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Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for Adults Experiencing Sheltered Homelessness During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What are the projected clinical outcomes and costs associated with strategies for reducing severe acute respiratory syndrome coronavirus 2 infections among people experiencing sheltered homelessness?

Findings  In this decision analytic model, daily symptom screening with polymerase chain reaction (PCR) testing of individuals who had positive symptom screening paired with nonhospital care site management of people with mild to moderate coronavirus disease 2019 (COVID-19) was associated with a substantial decrease in infections and lowered costs over 4 months compared with no intervention across a wide range of epidemic scenarios. In a surging epidemic, adding periodic universal PCR testing to symptom screening and nonhospital care site management was associated with improved clinical outcomes at modestly increased costs.

Meaning  In this study, daily symptom screening with PCR testing of individuals who had positive symptom screening and use of alternative care sites for COVID-19 management among individuals experiencing sheltered homelessness were associated with substantially reduced new cases and costs compared with other strategies.

Abstract

Importance  Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19).

Objective  To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness.

Design, Setting, and Participants  This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020.

Exposures  Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention.

Main Outcomes and Measures  Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented.

Results  The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission.

Conclusions and Relevance  In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 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 SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.

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Article Information

Accepted for Publication: October 6, 2020.

Published: December 22, 2020. doi:10.1001/jamanetworkopen.2020.28195

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Baggett TP et al. JAMA Network Open.

Corresponding Author: Kenneth A. Freedberg, MD, MSc, Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, Ste 1600, Boston, MA 02114 (kfreedberg@mgh.harvard.edu).

Author Contributions: Drs Freedberg and Baggett had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Kazemian and Freedberg contributed equally to this work.

Concept and design: Baggett, Scott, Le, Panella, Flanagan, Neilan, Siedner, Weinstein, Ciaranello, Kazemian, Freedberg.

Acquisition, analysis, or interpretation of data: Baggett, Le, Shebl, Panella, Losina, Gaeta, Neilan, Hyle, Mohareb, Reddy, Harling, Ciaranello, Kazemian, Freedberg.

Drafting of the manuscript: Baggett, Shebl, Kazemian, Freedberg.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Le, Shebl, Losina, Ciaranello.

Obtained funding: Freedberg.

Administrative, technical, or material support: Scott, Le, Panella, Flanagan, Gaeta, Neilan, Ciaranello.

Supervision: Baggett, Scott, Kazemian, Freedberg.

Conflict of Interest Disclosures: Dr Baggett reported receiving personal fees from UpToDate outside the submitted work. Dr Hyle reported receiving grants from the National Institutes of Health and Massachusetts General Hospital and receiving royalties from UpToDate outside the submitted work. Dr Mohareb reported receiving grants from National Institute of Allergy and Infectious Diseases outside the submitted work. Dr Weinstein reported receiving personal fees from Quadrant Health Economics and PrecisionHEOR outside the submitted work. Dr Ciaranello reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Freedberg reported receiving grants from the National Institutes of Health, the French National Agency for AIDS Research, and Unitaid outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grant T32 AI007433 from the National Institute of Allergy and Infectious Disease to Dr Mohareb, grant K24 AR057827 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases to Dr Losina, grant 210479/Z/18/Z from the Royal Society and Wellcome Trust to Dr Harling, and grant R37 AI058736-16S1 from the National Institute of Allergy and Infectious Disease to Dr Freedberg.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors, and the study’s findings and conclusions do not necessarily represent the official views of the National Institutes of Health, the Wellcome Trust, or other funders.

Additional Contributions: We thank Elizabeth Lewis, MBA, and Agnes Leung, MHA, for their assistance with clinical and cost data from Boston Health Care for the Homeless Program. We also thank Guner Ege Eskibozkurt, BA, and Mary Feser, BA (Medical Practice Evaluation Center, Massachusetts General Hospital, Boston), for research assistance. All acknowledged individuals contributed as part of their institutional roles.

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