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Title: Issues and Challenges in the Economics of Prevention and Treatment: Five Studies


1
Issues and Challenges in the Economics of
Prevention and Treatment Five Studies
  • E. Michael Foster and numerous collaborators
  • 4th Biennial Niagara Conference
  • July, 2005

www.personal.psu.edu/emf10/ foster_at_pop.psu.edu
2
Five Studies
  • Family Bereavement Project
  • Success Through IY
  • Fast Track Intervention
  • Incredible Years
  • MTA

3
There are many economic questions one might
consider
  • What is the most cost-effective research design?
  • What does an intervention cost (efficacy)?
  • What does an intervention cost II
    (effectiveness)?
  • Inputs (personnel, space)?
  • Scale?
  • How do those costs vary?

4
There are many economic… (cont)
  • Is an intervention cost-effective?
  • Does an intervention reduce the costs of illness?

5
Isnt this obvious? NO
  • Costs are experienced now, but benefits
    experienced in the future
  • (aside Olds NHV)
  • Prevention involves treating some individuals who
    will not experience the disorder
  • (aside low-income women in NHV)
  • Too many programs are cadillacs

6
1. Estimating the Costs of an Intervention
  • Family Bereavement Program
  • Success through the Incredible Years

7
Content of Presentation
  • Steps in Estimating Costs
  • Principles Shaping Estimation of Costs
  • Overview of the Incredible Years
  • Scope of study
  • Sources of data
  • Challenges in developing a cost framework
  • Results for teacher and parent training

8
Steps in Estimating Costs
  • Establish the perspective and scope of study
  • Identify the program inputs
  • Measure the use of these resources
  • Value the resources in terms of marginal,
    opportunity costs
  • Conduct sensitivity analyses

9
Principles of Sound Estimation
  • Perspective and scope of the costs analyses
    should be clearly stated
  • Costs should be presented for each of several
    perspectives, including the social perspective
  • Costs should be estimated for the program as
    delivered, but
  • Sensitivity analyses could include an attempt to
    estimate real-world costs

10
Principles of Sound Estimation of Costs
  • Relevant costs are marginal costs
  • Costs should not be double-counted
  • Costs of intervention development and of
    implementation should be tracked separately
  • Costs should be described in sufficient detail
    such that the reader can understand key
    assumptions and limitations.

11
Overarching Questions
  • What do high-quality interventions cost?
  • How large are implicit (or time) costs?
  • What would these programs cost in the real world?
  • How large are those costs relative to
  • the costs of clinical services?
  • the costs of illness?
  • the programs benefits?

12
1. Estimating the Costs of a Behavioral
Intervention The Family Bereavement Program
  • E. Michael Foster, Michele Porter, Tim S. Ayers,
    Debra Kaplan, Irwin N. Sandler

Research Supported by NIMH Grant P30- MH39246 for
a Prevention Research Center and NIMH Grant R0-
MH49155 to evaluate a preventive intervention for
bereaved children
13
Family Bereavement Program as an Example
  • Plan is to
  • Provide a brief overview of our efforts to
    estimate costs of FBP
  • Describe methods used in calculating the costs of
    FBP
  • Develop estimates of the costs of program
    development
  • Share cost estimates for delivering this
    preventive intervention in an efficacy trial

14
Family Bereavement Program as an Example
  • Goal is to
  • improve the practice and reporting of cost
    estimates of prevention programs
  • highlight issues to consider in designing and
    conducting efficacy trials that might improve the
    transition to effectiveness trials

15
Design of Efficacy Trial
  • Random assignment to
  • Psychoeducational group intervention
  • Comparison condition was a guided reading program
    (bibliotherapy)
  • Recruitment through schools, bereavement support
    agencies, mental health agencies, hospices,
    victim assistance programs etc.
  • Two clinical pilots were conducted prior to start
    of efficacy trial.

