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Cost-effectiveness in the quest to convince
the outside world
Dr. Jan Busschbach
De Viersprong
Erasmus MC
www.vispd.nl
2
Should we employ cost effectiveness research in personality disorder?
The obligatorily favourable arguments…– State-of-the-art research
– Legitimise reimbursement But cost effectiveness is not widely present….
– What stops us?
3
Arguments not to employ cost effectiveness research…
It has already been shown..– We know that psychotherapy is cost effective in PD
The methods are unfavourable for psychotherapy– The outcome measures (QALYs) are not sensitive for
changes in personality It is not important
– It does not matter in reimbursement decisions It is complex…
– An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis using a societal perspective….
4
Arguments not to employ cost effectiveness research…
It has already been shown..– We know that psychotherapy is cost effective in PD
The methods are unfavourable for psychotherapy– The outcome measures (QALYs) is not sensitive for
changes in personality It is not important
– It does not matter in reimbursement decisions It is complex…
– An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….
5
Elements of cost effectiveness…
£0
£5,000
£10,000
£15,000
£20,000
£25,000
£30,000
Dolan et al., Psychiatric Bulletin, 1996
Before treatment After treatment Costs of treatment
6
Productivity losses in months per year
0
1
2
3
4
5
Before treatment After treatment
30 borderline patients
Stevenson & Meares, AJP, 1992
7
But does that tell us: …how competitive is psychotherapy in PD?
What is de cost effectiveness of psychotherapy in PD? – Compared to treatment in oncology…– Compared to dialysis…– Compared to osteoporosis treatment …
Cost per health gain– Like cost per kilometre in cars
Outcome health: QALY– Quality Adjusted Life Years– Makes outcome in health care comparable– Both survival & quality of life
8
Car league table
Car € / Km Car € / Km
BMW 316 0.74 Daewoo Matiz 0.33
Mazda 626 2.0 0.58 Renault Twingo 1.2 inj
0.28
Citroën Xantia 1.8i 0.55 Hyundai Atos Multi 1.0
0.27
Opel Vectra 1.6 0.53 Daihatsu Cuore 1.0 0.27
Hyundai Lantra 1.5 0.47 Suzuki Alto 1.0 0.24
Cost per kilometre including gas, maintenance, debit, etc. Price level 2002. Calculations based on over 2,5 years use and 40.000 km. (Consumentenbond, Augustus 2003)
9
QALY league table
Intervention $ / QALY
GM-CSF in elderly with leukemia 235,958
EPO in dialysis patients 139,623
Lung transplantation 100,957
End stage renal disease management 53,513
Heart transplantation 46,775
Didronel in osteoporosis 32,047
PTA with Stent 17,889
Breast cancer screening 5,147
Viagra 5,097
Treatment of congenital anorectal malformations 2,778
10
Is there already evidence of cost effectiveness?
11
White raven
The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial.– Palmer, S., K. Davidson, et al. (2006). – J Personal Disord 20(5): 466-81
Outpatient psychotherapy for BPD: The cost-effectiveness of schema-focused therapy versus transference-focused psychotherapy– Thea van Asselt, Josephine Giesen-Bloo– University of Maastricht– This ISSPD conference
Modelling the cost-effectiveness of psychotherapy in personality disorders, long term inpatient versus short term inpatient– Djøra Soeteman et al. – Viersprong– This ISSPD conference
12
John Brazier, Prof in Health Economics – Leading institute, University of Sheffield– Psychological therapies […] for borderline
personality disorder: a systematic review and preliminary economic evaluation
– January, 2007 On the basis of an extensive review Converted all existing evidence into a health
economic model– “The results for [psychotherapy] are promising,
though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.”
Cumulative evidence can be classified as “a promise”
13
Arguments not to employ cost effectiveness research…
It has already been shown..– We know that psychotherapy is cost effective in PD
The methods are unfavourable for psychotherapy– The outcome measures (QALYs) are not sensitive for
changes in personality It is not important
– It does not matter in reimbursement decisions It is complex…
– An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….
14
Are the methods unfavourable for psychotherapy?
Cost effectiveness focuses on costs– Psychotherapy is labour intensive and thus expensive
Cost effectiveness uses generic outcomes: QALY – Quality Adjusted Life Years (QALYs)
• Are not sensitive
– The changes caused by psychotherapy are subtle• Functional changes
• Relations
• Enjoyment of life
– But is that an argument against QALYs?
15
QALY
Quality Adjusted Life Years Area under the curve
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 10 20 30 40 50 60 70 80
Life years
Ad
jus
me
nt
fac
tor
QA
LY
Co-morbidityWith psychotherapyNo psychotherapy
16
EQ-5D MOBILITY
– 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
– 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…..
Suspect
ed:
Not sensit
ive for P
D
The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs
17
But the EQ-5D is sensitive in PD….
