Cost-Effectiveness of Psychotherapy for Personality Disorders

Soeteman, Busschbach, Verheul

Comparing different dosages

Usually ...– comparison between theoretical orientation of therapy

Typically ...– amount of therapy is keep constant

This assumes ...– amount of therapy is relevant

Amount of therapy relates to costs Yet ...

– Relation between costs and effects is rarely investigated

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But isn’t there already evidence of cost effectiveness?

No state of the art

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White raven

The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from he BOSCOT trial.– Palmer, Davidson, et al. (2006). – J Personal Disord 20(5): 466-81

Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy.– van Asselt, Dirksen et al

– Br J Psychiatry. 2008 Jun;192(6):450-7.

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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

– “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”

Challenges

Randomization– Difficult to randomize patients between different treatment

settings and duration of treatment

– Use of naturalistic data

– Use statistical ‘corrections’ for different baseline levels Collection of all cost data

– Including productivity costs Introducing cost effectiveness models

– Djøra Soeteman Quality Adjusted Life Years (QALY) as outcome

QALY

Health economics addresses the efficient allocation of health care resources

For instance– Psychotherapy long versus short

– Psychotherapy in PD versus care for diabetics Make effects comparable

– Same effect parameter in diabetes as in PD Survival and Quality of Life Combined: Quality Adjusted Life Years (QALY)

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QALY

Quality Adjusted Life Years Area under the curve

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Life years

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Co-morbidity

With psychotherapy

No psychotherapy

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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…..

The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs

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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

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5000 Citations in PubMed

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1980 1985 1990 1995 2000 2005 2010

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1980[pdat] AND (QALY or QALYs)

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A new wheelchair for elderly (iBOT) Special post natal care

Which health care program is the most cost-effective?

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A new wheelchair for elderly (iBOT)– Increases quality of life = 0.1 – 10 years benefit– Extra costs: $ 3,000 per life year – QALY = Y x V(Q) = 10 x 0.1 = 1 QALY– Costs are 10 x $3,000 = $30,000– Cost/QALY = 30,000/QALY

Special post natal care– Quality of life = 0.8– 35 year– Costs are $250,000– QALY = 35 x 0.8 = 28 QALY– Cost/QALY = 8,929/QALY

Which health care program is the most cost-effective?

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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

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Burden as criteria

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Accepted Rejected

High burden Low burden

Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

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Dutch Council for Public Health and Health Care (RvZ, 2006)

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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

SCEPTRE

Study on Cost-Effectiveness of Personality Disorder Treatment

Start: March 2003 6 clinics

SCEPTRE

About 900 patient with PD Followed over 3 years Dosages compared

– Outpatient, day-hospital and inpatient psychotherapy

– Shorter than or equal to 6 months, longer than 6 months Clusters

– A; N = 58

– B; N = 241

– C; N = 466 Naturalistic design

Correction for selection bias

Propensity score– To correct for baseline differences

– A sophisticated co-variance analysis

– Combines several co-variates If successful

– Results can be interpreted as an RCT Several checks on validity Often used in (health) economics

Co-variates used in propensity score

Age Sex Diagnosis (SIDP-IV) Baseline GSI Motivation Measures of pathology

– DAPP-BQ; SIPP; OQ-45 Quality of life (EQ-5D)

Assumptions met in:

3 groups in cluster B– Inpatient

– Day-hospital

– Outpatient 5 groups in cluster C

– Short-term inpatient

– Long-term inpatient

– Short-term day-hospital

– Long-term day-hospital

– Long-term out-patient

First some effect data…

Global Severity Index Score (GSI)– Anna Bartak

• Bartak, Spreeuwenberg, Andrea, Holleman, Rijnierse, Rossum, Hamers, Meerman, Aerts J, Busschbach, Verheul, Stijnen, Emmelkamp

• Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorder: results of a large prospective multicentre study. Psychotherapy and Psychosomatics 

– In press Cost effectiveness later on…

– Djøra Soeteman

Uncorrected results cluster B

Propensity score in cluster B

Differences diminish till P = 0.06– Complicates conclusions

But costs could make the difference…

Uncorrected results cluster C

Corrected results C

GSI - Difference score

Treatment group

Long outpatient

Short day hospital

Long day hospital

Short inpatient

Short day hospital

-0.0770

Long day hospital

-0.1278 -0.0508

Short inpatient 0.3035 0.3805** 0.4313**

Long inpatient -0.0030 0.0740 0.1247 -0.3065*

* p < 0.05 ** p < 0.01 *** p < 0.001

Propensity score in cluster C

Better effects of short-term inpatient psychotherapy remain significant

But costs could still make a difference…

Conclusions: effects

Non difference in B (after correction)– But costs can then be decisive ….

Cluster C– Favorable results for short-term inpatient psychotherapy

– But is short-term inpatient worth the costs?