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Abstract

Background

Health economic evaluation findings assist stakeholders in improving the quality, availability, scalability, and sustainability of evidence-based services, and in maximizing the efficiency of service delivery. The Center for Health Economics of Treatment Interventions for Substance Use Disorders, HCV, and HIV (CHERISH) is a NIDA-funded multi-institutional center of excellence whose mission is to develop and disseminate health-economic research on healthcare utilization, health outcomes, and health-related behaviors that informs substance use disorder treatment policy, and HCV and HIV care of people who use substances.

Methods

We designed a consultation service that is free to researchers whose work aligns with CHERISH's mission. The service includes up to six hours of consulting time. After prospective consultees submit their request online, they receive a screening call from the consultation service director, who connects them with a consultant with relevant expertise. Consultees and consultants complete web-based evaluations following the consultation; consultees also complete a six-month follow-up. We report on the status of the service from its inception in July 2015 through June 2017.

Results

We have received 28 consultation requests (54% Early Stage Investigators, 57% MD or equivalent, 28% PhD, 61% women) on projects typically related to planning a study or grant application (93%); 71% were HIV/AIDS-related. Leading topics included cost-effectiveness (43%), statistical-analysis/econometrics (36%), cost (32%), cost-benefit (21%), and quality-of-life (18%). All consultees were satisfied with their overall experience, and felt that consultation expectations and objectives were clearly defined and the consultant's expertise was matched appropriately with their needs. Results were similar for consultants, who spent a median of 3 hours on consultations.

Conclusions

There is a need for health-economic methodological guidance among substance use, HCV, and HIV researchers. Lessons learned pertain to the feasibility of service provision, the need to implement systems to measure and improve service value, and strategies for service promotion.

Keywords

Economic evaluation HCV health economics health services research HIV opioid use disorder substance use disorders

Introduction

Approximately 21 million US individuals suffer from a substance use disorder, and 600,000 die prematurely each year as a result of their substance use.1^,2 More than 25% of drug overdose deaths worldwide occur in the U.S., where overdose death rates have more than tripled since 1999 and have risen at record levels since 2015.3^,4 Moreover, rates of HIV and viral hepatitis are substantially higher among illicit drug users than in the general population.5^,6 In recent estimates, substance use disorders including tobacco, alcohol, and illicit drugs cost the U.S. more than $740 billion annually ($831 billion in 2017 U.S. dollars) when taking into account healthcare costs, criminal justice resource utilization, and other markers of productivity.7

Reducing the burden of substance use disorder on individuals and society requires increased access to evidence-based treatments and prevention measures.8 Because resources are constrained, both effectiveness and costs must be taken into consideration to successfully reach the greatest number of individuals and match them with the best interventions. Thus, economic research is critical to help decision makers better understand and address the challenges of treating substance use disorders and related conditions.

As the burdens of substance use disorders continue to escalate, questions regarding the most economically attractive interventions persist. A 2017 report from the Council of Economic Advisors to the President highlights the need for economic analyses to evaluate and improve the delivery of substance use disorder treatment in the U.S.9 However, health economists are often contacted late in the process of writing a grant application or conducting a study. Just as statistical consultation is a necessary consideration in research design and identifying study resource requirements,10 economic consultation should occur early in the research process.

The Center for Health Economics of Treatment Interventions for Substance Use Disorders, HCV, and HIV (CHERISH) is a multi-institutional Center of Excellence, funded by the National Institute on Drug Abuse (NIDA).11 The Center is a collaboration among Weill Cornell Medicine, Boston Medical Center, University of Pennsylvania Leonard Davis Institute of Health Economics, and the University of Miami Miller School of Medicine. The Center's mission is to develop and disseminate health economic research on healthcare utilization, health outcomes, and health-related behaviors that informs substance use disorder treatment policy and HCV and HIV care of people who use substances. To support this mission and address the shortage of health economic expertise among substance use disorder and related researchers, CHERISH offers an economic consultation service. The service is free to researchers, regardless of affiliation, whose work aligns with CHERISH's mission and who are interested in incorporating an economic analysis into their research.

