Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute...

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Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Harvard School of Public Health, Boston, MA ISSPD NYC, August 23, 2009 1

Transcript of Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute...

Page 1: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

Cost-effectiveness of psychotherapy for personality disorders

Djøra SoetemanViersprong Institute for Studies on Personality Disorders

Erasmus Medical Center, Rotterdam

Harvard School of Public Health, Boston, MA

ISSPD NYC, August 23, 2009

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Page 2: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

SCEPTRE trial

Patient-level primary data was available from the largest existing clinical trial of psychotherapy for personality disorders (N = 924)

Dosage specified by treatment setting and duration Cluster C PD: N = 466 Cluster B PD: N = 241

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Cluster C PD

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Different dosages

Short-term outpatient excl. Long-term outpatient 21.4% Short-term day hospital 19.0% Long-term day hospital 23.0% Short-term inpatient 14.1% Long-term inpatient 22.5%

Short-term < = 6 months Long-term > 6 months

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Different costs

Psychotherapy dosage Treatment costs(€)

Long-term outpatient 10,005

Short-term day hospital 16,813

Long-term day hospital 27,648

Short-term inpatient 25,933

Long-term inpatient 49,260

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Total costs over 5 years

Psychotherapy dosage

Treatment costs (€)

Total costs over 5 years (€)

Long-term outpatient 10,005 89,936

Short-term day hospital 16,813 89,411

Long-term day hospital 27,648 105,940

Short-term inpatient 25,933 91,620

Long-term inpatient 49,260 119,946

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Page 7: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

Just costs?

Economics is more than just costs… Effects are equally important:

– Cost-effectiveness Are the effects worth the additional costs?

– What if the more expensive treatment is more

effective?

– What are the costs per recovered patient?

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Page 8: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

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Definition “recovered patient”

Clinically significant change: (Jacobson and Truax, 1991)

– Recovered: statistically reliable + ends up within normal limits– Improved: statistically reliable , but ends still dysfunctional– Unchanged: no statistically reliable – Relapsed or deteriorated: statistically reliable in the opposite

direction

General Symptom Index (BSI/SCL-90)

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Effect

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Psychotherapy dosage % recovered after 12 months

Long-term outpatient 19%Short-term day hospital 26%Long-term day hospital 37%Short-term inpatient 61%Long-term inpatient 41%

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Costs per recovered patient year

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Psychotherapy dosage % recovered after 12 months

Costs (€)

Long-term outpatient 19% 64,735Short-term day hospital 26% 46,131Long-term day hospital 37% 45,442Short-term inpatient 61% 32,837Long-term inpatient 41% 57,285

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Is that a lot?

How do we know if € x ,- per recovered patient year concerns a ‘cost-effective’ treatment strategy?

Compare it with other interventions– E.g., compared to lung transplantation or breast cancer

screening Generic outcome measure required in order to

compare different illnesses– Survival

– Quality of life

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Life years x quality of life index score Quality of life index score

– 1.0 = perfect health

– 0.0 = death Example

– Loss of eyesight

– Quality of life index = 0.5

– Life years = 80

– 0.5 x 80 = 40 QALYs

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Quality Adjusted Life Years (QALY)

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Effect over 5 years

Psychotherapy dosage QALYs

Long-term outpatient 3.30Short-term day hospital 3.44Long-term day hospital 3.49Short-term inpatient 3.57Long-term inpatient 3.49

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Costs per QALY

Psychotherapy dosage

QALYs Costs per QALY (€)

Long-term outpatient 3.30 27,239Short-term day hospital 3.44 26,027Long-term day hospital 3.49 30,353Short-term inpatient 3.57 25,674Long-term inpatient 3.49 34,350

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Page 15: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

Interested in both costs and effect

Less effective More effective

Low costs (savings)

High costs

Good

Better

Superb!

Forget it!

Difficult…

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Sensitivity analysis

Less effective More effective

Low costs (savings)

High costs

Superb!

Forget it!

Difficult…

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Good

Better

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Cost-effectiveness plane

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Good

Better

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Acceptability curve

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Cost-effectiveness of different dosages of psychotherapy for cluster C PD

Psychotherapy dosage Costs per QALY (threshold value

€0 – €16,570)

Costs per QALY (> €16,570)

Long-term outpatient

Short-term day hospital 1st choiceLong-term day hospital

Short-term inpatient 1st choiceLong-term inpatient

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Page 20: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

Cost-effectiveness of different dosages of psychotherapy for cluster C PD

Psychotherapy dosage

Costs per QALY (threshold value

€0 – €16,570)

Costs per QALY (> €16,570)

Costs per QALY (threshold value

of €40,000)

Long-term outpt

Short-term day h 1st choiceLong-term day h

Short-term inpt 1st choice 1st choiceLong-term inpt

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Cluster B PD

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Page 22: Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical.

Acceptability curve

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Cost-effectiveness of different modalities of psychotherapy for cluster B PD

Modality of psychotherapy

Costs per QALY (threshold value

€0 – €56,325)

Costs per QALY (> €56,325)

Outpatient 1st choiceDay hospital 1st choiceInpatient

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Cost-effectiveness of different modalities of psychotherapy for cluster B PD

Modality of psychotherapy

Costs per QALY (threshold value

€0 – €56,325)

Costs per QALY (> €56,325)

Costs per QALY (threshold value

of €40,000)

Outpatient 1st choice 1st choiceDay hospital 1st choiceInpatient

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Conclusion

Cost-effective treatment strategies are: Cluster C PD:

– Short-term inpatient psychotherapy (first choice)– Short-term day hospital psychotherapy

Sub-optimal treatment options are:– Long-term day hospital and long-term inpatient

Cluster B PD:– Outpatient psychotherapy (first choice)– Day hospital psychotherapy

Sub-optimal treatment option is:– Inpatient psychotherapy

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