Value based Health Care for Depression and Anxiety

Matthias Rose

Department of Psychosomatic MedicineCenter for Internal Medicine and DermatologyCharité Universitätsmedizin Berlin, Germany

Department of Quantiative Health SciencesUniversity of Massachusetts, USA

Symposium Value Based Health Care

Basel September 2018

Key numbers

▪ Mental disorders among the 10

diseases accounting for the

most years lived with

disability

▪ Depressive disorders account

for nearly 81 million years

▪ Anxiety disorders account for

nearly 27 million years

▪ Together, the economic burden

is upwards of $210 billion in the

US alone

Vos et al. The Lancet 2013

Disease BurdenGlobal Burden of Disease Study

Outcome Measurement

query Sep, 19th 2018

National Standardization

▪ As part of effort to

integrate mental health

into primary care, routine

outcome monitoring is used

for all patient visiting a

behavioral health provider

▪ Over 50,000 surveys now

administered monthly

▪ National initiative for routine

outcomes monitoring across the

mental health spectrum

▪ Data feed back for clinical care

as well as benchmarking

▪ Supported by health plans

▪ As part of effort to expand

access to psychotherapy,

routine outcome monitoring

established

▪ Demonstrated substantial

cost-effectiveness of

program and is now the

model for many system-wide

efforts worldwide

Veteran’s Affairs and

Military Health System (US) Stichting Benchmark (NL) IAPT (UK)

International

Standardization

ICHOM Approach

After outcomes and measures are defined, a similar

process was followed to identify and define an

accompanying set of case-mix factors

ICHOM Approach

Depression & Anxiety Group

Anne Crocker, Douglas Mental Health

University Institute; McGill University

Lucie Langford*

Alain Lesage, University of Montréal

David M. Clark, Oxford University

Dave Smithson*, Anxiety UK

Maria Kangas, Centre for Emotional Health,

Macquarie University

Edwin de Beurs, Stichting

Benchmark GGZ

Paul Emmelkamp, University

of Amsterdam

Erik Hedman,

Karolinska Institutet

Lee Baer, Harvard Medical School;

Massachusetts General Hospital

Kelly Woolaway-Bickel, Department of

the U.S. Army; Office of the Surgeon

General

Paul A. Pilkonis, University of Pittsburgh

Harold A. Pincus, Columbia University

Cathy Sherbourne, The RAND

CorporationDoris M. Mwesigire,

Makerere University

Sandra Nolte, Alexander

Obbarius & Matthias Rose,

Charité Universitätsmedizin

BerlinToshi A. Furukawa, Kyoto

University

Roberta Alvarenga Reis,

Universidade Federal do Rio

Grande do SulGraciela Rojas, University of Chile

Vikram Patel, Centre for

Chronic Conditions and

Injuries; Public Health

Foundation of India

Standardset Depression & Angst

Paul A. PilkonisUniversity of Pittsburgh

Working

Towards Agreement

ICHOM Methods

13th/14th

Call 2

June Jul Aug Sept Oct Nov Dec

Launch of ICHOM Standard Set for

Depression & Anxiety at ICHOM conference

Outcome domains

Call 3 Call 4 Call 5 Call 6Kick-off

meeting

Outcome measures

Risk factor domains

Risk factor measures

Scope

Prepare for launch and publication

Call 1

Jan

Transition to implementation

17th 1st 22nd 16th 14th 4th26th

Promote adoption

Inclusion Criteria

Psychopharmacotherapy

Psychotherapy

Lifestyle Interventions, Self-

guided help

Other Forms of Therapy

Patient population

Large variation across

conditions

Large variation across

conditions and treatments

Mortality

Disease Symptoms

Disease Burden

Health-related Quality of Life

Main Diagnosis: bipolar and

schizophrenic disorders as well

as other mental disorders (e.g.

personality disorders, substance

abuse)

Age < 18 years

DepressionDepressive Adaptive / Adjustment

Disorder

Major depressive disorderDepressive Disorder - NOS

Dysthymia

AnxietyGeneral Anxiety DisorderPhobic disorder

Panic disorderPost-Traumatic Stress Disorder

Treatment options Outcomes

Incl

ud

e

Constructs within the VBHC Framework

• Symptoms1

a. depression b. anxiety• Participation1

a. work b. social

• Functional status1

• Quality of Life1

• Length of inpatient stay

• Time to Symptom relief• Time to participation

• Time to achieve sufficient

functional status

• Medication side effects

• Side effects of other treatment (e.g. memory loss due to ECT)

