title: Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada.
abstract: OBJECTIVE
  Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods.
  
  
  METHODS
  Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment.
  
  
  METHODS
  Toronto and Ottawa, Canada.
  
  
  METHODS
  Simulated population of each city.
  
  
  METHODS
  Zero to five supervised injection facilities.
  
  
  METHODS
  Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios.
  
  
  RESULTS
  In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million.
  
  
  CONCLUSIONS
  Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.
authors.affiliation: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
authors.forename: Eva A
authors.identifier: http://orcid.org/0000-0003-0693-7358
authors.initials: EA
authors.lastname: Enns
authors.affiliation: Ivey Business School, Western University, London, ON, Canada.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Zaric
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.|Center for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada.
authors.forename: Carol J
authors.initials: CJ
authors.lastname: Strike
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Jairam
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
authors.forename: Gillian
authors.initials: G
authors.lastname: Kolla
authors.affiliation: Centre for Research on Inner City Health, Li KaShing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.|Department of Medicine, University of Toronto, Toronto, ON, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.|Division of General Internal Medicine, St Michael's Hospital, Toronto, ON, Canada.
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Bayoumi
mesh_terms: D000293:Adolescent; D000328:Adult; D002170:Canada; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000191:economics* / Q000517:prevention & control / Q000628:therapy; D017048:Health Care Costs; D006526:Hepatitis C / Q000191:economics* / Q000517:prevention & control / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D016485:Needle Sharing; D018671:Needle-Exchange Programs / Q000191:economics*; D009864:Ontario; D019057:Quality-Adjusted Life Years; D015819:Substance Abuse, Intravenous / Q000534:rehabilitation*; D055815:Young Adult
keywords: HCV; HIV/AIDS; Harm reduction; injection drug use; mathematical modeling; supervised injection facility