Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV

Veterans Affairs Health Economics Resource Center, 795 Willow Rd. (152 MPD), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA.
Drug and alcohol dependence (Impact Factor: 3.42). 02/2009; 100(1-2):115-21. DOI: 10.1016/j.drugalcdep.2008.09.017
Source: PubMed


The potential benefits of anti-retroviral therapy for HIV is not fully realized because of difficulties in adherence with demanding treatment regimens, especially among injection drug users.
HIV-positive methadone patients who were less than 80% adherent with their primary anti-retroviral therapy were randomized to a trial of incentives for on-time adherence. Adherence was rewarded with an escalating scale of vouchers redeemable for goods. Both intervention and control group visited a medication coach twice a month. The cost of the intervention was determined by micro-costing. Other costs were obtained from administrative data and patient report of out-of-system care.
During the 12-week intervention period, the incremental direct cost of the intervention, including treatment vouchers, was $942. The voucher group incurred $2572 in anti-retroviral drug cost, significantly more than the $1973 incurred by the comparison group (p<.01). Adherence, as measured by on-time openings of an electronically monitored vial, was 78% in the intervention group and 56% in the control group.
The incremental direct cost of voucher incentives was $292 per month. If the observed increase in adherence from voucher incentives can be sustained in the long-term, the literature suggests that disease progression will be slowed. Further research is needed to evaluate if the improvement can be sustained or achieved at lower cost. Mitigation of treatment resistance and reduction in HIV transmission are additional benefits that favor adoption.

Download full-text


Available from: Paul G Barnett
  • Source
    • "Five systematic reviews (6%) included no RCTs.7,26–28,49 Most cost-effectiveness studies (19, 66%) conducted a within-trial cost-effectiveness analysis using data from a single RCT86,87,100,102,105,106,112,113 or a non-randomized study, such as before and after90,96,99,101,103,114 or cohort studies.88,89,91,95,110 Eleven cost-effectiveness studies (38%) used a model, either based on a single study,92,104 a review of the literature93,97,107,108,109,111 or from expert evidence elicitation.94 "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: This review scopes the evidence on the effectiveness and cost-effectiveness of interventions to improve suboptimal use of medicines in order to determine the evidence gaps and help inform research priorities. Sources of data: Systematic searches of the National Health Service (NHS) Economic Evaluation Database, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. Areas of agreement: The majority of the studies evaluated interventions to improve adherence, inappropriate prescribing and prescribing errors. Areas of controversy: Interventions tend to be specific to a particular stage of the pathway and/or to a particular disease and have mostly been evaluated for their effect on intermediate or process outcomes. Growing points: Medicines optimization offers an opportunity to improve health outcomes and efficiency of healthcare. Areas timely for developing research: The available evidence is insufficient to assess the effectiveness and cost-effectiveness of interventions to address suboptimal medicine use in the UK NHS. Decision modelling, evidence synthesis and elicitation have the potential to address the evidence gaps and help prioritize research.
    Full-text · Article · Sep 2014 · British Medical Bulletin
  • Source
    • "The retention rates increased from 28% to 51% in one state and from 28% to 34% in the other, suggesting that financial aid can positively impact OST retention rates [19]. Another USA study in which patients were provided with incentive vouchers in order to increase program adherence similarly showed increased retention rates [25]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Opioid substitution therapy (OST) programs involve the dispensing of OST medicines to patients to address their dependence on heroin and/or other opioid substances. OST medicines are subsidised by the Australian government but patients need to pay the dispensing fees. This study explored opinions from OST patients and stakeholders about the potential impact of dispensing fees on compliance and OST program retention. Current and past experiences and the potential impact of OST dispensing fees were evaluated. Methods Mixed methodology was used to obtain data from OST patients and stakeholders. This involved 1) interviews with OST stakeholders, 2) a focus group of OST patients and 3) surveys of OST patients in Perth, Australia, between June and August 2013. Results The majority of the eight stakeholders declared cost as the factor mostly impacting on OST compliance. Almost all of the stakeholders commented that there was a positive correlation between time on the OST program and success in terms of relapse. Most stakeholders advocated for OST fees to contribute towards the Pharmaceutical Benefits Scheme Safety Net, and for fee subsidy. Focus group themes supported stakeholder interview findings. A total of 138 surveys were completed. Survey analysis illustrated a strong correlation between patient debt and impacted lifestyle: 82.4% (p < 0.001, Chi-square test) of the 138 survey participants stated that dispensing fees impacted significantly on patients’ finances and lifestyle, specifically those patients with major debt. The cost of dispensing fees was identified by 46.3% (64/138) of survey participants as the biggest impacting factor on patient success. Logistic regression models showed that the cost of dispensing fees was also found to significantly influence both the occurrence of debt (57.7%, p < 0.0001) and lifestyle difficulties (80.0%, p = 0.0004). Conclusion Findings provided insight into OST patients’ financial difficulties with data suggesting that dispensing fees are likely to have a negative impact on OST patients’ compliance with therapy, retention in the OST program and lifestyle. Government sponsorship of the OST dispensing fees should be considered as sponsorship would potentially increase the retention rates of income-poor OST program recipients.
    Full-text · Article · Aug 2014 · Substance Abuse Treatment Prevention and Policy
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We review evidence for effectiveness, cost-effectiveness, and coverage of antiretroviral therapy (ART) for injecting drug users (IDUs) infected with HIV, with particular attention to low-income and middle-income countries. In these countries, nearly half (47%) of all IDUs infected with HIV are in five nations--China, Vietnam, Russia, Ukraine, and Malaysia. In all five countries, IDU access to ART is disproportionately low, and systemic and structural obstacles restrict treatment access. IDUs are 67% of cumulative HIV cases in these countries, but only 25% of those receiving ART. Integration of ART with opioid substitution and tuberculosis treatment, increased peer engagement in treatment delivery, and reform of harmful policies--including police use of drug-user registries, detention of drug users in centres offering no evidence-based treatment, and imprisonment for possession of drugs for personal use--are needed to improve ART coverage of IDUs.
    Full-text · Article · Jul 2010 · The Lancet
Show more