• Suicide rate

• Sustainability of symptom relief,

participation and functional status1

• Recurrence of disease

• Emergency visits

• Need for medication

• Symptom shift

• Medication side effects (e.g. dyskinesia, physical dependency)

• Therapy induced dependency

• Secondary gain

Survival

Degree of health achieved or maintained

Time to recovery and return to normal activities

Disutility of the care or treatment process

Sustainability of health /recovery and nature of recurrences

Long-term consequences of therapy

Tier 1

Health status

achieved or

retained

Tier 2

Process of

Recovery

Tier 3

Sustainability

of health

DOMAIN SUGGESTED OUTCOMES

Obbarius et al.

Qual of Life Res 2017

From Construct to Instrument

From Construct to InstrumentCategory Domains Covered

PHQ SWLS CGI BDI BSI HRSQIDS-

SRWSAS

Q-LES-

QMADR-S

Symptom

Burden

Suicidal Thoughts

Depressed Mood and Thoughts

Insomnia

Other Symptoms

Functional Functional Functional Functional Status Status Status Status Overall Functional Status

Quality of Life Health-related Quality of Life

Practical

Considerations

# questions 10 5 3 21 53 or 18 21 16 5 16 10

# citations 3301 7739 1853 14693 3954 18278 689 396 870 6079

Year published 1999 1985 1976 1961 1983 1960 2003 2002 1993 1979

Cost None None None Yes Yes None None ? ? None

Translations 79 28 ? 46 3 13 46 ? 64 42

Light Focus Moderate Focus Heavy Focus

PHQ Patient Health Questionnaire BSI Brief Symptom Inventory WSAS Work and Social Adjustment Scale

SWLSSatisfaction with Life Scale

HRSHamilton Rating Scale

Q-LES-QQuality of Life Enjoyment and Satisfaction

Questionnaire

CGIClinical Global Impression

QIDS-SRQuick Inventory of Depressive

SymptomatologyMADR-S

Montgomery-Asberg Depression Rating Scale

BDI Beck Depression Inventory

From Construct to Instrument

number of available translations

psychometric soundness

comprehensiveness

available royalty free

Items

Items

CaseMix

Variables

Items

TreatmentVariables

Items

Outcomes

Items

Outcomes

Time Points

Standard Metric

Item Bank - Depression

Representative Samples

Item Location

���

���

��

��

�

��

���

����

�

���

� ���

�

�� ��

�

��

��

QQ

Q Q

Q

Q QQQQ Q

Q QQ

QQ

QQ

Q

Q

Q

QQ

QQ

QQ

Q

Q

QQ

Q Q

QQ

feelingdepressed feeling

guilty

lost ofinterest

suicidalideation

feelingdown

QQ

QQ

happy

relaxed

difficultiesconcentrate

populationmean ±±±±

standard deviation

high30 40 50 60 70 80 90

lowTheta ΘΘΘΘ

�

��

� �

��

��

� ���

�� ���

��

�

���

�

Patients with Depression7 Clinical Sites / 12 Health

Centers total n > 33,000

Wahl et al. J Clin Epi 2014

Item Bank - Depression

���

���

��

��

�

��

���

����

�

���

� ���

�

�� ��

�

��

��

QQ

Q Q

Q

Q QQQQ Q

Q QQ

QQ

QQ

Q

Q

Q

QQ

QQ

QQ

Q

Q

QQ

Q Q

QQ

QQ

QQ

Questionaire A

Questionnaire B

�

��

� �

��

��

� ���

�� ���

��

�

���

�

11 establishedinstruments

feelingdepressed feeling

guilty

lost ofinterest

suicidalideation

feelingdown

happy

relaxed

difficultiesconcentrate

30 40 50 60 70 80 90 Theta ΘΘΘΘhighlow

Wahl et al. J Clin Epi 2014

Standardized Metric

GAD-7 and PHQ-9 Conversion Tables

Promis Metric

Conclusion

Conclusion

However, if an instrument oriented measurementis standardized this would prevent to improve methodsin the future

