title: How Inexpensive Does an Alcohol Intervention in Kenya Need to be in Order to Deliver Favorable Value by Reducing HIV-Related Morbidity and Mortality? Cost-effectiveness of rapid hepatitis C virus (HCV) testing and simultaneous rapid HCV and HIV testing in substance abuse treatment programs. Randomized controlled trial to evaluate screening and brief intervention for drug-using multiethnic emergency and trauma department patients A randomized trial of effectiveness and cost-effectiveness of observed versus unobserved administration of buprenorphine-naloxone for heroin dependence. The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model Cost-utility analysis of methadone maintenance treatment in Lithuania. A taxonomy of model structures for economic evaluation of health technologies. A randomised trial of the cost effectiveness of buprenorphine as an alternative to methadone maintenance treatment for heroin dependence in a primary care setting Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.
abstract: HIV remains a major cause of preventable morbidity and mortality with 100000 new infections and an estimated 62000 deaths in 2011 . At the same time unhealthy alcohol consumption is an important risk factor for HIV acquisition and progression . Kenya has one of the highest rates of unhealthy alcohol use worldwide and as many as 13 % of new HIV infections in Kenya may be attributable to unhealthy alcohol use . R and omized controlled trials ( RCTs ) of cognitive behavioral therapy (CBT)-based interventions addressing unhealthy alcohol consumption in Kenya show promising results increasing abstinence by 45 % and decreasing risky sex . However alcohol remains conspicuously absent from programming in HIV and substance abuse . In low-re source setting s the benefits of scaling up an effective intervention must be balanced against the opportunity costs of using those re sources to scale up alternative interventions with potential benefit ( for example increasingly eligibility for first-line antiretroviral therapy ) . Accordingly the research ers used a published vali date d computer simulation of the HIV epidemic in Kenya incorporating HIV transmission and disease progression to evaluate the cost-effectiveness of the alcohol intervention reported by Papas et al. Given the uncertainty surrounding costs of scale-up they varied costing assumption over a wide range to identify the threshold at which its incremental cost-effectiveness ratio ( ICER ) descended below those of alternative re source uses ( e.g. when an alcohol intervention brought more “ health ” than alternative re source uses ) . [ excerpt AIMS To evaluate the cost-effectiveness of rapid hepatitis C virus ( HCV ) and simultaneous HCV/HIV antibody testing in substance abuse treatment programs . DESIGN We used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer , off-site HCV testing referral , on-site rapid HCV testing offer and on-site rapid HCV and HIV testing offer . Base case inputs included 11 % undetected chronic HCV , 0.4 % undetected HIV , 35 % HCV co-infection among HIV-infected , 53 % linked to HCV care after testing antibody-positive and 67 % linked to HIV care . Disease outcomes were estimated from established computer simulation models of HCV [ Hepatitis C Cost-Effectiveness ( HEP-CE ) ] and HIV [ Cost-Effectiveness of Preventing AIDS Complications ( CEPAC ) ] . SETTING AND PARTICIPANTS Data on test acceptance and costs were from a national r and omized trial of HIV testing strategies conducted at 12 substance abuse treatment programs in the United States . MEASUREMENTS Lifetime costs ( 2011 US$ ) and quality -adjusted life years ( QALYs ) discounted at 3 % annually ; incremental cost-effectiveness ratios ( ICERs ) . FINDINGS On-site rapid HCV testing had an ICER of $ 18,300/QALY compared with no testing , and was more efficient than ( dominated ) off-site HCV testing referral . On-site rapid HCV and HIV testing had an ICER of $ 64,500/QALY compared with on-site rapid HCV testing alone . In one- and two-way sensitivity analyses , the ICER of on-site rapid HCV and HIV testing remained < $ 100,000/QALY , except when undetected HIV prevalence was < 0.1 % or when we assumed frequent HIV testing elsewhere . The ICER remained < $ 100,000/QALY in 91 % of probabilistic sensitivity analyses . CONCLUSIONS On-site rapid hepatitis C virus and HIV testing in substance abuse treatment programs is cost-effective at a < $ 100,000/ quality -adjusted life year threshold Background Screening and brief intervention ( SBI ) is a comprehensive , integrated public health approach to identify and deliver a spectrum of early detection and intervention services for substance use in general medical care setting s. Although the