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Article Abstract

Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 12, Issue 1, 2009. Pages: 33-46
Published Online:30 March 2009

Copyright © 2009 ICMPE.


 

Cost-effectiveness Analysis of Integrated Care for People with HIV, Chronic Mental Illness and Substance Abuse Disorders

Marcia R. Weaver,1 Christopher J. Conover,2 Rae Jean Proescholdbell,3 Peter S. Arno,4 Alfonso Ang,Karina K. Uldall,6 Susan L. Ettner7

1PhD, Research Associate Professor, Department of Health Services and International Training and Education Center on Health, University of Washington, Seattle, WA, USA
2PhD, Research Scholar, Center for Health Policy, Durham, NC, USA
3PhD, Research Scholar, Center for Health Policy and Global Health Institute, Durham, NC, USA
4PhD, Professor, Department of Health Policy and Management, New York Medical College, New York, NY, USA
5PhD, Principal Statistician, Department of Family Medicine, University of California, Los Angeles, CA, USA.
6MD, MPH, Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
7PhD, Professor, Departments of Medicine and Health Services, University of California, Los Angeles, CA, USA

* Correspondence to: Marcia R. Weaver, PhD; 901 Boren, Suite 1100; Seattle, WA98104, USA
Tel.: +1-206-616 9173
Fax: +1-206-221 4945
E-mail: mweaver@u.washington.edu 

Source of Funding: This work was supported by a cooperative agreement for the ``HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study'' (HIV Cost Study), a collaboration of six Federal entities within the U.S. Department of Health and Human Services (DHHS): The Center for Mental health Services (CMHS), which had the lead administrative responsibility, and the Center for Substance Abuse Treatment (CSAT), both components of the Substance Abuse and Mental Health Services Administration (SAMHSA); the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA); the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), all parts of the National Institutes of Health (NIH).

Abstract

The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study evaluated the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services for triply diagnosed patients from a health-sector budget perspective. Patients from four sites were randomly assigned to intervention (n=232) or control group (n=199).  Cost (2002 dollars) of a comprehensive list of health services was measured at baseline and three, six, nine and 12 months.  Quality of life was measured at baseline and six and 12 months using the SF-6D. During the 12-month trial, total average monthly cost of health services for the intervention group decreased from $3235 to $3052 and for the control group decreased from $3556 to $3271, but the decreases were not significant.  For both groups, the percentage attributable to hospital care decreased significantly.  There were no significant differences in total annual cost of health services or quality of life between groups.

 

Background: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers.

Aims of the Study: The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective.

Methods: Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS).

Results: During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from $3235 to $3052 and for the control group decreased from $3556 to $3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group.

Implications for Health Care Provision and Use: The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study.

Implications for Health Policies: There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing.

Implications for Further Research: Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.


Received 6 June 2008; accepted 24 November 2008

Copyright 2009 ICMPE