Economic evaluation of psychotherapy for personality disorders: burden of disease and costeffectiven

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• Economic evaluation of psychotherapy for
  personality disorders burden of disease and
  cost-effectiveness
• Djøra Soeteman
• Viersprong Institute for Studies on Personality
  Disorders
• Erasmus Medical Center, Rotterdam
• Harvard School of Public Health, Boston, MA
• Rome, October 11, 2009

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Reimbursement decision
Necessity
Effectiveness
Cost-effectiveness
Reimbursement decision
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Reimbursement decision 3 criteria

• Necessary care
• How severe is the disease?
• Effectiveness
• Is treatment effective?
• Cost-effectiveness
• Are the effects worth the costs?

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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)

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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
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
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
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 3,12 billion
• Productivity losses 0,24- 3,60 billion
• Criminal justice resources 0,27 billion
• Total annual costs 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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Evidence for effectiveness
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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)
• Decision analytic (Markov) model 5-year time
  horizon
• 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 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

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Different costs
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Total costs over 5 years
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Only costs?

• Health 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?
• 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
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Costs per recovered patient year
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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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Example of QALY gain because of treatment

• QALYs gained blue area

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QALY league table
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Effect over 5 years
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Costs per QALY
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Interested in both costs and effect
Good
Forget it!
Better
Difficult
Superb!
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Sensitivity analysis
Forget it!
Good
Better
Difficult
Superb!
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Cost-effectiveness plane
Good
Better
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Acceptability curve
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Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
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Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
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• Cluster B PD

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Acceptability curve
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Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
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Cost-effectiveness of different modalities of
psychotherapy for cluster B PD
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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

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Conclusion

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs
• Effectiveness
• Psychotherapeutic treatments are effective
• Cost-effectiveness
• There are cost-effective treatments for cluster B
  en C PD

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• www.vispd.nl