Transcript Intro QALY & need assessment

A Health Economic View on
Borderline Personality Disorder
Prof. dr. Jan Busschbach
Viersprong Institute for studies on Personality Disorders
Medical Psychology and Psychotherapy
Erasmus MC
1
2002: Two books, and a hand full
of articles
2002: no state-of-the-art studies
 Studies
did not follow guide lines
 Articles and books often promoted state-of-the-art studies…
• ..but did not present results
 No
use of health economic relevant outcomes
 Effects not expressed as QALYs

• No comparison possible with somatic diseases
No societal cost involved
• Not all costs
3
2006
 Systematic
review and preliminary economic
evaluation
 Borderline personality disorder
 John Brazier, Sheffield, 2006
 Based
on the first studies MBT
 Bateman also presented some costs data
 No QALYs
• 2003
4
Cost offset by less care elsewhere
5
Full health economic model
 John
Brazier added:
 QALYs
 All cost
 Simultaneously testing of all uncertainty
• Cost
• Effects
6
We want both costs and effects….
High costs
Good
Forget it !
Better
Bad effects
Good effects
SUPER !
Cost effective savings …
Low costs
(savings)
7
Multiple sensitivity analysis
High costs
Forget it !
Good
Even Better
Bad effects
Good effects
SUPER !
Cost effective savings …
Low costs
(savings)
8
Probability being cost effective
Change being cost effective
1.0
0.0
Willingness to pay for effects
9
Cost effectiveness plane, Brazier, 2007
Not so good…
Forget it !
Good
Better
SUPER !
10
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
11
Conclusion 2007

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.”
 Cumulative
evidence can be classified
as “a promise”
 John Brazier
12
2012: More health economics…
Borderline Personality Disorder/economics[MeSH Terms] OR
Personality Disorders/economics[MeSH Terms]
12
Publications
10
8
6
4
2
0
1990
1995
2000
2005
2010
2015
13
2012: better health economics…
 State
of the art studies (in Borderline)
 Palmer, Davidson, Tyrer, 2006


5
• Cognitive behavior therapy
• University of York
Van Asselt, Giesen-Bloo, Arnzt et al, 2008
• Schema-focused vs transference-focused
• University of Maastricht
Soeteman, Busschbach, Verheul et al, 2010
• Out patient, day hospital, in-patients
• Erasmus MC
to 7 others…
 Bit not in BPD, or with lower quality
Palmer, Davidson,Tyrer
 Adding
cognitive behavior therapy
 Gives lower costs, and lower quality of life
 TAU has more changes on being cost effective
Van Asselt, Giesen-Bloo, Arntz
 Schema-focused
vs transference-focused
16
Bartak, Busschbach, Verheul, 2011
 Cluster
B patients
 Most effect in-patients psychotherapy
 Then day hospital
 Then out patients
17
Soeteman, Busschbach, Verheul
 Low
willingness to pay: Out-patient
 High willingness to pay: Day hospital
18
Favorable results in Borderline
 Additional
CBT is not cost effective
 Schema focus is cost effective
 Out patient is cost effective
 Day hospital also, with high willingness to pay
Why not general accepted?
 Only
three studies
 Cost effectiveness is not all that counts…
 Other issues
 Burden of disease
 Prevalence


• Budget impact
Own influence on health
• Perceived own influence
Consensus in the field
Burden of disease
 Willingness
to pay is function of burden
Costs/QALY versus Burden of disease
X
€ 80.000
X
€ 60.000
X
€ 40.000
X
€ 20.000
€
X
0
Burden of disease
22
Dutch Council for Public Health and
Health Care (RvZ, 2006)
23
Need to demonstrate Burden
 Burden
often demonstrated in technical terms
 Disease specific questionnaire results, jargon
 But
we need comparisons with (somatic)
diseases

 Generic measures


 EuroQol EQ-5D
 Health Utility Index
 SF-6D
MOBILITY



SELF-CARE




I have no problems with self-care
I have some problems…..
I am unable…
USUAL ACTIVITIES




I have no problems in walking about
I have some…….
I am confined to bed
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…..
24
Burden is considerable
Soeteman et al. Assessment of the burden of disease among inpatients in specialized units
that provide psychotherapy. Psychiat Serv. 2005 Sep;56(9):1153-5
25
Prevalence
 Prevalence
relates to:
 Budget impact


• The higher the budget impact, the more risk avers policy
makers become
Burden
• “If it is so common: why don’t I see al that misery?”
Own influence on disease
• “If it is common, others seem to deal with it…”
• “So why paying for treatment?”
 Being
enthusiastic about a high prevalence….
 ….might not be such a good idea
 And… in fact we do not know the prevalence of people that need
treatment…
Orphan drugs
 Pompe
disease
 Classical form: € 300.000 – 900.000 per QALY
 Non classical form: up to € 15.000.000 per QALY
 If maximum = € 80.000
• Ration is almost 1:200
 Low
cost effectiveness but…
 High burden
 Low prevalence
 Little own influence on disease
 High consensus in the field
• Coalition patient, industry, doctors and media
• Low perceived incertainty
27
What can we do now?
 We
can claim cost effectiveness
 We
can claim a high burden
 But 3 state-of-the-art cost effectiveness analysis in Borderline
 More research is on its way
 But investigation in the burden of disease is limited
 Be
restrictive with proclaiming high
prevalence
 Are all those people patients in need of treatment?
 What is the prevalence of patient in need of treatment?
 Try
to find consensus in the field
28
Can we improve cost effectiveness?
 Research
into cost effective components of
therapy
 Like adding CBT (See Palmer, 2005)
 What is the added value of for instance ‘drama therapy’
 Research
in the amount of therapy needed
 Volume drives costs
 See Soeteman et al, / Bartak et al.
29
Stop rules
 We
seem to know when a therapy is needed
 But do we know when to stop?
 If all the ‘potential’ of the patient is reached?
Within social health insurance
 Reasonable
stop rules might be:
 When no progress is made anymore
 When the patient is comparable with the general population
• > 5 – 10%
 For
this we need to monitor the patient
 ….frequently during therapy
 Looks like Routine Outcome Measure


• but with a high frequency
Monitor progress
Monitor position patients / normal population
31
Monitoring reduces the number
of treatments
 Michael
N
= 400
Lambert
 Kim de Jong et al in press
 Erasmus MC
…and gives better results
Feed back
Non feed back
33
Conclusion
 Cost
effectiveness in Borderline is on the
break of establishment
 We should ‘carefully’ claim cost effectiveness and a high
burden
 We
are in need of research into
 Cost effectiveness
 Burden of disease
 Research
focus on dosages
 Number of sessions, length of treatment
 Monitoring can be of help here
 We
should be careful with
 Statements about high prevalence