Cost Effectiveness of Interventions to Reduce Morbidity from Opioid Dependency

项目背景：在过去的十年里，阿片类药物的使用和注射毒品的使用，特别是海洛因注射， 在美国大多数人口群体中都有所增加，使阿片类药物使用相关的死亡率和发病率成为 退伍军人和非退伍军人都面临公共卫生危机。阿片类药物使用引起的发病率很高，包括 获得艾滋病毒和丙型肝炎病毒，这两种病毒通过共用注射的血液转移有效传播 设备。预防阿片类药物使用障碍发病率的干预措施包括阿片激动剂治疗， 心理社会干预，艾滋病毒暴露前预防，清洁针头计划和加强检测 通过血液传播的疾病，但这些干预措施在退伍军人事务部的成本效益尚未确定。在之前 工作中，我们评估了为注射毒品的人预防艾滋病毒的干预措施的成本效益 非退伍军人群体，并发现一些非常昂贵。 项目目标：这项研究将评估健康结果、成本、成本效益和预算影响 减少与阿片类药物使用障碍相关的发病率和死亡率的干预措施。分析将会 评估单独或联合应用于人群的干预措施的成本效益 退伍军人。 项目方法：为了实现我们的目标，我们将开发评估健康状况的成本效益模型 干预措施的结果、成本、成本效益和预算影响，以减少以下疾病的发病率和死亡率 阿片类药物使用障碍。我们将扩展我们之前开发的模型，以反映成本和 退伍军人的人口特征。我们的分析将包括阿片类激动剂治疗，心理社会 干预措施，艾滋病毒暴露前预防，纳洛酮的使用，艾滋病毒和丙型肝炎的密集筛查，以及其他 阿片类药物使用障碍治疗。为了制定干预措施的有效性和危害的参数估计， 我们将系统地审查干预研究，评估研究设计、研究质量、一致性和 适用于退伍军人群体。我们还将评估是否存在共病情况和接受社会福利 服务影响阿片类药物使用障碍的治疗效果。为了估计干预的成本，我们将 对VA尚未提供的干预措施使用基于文献的估计，并使用VA成本(如果有) 而且是适当的。 我们的分析将估计成本效益和预算影响。成本效益由 干预措施相对于次佳替代干预措施的增量效益除以 增量成本。单一干预措施不太可能提供与综合干预措施相同程度的好处 干预措施。然而，多项干预措施的成本效益如何变化需要仔细分析 因为干预措施可能是协同的，也可能是重复的。我们的分析将解释这些 相互依存。我们的分析将估计避免的死亡、治疗的不良事件、寿命 获得的、经质量调整的生命年数、避免的艾滋病毒或丙型肝炎病例(在适当的情况下)、成本以及 增量成本效益。成本效益提供了对价值和效率的洞察。然而，即使是 性价比高的项目可能需要大量的总投资。因此，我们还将估计 单独或组合中的计划的预算影响。预算影响捕获以下项目的总支出 在不同级别的覆盖范围或扩大范围内实施方案所需的。这项研究将提供一个 了解哪些干预措施或干预措施的组合可能最能改善 患有阿片类药物使用障碍的退伍军人，以及对这些计划的效率和总成本的估计。

Project Background: Over the past decade, opioid use and injection drug use, particularly heroin injection, have increased across most US demographic groups, making opioid-use-related mortality and morbidity a public health crisis both for Veterans and non-Veterans. Morbidity from opioid use is broad, including acquisition of HIV and HCV, which spread efficiently through the transfer of blood in shared injecting equipment. Interventions to prevent morbidity from opioid use disorder include opioid agonist therapy, psychosocial interventions, HIV pre-exposure prophylaxis, clean needle programs, and enhanced testing for blood-borne diseases, but the cost effectiveness of these interventions in VA has not been determined. In prior work, we have evaluated the cost effectiveness of interventions to prevent HIV for people who inject drugs in non-Veteran populations and found some to be very expensive. Project Objectives: This study will assess health outcomes, costs, cost effectiveness, and budget impact of interventions to reduce the morbidity and mortality associated with opioid use disorder. The analysis will assess the cost effectiveness of interventions used individually or in combination when applied to populations of Veterans. Project Methods: To accomplish our objectives we will develop cost effectiveness models that assess health outcomes, cost, cost effectiveness, and budget impact of interventions to reduce morbidity and mortality from opioid use disorders. We will extend models that we have developed previously to reflect the costs and population characteristics of Veterans. Our analyses will include opioid agonist therapy, psychosocial interventions, HIV pre-exposure prophylaxis, use of naloxone, intensive screening for HIV and HCV, and other opioid use disorder treatments. To develop parameter estimates of effectiveness and harms of interventions, we will systematically review studies of interventions and assess study design, study quality, consistency, and applicability to Veteran populations. We will also assess whether comorbid conditions and receipt of social services affects the effectiveness of opioid use disorder treatment. To estimate costs of interventions we will use both literature-based estimates for interventions that VA has not provided and VA costs where available and appropriate. Our analyses will estimate both cost effectiveness and budget impact. Cost effectiveness is determined by the incremental benefit of an intervention compared to the next best alternative intervention divided by the incremental costs. Single interventions are unlikely to provide the same degree of benefit as combined interventions. However, how cost effectiveness varies for multiple interventions requires careful analyses because interventions may be synergistic or duplicative. Our analyses will account for these interdependencies. Our analyses will estimate deaths averted, adverse events from treatment, life years gained, quality-adjusted life years gained, cases of HIV or HCV averted (where appropriate), costs, and incremental cost effectiveness. Cost effectiveness provides insight into value and efficiency. However, even programs that are cost effective may require large total investments. Therefore, we will also estimate the budget impact of programs singly or in a portfolio. Budget impact captures the total expenditures that are required for implementation of programs at various levels of coverage or scale up. The study will provide an understanding of which interventions or combinations of interventions are likely to most improve the health of Veterans with opioid use disorder, along with estimates of the efficiency and total costs of the programs.