Transcript Intro QALY & need assessment

(Cost-)Effectiveness of
Psychotherapy for Personality
Disorders
Prof. dr. Jan van Busschbach
Department of Medical Psychology & Psychotherapy
Erasmus MC
+31 10 7043807
[email protected]
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De Viersprong
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De Viersprong
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Personality Disorders
 Related
to social interactions…
 Inflexible and pervasive behavior and thoughts
 Maladaptive coping skills
 Unable to switch perspective
• Mentalization
• “Unable to stand in some others shoes”
 Insecure
attachment in child hood
 Inadequate representation of social rules
 Functional in family, not functional outside
 Genetic vulnerability
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Borderline
Fatal Attraction, 1987, Michael Douglas, Glenn Close
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10 personality disorders
 Cluster
A:odd or eccentric
 Cluster
B: dramatic, emotional or erratic
 Paranoid
 Schizoid: lack of interest in social relationships
 Schizotypal: odd behavior or thinking
 Antisocial: disregard for the law and the rights of others.
 Borderline: "black and white" thinking, instability in relationships,


self-image, identity and behavior often leading to self-harm and
impulsivity.
Histrionic: pervasive attention-seeking
Narcissistic
 Cluster
C: anxious or fearful disorders
 Avoidant
 Dependent
 Obsessive-compulsive
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High economic burden
5% – 14%
 € 7500 per year
 Prevalence:
 If treatment seeking
Soeteman DI, Hakkaart-van Roijen L, Verheul R, Busschbach JJ. The Economic Burden of Personality
Disorders in Mental Health Care. J Clin Psychiatry. 2008 Feb;69(2):259-65
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Low quality of life
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
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Not theories but “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
 Yet
...
of therapy relates to costs
 Relation between costs and effects is rarely investigated
Randomization failed
 RCT
 3 month in patient treatment
 Out patient treatment
 Patients
preference dominate
 Patients
SES influences treatment allocation
 After 1,5 year, 1 patient included
 Van Manen et al.Relationship between patient characteristics
and treatment allocation for patients with personality
disorders. Journal of Personality Disorders (in press)
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SCEPTRE
 Study
on Cost-Effectiveness of Personality
Disorder Treatment
 Naturalistic study
 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?
Multiple propensity score
K
groups
 K – 1 Propensity scores
 1 reference score
 PS
as dummy
 Co-variate
 2 PS score per bilateral
comparison
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
5
groups in cluster B
 Inpatient
 Day-hospital
 Outpatient
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, 2011 Oct 23;80(1):28-38.
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
GSI - Difference score
Treatment
group
Long
outpatient
Short day
hospital
Long day
hospital
Short day
hospital
-0.0770
Long day
hospital
-0.1278
-0.0508
Short inpatient
0.3035
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
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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
28
50
60
70
80

EQ-5D

The EuroQol EQ-5D is
specially designed to
measure the quality
of life index for
QALYs





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




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MOBILITY
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…..
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
Little difference
Much difference
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)
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Cost effectiveness Cluster C
Conclusion
 Cost-effective
 Cluster
treatment strategies are:
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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