cost-effectiveness of financial incentives for viral suppression · 2017-04-24 · financial...
TRANSCRIPT
Cost-Effectiveness of
Financial Incentives
for Viral Suppression
An Economic Model of HPTN 065
Blythe Adamson, MPH, PhD Candidate
University of Washington
Seattle, WA, USA
April 11, 2017
HPTN 065 aimed to assess the feasibility of
the “test and treat” model to decrease HIV
transmission at the community level.
To realize the benefits of anti-retroviral
therapy (ART), financial incentives promoted
linkage to care and viral suppression.
Background
TEST & TREAT FRAMEWORK
Population
DECREASE IN HIV TRANSMISSION
L2C Care site
TREAT
Counsel
TEST
Test site
Adherence & Suppression
VS
THERESA GAMBLE
TEST & TREAT FRAMEWORK
Population
DECREASE IN HIV TRANSMISSION
L2C Care site
TREAT
Counsel
TEST
Test site
Adherence & Suppression
VS
This analysis focuses on the value of
financial incentives (FI)
for viral suppression (VS)
THERESA GAMBLE
39 Clinics
The Bronx, New York Washington, D.C.
THERESA GAMBLE
39 Clinics Randomized
The Bronx, New York Washington, D.C.
To deliver standard HIV care OR care plus incentive for VS
THERESA GAMBLE
You
are
here
• $70 VISA gift cards
• Offered quarterly to patients on ART with viral suppression (VS <400 copies/ml)
• Duration: 2011-2013
• Supported startup costs, Financial Incentives Coordinator, and supplies at each site
Intervention
To evaluate the cost-effectiveness of
providing financial incentives for viral
suppression compared to standard HIV care
for patients using ART to inform public health
decisions in the United States.
Objective
valueassess
Conceptual Model of
Cost-Effectiveness
CHANGE IN HEALTH CARE COSTS ($)
CHANGE IN HEALTH STATUS (QALYs)
Incremental Cost-
Effectiveness Ratio
(ICER)
Based on “Cost-Effectiveness of Antiretroviral Therapy for Prevention” by Kahn et al., 2011
Conceptual Model of
Cost-Effectiveness
CHANGE IN HEALTH CARE COSTS ($)
CHANGE IN HEALTH STATUS (QALYs)
Incremental Cost-
Effectiveness Ratio
(ICER)
Increased
utilization
of services
Averted HIV
Infections
Based on “Cost-Effectiveness of Antiretroviral Therapy for Prevention” by Kahn et al., 2011
Effect of
intervention
Correlation with
healthcare costs
Program Costs
- Admin
- Gift cards
HPTN 065 / modeling
Published data / modeling
+ + -
More
ART use
Averted
Morbidity
+ -
Conceptual Model of
Cost-Effectiveness
CHANGE IN HEALTH CARE COSTS ($)
CHANGE IN HEALTH STATUS (QALYs)
Incremental Cost-
Effectiveness Ratio
(ICER)
More viral suppression
Increased
utilization
of services
Averted HIV
Infections
Averted HIV
Infections
Averted
Morbidity
More
ART use
Based on “Cost-Effectiveness of Antiretroviral Therapy for Prevention” by Kahn et al., 2011
Correlation
with health
Effect of
intervention
Effect of
intervention
Correlation with
healthcare costs
Program Costs
- Admin
- Gift cards
Longer
Survival
HPTN 065 / modeling
Published data / modeling
Averted
Morbidity
+ + + - -
+ ++
Measuring Health Benefits
Quality-Adjusted
Life Years (QALYs)
Health-related quality of life:
utility of health state between
1 (perfect health) and 0 (death)
birth death
1.0
0
Uti
lity
QALYs
HIV+QALYs gained
with intervention
age
QALYs = sum(life year * utility)
To capture the length and
quality of life for patients and
partners
Costs included:
• FI admin & gift cards
• Patient HIV-related healthcare costs– ART drugs
– Clinic visits
– Labs
• Other HIV-unrelated healthcare
• Partner health care costs
• Productivity: earnings
• Consumption: spending
Perspective
PAYER
Costs included:
• FI admin & gift cards
• Patient HIV-related healthcare costs– ART drugs
– Clinic visits
– Labs
• Other HIV-unrelated healthcare
• Partner health care costs
• Productivity: earnings
• Consumption: spending
Perspective
HEALTHCAR
E SECTOR
PAYER
Costs included:
• FI admin & gift cards
• Patient HIV-related healthcare costs– ART drugs