16
Design of Efficacy Trial
  • Recruitment occurred over course of three years
  • Six cohorts of intervention/comparison
  • 3 assessments pre, post and 11 month follow-up

17
Family Bereavement Program
  • Small group, psychoeducational format
  • Separate groups for parents, children and
    adolescents
  • 12 group sessions
  • 2 individual sessions for each participant
  • Delivered over 3 month period

18
Facilitators and Training
  • Intervention groups co-lead by two MA level
    clinicians who served as facilitators
  • Received 40 hrs of training prior to start of
    program
  • Received 2 hrs of training and 1.5 hrs of group
    supervision per week

19
Perspective of FBP Cost Analysis
  • Perspective of a public agency or funding source
    adopted
  • Focus on explicit costs personnel, consultants,
    benefits, intervention direct expenses, travel,
    miscellaneous supplies and equipment
  • Social perspective includes some implicit costs.
  • E.g. intervention space, volunteered time by
    faculty, clinical staff for supervision and
    project management purposes, plus the associated
    fringe benefits
  • Interest in estimating real world costs so these
    were important to calculate

20
Perspective of FBP Cost Analysis
  • Participant time was not calculated which would
    typically be included in a societal perspective
  • Debated this decision to include participant
    time ultimately did not have good data on time
    spent outside of group in intervention activities

21
Calculation of FBP Intervention Costs
  • Budget spread sheets used to enumerate project
    inputs and payments
  • Available for September 1994 through August 2000.
  • Enumerated project inputs

22
Calculation of FBP Intervention Costs
  • All FBP costs were separated into development,
    intervention and research
  • Research expenses were tracked and removed.
  • Each budget year was divided into both explicit
    and implicit categories

23
Explicit and Implicit Costs
  • Explicit (examples)
  • Salaries
  • Fringes
  • Implicit
  • Volunteer clinical supervisors time
  • Faculty time (2 PIs) that was not charged to the
    grant
  • University space and overhead

24
Explicit Expenses
  • Research only expenses e.g. travel for
    interviewers, subject fees, professional books,
    statistical software costs.
  • Intervention only expenses e.g. printing
    handouts and manuals, catering of meals,
    counseling referral services, transportation to
    group, snacks and incentives.

25
Study Periods Delineated
June 94
Dec 95
Jan 96
Jan 95
Dec 98
Jan 97
Jan 98
Development Period
Intervention Period
Two Pilots
Six Cohorts
  • Study periods were delineated, and costs were
    calculated for each period

26
Further Segmenting of Time Periods
  • On Time Periods high in intervention
    activities
  • Off Time Periods intervention not delivered
    and low in intervention activities.

Cohort 1
Cohort 6
Intervention Period
27
More Time Distinctions
  • Divided into
  • Pre Intervention recruitment, interviews, and
    training
  • Intervention delivery of the psychoeducational
    group
  • Post Intervention follow-up and debriefing

28
Intervention vs. Research Costs
  • Expenses were further delineated by determining
    ratio of time to development, pilot delivery and
    intervention delivery.
  • Division of supplies and materials were fairly
    straight forward to divide into research vs.
    intervention related.
  • Dividing personnel time into research vs.
    intervention was more difficult for staff
    involved in both.
  • Project Director, PI, Field Manager and Group
    Facilitators

29
Proportioning Personnel Time
  • Time diaries and time sheets recorded job tasks
    related to intervention and research
  • Project Director kept an electronic diary of time
    spent on FBP

30
Proportioning Group Facilitators Time
  • Group facilitators were required to fill out
    weekly timesheets in which they recorded time
    spent in 9 separate categories of activities
  • This information allowed us to accurately
    estimate the proportion of their time engaged in
    different intervention related tasks
  • We were able to examine these proportions for the
  • pre-intervention,
  • intervention and
  • post intervention segments
  • of the On Time Periods and across the six
    cohorts
  • All activities except time completing evaluation
    materials, e.g. process evaluations were coded as
    intervention related.
  • These proportions were applied to the actual
    payments (salary and fringe benefits) made to
    group facilitators

In advance, we tracked group facilitator time
carefully across activities. This information
will help us in estimating the costs of
delivering the program in the real world.
31
Implicit Costs
  • Although not actually expended, do reflect value
    of resources used in the delivery of the
    intervention
  • Within FBP the following reflected implicit costs
  • PIs and Co-investigators time
  • Volunteered clinical supervision
  • Cost of intervention space and overhead

32
Calculation of Implicit Costs
  • PIs Co-Investigators time spent more time
    on project than was reflected in their
    salaries/benefits
  • Volunteered Clinical Supervision
  • Two cohorts had unpaid clinical supervision
  • Valued at the standard rate and applied as
    implicit costs to these cohorts

33
Intervention Space and Overhead
  • The site at which the FBP was delivered was
    rotated between a local school and the
    university.
  • No charges, except custodial fees at the local
    schools were assigned.
  • Used standard university rental rate to value the
    use of this space
  • Local real estate analysis helped to value the
    cost of space within the schools
  • Overhead was calculated using salaries of those
    with offices.
  • A standard space/overhead -age based on local
    real estate analysis and the proportion staff
    members spent in intervention vs research
    activities was used to calculate overhead costs.

