Ambroise,
Alison Edwards,
Jessica Hippolyte,
Daniel W Fitzgerald,
Jolion McGreevy,
Cynthia Riviere,
Serge Marcelin,
Rode Secours,
Warren D Johnson,
Jean W Pape, Bruce R Schackman
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ABSTRACT: In a randomized clinical trial of early versus standard antiretroviral therapy (ART) in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm³ in Haiti, early ART decreased mortality by 75%. We assessed the cost-effectiveness of early versus standard ART in this trial.
Trial data included use of ART and other medications, laboratory tests, outpatient visits, radiographic studies, procedures, and hospital services. Medication, laboratory, radiograph, labor, and overhead costs were from the study clinic, and hospital and procedure costs were from local providers. We evaluated cost per year of life saved (YLS), including patient and caregiver costs, with a median of 21 months and maximum of 36 months of follow-up, and with costs and life expectancy discounted at 3% per annum. Between 2005 and 2008, 816 participants were enrolled and followed for a median of 21 months. Mean total costs per patient during the trial were US$1,381 for early ART and US$1,033 for standard ART. After excluding research-related laboratory tests without clinical benefit, costs were US$1,158 (early ART) and US$979 (standard ART). Early ART patients had higher mean costs for ART (US$398 versus US$81) but lower costs for non-ART medications, CD4 cell counts, clinically indicated tests, and radiographs (US$275 versus US$384). The cost-effectiveness ratio after a maximum of 3 years for early versus standard ART was US$3,975/YLS (95% CI US$2,129/YLS-US$9,979/YLS) including research-related tests, and US$2,050/YLS excluding research-related tests (95% CI US$722/YLS-US$5,537/YLS).
Initiating ART in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm³ in Haiti, consistent with World Health Organization advice, was cost-effective (US$/YLS <3 times gross domestic product per capita) after a maximum of 3 years, after excluding research-related laboratory tests.
ClinicalTrials.gov NCT00120510.
PLoS Medicine 09/2011; 8(9):e1001095. · 16.27 Impact Factor
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Susan Tross,
Aimee N C Campbell,
Donald A Calsyn,
Lisa R Metsch,
James L Sorensen,
Steven Shoptaw,
Louise Haynes,
George E Woody,
Robert M Malow,
Lawrence S Brown, [......],
Robert E Booth,
Raul N Mandler,
Carmen Masson,
Beverly W Holmes,
Grant Colfax,
Audrey J Brooks,
Denise A Hien, Bruce R Schackman,
P Todd Korthuis,
Gloria M Miele
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ABSTRACT: HIV continues to be a significant problem among substance users and their sexual partners in the United States. The National Drug Abuse Treatment Clinical Trials Network (CTN) offers a national platform for effectiveness trials of HIV interventions in community substance abuse treatment programs. This article presents the HIV activities of the CTN during its first 10 years.
While emphasizing CTN HIV protocols, this article reviews the (1) HIV context for this work; (2) the collaborative process among providers, researchers, and National Institute on Drug Abuse CTN staff, on which CTN HIV work was based; (3) results of CTN HIV protocols and HIV secondary analyses in CTN non-HIV protocols; and (4) implications for future HIV intervention effectiveness research in community substance abuse treatment programs.
While the feasibility of engaging frontline providers in this research is highlighted, the limitations of small to medium effect sizes and weak adoption and sustainability in everyday practice are also discussed.
The American Journal of Drug and Alcohol Abuse 09/2011; 37(5):283-93. · 1.55 Impact Factor
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ABSTRACT: Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.
To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients.
Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).
Twenty primary care practices.
A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa).
Algorithm-based recommendations to physicians and care management by care managers.
Antidepressant use, depressive symptoms, and intensity of DCM over 2 years.
The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education.
The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities.
clinicaltrials.gov Identifier for PROSPECT: NCT00279682.
Archives of general psychiatry 06/2011; 68(6):627-36. · 12.26 Impact Factor
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Bruce R Schackman,
Jared A Leff,
Michael Botsko,
David A Fiellin,
Fredrick L Altice,
P Todd Korthuis,
Nancy Sohler,
Linda Weiss,
James E Egan,
Julie Netherland,
Jonathan Gass,
Ruth Finkelstein
[show abstract]
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ABSTRACT: Implementing integrated HIV and buprenorphine/naloxone treatment requires cost estimates to plan and obtain funding.