– Clinic visits
– Labs
• Other HIV-unrelated healthcare
• Partner health care costs
• Productivity: earnings
• Consumption: spending SOCIETAL
Perspective
HEALTHCAR
E SECTOR
PAYER
• Cohort-based semi-Markov model of HIV disease progression and primary transmission to sexual partners– Assumes financial incentive
effect diminishes to zero over 6 months after FI end
• Cost-effectiveness analysis: – Patient lifetime horizon
– 3% annual discount rate
Modeling
Approach
PATIENT COHORT
PARTNER COHORT
0% 20% 40% 60% 80%
VS
No
VS
Proportion of patients
<200
200-349
350-499
>500
CD4+ Count
Death
Healthy
<200200
-349
350
-499>500
dead
Program characteristics
and key model inputs Median (Range) Source
Average clinic size, number of patients in care 456 (43 – 2,262) HPTN 065
Baseline proportion of patients virally suppressed 61.9% (8.4 - 84.6%) HPTN 065
Effectiveness: change in viral suppression Average percentage points increase from baseline clinic proportion
3.7% (0.5 – 6.9%) HPTN 065
Increase in outpatient visits due to incentives, % 8.7% (4.2 - 13.2%) HPTN 065
HIV Utility, by CD4 strata 0.69 - 0.73 (0.58 - 0.83) Whitham 2016
Quarterly healthcare costs related to HIV, by CD4 strata Disaggregated by ART, outpatient visits and labs, and other costs [e.g.,
treatment of opportunistic infections]
$4,902 - $7,675
($4,736 – $8,348)Gebo 2010
Program characteristics
and key model inputs Median (Range) Source
Average clinic size, number of patients in care 456 (43 – 2,262) HPTN 065
Baseline proportion of patients virally suppressed 61.9% (8.4 - 84.6%) HPTN 065
Effectiveness: change in viral suppression Average percentage points increase from baseline clinic proportion
3.7% (0.5 – 6.9%) HPTN 065
Increase in clinic attendance, % 8.7% (4.2 - 13.2%) HPTN 065
HIV Utility, by CD4 strata 0.69 - 0.73 (0.58 - 0.83) Whitham 2016
Quarterly healthcare costs related to HIV, by CD4 strata Disaggregated by ART, outpatient visits and labs, and other costs [e.g.,
treatment of opportunistic infections]
$4,902 - $7,675
($4,736 – $8,348)Gebo 2010
Program characteristics
and key model inputs Median (Range) Source
Average clinic size, number of patients in care 456 (43 – 2,262) HPTN 065
Baseline proportion of patients virally suppressed 61.9% (8.4 - 84.6%) HPTN 065
Effectiveness: change in viral suppression Average percentage points increase from baseline clinic proportion
3.7% (0.5 – 6.9%) HPTN 065
Increase in clinic attendance, % 8.7% (4.2 - 13.2%) HPTN 065
HIV Utility, by CD4 strata 0.69 - 0.73 (0.58 - 0.83) Whitham 2016
Quarterly healthcare costs related to HIV, by CD4 strata Disaggregated by ART, outpatient visits and labs, and other costs [e.g.,
treatment of opportunistic infections]
$4,902 - $7,675
($4,736 – $8,348)Gebo 2010
Compared to standard care, for the FI program cohort the model projects:
• Participants on average survive 1 month longer
• Gain of 0.05 QALYs per patient
• 1 HIV infection avoided per 200 FI participants (9% reduction in primary HIV transmission)
RESULTS:
Health
Outcomes
Modeled
RESULTS: Projected lifetime
costs per patient
$0
$50,000
$100,000
$150,000
$200,000
$250,000
Life
tim
e C
ost*
per
Pa
tie
nt
*Limited societal perspective costs using lifetime horizon, discounted 3% annually, and adjusted to 2015 US$
CO
NT
RO
L
INT
ER
VE
NT
ION
Raised cost
Lowered cost
Effect of Intervention on
Lifetime Societal Cost
Total cost
$205,000
$210,000
$215,000
$220,000
Life
tim
e C
ost*
per
Pa
tie
nt
*Limited societal perspective costs using lifetime horizon, discounted 3% annually, and adjusted to 2015 US$
$706
CO
NT
RO
L
INT
ER
-
VE
NT
ION
Raised cost
Lowered cost
Effect of Intervention on
Lifetime Societal Cost
Total cost
$0
RESULTS: Projected lifetime
costs per patient
Cost-Effectiveness
QALYs Gained
Incre
men
tal C
ost
“DOMINANT”:COST SAVING &
GAINS HEALTH
?
