Transcript Dia 1 - XS4ALL
(Cost-)Effectiveness of Psychotherapy for Personality Disorders Jan van Busschbach
Prof. Dr. J. van Busschbach Department of Medical Psychology and Psychotherapy Erasmus MC PO Box 2040 3000 CA Rotterdam +31 10 7043807 (direct: 7044306) [email protected]
An different mindset: Comparing “dosages”
Usually ...
– Comparison between theoretical orientation of therapy
Typically ...
– Amount of therapy is keep constant
This assumes ...
– amount of therapy is relevant
Little differences
– Nonspecific factors seems to drive treatment success
Amount of therapy relates to costs Yet ...
– Relation between costs and effects is rarely investigated
SCEPTRE
Study on Cost-Effectiveness of Personality Disorder Treatment Start: March 2003 6 clinics
SCEPTRE
About 900 patient with PD Followed over 3 years Dosages compared
– Outpatient, day-hospital and inpatient psychotherapy – Shorter than or equal to 6 months, longer than 6 months
Clusters
– A; N = 58 – B; N = 241 – C; N = 466
Naturalistic design
In need of a super covariate
Question to clinician:
– “What are the important variables for treatment allocation?”
Answer:
– “Everything is important!”
How to control for everything?
– “We are in need of a super covariate”
Correction for selection bias
Propensity score
– A sophisticated co-variance analysis – Combines several co-variates – To correct for baseline differences
If successful
– Results can be interpreted as an RCT
Several checks on validity Often used in
– (health) economics – Epidemiology
Super Covariate: the propensity score
Age Sex Diagnosis (SIDP-IV) Baseline GSI Motivation Measures of pathology
– DAPP-BQ; SIPP; OQ-45
Quality of life (EQ-5D)
Can super covariate fly?
Psychotherapy and Psychosomatics, 2009 Separate PhD, 2010 Medical Care, 2010
Cluster A: one of the largest studies ever
Bartak, et al. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster A personality disorder. Accepted for publication
Psychotherapy and Psychosomatics
But assumptions are not met in cluster A
Assumptions met in:
3 groups in cluster B
– Inpatient – Day-hospital – Outpatient
5 groups in cluster C
– Short-term inpatient – Long-term inpatient – Short-term day-hospital – Long-term day-hospital – Long-term out-patient
Results cluster B
Bartak et al. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorder.
Psychotherapy and Psychosomatics, in press
But no significant results in cluster B…
Differences diminish till P = 0.06
– After correction with the propensity score – Complicates conclusions
Assumptions of propensity score are met
– Effect are reduces after correction
But costs could make the difference…
Results cluster C
Corrected rsults C
Treatment group Short day hospital Long day hospital Short inpatient GSI - Difference score Long outpatient Short day hospital Long day hospital -0.0770
-0.1278
0.3035
-0.0508
0.3805** 0.4313** Long inpatient -0.0030
0.0740
0.1247
* p < 0.05 ** p < 0.01 *** p < 0.001
Short inpatient -0.3065*
Propensity escore in cluster C
Better effects of short-term inpatient psychotherapy remain significant Assumptions propensity score are met
– Results maintain
But costs could still make a difference…
Conclusions: effects
No comparison possible in cluster A
– But psychotherapy seems to work – Inpatient / day hospital seems better
Non difference in B (after correction)
– But costs can be decisive ….
Cluster C
– Favorable results for short-term inpatient psychotherapy – Expect to dominates long in-patient – But is short-term inpatient worth the costs?
• Compared to long day hospital / short day hospital
QALY
Health economics addresses the efficient allocation of health care resources For instance
– Psychotherapy “long” versus “short” – “Psychotherapy in PD” versus “Care for diabetics”
Make effects comparable
– Same effect parameter in diabetes as in PD
Survival and Quality of Life Combined: Quality Adjusted Life Years (QALY)
QALY
Quality Adjusted Life Years Area under the curve 0,3 0,2 0,1 0 1 0,9 0,8 0,7 0,6 0,5 0,4 0 10 20 30 40 Life years 50 60 70 80
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Co-morbidity With psychotherapy No psychotherapy
EQ-5D
The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs
MOBILITY
– I have no problems in walking about – I have some……. – I am confined to bed
SELF-CARE
– I have no problems with self-care – I have some problems….. – I am unable…
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…..
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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,
2008;22:259-68 . Soeteman et al.
Psychiatric Services,
56, 1153-1155, 2005
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Markov model Cluster B
Soeteman et al. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396 –403.
Costs and effects in Cluster B
Cost per QALY
Costs and effects Cluster C
Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press) 25
Cost effectiveness Cluster C
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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