Transcript Dia 1 - de Viersprong

Cost-effectiveness
in the quest to convince
the outside world
Dr. Jan Busschbach
De Viersprong
Erasmus MC
www.vispd.nl
Should we employ cost effectiveness
research in personality disorder?
 The obligatorily favourable arguments…
– State-of-the-art research
– Legitimise reimbursement
 But cost effectiveness is not widely present….
– What stops us?
2
Arguments not to employ cost
effectiveness research…
 It has already been shown..
– We know that psychotherapy is cost effective in PD
 The methods are unfavourable for psychotherapy
– The outcome measures (QALYs) are not sensitive for
changes in personality
 It is not important
– It does not matter in reimbursement decisions
 It is complex…
– An incremental cost effectiveness ratio from a probabilistic
Markov Model with a multiple sensitivity analysis using a
societal perspective….
3
Arguments not to employ cost
effectiveness research…
 It has already been shown..
– We know that psychotherapy is cost effective in PD
 The methods are unfavourable for psychotherapy
– The outcome measures (QALYs) is not sensitive for
changes in personality
 It is not important
– It does not matter in reimbursement decisions
 It is complex…
– An incremental cost effectiveness ratio from a probabilistic
Markov Model with a multiple sensitivity analysis….
4
Elements of cost effectiveness…
Dolan et al., Psychiatric Bulletin, 1996
£30,000
£25,000
£20,000
£15,000
£10,000
£5,000
£0
Before treatment
5
After treatment
Costs of treatment
Productivity losses in months per year
Stevenson & Meares, AJP, 1992
5
4
3
2
1
0
Before treatment
After treatment
30 borderline patients
6
But does that tell us:
…how competitive is psychotherapy in PD?
 What is de cost effectiveness of psychotherapy in PD?
– Compared to treatment in oncology…
– Compared to dialysis…
– Compared to osteoporosis treatment …
 Cost per health gain
– Like cost per kilometre in cars
 Outcome health: QALY
– Quality Adjusted Life Years
– Makes outcome in health care comparable
– Both survival & quality of life
7
Car league table
Car
€ / Km
Car
Daewoo Matiz
€ / Km
BMW 316
0.74
Mazda 626 2.0
0.58
Citroën Xantia 1.8i
0.55
Opel Vectra 1.6
0.53
Daihatsu Cuore 1.0
0.27
Hyundai Lantra 1.5
0.47
Suzuki Alto 1.0
0.24
Renault Twingo 1.2
inj
Hyundai Atos Multi
1.0
0.33
0.28
0.27
Cost per kilometre including gas, maintenance, debit, etc. Price level 2002.
Calculations based on over 2,5 years use and 40.000 km.
(Consumentenbond, Augustus 2003)
8
QALY league table
Intervention
9
$ / QALY
GM-CSF in elderly with leukemia
235,958
EPO in dialysis patients
139,623
Lung transplantation
100,957
End stage renal disease management
53,513
Heart transplantation
46,775
Didronel in osteoporosis
32,047
PTA with Stent
17,889
Breast cancer screening
5,147
Viagra
5,097
Treatment of congenital anorectal malformations
2,778
Is there already evidence of cost
effectiveness?
10
White raven