Methods

The consultation service

The consultation service provides guidance to researchers on the design and implementation of observational and interventional studies related to treatment interventions for substance use disorder, HCV, and HIV, to ensure that planned economic analyses are methodologically sound and feasible. Consultants are typically investigators funded through CHERISH, or CHERISH Research Affiliates, a group of investigators and colleagues who share in the CHERISH mission and offer a diverse set of methodological expertise. The service includes up to six free hours of consulting time for qualifying researchers; consultants are compensated through CHERISH. Six hours was chosen at the outset based on resource constraints and prior experience in assisting colleagues with health economic methodological questions that did not include collaborating on the study.

Figure 1 displays the consultation process. Researchers submit their consultation request (Appendix A) through an encrypted web portal. Within five days of the submission, the consultation service director, who is a member of the CHERISH Methodology Core, contacts the prospective consultee to schedule a screening call. During the call, the two parties discuss the project in-depth, including the prospective consultee's timeline and the next steps of the consultation process. Subsequent to the screening call, the consultation service director discusses the consultation request with other members of the CHERISH consultation committee, who are also members of the CHERISH Methodology Core, to ensure that the project aligns with CHERISH's mission, and to determine which CHERISH investigator's or Research Affiliate's expertise is most relevant to the project. These discussions happen in-person, by phone or e-mail, or during monthly Methodology Core meetings. In some instances, more than one individual is asked to consult on a given project. If the project is not a good fit, the consultation service director will attempt to provide the researcher with guidance on other potential sources of assistance.

Figure 1

consultation service request and evaluation process

Once the CHERISH investigator or Research Affiliate agrees to consult on a project, the consultation service director introduces the consultee to the consultant by e-mail. Consultations are typically completed by telephone or through a web-based video-conferencing portal. Throughout the consultation, the director periodically checks in with both parties to address any issues that may arise. For example, the consultation may identify a need for health economic expertise beyond the consultation. If so, the consultation service director can facilitate the identification of potential collaboration partners. In some cases, this collaboration may occur with the consultant who completed the consultation; however, the terms of this collaboration must be negotiated separately between these parties at the end of the consultation. Consultees also have access to additional online and training resources available through CHERISH.12 The consultation service director can help arrange a letter of support describing these available resources.

Once the consultation is concluded, consultees and consultants are asked to complete a web-based evaluation of the service (Appendix B). The evaluation form includes reporting the amount of time spent on all aspects of the consultation and four-point Likert scale questions regarding satisfaction with the service in terms of management of expectations, alignment of areas of expertise, willingness to recommend the service to other potential consultees or consultants, and overall satisfaction, as well as a free text space for additional feedback. Finally, consultants are asked to complete a follow-up survey approximately six months after the consultation is over to report on the status of their project and attributable outcomes, including grants, conference presentations, and manuscripts (Appendix C).

Initial outreach activities included the development of promotional materials describing the consultation service (Appendix D). These materials were disseminated through targeted e-mails to collaborators, many of whom were located in the Northeast U.S. and conducted HIV-related research; distributed at national scientific conferences on substance use disorders, HCV, and HIV; and, distributed at invited talks at academic institutions where CHERISH collaborators had existing relationships.

Analysis

We report on the status of the consultation service from its inception in July 2015 through June 2017. Specifically, we provide descriptive statistics for consultees, the types of consultation requests we have received, self-reported consultant and consultee time spent on the consultations, and an overview of referral sources. Additionally, we discuss quantitative and qualitative data on the level of satisfaction with the service from the perspective of both consultees and consultants, as well as preliminary data on follow-up outcomes.

Results

The CHERISH consultation service received 28 requests in its first two years (Figure 2), all of which received formal consultations. Three consultations had two consultants. Table 1 provides descriptive statistics on consultees and the types of requests received. Most consultees had an advanced degree of MD or equivalent (57%) or PhD (29%), and the majority were female (61%). More than half of the consultees were Early Stage Investigators, as defined by the NIH.13 Almost 80% of the consultees were from an academic medical center with only four from CHERISH-affiliated institutions, consistent with our goal for this program to target researchers outside of our institutions. Nearly all consultation requests were related to planning a study or grant application (93%), and were submitted by researchers in the Northeast U.S. (93%). Approximately 70% of requests were HIV/AIDS-related, defined as conforming to “medium” or “high” NIH HIV/AIDS priority funding considerations.14 Researchers requested assistance with the following methodology topics: cost-effectiveness (43%), statistical analysis / econometrics (36%), cost (32%), cost-benefit (21%), quality-of-life (18%), conjoint analysis (4%), budget impact analysis (4%), and qualitative analysis (4%). Consultants reported spending a median of 3 hours on the consultation and consultees reported spending a median of 4 hours.

