Transcript Dia 1 - de Viersprong

Economic evaluation of psychotherapy
for personality disorders:
burden of disease, cost-effectiveness, and value of
information and implementation
Djøra Soeteman
Viersprong Institute for Studies on Personality Disorders
Erasmus Medical Center, Rotterdam
Center for Health Decision Science, Boston, MA
Boston, December 2, 2009
1
Efficient health care provision
 Three questions need to be addressed:
- Which treatments are cost-effective and should be
adopted? (reimbursement decision);
- Is it worthwhile to conduct additional research
(research decision);
- Is it cost-effective to implement treatments into clinical
practice (implementation decision).
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Reimbursement decision
3
Reimbursement decision
Necessity
Effectiveness
Cost-effectiveness
Reimbursement
decision
4
Reimbursement decision: 3 criteria
 Necessary care
– How severe is the disease?
 Effectiveness
– Is treatment effective?
 Cost-effectiveness
– Are the effects worth the costs?
5
Reimbursement decision: criterion 1
 Necessity: how severe is the disease?
– Is it a common disease? (prevalence)
– Does the patient suffers? (individual burden)
– What are the costs? (economic burden)
6
Prevalence
 Prevalence in the general population: 13,5%
– Verheul et al., 1999
 Treatment seeking: 19,1%
– in the year prior to interview
– Andrews et al., 2001
 422.285 patients in the Netherlands
– Prevalence x population x treatment seekers
– 13,5% x 16.377.153 x 19,1%
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Individual burden
General population
HIV infected pt
Schizophrenia outpatients
(treated with neuroleptics)
Type II diabetes
Parkinson’s disease
Lung cancer
Personality disorders
Rheumatic disease
Pt with renal failure on heamodialysis
Major depressive disorder
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
EQ-5D score
Soeteman et al., 2008 The burden of disease in personality disorders: diagnosis-specific quality of life. Journal of
Personality Disorders, 22, 259-268
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Relation between funding and burden
30
25
20
15
10
5
0
Accepted
High burden
Rejected
Low burden
Pronk et al., 2004 Outpatient drug policy by clinical assessment rather than financial constraints. Eur J Health
Econom, 5, 274-277
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Economic burden
Mean annual costs per patient
€ 12,000
€ 10,000
Costs (€)
€ 8,000
Total costs
Direct
Indirect
€ 6,000
€ 4,000
€ 2,000
€Personality disorders
Schizophrenia
Depression
Generalized
anxiety disorder
Soeteman et al., 2008 The economic burden of personality disorders in mental health care. Journal of Clinical
Psychiatry, 69, 259-265
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Total societal costs




Health care utilization
Productivity losses
Criminal justice resources
Total annual costs
€ 3,12 billion
€ 0,24- € 3,60 billion
€ 0,27 billion
+
€ 3,6- € 7,0 billion
(conservative estimate not included e.g., costs of
non-treatment seekers, intergenerational transfer)
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Reimbursement decision: criterion 1
 Necessary care
– Highly prevalent
– Low quality of life
– High societal costs
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Reimbursement decision: criterion 2
 Necessary care
– Highly prevalent
– Low quality of life
– High societal costs
 Effectiveness
– Is treatment effective?
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14
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Evidence for effectiveness
Broad
spectrum
Borderline
PD
Avoidant
PD
Outpatient
individual
++++
++++
-
Outpatient
group
++
+++
+++
++++
+++
-
+++
-
-
Day hospital
Inpatient
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Reimbursement decision: criterion 2
 Necessary care
– Highly prevalent
– Low quality of life
– High societal costs
 Effectiveness
– Psychotherapeutic treatments are effective
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Reimbursement decision: criterion 3
 Necessary care
– Highly prevalent
– Low quality of life
– High societal costs
 Effectiveness
– Psychotherapeutic treatments are effective
 Cost-effectiveness
– Are the effects worth the costs?
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Current evidence?
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Current evidence ‘a promise’
Brazier et al., 2007
 John Brazier, Prof. of Health economics.
– University of Sheffield
– Psychological therapies […] for borderline
personality disorder: a systematic review and
preliminary economic evaluation
 Integrating existing evidence in health
economic model
– “The results are promising [for psychotherapy],
though […] surrounded by a high degree of
uncertainty. There is a need for considerable
research in this area.”
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First (!) state-of-the-art cost-effectiveness
study from the Netherlands
 RCT Van Asselt et al., 2008 (BJP)
– Compared Transference-Focused Psychotherapy and
Schema-Focused Therapy for borderline PD
 % recovered after 4 years
– SFT: 52.3%
– TFP: 28.6%
 Treatment costs
– SFT: € 12,946
– TFP: € 10,876
 Total costs over 4 years
– SFT: € 37,826
– TFP: € 46,795
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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
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Cluster C PD
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Different dosages






