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The American Journal of Managed Care November 2018
The American Journal of Managed Care November 2018
CLINICAL
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
COMMENTARY
Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
From The Editorial Board
Glen D. Stettin, MD
LETTERS TO THE EDITORS
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
METHODS
Currently Reading
Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
TRENDS FROM THE FIELD
Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
WEB EXCLUSIVE
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD
Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
The mean 24-week cost per participant was $5416 for extended-release injectable naltrexone (57% detoxification, 37% medication, 6% provider/patient) and $4148 for buprenorphine-naloxone (64% detoxification, 12% medication, 24% provider/patient).
ABSTRACT
Objectives: To estimate the costs of providing extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) following inpatient detoxification using data derived from a multisite randomized controlled trial at 8 US community-based treatment programs.
Study Design: Cost data were collected for 3 intervention phases: program start-up, inpatient detoxification, and up to 24 weeks of medication induction and management visits (post detoxification). Cost analyses were from the healthcare sector perspective (2015 US$); patient costs are also reported.
Methods: We conducted site visits, administered a cost survey to treatment programs, and analyzed study data on medication and services utilization. Nationally representative sources were used to estimate unit costs. Uncertainty was evaluated in sensitivity analyses.
Results: Mean start-up costs were $1071 per program for XR-NTX and $828 per program for BUP-NX. Mean costs per participant were $5416 for XR-NTX (57% detoxification, 37% medication, 3% provider, 3% patient) and $4148 for BUP-NX (64% detoxification, 12% medication, 10% provider, 14% patient). Total cost per participant ranged by site from $2979 to $8963 for XR-NTX and from $2521 to $6486 for BUP-NX.
Conclusions: For treatment providers, offering XR-NTX and/or BUP-NX as part of existing detoxification treatment modalities generates modest costs in addition to the costs of detoxification, which vary substantially among the 8 sites. From the patient’s perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.
Am J Manag Care. 2018;24(11):526-531Takeaway Points
Recent clinical trials have established similar effectiveness of these medications in preventing relapse up to 6 months among those who successfully initiate treatment post detoxification.6,7 Adoption of these medications by treatment providers is low, however, and reimbursement for these medications varies considerably among private and public payers.8 Other provider concerns, such as staff burden, increased practice costs, large patient caseloads, and long-term effectiveness, may also contribute to limited adoption.9
As new evidence regarding the effectiveness and cost-effectiveness of these treatments is established, providers, payers, and other stakeholders need to understand the resources and associated costs of implementation and ongoing provision of different treatment models. This information can help address and quantify some of the barriers to adoption by enumerating the types of resources required to successfully provide treatment, categories of expenditures (eg, training, staff time, special equipment), and total expected annual and per-patient costs.
This study describes the approach and results of a comprehensive multisite cost analysis of the first head-to-head randomized clinical trial in the United States of extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) for preventing opioid relapse (NCT02032433).7 Our objective was to provide rigorous estimates of the costs of introducing pharmacotherapy treatment at the programs, inpatient detoxification, and medication management (MM) visits over the 24-week intervention phase, highlighting the variation in these costs across sites.
STUDY DESIGN
The cost analysis was conducted alongside the NIDA Clinical Trials Network CTN-0051: Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT) trial, a multisite, 2-arm, open-label, randomized controlled trial that tested the effectiveness of XR-NTX versus BUP-NX with regard to patient survival, free of opioid relapse, at 24 weeks.10 Participants (n = 570) were recruited from 8 US community-based inpatient detoxification or short-term residential treatment programs and randomized 1:1 to XR-NTX (n = 283) or BUP-NX (n = 287). Participant-level data (eg, intervention medication dispensing/administration, opioid relapse) were collected at each study visit as part of the main X:BOT protocol, whereas economic data on the costs of providing inpatient detoxification, XR-NTX and BUP-NX medications, and MM, as well as the time and travel costs incurred by study participants, were collected from agency research and clinical staff at in-person site visits.
METHODS
Analytic Overview
We employed a microcosting approach from the healthcare sector and patient perspectives.11,12 The costs of research-related activities were excluded.12 Resource utilization and expenditures were categorized by 3 distinct X:BOT study phases: setup/preimplementation (eg, training and other preparations needed to offer the medications), inpatient/residential detoxification treatment, and the intervention phase following randomization to XR-NTX or BUP-NX (medication induction and up to 24 weeks of MM).
Across all sites, cost estimates per participant are reported as means for future economic evaluation purposes and as medians/interquartile ranges for programmatic comparison.12 Cost data were collected for fiscal years 2015 or 2016 and were adjusted using the consumer price index for all consumer goods and reported in 2015 US dollars.12,13 The Weill Cornell Medical College Institutional Review Board reviewed and approved study procedures. Cost data were analyzed in Microsoft Excel 2013 (Microsoft Corp; Redmond, Washington) and Stata 15.1 (Stata Corp; College Station, Texas).