34
Estimated Costs of Intervention
  • Costs were calculated at 3 levels
  • Per family
  • Per person
  • Per hour of contact
  • Calculated from a
  • Public agency perspective
  • Societal perspective

35
Intervention Costs A Public Agency Perspective
Costs varied across cohorts. A driver was cohort
size, but costs still varied for cohorts of the
same size (e.g., c4 v. c5). Surprisingly, the
intervention costs per family were not much
higher for the pilot cohorts.
36
Intervention Costs A Societal Perspective
37
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38
1. Estimating the Costs of an Intervention
Success Through the Incredible Years
  • Deb Johnson-Shelton, E. Michael Foster and Ted
    Taylor

39
Expand on two themes
  • Magnitude of time costs
  • Sensitivity analyses

40
Overview of The Incredible Years
  • School level
  • 6 teacher workshops for 7 hours each session
  • Classroom management
  • Dinosaur School (child social skill training)
  • Family level
  • 12 parent training group sessions for 2 hours
    each session (including some self-administered
    sessions through video-taped curriculum)
  • Child-centered play, encouragement, good
    directions, and positive discipline

41
Scope of Study
  • Effort at low cost approach to implementing
    intervention
  • Modest level of supervision
  • Only one group leader
  • Experienced, trained facilitators
  • Use of existing school, community facilities
  • Time-limited intervention
  • Resources focused on teacher component

42
Evaluation of Success
  • Evaluation of targeted components
  • Longitudinal study of 162 children
  • (3 children per class X 2 classrooms X 27
    schools)
  • Participants identified as at risk in K using
    teacher reports

43
Evaluation of Success (cont)
  • Random assignment of high-risk children within
    schools
  • Data collection through
  • Annual parent interview two phone interviews
  • Through grades 2-3-4 (depending on the cohort)

44
Evaluation of Success (cont)
  • Track 648 additional children
  • (12 children per class X 2 classrooms X 27
    schools)
  • Extends data collection two years
  • Adds economic analysis of entire project

45
Challenges in Cost Assessment Valuation of
Staff, Teacher, and Parent Time
We calculated an rate (plus appropriate fringes)
per minute averaged across all persons in a
position. For example Child care providers
mean 9.9 an hour Group leaders mean 22.17
an hour Interventionists 47.04 an hour
Support staff 16.48 an hour Teachers
39.12 an hour (40,000 annual salary/170 days/8
hours) Administrator 33.20 an hour
46
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48
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49
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50
2. What Would These Programs Cost In The Real
World?
Ted K. Taylor Oregon Research Institute E.
Michael Foster
51
What Assumptions Differ from These Settings to
the Real World
  • The previous presentations highlight tracking the
    cost of implementing the intervention in research
    settings.
  • How would delivery differ in the real world?

52
1. Training Supervision Costs
  • Costs may be higher or lower depending on
  • How often training is conducted
  • How steep or flat is the learning curve

53
2. Supervision Efforts to Ensure Fidelity
  • Costs may be higher or lower depending on
  • Amount of supervision and efforts to ensure
    fidelity
  • Training level of staff

54
3. Benefits of Specialization
  • Costs may be higher or lower depending on
  • Level of specialization and how it affects staff
    performance.

55
4. Differences in Staffing
  • Costs may be higher or lower depending on
  • Terms of interventionists contracts (e.g., hourly
    v. salary)
  • In two of the previous examples, the therapist
    time is considered hourly. If groups are
    delayed, staff arent paid. This is possible with
    part-time staff, or staff that can fulfill other
    research responsibilities during that time.
  • Whether therapists are get paid during slow
    periods and/or agency can smooth work flow to
    keep staff busy.
  • Range of activities and responsibilities for
    interventionists and administrative staff.
  • Availability of low-cost labor.

56
Summary The Real World May Cost More, Not Less
  • My own belief is that doing these interventions
    in the real world may cost MORE, not less, than
    in research trials.
  • However, implementing other interventions which
    have no evidence is even more expensive to
    society.
  • The challenge will be to disseminate
    interventions in ways that maximize fidelity and
    adherence while containing costs.
  • There will be important implications for the
    effect of the intervention.

57
The Answer to these Questions
  • Likely depends on a variety of contextual factors
  • Culture of the agency
  • Economies of scale
  • Economies of scope (range of activities)
  • Nature of the local labor market

58
Costs in the Natural Service Delivery Settings
  • Two different approaches
  • Simply use different input costs based on
    standard rates in these natural service
    delivery settings
  • Calculate costs based on the assumption youd
    modify practice i.e. less clinical supervision,
    training etc.

