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Cost-effectiveness of psychotherapy for personality disorders Dj ø ra Soeteman

Cost-effectiveness of psychotherapy for personality disorders Dj ø ra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Harvard School of Public Health, Boston, MA ISSPD NYC, August 23, 2009. SCEPTRE trial.

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Cost-effectiveness of psychotherapy for personality disorders Dj ø ra Soeteman

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  1. Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Harvard School of Public Health, Boston, MA ISSPD NYC, August 23, 2009

  2. SCEPTRE trial • Patient-level primary data was available from the largest existing clinical trial of psychotherapy for personality disorders (N = 924) • Dosage specified by treatment setting and duration • Cluster C PD: N = 466 • Cluster B PD: N = 241

  3. Cluster C PD

  4. 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 < = 6 months • Long-term > 6 months

  5. Different costs

  6. Total costs over 5 years

  7. Just costs? • 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? • What are the costs per recovered patient?

  8. 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) 8

  9. Effect 9

  10. Costs per recovered patient year 10

  11. 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

  12. 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 Quality Adjusted Life Years (QALY) 12

  13. Effect over 5 years

  14. Costs per QALY

  15. High costs Less effective More effective Low costs (savings) Interested in both costs and effect Good Forget it! Better Difficult… Superb!

  16. High costs Less effective More effective Low costs (savings) Sensitivity analysis Forget it! Good Better Difficult… Superb!

  17. Cost-effectiveness plane Good Better 17

  18. Acceptability curve

  19. Cost-effectiveness of different dosages of psychotherapy for cluster C PD

  20. Cost-effectiveness of different dosages of psychotherapy for cluster C PD

  21. Cluster B PD

  22. Acceptability curve

  23. Cost-effectiveness of different modalities of psychotherapy for cluster B PD

  24. Cost-effectiveness of different modalities of psychotherapy for cluster B PD

  25. 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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