Figure 2

Number of consultation requests per quarter over first two years

Table 1

Consultation service overview (n = 28 requests)

Consultation service recipient and request characteristics	n	%
Highest degree
MD or equivalent	16	57.1%
PhD	8	28.6%
Bachelorsa	3	10.7%
Masters	1	3.6%
Early Stage Investigatorb	15	53.6%
Sex, female	17	60.7%
Primary affiliation
Academic Medical Centerc	22	78.6%
Non-profit Organization	3	10.7%
Industry	2	7.1%
Health Department	1	3.6%
Institution located in the Northeast	26	92.9%
Timing of request
Year 1 (July 2015 – June 2016)	8	28.6%
Year 2 (July 2016 – June 2017)	20	71.4%
Purpose
Planning a study / grant application	26	92.9%
Manuscript	2	7.1%
Type of methodological assistance
Cost-effectiveness	12	42.9%
Statistical analysis / Econometrics	10	35.7%
Cost	9	32.1%
Cost-benefit	6	21.4%
Quality-of-life	5	17.9%
Otherd	3	10.7%
HIV-relatede	20	71.4%
Median (Interquartile range) time spent on consultation, hrs
Consultant	3 (3 – 5)	N / A
Consultee	4 (3 – 8)	N / A

Note. N A = not applicable

n = 2 enrolled in a PhD program

within 10 years of completing their terminal research degree or their medical residency¹³

includes n = 4 from CHERISH-affiliated institutions

conjoint analysis (n = 1), budget impact (n = 1), qualitative analysis (n = 1)

conforming to “medium” or “high” NIH HIV/AIDS priority funding considerations¹⁴

The majority of consultation requests were the result of referrals from collaborators and colleagues (n = 18). Other consultation requests can be attributed to networking by CHERISH investigators at professional events, such as academic conferences (n = 3) and invited talks given by CHERISH investigators (n = 2). We also received consultation requests from CHERISH-sponsored events and activities, including an introductory training on conducting health economic research on substance use disorder interventions (n = 2), and a targeted e-mail awareness campaign (n = 3).

Twenty-five of the 28 consultations have been completed. Evaluation responses were received from 22 consultees (88% response rate) and 27 consultants (96% response rate). All consultees agreed or strongly agreed that consultation expectations and objectives were clearly defined, the consultant's expertise was matched appropriately with their needs, and that they were satisfied with the overall experience (Table 2). All consultees stated that they would be willing to recommend the service to fellow researchers. Results were similar for consultants with regard to expectations / objectives (89%), expertise (96%), willingness to recommend the service (100%), and overall satisfaction (96%).

Table 2

Consultation service evaluation results

Question	Consultee (n = 22 responses)^a				Consultant (n = 27 responses)^b
Question	Strongly Disagree	Disagree	Agree	Strongly Agree	Strongly Disagree	Disagree^c	Agree	Strongly Agree
The consultation expectations and objectives were clearly defined	0%	0%	41%	59%	0%	11%	61%	28%
The consultant's expertise was matched appropriately with the consultee's needs	0%	0%	32%	68%	0%	4%	25%	71%
I would recommend this consultation service to other researchers	0%	0%	27%	73%	0%	0%	25%	75%
I am satisfied with my overall experience with this consultation	0%	0%	32%	68%	0%	4%	36%	60%

Note. Twenty-five of 28 consultations are closed and eligible for evaluation. Three of 25 closed consultations had two consultants.

25 eligible respondents

28 eligible respondents

All consultant responses of “Disagree” were matched to consultee responses of “Agree” or “Strongly Agree

Comments by consultees (Appendix E) reflect the need for a health economic consultation service, particularly with regard to designing methodologically sound economic evaluations, and providing the proper context in which to interpret economic outcomes. Comments by consultants identified areas for potential improvement such as ensuring consultees enter the service with a defined research question and defining realistic expectations of what can be accomplished in the allotted six hours.

