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Interactive Introduction Cost Effectiveness and Psychotherapy

Interactive Introduction Cost Effectiveness and Psychotherapy. Jan J. v. Busschbach, Ph.D. Psychotherapeutic Centrum ‘De Viersprong’, Halsteren Jan.Busschbach@deviersprong.nl +31 164 632200 Department of Medical Psychology and Psychotherapy, Erasmus MC j.vanbusschbach@erasmusmc.nl

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Interactive Introduction Cost Effectiveness and Psychotherapy

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  1. Interactive Introduction Cost Effectiveness and Psychotherapy • Jan J. v. Busschbach, Ph.D. • Psychotherapeutic Centrum ‘De Viersprong’, Halsteren • Jan.Busschbach@deviersprong.nl • +31 164 632200 • Department of Medical Psychology and Psychotherapy, Erasmus MC • j.vanbusschbach@erasmusmc.nl • +31 10 4087807

  2. Psychotherapy or cancer treatment Symptoms of illnessPsycho Chemo Additional Survival 0 years 0.5 year Quality of life 0.5  0.75 0.0  0.5 Days benefit / patient 10 year 0.5 year Costs of treatment 20.000 € 2.000 € Savings (medical) 5.000 € 0 € Savings (productivity) 5.000 € 0 €

  3. Issues in health economics • Issues • Quality of life measurement • Rule of rescue • Equity • Burden of disease • Productivity costs • Discounting • Non issues • Determination of effects • Direct medical costs • Survival / days of benefit

  4. Standardise Quality of Life • EuroQol EQ-5D • Recommend by the Dutch Health Council (CvZ) • Also 5 questions: • MOBILITY • I have no problems in walking about • I have some problems in walking about • I am confined to bed • SELF-CARE • I have no problems with self-care • I have some problems washing or dressing myself • I am unable to wash or dress myself • USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) • I have no problems with performing my usual activities • I have some problems with performing my usual activities • I am unable to perform my usual activities • PAIN/DISCOMFORT • I have no pain or discomfort • I have moderate pain or discomfort • I have extreme pain or discomfort • ANXIETY/DEPRESSION • I am not anxious or depressed • I am moderately anxious or depressed • I am extremely anxious or depressed

  5. Value a health state • Wheelchair • Some problems in walking about • Some problems washing or dressing • Some problems with performing usual activities • Some pain or discomfort • No psychosocial problems

  6. Time Trade-Off • TTO • Wheelchair • With a life expectancy: 50 years • How many years would you trade-off for a cure? • Max. trade-off is 10 years • QALY(wheel) = QALY(healthy) • Y * V(wheel) = Y * V(healthy) • 50 V(wheel) = 40 * 1 • V(wheel) = .8

  7. EuroQol EQ-5D • MOBILITY • I have no problems in walking about • I have some problems in walking about • I am confined to bed • SELF-CARE • I have no problems with self-care • I have some problems washing or dressing myself • I am unable to wash or dress myself • USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) • I have no problems with performing my usual activities • I have some problems with performing my usual activities • I am unable to perform my usual activities • PAIN/DISCOMFORT • I have no pain or discomfort • I have moderate pain or discomfort • I have extreme pain or discomfort • ANXIETY/DEPRESSION • I am not anxious or depressed • I am moderately anxious or depressed • I am extremely anxious or depressed

  8. Direct measurement

  9. Indirect measurement • MOBILITY • I have no problems in walking about • I have some problems in walking about • I am confined to bed • SELF-CARE • I have no problems with self-care • I have some problems washing or dressing myself • I am unable to wash or dress myself • USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) • I have no problems with performing my usual activities • I have some problems with performing my usual activities • I am unable to perform my usual activities • PAIN/DISCOMFORT • I have no pain or discomfort • I have moderate pain or discomfort • I have extreme pain or discomfort • ANXIETY/DEPRESSION • I am not anxious or depressed • I am moderately anxious or depressed • I am extremely anxious or depressed

  10. Indirect measurement

  11. Describe health states Have values from the general public Rosser QWB 15D HUI Mark 2 HUI Mark 3 EuroQol EQ-5D Validated Questionnaires

  12. Effect psychotherapy

  13. QALY • Count life years • Value (V) quality of life (Q) • V(Q) = [0..1] • 1 = Healthy • 0 = Dead • One dimension • Adjusted life years (Y) for value quality of life • QALY = Y * V(Q) • Y: numbers of life years • Q: health state • V(Q): the value of health state Q • Also called “utility analysis”

  14. Which health care program is the most cost-effective? • A new wheelchair for elderly • 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

  15. Example STIP • STIP • Short-Term Inpatient Psychotherapy • Cost price • Per patient day: 210.34 € • 3 mouths = 91.3 day • 91.3 x 210 = 19,194.53 € • Effect • Assume quality of life increase of 0.25 • Over 10 year • Cost / QALY • 19,194.54 / (10 x 0.25) = 7,677.41 € Although gold standard…Cost per QALY of psychotherapy have never been published

  16. QALY league table

  17. Car economics • Should we spend our money on a • Suzuki Alto 1.0 • BMW 316 • Comparing costs • Comparing outcome • Relate costs to outcome • Cost per outcome • Cost per kilometer • Suzuki Alto 1.0 • BMW 316

  18. Car league table

  19. Egalitarian Concerns 1.0 Utility of Health 0.0 A B C

  20. Implications shifting threshold • QALY are weighted • Weighted QALYs are maximized • Health is no longer the only thing maximized • Health status population will drop • Differences in health will drop • Egalitarian consideration are incorporated • Burden of disease becomes a criteria • Equity

  21. CE-ratio by equity

  22. Burden of disease based on STEP-data (N = 641)

  23. Are health economic results used? • Must we be afraid of the uncontrolled use of QALY? • QALY league table are difficult to make • Largest at Harvard School of Public Health • www.hsph.harvard.edu/organizations/hcra/cuadatabase/intro.html • a comprehensive league table • a catalogue of preference scores • QALY league tables are not used • At least not in The Netherlands • There used to be a mysterious list in UK….

  24. Health economic are used next to other criteria • Burden of disease • Ethical constrains • Financial constrains

  25. Reimbursement arguments • Dunning’s Funnel • 1990 • Government declaration 2002 • Necessary care • Need • Equity elements • Efficacy • Cost effectiveness • Own account and responsibility

  26. Reimbursement arguments Impact on QoL Effect on QoL Cost effectiveness ? QALYs

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