51. Health outcomes and cost-effectiveness of diversion programs for low-level drug offenders: A model-based analysis
- Author
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Isabelle J. Rao, Margaret L. Brandeau, Cora L Bernard, and Konner K Robison
- Subjects
RNA viruses ,Male ,Cost effectiveness ,Epidemiology ,Cost-Benefit Analysis ,Psychological intervention ,Social Sciences ,HIV Infections ,Hepacivirus ,030204 cardiovascular system & hematology ,Pathology and Laboratory Medicine ,Men who have sex with men ,Drug Users ,0302 clinical medicine ,Immunodeficiency Viruses ,Health care ,Outcome Assessment, Health Care ,Medicine and Health Sciences ,030212 general & internal medicine ,Substance Abuse, Intravenous ,health care economics and organizations ,education.field_of_study ,Hepatitis C virus ,Pharmaceutics ,General Medicine ,Health Care Costs ,Middle Aged ,Hepatitis C ,Substance abuse ,Government Programs ,Medical Microbiology ,HIV epidemiology ,Viral Pathogens ,Viruses ,Medicine ,Infectious diseases ,Pathogens ,Research Article ,Diversion program ,Medical conditions ,Adult ,Washington ,medicine.medical_specialty ,Substance-Related Disorders ,Population ,Viral diseases ,Microbiology ,03 medical and health sciences ,Drug Therapy ,Environmental health ,Retroviruses ,medicine ,Humans ,education ,Microbial Pathogens ,Flaviviruses ,business.industry ,Public health ,Lentivirus ,Organisms ,Biology and Life Sciences ,HIV ,Criminals ,Models, Theoretical ,medicine.disease ,Hepatitis viruses ,Medical Risk Factors ,Prisons ,Quality of Life ,Law and Legal Sciences ,business ,Criminal Justice System - Abstract
Background Cycles of incarceration, drug abuse, and poverty undermine ongoing public health efforts to reduce overdose deaths and the spread of infectious disease in vulnerable populations. Jail diversion programs aim to divert low-level drug offenders toward community care resources, avoiding criminal justice costs and disruptions in treatment for HIV, hepatitis C virus (HCV), and drug abuse. We sought to assess the health benefits and cost-effectiveness of a jail diversion program for low-level drug offenders. Methods and findings We developed a microsimulation model, calibrated to King County, Washington, that captured the spread of HIV and HCV infections and incarceration and treatment systems as well as preexisting interventions such as needle and syringe programs and opiate agonist therapy. We considered an adult population of people who inject drugs (PWID), people who use drugs but do not inject (PWUD), men who have sex with men, and lower-risk heterosexuals. We projected discounted lifetime costs and quality-adjusted life years (QALYs) over a 10-year time horizon with and without a jail diversion program and calculated resulting incremental cost-effectiveness ratios (ICERs) from the health system and societal perspectives. We also tracked HIV and HCV infections, overdose deaths, and jail population size. Over 10 years, the program was estimated to reduce HIV and HCV incidence by 3.4% (95% CI 2.7%–4.0%) and 3.3% (95% CI 3.1%–3.4%), respectively, overdose deaths among PWID by 10.0% (95% CI 9.8%–10.8%), and jail population size by 6.3% (95% CI 5.9%–6.7%). When considering healthcare costs only, the program cost $25,500/QALY gained (95% CI $12,600–$48,600). Including savings from reduced incarceration (societal perspective) improved the ICER to $6,200/QALY gained (95% CI, cost-saving $24,300). Sensitivity analysis indicated that cost-effectiveness depends on diversion program participants accessing community programs such as needle and syringe programs, treatment for substance use disorder, and HIV and HCV treatment, as well as diversion program cost. A limitation of the analysis is data availability, as fewer data are available for diversion programs than for more established interventions aimed at people with substance use disorder. Additionally, like any model of a complex system, our model relies on simplifying assumptions: For example, we simplified pathways in the healthcare and criminal justice systems, modeled an average efficacy for substance use disorder treatment, and did not include costs associated with homelessness, unemployment, and breakdown in family structure. Conclusions We found that diversion programs for low-level drug offenders are likely to be cost-effective, generating savings in the criminal justice system while only moderately increasing healthcare costs. Such programs can reduce incarceration and its associated costs, and also avert overdose deaths and improve quality of life for PWID, PWUD, and the broader population (through reduced HIV and HCV transmission)., Cora Bernard and co-workers investigate the health and societal value of diversion programs for people who misuse drugs., Author summary Why was this study done? Strategies for people with substance use disorder based on criminalization and aggressive law enforcement have created barriers to harm reduction while having little or no impact on the number of people who use drugs. Diversion programs redirect individuals with low-level drug and prostitution offenses away from the criminal justice system and into community-based services such as treatment for substance use disorder, housing, and mental health care. Our model-based analysis was designed to assess the health benefits and cost-effectiveness of a jail diversion program for low-level drug offenders. What did the researchers do and find? We developed a stochastic microsimulation model of adults in King County, Washington that captures sexual and injecting-based risk behaviors and partnerships and tracks the 10-year trajectories of people who inject drugs, people who use drugs but do not inject, and the lower-risk general population, with and without a diversion program. We projected HIV and hepatitis C virus (HCV) incidence, fatal overdoses, jail population size, and lifetime costs and quality-adjusted life years (QALYs) experienced in the population, with and without a diversion program. We estimated that the diversion program would reduce cumulative HIV and HCV incidence, fatal overdoses, and the jailed population, would lead to gains in QALYs, and would be highly cost-effective. What do these findings mean? A 2016 United Nations AIDS Programme (UNAIDS) report found that the status quo of criminalizing drug abuse is failing from the public safety and public health perspectives. Our study demonstrates that these perspectives can be aligned. Our analysis suggests that diversion programs are likely to substantially reduce spending in the criminal justice system while moderately increasing spending in the healthcare sector and are likely to be highly cost-effective. The spread of infectious disease stemming from drug injection and the global overcrowding of jails and prisons suggest that, more than ever, effective, cost-effective, and innovative approaches are required to address these crises. Diversion programs are one such program.
- Published
- 2020