0.5
0.6
0.7
0.8
0.9
1.0
Intake 1 year after 2 years
EQ
-5D
QA
LY v
alue
sClinic 12 monthsClinic 6 monthsClinic 3 monthsOut-patient clinic
18
Cost effectiveness is already employed in metal health
Schizophrenia– "Schizophrenia"[Mesh] AND "Cost-Benefit Analysis"[Mesh]
– 307 Hits in PubMed Depression
– "Depression"[Mesh] AND "Cost-Benefit Analysis"[Mesh]
– 104 Hits
19
Arguments not to employ cost effectiveness research…
It has already been shown..– We know that psychotherapy is cost effective in PD
The methods are unfavourable for psychotherapy– The outcome measures (QALYs) are not sensitive for
changes in personality It is not important
– It does not matter in reimbursement decisions It is complex…
– An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….
20
Car league table
Car € / Km Car € / Km
BMW 316 0.74 Daewoo Matiz 0.33
Mazda 626 2.0 0.58 Renault Twingo 1.2 inj
0.28
Citroën Xantia 1.8i 0.55 Hyundai Atos Multi 1.0
0.27
Opel Vectra 1.6 0.53 Daihatsu Cuore 1.0 0.27
Hyundai Lantra 1.5 0.47 Suzuki Alto 1.0 0.24
Cost per kilometre including gas, maintenance, debit, etc. Price level 2002. Calculations based on over 2,5 years use and 40.000 km. (Consumentenbond, Augustus 2003)
21
Is cost effectiveness important?
Indeed other factor are also important: – Burden of disease
– Budget impact
0
5
10
15
20
25
30
Accepted Rejected
High burden Low burden
Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277
22
Burden of Disease and Budget Impact are imbedded in cost effectiveness
Burden of disease
– In term of cost• Uses same cost prises estimates
– In term of quality of life• Uses same generic quality of life estimates
• EQ-5D
Budget impact
– Uses same cost prises estimates
– Plus estimates of prevalence
23
Burden of disease: EQ-5D
0 0.2 0.4 0.6 0.8 1
Major depression
Heamodialysis
Rheumatic disease
Personality disorder
Lung cancer
Parkinson
Diabetes II
Schizophrenia (treated)
HIV
Normal population
Soeteman et al. Journal of Personality Disorders. 2007 in press. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
24
Cost of illness
Total costs per patient
€0 €2,000 €4,000 €6,000 €8,000 €10,000 €12,000
Depression
Anxiety
Personality disorder
Soeteman, et al. Journal of Clinical Psychiatry, 2007 in press
25
Cost effectiveness becomes more important
1980[pdat] AND (QALY or QALYs)
0
100
200
300
400
500
600
1980 1985 1990 1995 2000 2005 2010
Pub
licat
ions
per
yea
r
26
Reimbursement of pharmaceuticals in Australia
27
Arguments not to employ cost effectiveness research…
It has already been shown..– We know that psychotherapy is cost effective in PD
The methods are unfavourable for psychotherapy– The outcome measures (QALYs) are not sensitive for
changes in personality It is not important
– It does not matter in reimbursement decisions It is complex…
– An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….
28
Models can be complex….As it tries to model real life…..
29
Model of Soeteman et al, ISSPD conference The Hague
€ 15,560
0.62
€ 5,979
0.81
mr[age]
0.02
0.25-0.03
0.02 + mr[age]
Psychotherapy
Improved,not recovered
Recovered
Deathmr[age]
0.67
€ 9,319
€ 11,279
0.71Unchanged / deteriorated
mr[age]
0.11
-0.03
€ 0
0
30
We want both costs and effects….
Bad effects Good effects
Low costs (savings)
High costs
Good
Better
SUPER !
Forget it !
Difficult…
31
Multiple sensitivity analysis
Bad effects Good effects
Low costs (savings)
High costs
Good
Better
SUPER !
Forget it !
Difficult…
32
John Brazier, Prof in Health Economics – Leading institute, University of Sheffield– January, 2007
On the basis of an extensive review Converted all existing evidence into a health
economic model– “The results for [psychotherapy] are promising,
though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.”
Psychological therapies […] for borderline personality disorder: a systematic review and
preliminary economic evaluation
33
Cost effectiveness plane, Brazier, 2007
Good
Better
SUPER !
Not so good…
Forget it !
34
Cost effectiveness threshold, Brazier, 2007
Our uncertainty about the cost effectiveness is not (further) determined by willingness to pay, but by the uncertainty of our own research results
35
Arguments to employ cost effectiveness research…
We should research whether psychotherapy is cost effective in PD– It has already been shown..
The methods are favourable for psychotherapy– The methods are unfavourable for psychotherapy…
It is important– It does not matter in reimbursement decisions…
It is complex…– It is not of our psychotherapeutic world
– It is more the outside world…
Let convince the outside world, before the outside world convinces
us…..
37
Hopeful, but incomplete
Psychotherapy appears to have a beneficial impact on a variety of costs […in…] borderline personality disorder. – Reviews of Gabbert et al., AJP, 1997– Note: no integration with effects
"Until […] there is conclusive evidence of the efficacy and the cost-effectiveness of long-term psychotherapy, restraint needs to be exercised in administering such therapy [in personality disorder]." – Dutch Health Council, 2001
The results for [psychotherapy] are promising, though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.– Brazier, 2007
