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Economic evaluation of psychotherapy for personality disorders: burden of disease and cost-effectiveness

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Title: Economic evaluation of psychotherapy for personality disorders: burden of disease and cost-effectiveness


1
  • 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
  • Rotterdam, October 30, 2009

2
Reimbursement decision
Necessity
Effectiveness
Cost-effectiveness
Reimbursement decision
3
Reimbursement decision 3 criteria
  • Necessary care
  • How severe is the disease?
  • Effectiveness
  • Is treatment effective?
  • Cost-effectiveness
  • Are the effects worth the costs?

3
4
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)

5
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

6
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
7
Economic burden
8
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)


9
Economic burden
Soeteman et al., 2008 The economic burden of
personality disorders in mental health care.
Journal of Clinical Psychiatry, 69, 259-265
10
Reimbursement decision criterion 1
  • Necessary care
  • Highly prevalent
  • Low quality of life
  • High societal costs

11
Reimbursement decision criterion 2
  • Necessary care
  • Highly prevalent
  • Low quality of life
  • High societal costs
  • Effectiveness
  • Is treatment effective?

12
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13
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14
Evidence for effectiveness
Broad spectrum Borderline PD Avoidant PD
Outpatient individual -
Outpatient group
Day hospital -
Inpatient - -
15
Reimbursement decision criterion 2
  • Necessary care
  • Highly prevalent
  • Low quality of life
  • High societal costs
  • Effectiveness
  • Psychotherapeutic treatments are effective

16
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?

17
Current evidence?
18
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.

19
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

20
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

21
  • Cluster C PD

22
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

23
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
24
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
25
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?

26
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)

26
27
Effect
Psychotherapy dosage recovered patient-years
Long-term outpatient 1.38
Short-term day hospital 1.93
Long-term day hospital 2.32
Short-term inpatient 2.79
Long-term inpatient 2.11
27
28
Costs per recovered patient year
Psychotherapy dosage recovered patient-years Costs ()
Long-term outpatient 1.38 64,735
Short-term day hospital 1.93 46,131
Long-term day hospital 2.32 45,442
Short-term inpatient 2.79 32,837
Long-term inpatient 2.11 57,285
28
29
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

30
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

30
31
Example of QALY gain because of treatment
  • QALYs gained blue area

32
QALY league table
33
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
34
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
35
Interested in both costs and effect
Good
Forget it!
Better
Difficult
Superb!
36
Sensitivity analysis
Forget it!
Good
Better
Difficult
Superb!
37
Cost-effectiveness plane
Good
Better
37
38
Acceptability curve
39
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
40
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
41
  • Cluster B PD

42
Acceptability curve
43
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
44
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
45
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

46
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

47
  • www.vispd.nl
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