Objectives: To estimate the costs of providing extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) following inpatient detoxification using data derived from a multisite randomized controlled trial at 8 US community-based treatment programs.
Study Design: Cost data were collected for 3 intervention phases: program start-up, inpatient detoxification, and up to 24 weeks of medication induction and management visits (post detoxification). Cost analyses were from the healthcare sector perspective (2015 US$); patient costs are also reported.
Methods: We conducted site visits, administered a cost survey to treatment programs, and analyzed study data on medication and services utilization. Nationally representative sources were used to estimate unit costs. Uncertainty was evaluated in sensitivity analyses.
Results: Mean start-up costs were $1071 per program for XR-NTX and $828 per program for BUP-NX. Mean costs per participant were $5416 for XR-NTX (57% detoxification, 37% medication, 3% provider, 3% patient) and $4148 for BUP-NX (64% detoxification, 12% medication, 10% provider, 14% patient). Total cost per participant ranged by site from $2979 to $8963 for XR-NTX and from $2521 to $6486 for BUP-NX.
Conclusions: For treatment providers, offering XR-NTX and/or BUP-NX as part of existing detoxification treatment modalities generates modest costs in addition to the costs of detoxification, which vary substantially among the 8 sites. From the patient’s perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.
Am J Manag Care. 2018;24(11):526-531Takeaway Points
- Offering extended-release injectable naltrexone and/or buprenorphine-naloxone as part of existing detoxification treatment generated modest costs beyond the cost of inpatient detoxification.
- From the patient’s perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.
Recent clinical trials have established similar effectiveness of these medications in preventing relapse up to 6 months among those who successfully initiate treatment post detoxification.6,7 Adoption of these medications by treatment providers is low, however, and reimbursement for these medications varies considerably among private and public payers.8 Other provider concerns, such as staff burden, increased practice costs, large patient caseloads, and long-term effectiveness, may also contribute to limited adoption.9
As new evidence regarding the effectiveness and cost-effectiveness of these treatments is established, providers, payers, and other stakeholders need to understand the resources and associated costs of implementation and ongoing provision of different treatment models. This information can help address and quantify some of the barriers to adoption by enumerating the types of resources required to successfully provide treatment, categories of expenditures (eg, training, staff time, special equipment), and total expected annual and per-patient costs.
This study describes the approach and results of a comprehensive multisite cost analysis of the first head-to-head randomized clinical trial in the United States of extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) for preventing opioid relapse (NCT02032433).7 Our objective was to provide rigorous estimates of the costs of introducing pharmacotherapy treatment at the programs, inpatient detoxification, and medication management (MM) visits over the 24-week intervention phase, highlighting the variation in these costs across sites.
STUDY DESIGN
The cost analysis was conducted alongside the NIDA Clinical Trials Network CTN-0051: Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT) trial, a multisite, 2-arm, open-label, randomized controlled trial that tested the effectiveness of XR-NTX versus BUP-NX with regard to patient survival, free of opioid relapse, at 24 weeks.10 Participants (n = 570) were recruited from 8 US community-based inpatient detoxification or short-term residential treatment programs and randomized 1:1 to XR-NTX (n = 283) or BUP-NX (n = 287). Participant-level data (eg, intervention medication dispensing/administration, opioid relapse) were collected at each study visit as part of the main X:BOT protocol, whereas economic data on the costs of providing inpatient detoxification, XR-NTX and BUP-NX medications, and MM, as well as the time and travel costs incurred by study participants, were collected from agency research and clinical staff at in-person site visits.
METHODS
Analytic Overview
We employed a microcosting approach from the healthcare sector and patient perspectives.11,12 The costs of research-related activities were excluded.12 Resource utilization and expenditures were categorized by 3 distinct X:BOT study phases: setup/preimplementation (eg, training and other preparations needed to offer the medications), inpatient/residential detoxification treatment, and the intervention phase following randomization to XR-NTX or BUP-NX (medication induction and up to 24 weeks of MM).
Across all sites, cost estimates per participant are reported as means for future economic evaluation purposes and as medians/interquartile ranges for programmatic comparison.12 Cost data were collected for fiscal years 2015 or 2016 and were adjusted using the consumer price index for all consumer goods and reported in 2015 US dollars.12,13 The Weill Cornell Medical College Institutional Review Board reviewed and approved study procedures. Cost data were analyzed in Microsoft Excel 2013 (Microsoft Corp; Redmond, Washington) and Stata 15.1 (Stata Corp; College Station, Texas).
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