Transcript Dia 1 - de Viersprong

Cost-effectiveness of psychotherapy for
personality disorders
Djøra Soeteman
Viersprong 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
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%
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
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)
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Effect
Psychotherapy dosage
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% 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
Psychotherapy dosage
% recovered after 12
months
Costs (€)
Long-term outpatient
19%
64,735
Short-term day hospital
26%
46,131
Long-term day hospital
37%
45,442
Short-term inpatient
61%
32,837
Long-term inpatient
41%
57,285
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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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Quality Adjusted Life Years (QALY)
 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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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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Interested in both costs and effect
High costs
Forget it!
Good
Better
Less effective
Difficult…
More effective
Superb!
Low costs (savings)
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Sensitivity analysis
High costs
Forget it!
Good
Better
Less effective
Difficult…
More effective
Superb!
Low costs (savings)
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Cost-effectiveness plane
€ 250,000
Good
€ 200,000
long out
€ 150,000
Cost
short day
long day
short in
€ 100,000
long in
€ 50,000
Better
€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
Acceptability curve
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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 (€)
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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 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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Cluster B PD
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Acceptability curve
1
Probability cost-effective
0.9
0.8
0.7
0.6
Outpatient
Day hospital
0.5
Inpatient
0.4
0.3
0.2
0.1
0
Societal WTP for a QALY (€)
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Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
Modality of
psychotherapy
Outpatient
Day hospital
Inpatient
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Costs per QALY
(threshold value
€0 – €56,325)
Costs per QALY
(> €56,325)
1st choice
1st choice
Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
Modality of
psychotherapy
Outpatient
Day hospital
Inpatient
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Costs per QALY
(threshold value
€0 – €56,325)
Costs per QALY
(> €56,325)
1st choice
Costs per QALY
(threshold value
of €40,000)
1st choice
1st choice
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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