Bruce Schackman

Bruce Schackman

Saul P. Steinberg Distinguished Professor of Healthcare Policy and Research and of Population Health Sciences, Department of Population Health Sciences, Weill Cornell Medicine
Professor of Healthcare Policy and Research, Department of Medicine and Department of Psychiatry, Weill Cornell M

Dissertation Title:  "The Cost-Effectiveness of Early Antiretroviral Therapy for HIV-Infected Adults"Since 1996 there has been a dramatic shift in the treatment outlook for HIV-infected individuals as a result of the introduction of new antiviral drug regimens. The decision when to initiate antiretroviral drug therapy requires making a tradeoff between the benefits of early treatment and possible long-term drug toxicities. Because the government is the primary health care payer for the majority of HIV-infected patients, their access to early therapy is determined by the availability of government programs.

Chapter One develops a set of baseline utility weights for examining treatment-related quality of life tradeoffs, using data from a survey of HIV-infected patients at various stages of disease. Differences between community and patient utility weights and their implications for cost-effectiveness analyses are explored. Patient utility weights for HIV/AIDS health states were generally higher than community utility weights, and when treatment side effects were important these differences could affect cost-effectiveness ratios for early versus later initiation of therapy.

Chapter Two examines the impact of two antiretroviral treatment side effects, cholesterol changes and fat redistribution symptoms, on the cost-effectiveness of early antiretroviral therapy. The analysis was conducted using a state-transition computer model to simulate the natural history of HIV disease and the impact of the treatment side effects on life expectancy and quality of life. Changes in cholesterol associated with antiretroviral therapy alone did not appear to be sufficient to justify deferral of treatment. Although the impact of fat redistribution symptoms on quality of life will vary among individual patients, this effect is unlikely to substantially change the cost-effectiveness of initiating early therapy under current treatment guidelines for most patients.

Chapter Three projects the costs to government payers of Section 1115 Medicaid demonstration projects to improve access to early treatment for HIV-infected patients in Georgia and Massachusetts. The proposed demonstration projects affected the budgets of several government payers including Medicaid, Medicare, AIDS Drug Assistance Programs, and other state payers. In assessing expanded access to early treatment, government payers should consider overall budgetary effects and should assess costs separately for each year's enrollees in order to avoid incentives to cap program enrollments.


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