3xGDP
1
Willingness to Pay
Cost-effectiveness threshold of
$50,000 - $150,000 per QALY
gained (1-3 x GDP per capita)1xGDP
Cost-Effectiveness
QALYs Gained
Incre
men
tal C
ost
“DOMINANT”:COST SAVING &
GAINS HEALTH
$4,600
Willingness to Pay
Cost-effectiveness threshold of
$50,000 - $150,000 per QALY
gained (1-3 x GDP per capita)
payer
Results reported per participant
$113,900/QALY
ICER, given perspective
HOW TO INTERPRET AN ICER: The incremental cost per
QALY gained from offering financial incentives for viral
suppression as compared to standard HIV care
0.4
Cost-Effectiveness
QALYs Gained
Incre
men
tal C
ost
“DOMINANT”:COST SAVING &
GAINS HEALTH
$4,600
0.5
Willingness to Pay
Cost-effectiveness threshold of
$50,000 - $150,000 per QALY
gained (1-3 x GDP per capita)
payer
health
sector
Results reported per participant
$51,600/QALY
$113,900/QALY
ICER, given perspective
$2,800
Includes
partner
benefit
HOW TO INTERPRET AN ICER: The incremental cost per
QALY gained from offering financial incentives for viral
suppression as compared to standard HIV care
0.4
Cost-Effectiveness
QALYs Gained
Incre
men
tal C
ost
“DOMINANT”:COST SAVING &
GAINS HEALTH
$4,600
0.5
Willingness to Pay
Cost-effectiveness threshold of
$50,000 - $150,000 per QALY
gained (1-3 x GDP per capita)
payer
health
sector
societal
Results reported per participant
Dominant
$51,600/QALY
$113,900/QALY
ICER, given perspective
-$3,500
Includes
partner
benefit
HOW TO INTERPRET AN ICER: The incremental cost per
QALY gained from offering financial incentives for viral
suppression as compared to standard HIV care
0.4
$2,800
• League tables
compare the value
of different
interventions
• Lower ICERs
correspond to
greater value
• Cost-effectiveness
depends on
willingness to pay
for health gains
Comparative Health
Interventions in US
ICER
(Cost/QALY)Source
Financial Incentives for
Viral Suppression
Lower cost &
Health gainsAnalyzed Here
HPV Vaccine$4,000 -
$14,000*Chesson 2008
Statins for Coronary
Heart Disease$22,000 Franco 2005
PrEP in US high risk$120,000 -
$600,000*
Gomez 2013, Paltiel
2009, Juusola 2012,
Desai 2008, and
Koppenhaver 2011
*2005 US$, **2012 US$,
Sensitivity Analysis
-$100,000 $ $100,000 $200,000 $300,000
base-case
ICER
Parameter Range
Low High
ICER, Cost per QALY gained
Effectiveness improving VS
Hazard non-AIDS death <500 CD5
Utilization increase among FI
Avg. rate of disease progression
Incentives not
good investment
in lower range of
VS effectiveness
confidence
0
Cost-Effective
3.7
%
0.5
%
6.9
%
• Financial incentives as used in HPTN 065 are likely to be cost-effective compared to standard HIV care in the US
• Limited by uncertainty in effectiveness
• Implications for global health
• NYC Housing Works Undetectables now provide financial incentives for viral suppression
Summary
The HIV Prevention Trials Network is sponsored by the
National Institute of Allergy and Infectious Diseases,
the National Institute of Mental Health, and the National
Institute on Drug Abuse, all components of the
U.S. National Institutes of Health.
ACKNOWLEDGEMENTS
The HPTN 065 Study team acknowledges
Dobromir Dimitrov, Fred Hutchinson Cancer Research Center
The HPTN Modeling Center
Louis Garrison, University of Washington
Josh Carlson, University of Washington
Ruanne Barnabas, University of Washington
Supplementary Material
Improved viral
suppression
Patient QALYs
Increased
utilization
of services
STEP 5 LONG-TERM
OUTCOMES
TOTAL COSTS
Financial
Incentives
Program Costs
Improved
adherence
Engagement
in HIV care
Coordinator
Supplies
Gift cardsHealthcare Costs
Life
Years
Quality
of Life
Fewer HIV
Transmissions
to Partners
Partner QALYs
Life
Years
Quality
of Life
More
ART Refills
STEP 1INTERVENTION
STEP 2 INTENTION
STEP 3 BEHAVIOR
STEP 4 SHORT-TERM
OUTCOMES
TO
TA
L Q
ALY
s
CONCEPTUAL FRAMEWORK
FOR COSTS & BENEFITS
Cost of Clinic
Visits and LabsDrug Costs
HPTN 065 / modeling
Published literature / modeling
Results from other perspectives
Disease Progression and
Predicted Survival
Modeling Outcomes
Probabilistic Sensitivity Analysis