Twelve of 25 completed consultations have been closed for at least six months. Preliminary data from follow-up surveys indicate that six of the research projects supported by consultations resulted in grant submissions with four grants awarded. Three of the awarded grants were funded by NIDA, and one was a Developmental Award from a Center for AIDS Research funded by the National Institute of Allergy and Infectious Diseases (NIAID). Of the remaining grants submitted, one was not selected for funding by the Centers for Disease Control and Prevention (CDC), and the other is currently under review by NIDA. Further, one consultation resulted in a peer-reviewed publication, and one of the consultations that culminated in a funded grant also resulted in a conference proceeding. Four of the grant submissions, including three of the awarded grants and the published manuscript, led to further collaborations with CHERISH investigators or Research Affiliates beyond the consultation itself.

Conclusion

To the best of our knowledge, the CHERISH health-economic consultation service for researchers conducting work related to substance use disorders is the first and only free resource of its kind. In its first two years, the CHERISH consultation service has assisted 28 researchers, and their colleagues, with incorporating economic analyses into their work. Both consultees and consultants expressed satisfaction with the service and indicated that they would be willing to recommend it to other researchers and potential consultants. Although reviews are not anonymous, they are voluntary and confidential.

We offer several lessons learned. First, we found a need for health-economic consultation services, and limiting consultations to six hours feasible. Second, we realized the need for a formalized process to document and track feedback on short-term and long-term outcomes from consultees and consultants, measure services delivered, and, identify opportunities for growth. Third, in response to feedback from consultants that identified the need for researchers to enter the service with a well-defined research question, we incorporated a screening call with the consultation service director to set realistic expectations prior to being connected with a consultant. Fourth, we found that investing in promotion through trainings and presentations at academic conferences, at invited lectures, and through referrals from colleagues were necessary to encourage use of the service. Our program evaluation results add to the limited available information on academic consulting services.10

We are now embarking on efforts to expand the number of consultations and our geographic reach. We are actively recruiting CHERISH Research Affiliates from other institutions who can act as consultants and referral sources, and we are continuing to promote the service at national meetings such as the Association for Medical Education and Research in Substance Abuse (AMERSA) National Conference, through CHERISH online and in-person activities, and though outreach to other related research centers and training programs.

Author contributions

All authors contributed to the conception and design of the study. SMM and JAL gathered data, performed analyses, and wrote the initial draft. BPL, JRM, KM, and BRS performed critical reviews, and collaborated with SMM and JAL on manuscript revisions. All authors approved the final manuscript and are responsible for the final content.

Footnotes

Acknowledgements

The authors wish to thank Sarah Gutkind, MSPH, for assistance with developing evaluation forms and editorial assistance; Michelle Papp for assistance with collection of evaluation forms and editorial assistance; Sherry Deren, PhD, for comments on an earlier draft of the manuscript; and Shashi Kapadia, MD, MS for editorial assistance.

Portions of this paper were presented at the 2017 Association for Medical Education and Research in Substance Abuse (AMERSA) National Conference on November 2–4, 2017, in Washington, DC, and at the National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) Annual Scientific Meeting on March 20–22, 2018, in North Bethesda, Maryland.

This study was supported by the National Institute on Drug Abuse (P30DA040500). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies or the US government.

Author contributions

All authors contributed to the conception and design of the study. S.M.M. and J.A.L. gathered data, performed analyses, and wrote the initial draft. B. P.L., J.R.M., K.M., and B.R.S. performed critical reviews and collaborated with S.M.M. and J.A.L. on manuscript revisions. All authors approved the final manuscript and are responsible for the final content.

All authors are affiliated with the consultation service discussed herein.

References

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Substance Abuse and Mental Health Services Administration. Substance use disorders. https://www.samhsa.gov/disorders/substance-use. Accessed September 14, 2017.

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Implementation of a Nationwide Health Economic Consultation Service to Assist Substance use Researchers: Lessons Learned

Abstract

Background

Methods

Results

Conclusions

Keywords

Introduction

Methods

The consultation service

Analysis

Results

Conclusion

Author contributions

Footnotes

Acknowledgements

Author contributions

References

Supplementary Material