59
Modifying Practice
Approx
  • Informal survey with agencies that provide
    bereavement related services
  • Relative to efficacy trial we ran training is
    considered a one time cost. They would not
    provide training prior to each group
  • Supervision would occur within the context of
    peer supervision within the agency and does not
    come close to approximating an hour for hour
    supervision to direct contact ratio.
  • Preparation for the intervention is considered to
    be the responsibility of the therapist.
    Therapists in order to pay themselves for
    training try to ensure that their group size is
    large enough to reimburse themselves for the time
    spent in preparation.
  • Assume that time spent in group intervention,
    doing clinical notes and all other direct contact
    would happen at the same rate.

27 4
1 --
4
11 4 2
-- 53
60
Adjustments to costs
  • Not only would Group Facilitator time need to be
    reduced
  • Time spent by faculty in training and supervision
    would also need to be reduced
  • 33 of certain faculty members time was spent in
    doing this additional training and supervision
  • Re-calculation of costs based on the adjustments
    to both Group Facilitator and Facultys time
    results in the following costs based on a public
    agency perspective
  • originally 59 per hour of contact

61
3. How Large Are These Costs Relative To Costs
Of Illness (COI)?
  • Damon Jones, Michael Foster and Elizabeth Gifford

62
Why Examine Real Costs?
  • We cannot hope to measure all benefits of an
    intervention.
  • However, a key outcome involves the behaviors
    that are costly to public sectors and society
    more generally.
  • Measuring these costs requires additional sources
    of data.

63
Measuring Direct Costs
  • Measuring frequency of service use
  • Through self-report
  • Through examination of service records
  • Applying cost estimates
  • From research
  • From examination of records

64
Methodological Issues
  • Need cooperation to examine information
  • From participants
  • From facilities
  • Need to understand/decipher information
  • Understand cost arrangements
  • Understand what records are involved
  • Need to have missing data strategy (multiple
    imputation combining sources)
  • Incorporating an oversample included in the data
    using weights

65
Cost of Illness Example
  • Using Fast Track sample
  • Service categories
  • Mental health facilities
  • General health facilities
  • Juvenile justice facilities
  • School services (IEP, counseling)
  • Medications (for emotional/behavioral issues)

66
Research Questions
  • How large are (a subset of) the COI for
    conduct-disordered children?
  • Are those costs lower for children with lower
    (sub-clinical) levels of problems?

67
Characteristics of Sample
  • Data available for many service areas
  • Data available longitudinally (grades 6-12)
  • Data for over 600 children (not including Tx
    participants)
  • Cost data available from multiple sources
  • Diagnostic grouping

68
Used Best Estimates
  • Used costs from literature review
  • Sound estimates in the literature
  • JJ (detention facility, cost of arrest) from Fass
    Pi (2000)
  • Medication costs per child Zuvekas (2001)
  • Not enough RR data to have great estimates (Day
    Treatment Center DA clinic)
  • Used costs from the record review data
  • Likely better estimates due to regional data
    (family doctor ER)
  • Lack of good information in literature (RTC
    Group Home services)

69
Characteristics of Sample (contd)
  • Used the DISC (Diagnostic Interview Schedule for
    Children)
  • Children diagnosed with/without conduct disorder
  • Also examined children who were on the border for
    being diagnosed, or who were diagnosed with ODD

70
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71
TOTAL Average Costs Per Child (by CD grouping)
Time trends reflect development and non-MAR
attrition.
72
Average JJ Costs Per Child (by CD grouping)
73
Average Inpatient MH costs per child (by CD
grouping)
74
Average Medications Costs Per Child (by CD
grouping)
75
3. How Large Are Those Costs Relative To The
Program Benefits?
76
Are More Complex Treatments Cost-Effective for
More Complex Cases?
  • E. Michael Foster
  • Professor of Health Policy and Demography
  • Pennsylvania State University

