Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics.
Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics.
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DOI：
10.1001/jamanetworkopen.2023.7888
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发表时间：
2023-04-03
影响因子：
13.8
通讯作者：
Barocas, Joshua A.
中科院分区：
文献类型：
--
作者：
Jawa, Raagini;Tin, Yjuliana;Nall, Samantha;Calcaterra, Susan L.;Savinkina, Alexandra;Marks, Laura R.;Kimmel, Simeon D.;Linas, Benjamin P.;Barocas, Joshua A.
将丁丙诺啡和减少伤害药盒整合到注射阿片类药物的人的初级保健中的估计临床结果、成本和成本效益是什么？在这一决策分析模型中，使用减少与药物使用有关的感染的成本-效果模型，单用丁丙诺啡可将折现预期寿命延长0.16年，丁丙诺啡与减少危害套件联合使用可将折现预期寿命延长0.17年。与现状相比，丁丙诺啡和减害药盒将与药物使用相关的死亡率降低了33%，而且具有成本效益。这些发现表明，将丁丙诺啡和减少危害试剂盒整合到初级保健中可能会改善临床结果，适度增加成本，并对卫生系统具有成本效益。这个由注射阿片类药物的模拟代表性队列组成的决策分析模型估计了将成瘾治疗纳入美国初级保健的不同策略的长期临床结果、成本和成本效益。美国初级保健从业者(PCP)是最大的临床劳动力，但很少提供成瘾护理。初级保健是扩大成瘾服务的实际场所，包括丁丙诺啡和减少伤害套件，但临床结果和卫生保健部门的成本尚不清楚。评估注射阿片类药物的人在初级保健中综合丁丙诺啡和减少伤害试剂盒的长期临床结果、成本和成本效益。在这项模拟研究中，追踪严重注射相关感染、过量用药、住院和死亡的减少药物使用相关感染成本效益(REDUTE)微模拟模型被用来检查以下治疗策略：(1)PCP服务和外部转介成瘾治疗(现状)，(2)PCP服务加现场丁丙诺啡处方，转介到非现场减少伤害成套(BUP)，以及(3)PCP服务加现场丁丙诺啡处方和减害成套(BUP加HR)。模型投入来自临床试验和观察队列，成本每年以3%的比例贴现。从改进的卫生保健部门的角度对成本效益进行了终生评估，并进行了敏感性分析以解决不确定性。模型模拟从2021年1月1日开始，在队列的整个生命周期中运行。寿命年(Lys)、住院、后遗症(过量用药、严重皮肤和软组织感染以及心内膜炎)死亡率、成本和增量成本-效果比(ICER)。模拟队列包括225万人，反映了注射阿片类药物的美国人的年龄和性别。现状导致了6.56LY的折扣，折扣成本为每人203 500美元(95%可信区间，203 000美元-222 000美元)。每种策略都延长了贴现预期寿命：BUP延长了0.16年，BUP加HR延长了0.17年。与现状相比，BUP加HR降低了33%的后遗症相关死亡率。BUP和BUP+HR的人均折现终生成本高于现状策略。主导策略为BUP+HR。与现状相比，BUP加HR具有成本效益(ICER，每LY 34 400美元)。在5年的时间范围内，BUP加HR每个PCP业务的成本约为13 000美元。这项初级保健中综合成瘾服务的模拟研究发现，临床结果有所改善，成本略有增加。将成瘾服务纳入初级保健实践应是保健系统的优先事项。
What are the estimated clinical outcomes, costs, and cost-effectiveness of integrating buprenorphine and harm reduction kits into primary care for people who inject opioids? In this decision analytical model using the Reducing Infections Related to Drug Use Cost-Effectiveness model, integrating buprenorphine alone extended discounted life expectancy by 0.16 years and buprenorphine combined with harm reduction kits extended discounted life expectancy by 0.17 years. Compared with the status quo, buprenorphine and harm reduction kits reduced drug use–related mortality by 33% and was cost-effective. These findings suggest that integrating buprenorphine and harm reduction kits into primary care may improve clinical outcomes, modestly increase costs, and be cost-effective to health systems. This decision analytical model of a simulated representative cohort of people who inject opioids estimates the long-term clinical outcomes, costs, and cost-effectiveness of different strategies of integrating addiction treatment into US primary care. US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown. To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids. In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort. Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs). The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000. This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.
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影响因子：
4.2
作者：
Caudarella, Alexander;Dong, Huiru;Hayashi, Kanna
通讯作者：
Hayashi, Kanna
影响因子：
4.2
作者：
Cedarbaum, Emily R.;Banta-Green, Caleb J.
通讯作者：
Banta-Green, Caleb J.
DOI：
10.1377/hlthaff.2019.01559
发表时间：
2020-08
期刊：
Health affairs (Project Hope)
影响因子：
--
作者：
Gertner AK;Robertson AG;Powell BJ;Jones H;Silberman P;Domino ME
通讯作者：
Domino ME
影响因子：
4.4
作者：
Buresh, Megan;Genberg, Becky L.;Mehta, Shruti H.
通讯作者：
Mehta, Shruti H.
影响因子：
3.9
作者：
Behrends, Czarina N.;Paone, Denise;Schackman, Bruce R.
通讯作者：
Schackman, Bruce R.