Cost-effectiveness of psychotherapy for personality disorders

1

• 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

2
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

3

• Cluster C PD

4
Different dosages

• Short-term outpatient excl.
• Long-term outpatient 21.4
• Short-term day hospital 19.0
• Long-term day hospital 23.0
• Short-term inpatient 14.1
• Long-term inpatient 22.5
• Short-term lt 6 months
• Long-term gt 6 months

5
Different costs
Psychotherapy dosage 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
6
Total costs over 5 years
Psychotherapy dosage 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
7
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?

8
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)

8
9
Effect
Psychotherapy dosage 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
9
10
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
10
11
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

12
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

12
13
Effect over 5 years
Psychotherapy dosage 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
14
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
15
Interested in both costs and effect
Good
Forget it!
Better
Difficult
Superb!
16
Sensitivity analysis
Forget it!
Good
Better
Difficult
Superb!
17
Cost-effectiveness plane
Good
Better
17
18
Acceptability curve
19
Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
Psychotherapy dosage Costs per QALY (threshold value 0 16,570) Costs per QALY (gt 16,570)
Long-term outpatient
Short-term day hospital 1st choice
Long-term day hospital
Short-term inpatient 1st choice
Long-term inpatient
20
Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
Psychotherapy dosage Costs per QALY (threshold value 0 16,570) Costs per QALY (gt 16,570) Costs per QALY (threshold value of 40,000)
Long-term outpt
Short-term day h 1st choice
Long-term day h
Short-term inpt 1st choice 1st choice
Long-term inpt
21

• Cluster B PD

22
Acceptability curve
23
Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
Modality of psychotherapy Costs per QALY (threshold value 0 56,325) Costs per QALY (gt 56,325)
Outpatient 1st choice
Day hospital 1st choice
Inpatient
24
Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
Modality of psychotherapy Costs per QALY (threshold value 0 56,325) Costs per QALY (gt 56,325) Costs per QALY (threshold value of 40,000)
Outpatient 1st choice 1st choice
Day hospital 1st choice
Inpatient
25
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