Short-term outpatient
Long-term outpatient
Short-term day hospital
Long-term day hospital
Short-term inpatient
Long-term inpatient
 Short-term < = 6 months
 Long-term > 6 months
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excl.
21.4%
19.0%
23.0%
14.1%
22.5%
Model structure
 Markov
25
model: 5-year time horizon
Different costs
Psychotherapy dosage
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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
Total costs over 5 years
Psychotherapy
dosage
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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
Effect over 5 years
Psychotherapy dosage
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QALYs
Long-term outpatient
3.30
Short-term day hospital
3.44
Long-term day hospital
3.49
Short-term inpatient
3.57
Long-term inpatient
3.49
Costs per QALY
Psychotherapy
dosage
QALYs
Costs per QALY
(€)
Long-term outpatient
3.30
27,239
Short-term day hospital
3.44
26,027
Long-term day hospital
3.49
30,353
Short-term inpatient
3.57
25,674
Long-term inpatient
3.49
34,350
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Uncertainty
€ 250,000
€ 200,000
long out
€ 150,000
Cost
short day
long day
short in
€ 100,000
long in
€ 50,000
€0
2.8
2.9
3.0
3.1
3.2
3.3
QALYs
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3.4
3.5
3.6
3.7
3.8
CEAC
1
Probability cost-effective
0.9
0.8
0.7
Long outpatient
0.6
Short day hospital
Long day hospital
0.5
Short inpatient
0.4
Long inpatient
0.3
0.2
0.1
0
Societal WTP for a QALY (€)
31
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 choice
Long-term day hospital
Short-term inpatient
Long-term inpatient
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1st choice
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)
1st choice
1st choice
Long-term outpt
Short-term day h
1st choice
Long-term day h
Short-term inpt
Long-term inpt
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Conclusion
 Cluster C PD
 Cost-effective treatment strategies are:
– Short-term inpatient psychotherapy (first choice)
– Short-term day hospital psychotherapy
 Sub-optimal treatment options are:
– Long-term day hospital and long-term inpatient
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Reimbursement decision: 3 criteria
 Necessary care
– Highly prevalent
– Low quality of life
– High societal costs
 Effectiveness
– Psychotherapeutic treatments are effective
 Cost-effectiveness
– Cost-effective treatment strategies for cluster C PD are
available
35
Research decision
36
Decision uncertainty
 Uncertainty in cost-effectiveness
– Current information on costs and effects is imperfect
1
0,9
Probability cost-effective
0,8
0,7
0,6
Short day hospital
0,5
Short inpatient
0,4
0,3
0,2
0,1
Societal WTP for a QALY (€)
37
0
10
0.
00
90
.0
00
80
.0
00
70
.0
00
60
.0
00
50
.0
00
40
.0
00
30
.0
00
20
.0
00
0
10
.0
00
0
EVPI
Population EVPI (€)
Million
 Population expected value of perfect information
800
700
600
500
400
5-year
300
200
100
0
0
20.000
40.000
60.000
80.000 100.000 120.000 140.000
Societal WTP for a QALY (€)
38
EVPPI
Million
 EVPI for parameter groups
700
600
pEVPPI (€)
500
400
300
200
100
0
Overall EVPI
Transition
probabilities
Treatment costs
Parameter groups
39
Health state
costs
Health state
utilities
Implementation decision
40
EVPIM
Population EVPI (€)
Million
 Population expected value of perfect implementation
3.000
2.500
2.000
pEVPI
1.500
pEVPIM
1.000
500
0
0
20.000
40.000
60.000
80.000
100.000 120.000 140.000
Societal WTP for a QALY (€)
41
Efficient health care provision
 Recommendations based on three questions
– Based on currently available evidence: short-term
inpatient psychotherapy is the most cost-effective
choice (at threshold value of €40,000 per QALY)
– Before implementing this cost-effective treatment
strategy into clinical practice, further research is
valuable especially when prioritizing information on
treatment costs and transition probabilities.
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