11
The cost-effectiveness of cognitive behavior therapy for borderline
personality disorder: results from the BOSCOT trial.
– Palmer, S., K. Davidson, et al. (2006).
– J Personal Disord 20(5): 466-81
Outpatient psychotherapy for BPD: The cost-effectiveness of schemafocused therapy versus transference-focused psychotherapy
– Thea van Asselt, Josephine Giesen-Bloo
– University of Maastricht
– This ISSPD conference
Modelling the cost-effectiveness of psychotherapy in personality
disorders, long term inpatient versus short term inpatient
– Djøra Soeteman et al.
– Viersprong
– This ISSPD conference
Cumulative evidence can be classified
as “a promise”
 John Brazier, Prof in Health Economics
– Leading institute, University of Sheffield
– Psychological therapies […] for borderline
personality disorder: a systematic review and
preliminary economic evaluation
– January, 2007
 On the basis of an extensive review
 Converted all existing evidence into a health
economic model
– “The results for [psychotherapy] are promising,
though […] surrounded by a high degree of
uncertainty. There is a need for considerable
research in this area.”
12
Arguments not to employ cost
effectiveness research…
 It has already been shown..
– We know that psychotherapy is cost effective in PD
 The methods are unfavourable for psychotherapy
– The outcome measures (QALYs) are not sensitive for
changes in personality
 It is not important
– It does not matter in reimbursement decisions
 It is complex…
– An incremental cost effectiveness ratio from a probabilistic
Markov Model with a multiple sensitivity analysis….
13
Are the methods unfavourable for
psychotherapy?
 Cost effectiveness focuses on costs
– Psychotherapy is labour intensive and thus expensive
 Cost effectiveness uses generic outcomes: QALY
– Quality Adjusted Life Years (QALYs)
• Are not sensitive
– The changes caused by psychotherapy are subtle
• Functional changes
• Relations
• Enjoyment of life
– But is that an argument against QALYs?
14
QALY
 Quality Adjusted Life Years
 Area under the curve
1
Adjusment factor QALY
0.9
0.8
0.7
0.6
Co-morbidity
With psychotherapy
No psychotherapy
0.5
0.4
0.3
0.2
0.1
0
0
10
20
30
40
Life years
15
50
60
70
80

MOBILITY
– I have no problems in walking about
– I have some…….
– I am confined to bed
EQ-5D

SELF-CARE
– I have no problems with self-care
– I have some problems…..
– I am unable…
The EuroQol EQ-5D is
specially designed to
measure the quality of
life index for QALYs

USUAL ACTIVITIES
– I have no problems with performing my usual
activities
– I have some problems…
– I am unable….

PAIN/DISCOMFORT
– I have no pain or discomfort
– I have moderate …..
– I have extreme……..

