title: The costs of HIV antiretroviral therapy adherence programs and impact on health care utilization.
abstract: From a trial comparing interventions to improve adherence to antiretroviral therapy-directly administered antiretroviral therapy (DAART) or an intensive adherence case management (IACM)-to standard of care (SOC), for HIV-infected participants at public HIV clinics in Los Angeles County, California, we examined the cost of adherence programs and associated health care utilization. We assessed differences between DAART, IACM, and SOC in the rate of hospitalizations, hospital days, and outpatient and emergency department visits during an average of 1.7 years from study enrollment, beginning November 2001. We assigned costs to health care utilization and program delivery. We calculated incremental costs of DAART or IACM v SOC, and compared those costs with savings in health care utilization among participants in the adherence programs. IACM participants experienced fewer hospital days compared with SOC (2.3 versus 6.7 days/1000 person-days, incidence rate ratio [IRR]: 0.34, 97.5% confidence interval [CI]: 0.13-0.87). DAART participants had more outpatient visits than SOC (44.2 versus 31.5/1000 person-days, IRR: 1.4; 97.5% CI: 1.01-1.95). Average per-participant health care utilization costs were $13,127, $8,988, and $14,416 for DAART, IACM, and SOC, respectively. Incremental 6-month program costs were $2,120 and $1,653 for DAART and IACM participants, respectively. Subtracting savings in health care utilization from program costs resulted in an average net program cost of $831 per DAART participant; and savings of $3,775 per IACM participant. IACM was associated with a significant decrease in hospital days compared to SOC and was cost saving when program costs were compared to savings in health care utilization.
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. ssansom@cdc.gov
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Sansom
authors.forename: Monique N
authors.initials: MN
authors.lastname: Anthony
authors.forename: Wendy H
authors.initials: WH
authors.lastname: Garland
authors.forename: Kathleen E
authors.initials: KE
authors.lastname: Squires
authors.forename: Mallory D
authors.initials: MD
authors.lastname: Witt
authors.forename: A
authors.initials: A
authors.lastname: Kovacs Andrea
authors.forename: Robert A
authors.initials: RA
authors.lastname: Larsen
authors.forename: Rosa
authors.initials: R
authors.lastname: Valencia
authors.forename: Sherri L
authors.initials: SL
authors.lastname: Pals
authors.forename: Shannon
authors.initials: S
authors.lastname: Hader
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Weidle
authors.forename: Amy R
authors.initials: AR
authors.lastname: Wohl
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy / Q000191:economics; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics* / Q000379:methods; D002140:California; D019090:Case Management / Q000191:economics; D016001:Confidence Intervals; D017046:Cost Savings; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D023801:Directly Observed Therapy / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics; D017048:Health Care Costs; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data*; D018570:Risk Assessment; D014481:United States; D014492:United States Public Health Service / Q000191:economics / Q000706:statistics & numerical data; D014505:Urban Population