77
  • Cost-Effectiveness of ADHD Treatments Findings
    from the MTA Study
  • Forthcoming in the American Journal of Psychiatry
  • Peter S. Jensen, M.D.,
  • Joe Albert Garcia, Ph.D.,
  • Sherry Glied, Ph.D.,
  • Maura Crowe, B.A.,
  • E. Michael Foster, Ph.D.,
  • Michael Schlander, M.D.,
  • Stephen Hinshaw, Ph.D.,
  • Benedetto Vitiello, M.D.,
  • L. Eugene Arnold, M.D.,
  • Glen Elliott, M.D.,
  • Lily Hechtman, M.D.,
  • Jeffrey H. Newcorn, M.D.,
  • William E. Pelham, Ph.D.,
  • James Swanson, Ph.D.,
  • Karen Wells, Ph.D.
  • The Cost-Effectiveness of Treatment for ADHD
    Variation by Comorbidity
  • Under review at Health Services Research.
  • Foster, Jensen among others

78
Outline
  • Brief Review of MTA
  • Study Design
  • Prior Findings
  • CEAround 1
  • CEACa better alternative
  • CEACround 2
  • What should a policy makers WTP be?

79
Brief Review of MTA--Design
  • 6 sites
  • 579 Children ages 7-10
  • Randomized to four arms
  • Co-morbidities common

80
Presence of Comorbidities
81
Brief Review of MTA--Design
  • 14 months of treatment
  • Wide range of outcomes across multiple domains
    and respondents
  • Four arms
  • Community care (CC)
  • Two-thirds received medications
  • Medication management (MM)
  • Careful titration
  • Monthly med checks with pharmacotherapist
  • Intensive behavioral treatment (Beh)
  • Parent training
  • Child training (STP)
  • Biweekly teacher consultation trained classroom
    aide
  • Combination (Comb)

82
Brief Review of MTAInitial Findings
  • Participants in all groups improved
  • Core symptoms Comb, MM gt Beh or CC
  • Broader outcomes Comb gt MM
  • Significant moderation by comorbidity status

83
TABLE 1. Rates of Normalization
84
Rates of Normalization
85
Brief Review of MTAInitial Findings
  • Participants in all groups improved
  • Core symptoms Comb, MM gt Beh or CC
  • Broader outcomes Comb gt MM
  • Significant moderation by comorbidity status

86
CEA Round 1
  • Costs were measured according to economic
    principles
  • Research costs were excluded
  • All costs included regardless of payor
  • Wholesale prices of medications were extracted
    from the National Database of Drug Formularies
    (NDDF)

87
CEA Round 1
  • The costs of personnel were calculated using
    hourly wages and fringes taken from national
    databases (such as the AMA)
  • STP costs were labor only

88
TABLE 2 Costs Per Subject Per Treatment Arm
89
TABLE 3 Costs Per Subject Per Treatment Arm for
Comorbidity
90
Skip to CEAC
91
X
15,993
55,253
68,128
360
92
Incremental Cost Effectiveness of Alternative Tx
Relative to Control
Combination
5000
Behavioral
Therapy
Incremental Costs
3000
1000
Community
Medication
Care
Management
-1000
-.1
0
.1
.2
.3
.4
.5
.6
Incremental Benefits
93
Results from IYP
  • Stacking intervention components
  • Move away from ICER presentationkind of obscure

94
CEA of Program Outcomes
  • Three Treatment Components
  • Child Training
  • Parent Training
  • Teacher Training
  • Ecological Treatment Approach
  • Key Question Is Stacking Intervention
    Components Cost-Effective?
  • Trade-Off Treatment Intensity vs. Number of
    Children Treated

95
Results Treatment Costs
  • Control 0.00 (n21)
  • CT only 1,164 (n54)
  • CTTT 1,454 (n11)
  • PT only 1,579 (n292)
  • PTTT 1,868 (n24)
  • CTPT 2,713 (n38)
  • CTPTTT 3,003 (n19)

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98
Cost-Effectiveness Analysis of Fast Track
  • E. Michael Foster
  • Damon Jones and
  • Conduct Problems Prevention Research Group

99
Fast Track Sample
  • Change in sample
  • Add back the treatment group
  • Remove the lower-risk youth
  • Three outcomes
  • Diagnosis of conduct disorder
  • Act of interpersonal violence
  • Index offense

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103
Are More Complex Treatments Cost-Effective for
More Complex Cases?
So, whats the answer?
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106
But, we should note
  • Comorbid children differ in other ways, and
  • Other factors may serve as moderators, but
    supplemental analyses reveal that the effect of
    comorbidity is distinct.

107
Economic Analysis of Family Bereavement Project
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Conclusion
  • Economic analysis takes substantial resources and
    planning.
  • This task involves difficult conceptual issues
    above and beyond nuts -n- bolts, budgeting
    issues.
  • You will benefit from knowing where your money
    really goes.
  • Were making progress but have much to learn,
    especially about effectiveness studies.
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