ANXIETY/DEPRESSION
– I am not anxious or depressed
– I am moderately……..
– I am extremely…..
16
But the EQ-5D is sensitive in PD….
Clinic 12 months
Clinic 6 months
Clinic 3 months
Out-patient clinic
1.0
EQ-5D QALY values
0.9
0.8
0.7
0.6
0.5
Intake
17
1 year after
2 years
Cost effectiveness is already employed
in metal health
 Schizophrenia
– "Schizophrenia"[Mesh] AND "Cost-Benefit Analysis"[Mesh]
– 307 Hits in PubMed
 Depression
– "Depression"[Mesh] AND "Cost-Benefit Analysis"[Mesh]
– 104 Hits
18
Arguments not to employ cost
effectiveness research…
 It has already been shown..
– We know that psychotherapy is cost effective in PD
 The methods are unfavourable for psychotherapy
– The outcome measures (QALYs) are not sensitive for
changes in personality
 It is not important
– It does not matter in reimbursement decisions
 It is complex…
– An incremental cost effectiveness ratio from a probabilistic
Markov Model with a multiple sensitivity analysis….
19
Car league table
Car
€ / Km
Car
Daewoo Matiz
€ / Km
BMW 316
0.74
Mazda 626 2.0
0.58
Citroën Xantia 1.8i
0.55
Opel Vectra 1.6
0.53
Daihatsu Cuore 1.0
0.27
Hyundai Lantra 1.5
0.47
Suzuki Alto 1.0
0.24
Renault Twingo 1.2
inj
Hyundai Atos Multi
1.0
0.33
0.28
0.27
Cost per kilometre including gas, maintenance, debit, etc. Price level 2002.
Calculations based on over 2,5 years use and 40.000 km.
(Consumentenbond, Augustus 2003)
20
Is cost effectiveness important?
 Indeed other factor are also important:
– Burden of disease
– Budget impact
30
25
20
15
10
5
0
Accepted
High burden
Rejected
Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
21
Burden of Disease and Budget Impact
are imbedded in cost effectiveness
 Burden of disease
– In term of cost
• Uses same cost prises estimates
– In term of quality of life
• Uses same generic quality of life estimates
• EQ-5D
 Budget impact
– Uses same cost prises estimates
– Plus estimates of prevalence
22
Burden of disease: EQ-5D
Normal population
HIV
Schizophrenia (treated)
Diabetes II
Parkinson
Lung cancer
Personality disorder
Rheumatic disease
Heamodialysis
Major depression
0
0.2
0.4
0.6
0.8
Soeteman et al. Journal of Personality Disorders. 2007 in press.
Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
23
1
Cost of illness
Total costs per patient
Personality disorder
Anxiety
Depression
€0
€2,000
€4,000
€6,000
€8,000 €10,000 €12,000
Soeteman, et al. Journal of Clinical Psychiatry, 2007 in press
24
Cost effectiveness becomes more
important
1980[pdat] AND (QALY or QALYs)
Publications per year
600
500
400
300
200
100
0
1980
25
1985
1990
1995
2000
2005
2010
Reimbursement of pharmaceuticals
in Australia
300000
cost/QALY (Austr $)
250000
200000
150000
100000
50000
0
0
Recommended
1
at price
Recommended
2
at lower price
Funding decision
26
Rejected
3
4
Arguments not to employ cost
effectiveness research…
 It has already been shown..
– We know that psychotherapy is cost effective in PD
 The methods are unfavourable for psychotherapy
– The outcome measures (QALYs) are not sensitive for
changes in personality
 It is not important
– It does not matter in reimbursement decisions
 It is complex…
– An incremental cost effectiveness ratio from a probabilistic
Markov Model with a multiple sensitivity analysis….
27
Models can be complex….
As it tries to model real life…..
28
Model of Soeteman et al,
ISSPD conference The Hague
€ 15,560
Psychotherapy
€0
0.02
0.11
0.62
Death
mr[age]
€ 5,979
0
Recovered
mr[age]
€ 11,279
0.81
0.02 + mr[age]
Improved,not
mr[age]
recovered
0.25
€ 9,319
-0.03
Unchanged /
deteriorated
0.67
29
-0.03
0.71
We want both costs and effects….
High costs
Forget it !
Good
Better
Bad effects
Good effects
Difficult…
SUPER !
Low costs (savings)
30
Multiple sensitivity analysis
High costs
Forget it !
Good
Better
Bad effects
Good effects
Difficult…
SUPER !
Low costs (savings)
31
Psychological therapies […] for borderline
personality disorder: a systematic review and
preliminary economic evaluation
 John Brazier, Prof in Health Economics
– Leading institute, University of Sheffield
– January, 2007
 On the basis of an extensive review
 Converted all existing evidence into a health
economic model
– “The results for [psychotherapy] are promising,
though […] surrounded by a high degree of
uncertainty. There is a need for considerable
research in this area.”
32
Cost effectiveness plane, Brazier, 2007
Not so good…
Forget it !
Good
Better
SUPER !
33
Cost effectiveness threshold, Brazier, 2007
Our uncertainty about the cost
effectiveness is not (further) determined
by willingness to pay, but by the
uncertainty of our own research results
34
Arguments to employ cost effectiveness
research…
 We should research whether psychotherapy is cost
effective in PD
– It has already been shown..
 The methods are favourable for psychotherapy
– The methods are unfavourable for psychotherapy…
 It is important
– It does not matter in reimbursement decisions…
 It is complex…
– It is not of our psychotherapeutic world
– It is more the outside world…
35
Let convince the outside world,
before the outside world convinces
us…..
Hopeful, but incomplete
 Psychotherapy appears to have a beneficial impact on a variety
of costs […in…] borderline personality disorder.
– Reviews of Gabbert et al., AJP, 1997
– Note: no integration with effects
 "Until […] there is conclusive evidence of the efficacy and the
cost-effectiveness of long-term psychotherapy, restraint needs
to be exercised in administering such therapy [in personality
disorder]."
– Dutch Health Council, 2001
 The results for [psychotherapy] are promising, though […]
surrounded by a high degree of uncertainty. There is a need for
considerable research in this area.
– Brazier, 2007
37