SBI approach has shown promise for alcohol use , relatively little is known about its effectiveness for illicit drug use . We are evaluating the SBI approach for drug use using a rigorous r and omized controlled trial . The purpose of the report is to describe the overall trial and its programmatic and method ological strengths with a focus on health educator ( HE ) selection and training . In addition , the baseline characteristics of the recently enrolled multiethnic cohort are described . Methods / design A r and omized two-group repeated measures design is being used in which drug-related outcomes of an intervention group will be compared with those of an attention-placebo control group . Selection of bicultural paraprofessional HEs — their training in research concepts , comorbid mental health issues , special treatment of marijuana use , and nonscripted enhanced motivational interviewing as well as their ongoing monitoring and evaluation — are among the features described . The HEs enrolled , consented , and conducted an intervention among 700 illicit drug users in two large hospital emergency departments/trauma units . To be eligible , a participant needed to be an adult ( age ≥18 years ) , an English or Spanish speaker , awake and able to give consent , and reachable by telephone to schedule a six-month follow-up interview . Discussion A comprehensive HE training protocol combined with rigorous , ongoing process measurement result ed in skill mastery in many areas and a successful participant recruitment period . Strengths and limitations of the study protocol are discussed as well as the characteristics of those recruited . This trial will be among the first to provide information about the effectiveness of SBI  for illicit drug use . Outcome analysis has not yet been completed , but demonstrated programming and design successes have implication s for future research and service delivery . Trial registration AIMS To compare the effectiveness and cost-effectiveness of unobserved versus observed dosing of patients seeking treatment of heroin dependence . DESIGN R and omized controlled trial and cost-effectiveness analysis . Setting Specialist out-patient drug treatment centres in Australia . PARTICIPANTS Heroin users seeking maintenance treatment . INTERVENTION Participants were allocated r and omly to observed or unobserved dosing for 3 months . All subjects received buprenorphine-naloxone and weekly clinical review s. MEASUREMENTS Primary end-points were retention in treatment and heroin use at 3 months . Costs of treatment were measured ( in Australian dollars , AU$ ) and cost-effectiveness compared . Secondary outcomes included quality of life , psychological symptoms and use of non-opioid drugs . FINDINGS A total of 119 subjects were r and omized and analysed . At 3 months , 33/58 ( 57 % ) r and omized to unobserved treatment , and 37/61 ( 61 % ) observed were retained ( log-rank chi2 = 0.04 , df = 1 , P = 0.84 ) . On an intention-to-treat analysis , reductions in days of heroin use in the preceding month , from baseline to 3 months , did not differ significantly ; 18.5 days ( 95 % CI : 21.8 - 15.3 ) and 22.0 days ( 95 % CI : 24.3 - 19.7 ) , respectively ( Mann-Whitney U = 807.5 , P = 0.13 ) . The mean cost for the unobserved group was AU$1,663 ( 95 % CI 1308 - 2017 ) per treatment episode , significantly less than the mean cost for the observed group at AU$2,138 ( 95 % CI 1713 - 2562 ) . CONCLUSIONS Retention and heroin use was not significantly different between observed and unobserved dosing groups . Attendance for observed dosing was not associated with worse retention . Treatment with close clinical monitoring , but no observation of dosing , was significantly cheaper and therefore significantly more cost-effective Objectives To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels ( DRLs ) as defined by the WHO , and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases , injuries and deaths . Design Decision modelling using Markov chains compared costs and effects over 5 years . Setting The analysis was from the perspective of the National Health Service ( NHS ) in Engl and and Wales . Participants The model considered the licensed population for nalmefene , specifically adults with both alcohol dependence and high/very high DRLs , who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment . Data sources We modelled treatment effect using data from three clinical trials for nalmefene ( ESENSE 1 ( NCT00811720 ) , ESENSE 2 ( NCT00812461 ) and SENSE ( NCT00811941 ) ) . Baseline characteristics of the model population , treatment re source utilisation and utilities were from these trials . We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies . Health-related costs were from UK sources . Main outcome measures We measured incremental cost per quality -adjusted life year ( QALY ) gained and number of alcohol-attributable harmful events avoided .  