II

I ICHOM provides the prerequisite to learnfrom large data sets

One way to avoid this is an agreement on the constructs with common metrics

III

Vielen Dank

Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, 2008, s.a. SGB V, §23

Relevance of the Patients’ Perspective in Germany

Parking Lot

45

Standardized Metric

BDI

5

20

1961

60

WHO-5

50

30

70

Depression

50

HADS

10

8

3

1983 1998 2012

Cut-OffDepression

MeanRepresentative

Sample55

60

65

70

Theta ΘΘΘΘ

10

15

25 75

40

20

5

12

Beck Depression Inventory

Well-Being Index

Hospital AnxietyDepression Scale

Phenotype of Depressivity

Hasselmann et al. Multiple Sclerosis Journal 2016

Treatment approaches

covered

▪ Psychopharmacotherapy

▪ Psychotherapy

▪ Lifestyle interventions

▪ Self-guided help

▪ Other forms of therapy

© 2015 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so that this

organization can continue its work to define more standard outcome sets.

A "reference guide"

contains all the details

to measure in a

standard way the

outcomes

recommended

(available at ichom.org)

Distribution of outcomes and case-mix variables across time

Baseline ( )

▪ Age

▪ Sex▪ Educational level

▪ Living status▪ Social support

▪ Comorbidities

▪ Prior episodes of depression

▪ Duration of symptoms▪ Prior treatment

▪ Outcome expectancy

With treatment ( ) Annual ( )

Case-mix

variables

Outcomes

▪ Symptom burden (PHQ-9,

GAD-7, specific anxiety questionnaires depending

on diagnosis)▪ Medication side effects

▪ Functioning (WHO-DAS

2.0)▪ Work status

▪ Absenteeism

▪ Symptom burden (PHQ-9,

GAD-7, specific phobia questionnaires depending

on diagnosis)▪ Functioning (single item

from PHQ-9)

▪ Medication side effects

▪ Symptom burden (PHQ-9,

GAD-7, specific anxiety questionnaires depending on

diagnosis)▪ Medication side effects

▪ Recurrent episode

▪ Functioning (WHO-DAS)▪ Work status

▪ Absenteeism▪ Overal success of treatment

▪ Global assessment

▪ Current treatment ▪ Living status

▪ Comorbidities▪ Prior and current treatment

▪ Social support ▪ Outcome expectancy

• Proposed in by IsHaket al., 2011

• Team of UCLA psychiatrists, biostatisticians, physicians, etc

• Developed through data analysis of Cedars-Sinai Psychiatric Treatment Outcome Registry

• Consists of composite score of three PROMs

QIDS-SR WSAS Q-LES-Q

Suicidal Thoughts

Depressed Mood and

Thoughts

Insomnia

Other Symptoms

Functional Status

(impairment of work

ability, impairment of

enjoying leisurely

activities, impairment

in maintaining close

relationships, loss of

motivation)

Quality of Life

Number of Questions16 5 16

Number of translations46 ? 64

Measurement Range

Depression

Depression

Depression

Fisher et al. 2014

Fisher et al. 2014

Consent Building Efforts

Anxiety & Depression

Obbarius et al. Quality of Life Res 2017

Choosing the Right Perspective

γ-globulin

creatinine

hemoglobin

fatigue

plasmacytomakidney failure

σύµπτωµα (symptoma)=it falls together with something

Nephrology Hematology

disease specific measures=compilation of health parameters

?

but is not unique to it

… from the instrument to the construct !

Synergies

Physical Function

Pain

Fatigue

Depression

Sleep Issues

Social Function

Dia

bete

s

Hea

rt F

ailu

re

Kne

e &

Hip

Rep

lace

men

t

Dep

ress

ion

CO

PD

Bre

ast C

ance

r

Infla

mm

ator

yB

owl D

isea

se

↓

↑

↓↓↓

↑↑

↓↓↓↓↓

↑↑↑ ↑

↑↑

↑↑ ↑

↑↑

↑↑↑

↓↓ ↓

↑↑

↓

↑

Disease Perspective

modernmetricinstrumentindipendent

self-

repo

rted

he

alth

Disease / ContextSpecific Issues

Composite Score

↑ ↑ ↑ ↑ ↑ ↑ ↑

xycont

ext o

r di

seae

spec

ific

standard tools