Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute...
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Transcript of Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute...
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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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
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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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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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)
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%
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
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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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
Cost-effectiveness plane
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Good
Better
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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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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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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