We identified costs incurred at HIV clinical sites participating in a cross-site evaluation of integrated care that followed patients for 1 year. Costs include labor, overhead, and urine toxicology analyses (clinic perspective), buprenorphine/naloxone (payer perspective) and patient time and transportation (patient perspective). Sites provided resource utilization quarterly, and providers estimated time required for each activity. With site as the unit of analysis, results are reported as median (range) of average site costs in 2008 US dollars.
The median number of monthly provider encounters for integrated care patients was 3.2 (1.5-13.3) compared with 1.7 (1.1-4.2) for similar patients not in integrated care, but integrated care patients had fewer physician encounters. Median monthly clinic costs per integrated care patient were $136 ($67-$677) for labor and overhead and $8 ($2-$23) for toxicology analyses, $22 higher than clinic costs for patients not in integrated care. Median monthly costs for buprenorphine/naloxone were $209 ($165-$272), and monthly patient costs in integrated care were $11 ($1-$54) higher.
Integrated HIV and buprenorphine/naloxone treatment requires different resources, including costs that are not third-party reimbursed. Implementing integrated care will require funding for training and for new staff such as buprenorphine coordinators, in addition to reimbursement for buprenorphine/naloxone. Further research is needed to identify potential cost offsets outside of the clinic setting.
JAIDS Journal of Acquired Immune Deficiency Syndromes 03/2011; 56 Suppl 1:S76-82. · 4.43 Impact Factor
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Bruce R Schackman
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ABSTRACT: Implementation science is the scientific study of methods to promote the integration of research findings and evidence-based interventions into health care policy and practice and hence to improve the quality and effectiveness of health services and care. Implementation science is distinguished from monitoring and evaluation by its emphasis on the use of the scientific method. The origins of implementation science include operations research, industrial engineering, and management science. Today, implementation science encompasses a broader range of methods and skills including decision science and operations research, health systems research, health outcomes research, health and behavioral economics, epidemiology, statistics, organization and management science, finance, policy analysis, anthropology, sociology, and ethics. Examples of implementation science research are presented for HIV prevention (prevention of mother-to-child transmission of HIV, male circumcision) and HIV and drug use (syringe distribution, treating drug users with antiretroviral therapy and opioid substitution therapy). For implementation science to become an established field in HIV/AIDS research, there needs to be better coordination between funders of research and funders of program delivery and greater consensus on scientific research approaches and standards of evidence.
JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2010; 55 Suppl 1:S27-31. · 4.43 Impact Factor
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ABSTRACT: The US Centers for Disease Control and Prevention (CDC) recently revised their HIV screening guidelines to promote testing and earlier entry to care. Prior analyses have examined the policy's cost-effectiveness but have not evaluated its impact on government budgets.
We used a simulation model of HIV screening, disease, and treatment to determine the budget impact of expanded HIV screening to US government discretionary, entitlement, and testing programs. We estimated total and incremental testing and treatment costs over a 5-year time horizon under current and expanded screening scenarios. We used CDC estimates of HIV prevalence and annual incidence, and considered variations in screening frequency, test return rates, linkage to care, test characteristics, and eligibility for government screening and treatment programs.
Under current practice, 177,000 new HIV cases will be identified over 5 years. Expanded screening will identify an additional 46,000 cases at an incremental 5-year cost of $2.7 billion. The financial burden of expanded HIV screening will fall disproportionately on discretionary programs that fund care for newly identified patients and will not be offset by entitlement program savings. Testing will represent a small proportion (18%) of the total budget increase. Costs are sensitive to the frequency of screening and the proportion linked to care.
The expanded HIV screening program will have a large downstream impact on government programs that fund HIV care. Expanded HIV screening will not meet early treatment goals unless government programs have sufficient budgets to expand testing and provide care for newly identified cases.
Value in Health 10/2010; 13(8):893-902. · 2.19 Impact Factor
