Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic
Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic
ABSTRACT ImportanceApproximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. ObjectiveTo assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. DesignWe developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. Setting & ParticipantsSimulated cohort of 2,258 adults residing in homeless shelters in Boston. InterventionsWe assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. Main Outcomes and MeasuresCumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. ResultsWe simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions & RelevanceIn this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges. Key PointsQuestionWhat are the projected clinical outcomes and costs of strategies for reducing COVID-19 infections among people experiencing sheltered homelessness?FindingsIn this microsimulation modeling study, daily symptom screening with polymerase chain reaction (PCR) testing of screen-positive individuals, paired with non-hospital care site management of people with mild to moderate COVID-19, substantially reduced infections and lowered costs over 4 months compared to no intervention, across a wide range of epidemic scenarios. In a surging epidemic, adding periodic universal PCR testing to symptom screening and non-hospital care site management improved clinical outcomes at modestly increased costs. Periodic universal PCR testing paired with temporary housing further reduced infections but at much higher cost.MeaningDaily symptom screening with PCR testing of screen-positive individuals and use of alternate care sites for COVID-19 management among sheltered homeless people was associated with substantially reduced new cases and costs compared to other strategies.
Kazemian Pooyan、Harling Guy、Flanagan Clare、Neilan Anne、Hyle Emily P.、Siedner Mark J.、Weinstein Milton C.、Baggett Travis P.、Le Mylinh H.、Ciaranello Andrea、Losina Elena、Mohareb Amir、Freedberg Kenneth A.、Shebl Fatma M.、Panella Christopher、Scott Justine A.、Gaeta Jessie M.、Reddy Krishna P.
Department of Operations, Weatherhead School of Management, Case Western Reserve UniversityDepartment of Epidemiology and Harvard Center for Population & Development Studies, Harvard T.H. Chan School of Public Health||Africa Health Research Institute, KwaZulu-Natal||Institute for Global Health, University College London||MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of WitwatersrandMedical Practice Evaluation Center, Massachusetts General HospitalHarvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General Hospital||Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General HospitalHarvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General Hospital||Harvard University Center for AIDS ResearchHarvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General Hospital||Africa Health Research Institute, KwaZulu-NatalDepartment of Health Policy and Management, Harvard T. H. Chan School of Public HealthDivision of General Internal Medicine, Massachusetts General Hospital||Harvard Medical School||Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless ProgramMedical Practice Evaluation Center, Massachusetts General HospitalHarvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General Hospital||Harvard University Center for AIDS ResearchDepartment of Biostatistics, Boston University School of Public Health||Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women?ˉs Hospital||Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women?ˉs HospitalMedical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General HospitalDivision of General Internal Medicine, Massachusetts General Hospital||Harvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Infectious Diseases, Massachusetts General Hospital||Harvard University Center for AIDS Research||Department of Health Policy and Management, Harvard T. H. Chan School of Public HealthMedical Practice Evaluation Center, Massachusetts General HospitalMedical Practice Evaluation Center, Massachusetts General HospitalMedical Practice Evaluation Center, Massachusetts General HospitalInstitute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program||Section of General Internal Medicine, Boston University School of MedicineHarvard Medical School||Medical Practice Evaluation Center, Massachusetts General Hospital||Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital
预防医学医学研究方法临床医学
HomelessnessCOVID-19cost-effectiveness analysissimulation model
Kazemian Pooyan,Harling Guy,Flanagan Clare,Neilan Anne,Hyle Emily P.,Siedner Mark J.,Weinstein Milton C.,Baggett Travis P.,Le Mylinh H.,Ciaranello Andrea,Losina Elena,Mohareb Amir,Freedberg Kenneth A.,Shebl Fatma M.,Panella Christopher,Scott Justine A.,Gaeta Jessie M.,Reddy Krishna P..Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic[EB/OL].(2025-03-28)[2025-08-03].https://www.medrxiv.org/content/10.1101/2020.08.07.20170498.点此复制
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