The implementation & sustainment facilitation (ISF) strategy: Cost and cost-effectiveness results from a 39-site cluster randomized trial integrating substance use services in community-based HIV service organizations

Abstract

Background: As part of the Substance Abuse Treatment to HIV Care Project, the Implementation & Sustainment Facilitation (ISF) strategy was found to be an effective adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for substance use disorders. This study presents the cost and cost-effectiveness results. Methods: Thirty-nine HIV service organizations were randomized to receive the ATTC-only condition or the ATTC + ISF condition. Two staff from each organization received the ATTC-training. In ATTC + ISF organizations, the same two staff and additional support staff participated in facilitation sessions to support MIBI implementation. We estimated costs using primary data on the time spent in each strategy and the time spent delivering 409 MIBIs to clients. We estimated staff-level cost-effectiveness for the number of MIBIs delivered, average MIBI quality scores, and total client days abstinent per staff. We used sensitivity analyses to test how changes to key variables affect the results. Results: Adjusted per-staff costs were $2,915 for the ATTC strategy and $5,371 for ATTC + ISF, resulting in an incremental cost of $2,457. ATTC + ISF significantly increased the number of MIBIs delivered (3.73) and the average MIBI quality score (61.45), yielding incremental cost effectiveness ratios (ICERs) of $659 and $40. Client days abstinent increased by 59 days per staff with a quality-adjusted life-year ICER of $40,578 (95% confidence interval $29,795–$61,031). Conclusions: From the perspective of federal policymakers, ISF as an adjunct to the ATTC strategy may be cost-effective for improving the integration of MIBIs within HIV service organizations, especially if scaled up to reach more clients. Travel accounted for nearly half of costs, and virtual implementation may further increase value. We also highlight two considerations for cost-effectiveness analysis with hybrid trials: study protocols kept recruitment low and modeling choices affect how we interpret the effects on client-level outcomes.

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial

“…The consistency and quality of implementation (i.e., implementation effectiveness) is believed to be the greatest when it is expected, supported, and rewarded [17][18][19]. Building upon our prior research [13,40,41,52], the current study ndings support the effectiveness of using P4P to improve implementation of a MIBI for SUD within HIV service settings. An examination of cost-effectiveness is needed, as is an examination of how effective and cost-effective P4P may be for improving the implementation of other clinical innovations that are both evidence-based and underutilized in real-world practice settings.…”

“…1, the aims of this 26-site cluster-randomized type 3 hybrid trial included testing the effectiveness of P4P for improving implementation outcomes as well as client outcomes. We hypothesized that relative to MIBI staff trained and supported using the TFC + ISF strategy (control condition), which had been the most effective and costeffective strategy in the prior trial [13,52], that MIBI staff trained, supported, and rewarded using the TFC + ISF + P4P strategy (experimental condition) would achieve signi cantly greater: (a) MIBI implementation consistency, (b) MIBI implementation quality, (c) MIBI implementation effectiveness (i.e., the consistency and quality of implementation), and client participants in the experimental condition would achieve signi cantly greater (d) reductions in days of primary substance use, and (e) reductions in anxiety symptom severity.…”

Organize and mobilize for implementation effectiveness to improve overdose education and naloxone distribution from syringe services programs: a randomized controlled trial

“…These findings are particularly important as prior studies have directly linked higher levels of these two outcomes with reductions in opioid overdose mortality at the population level [ 17 , 47 , 48 ]. The multifaceted OMIE approach was modelled after the evidence-based ISF strategy [ 44 , 51 ], and our findings contribute to the growing evidence base that supports facilitation-based implementation strategies [ 28 – 39 ]. These findings are particularly encouraging given SSPs typically face substantial external barriers such as lack of adequate funding, fluctuating costs of naloxone, unsupportive legal environments, and community opposition or harassment which can restrict services [ 23 ].…”

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a parallel cluster-randomized type 3 hybrid trial

“…1, the aims of this parallel 26-site cluster-randomized type 3 hybrid trial included testing the effectiveness of P4P for improving implementation outcomes as well as client outcomes. We hypothesized that relative to MIBI staff trained and supported using the TFC + ISF strategy (control condition), which had been the most effective and cost-effective strategy in the prior trial [13,41], that MIBI staff trained, supported, and rewarded using the TFC + ISF + P4P strategy (experimental condition) would achieve signi cantly greater: (a) MIBI implementation consistency, (b) MIBI implementation quality, (c) MIBI implementation effectiveness (i.e., the consistency and quality of implementation), and client participants in the experimental condition would achieve signi cantly greater (d) reductions in days of primary substance use, and (e) reductions in anxiety symptom severity.…”