Results Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio ( ICER ) of £ 5204 per QALY gained , and was therefore cost-effective at the £ 20 000 per QALY gained decision threshold . Sensitivity analyses showed that the conclusion was robust . Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100 000 patients compared to psychosocial support alone over the course of 5 years . Conclusions Nalmefene can be seen as a cost-effective treatment for alcohol dependence , with substantial public health benefits . Trial registration numbers This cost-effectiveness analysis was developed based on data from three r and omised clinical trials : ESENSE 1 ( NCT00811720 ) , ESENSE 2 ( NCT00812461 ) and SENSE ( NCT00811941 ) BACKGROUND Economic evaluations in health care involve the identification , measurement , valuation , and then comparison of the costs ( inputs ) and outcomes of treatments or preventive activities . The aim was to analyze the cost-utility of six-month methadone maintenance treatment program in a Lithuanian primary health care setting . METHODS A prospect i ve study design was used . All the information was obtained through the vali date d question naires at the baseline and 3- and 6-month follow-ups . WHOQOL-BREF was used to assess the quality of life ; the costs were assessed using the DATCAP methodology from the perspective of a patient and outpatient clinic during follow-up period . RESULTS A total of 102 opioid-dependent patients were recruited in the study ; 512 follow-up patient-months were obtained . The methadone maintenance treatment has significantly improved physical , psychological , and environmental components of quality of life during follow-up . Total program costs were 61 288.87 EUR . Cost paid by a patient comprised about 31 % of total program costs . Cost per quality -adjusted life-month ( QALM ) for physical domain was 2227.55 EUR ; for psychological domain , 1879.50 EUR ; for social domain , 5467.64 EUR ; and for environmental domain , 4626.47 EUR . Costs per QALM and quality -adjusted life-year ( QALY ) for total quality of life in the maintenance program were 2864.00 EUR and 34 368.00 EUR , respectively . CONCLUSIONS Our results showed that 6-month methadone maintenance program was effective in the terms of quality -of-life improvement .  Methadone maintenance treatment program was less effective in terms of cost per QALY Models for the economic evaluation of health technologies provide valuable information to decision makers . The choice of model structure is rarely discussed in published studies and can affect the results produced . Many papers describe good modelling practice , but few describe how to choose from the many types of available models . This paper develops a new taxonomy of model structures . The horizontal axis of the taxonomy describes assumptions about the role of expected values , r and omness , the heterogeneity of entities , and the degree of non-Markovian structure . Commonly used aggregate models , including decision trees and Markov models require large population numbers , homogeneous sub-groups and linear interactions . Individual models are more flexible , but may require replications with different r and om numbers to estimate expected values . The vertical axis of the taxonomy describes potential interactions between the individual actors , as well as how the interactions occur through time . Models using interactions , such as  system dynamics  , some  Markov models  , and  discrete event simulation  are fairly uncommon in the health economics but are necessary for modelling infectious diseases and systems with constrained re sources . The paper provides guidance for choosing a model , based on key requirements , including output requirements , the population size , and system complexity Abstract Background and aim : Buprenorphine offers an alternative to methadone in the treatment of heroin dependence , and has the advantage of allowing alternate-day dosing . This study is the first to examine the cost effectiveness of buprenorphine as maintenance treatment for heroin dependence in a primary care setting using economic and clinical data collected within a r and omised trial . Study design and methods : The study was a r and omised , open-label , 12-month trial of 139 heroin-dependent patients in a community setting receiving individualised treatment regimens of buprenorphine or methadone . Those who were currently on a methadone program ( n = 57 ; continuing therapy subgroup ) were analysed separately from new treatment recipients ( n = 82 ; initial therapy subgroup ) . The study took a broad societal perspective and included health , crime and personal costs . Data on re source use and outcomes were a combination of clinical records and self report at interview . The main outcomes were incremental cost per additional day free of heroin use and per QALY . An analysis of uncertainty calculated the likelihood of net benefits for a range of acceptable money values of outcomes . All costs were in 1999 Australian dollars ( $ A ) . Results : The estimated mean number of heroin-free days did not differ significantly between those r and omised to methadone ( 225 [ 95 % CI 91 , 266 ] ) , or buprenorphine ( 222 [ 95 % CI 194 , 250 ] ) over the year of the trial . Buprenorphine was associated with an average 0.03 greater QALYs over 52 weeks ( not significant ) . The total cost was $ A17 736 ( 95 % CI −$A2981 , $ A38 364 ) with methadone and $ A11 916 ( 95 % CI $ A7697 , $ A16 135 ) with buprenorphine ; costs excluding crime were $ A4513 ( 95 % CI $ A3495 , $ A5531 ) and $ A5651 ( 95 % CI $ A4202 , $ A7100 ) . With additional heroin-free days as the outcome , and crime costs included buprenorphine has a lower cost but less heroin-free days . If crime costs are excluded buprenorphine has a higher cost and worse outcome than methadone . With additional QALYs as the outcome , the cost effectiveness of buprenorphine is $ A39 404 if crime is excluded , but buprenorphine is dominant if crime is included . Conclusions : The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance in this particular setting . Although some of the results suggest that methadone may have a cost advantage , it is difficult to infer from the trial data that offering buprenorphine as an alternative would have a significant effect on total costs or outcomes . The point estimates of costs and outcomes suggest that buprenorphine may have an advantage in those initiating therapy . The confidence intervals were wide , however , and the likelihood of net benefits from substituting one treatment for another was close to 50 % IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse , based in part on evidence of efficacy for unhealthy alcohol use . However , it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy . OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use ( any illicit drug use or prescription drug misuse)-a brief negotiated interview ( BNI ) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention . DESIGN , SETTING , AND PARTICIPANTS This 3-group r and omized trial took place at an urban hospital-based primary care internal medicine practice ; 528 adult primary care patients with drug use ( Alcohol , Smoking , and Substance Involvement Screening Test [ ASSIST ] substance-specific scores of ≥4 ) were identified by screening between June 2009 and January 2012 in Boston , Massachusetts . INTERVENTIONS Two interventions were tested : the BNI is a 10- to 15-minute structured interview conducted by health educators ; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master's-level counselors . All study participants received a written list of substance use disorder treatment and mutual help re sources . MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a vali date d calendar method at 6 months . Secondary outcomes included other self-reported measures of drug use , drug use according to hair testing , ASSIST scores ( severity ) , drug use consequences , unsafe sex , mutual help meeting attendance , and health care utilization . RESULTS At baseline , 63 % of participants reported their main drug was marijuana , 19 % cocaine , and 17 % opioids . At 6 months , 98 % completed follow-up . Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group ( incidence rate ratio [ IRR ] , 0.97 ; 95 % CI , 0.77 - 1.22 ) and 12 for the MOTIV group ( IRR , 1.05 ; 95 % CI , 0.84 - 1.32 ; P = .81 for both comparisons vs no brief intervention ) . There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity . CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening . These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00876941
target: Overall , the cohort Markov models remain the most popular approach , followed by decision trees , Individual based model and System dynamics model ( SD ) .
  Conclusions This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions
background: Background The overarching goal of health policies is to maximize health and societal benefits .
  Economic evaluations can play a vital role in assessing whether or not such benefits occur .
  This paper review s the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to ( i ) modelling paradigms themselves ; ( ii ) perspectives of costs and benefits and ( iii ) time frame .