A Health Economic View on Borderline Personality Disorder

1. A Health Economic View on Borderline Personality Disorder Prof. dr. Jan Busschbach Viersprong Institute for studies on Personality Disorders Medical Psychology and Psychotherapy Erasmus MC

2. 2002: Two books, and a hand full of articles

3. 2002: no state-of-the-art studies • Studies did not follow guide lines • Articles and books often promoted state-of-the-art studies… • ..but did not present results • No use of health economic relevant outcomes • Effects not expressed as QALYs • No comparison possible with somatic diseases • No societal cost involved • Not all costs

4. 2006 • Systematic review and preliminary economic evaluation • Borderline personality disorder • John Brazier, Sheffield, 2006 • Based on the first studies MBT • Bateman also presented some costs data • No QALYs • 2003

5. Cost offset by less care elsewhere

6. Full health economic model • John Brazier added: • QALYs • All cost • Simultaneously testing of all uncertainty • Cost • Effects

7. High costs Bad effects Good effects Low costs (savings) We want both costs and effects…. Good Forget it ! Better SUPER ! Cost effective savings …

8. High costs Bad effects Good effects Low costs (savings) Multiple sensitivity analysis Good Forget it ! Even Better SUPER ! Cost effective savings …

9. Probability being cost effective Change being cost effective 1.0 0.0 Willingness to pay for effects

10. Good Better SUPER ! Cost effectiveness plane, Brazier, 2007 Not so good… Forget it !

11. 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

12. Conclusion 2007 • 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” • John Brazier

13. 2012: More health economics…

14. 2012: better health economics… • State of the art studies (in Borderline) • Palmer, Davidson, Tyrer, 2006 • Cognitive behavior therapy • University of York • Van Asselt, Giesen-Bloo, Arnzt et al, 2008 • Schema-focused vs transference-focused • University of Maastricht • Soeteman, Busschbach, Verheul et al, 2010 • Out patient, day hospital, in-patients • Erasmus MC • 5 to 7 others… • Bit not in BPD, or with lower quality

15. Palmer, Davidson,Tyrer • Adding cognitive behavior therapy • Gives lower costs, and lower quality of life • TAU has more changes on being cost effective

16. Van Asselt, Giesen-Bloo, Arntz Schema-focused vs transference-focused

17. Cluster B patients Most effect in-patients psychotherapy Then day hospital Then out patients Bartak, Busschbach, Verheul, 2011

18. Low willingness to pay: Out-patient High willingness to pay: Day hospital Soeteman, Busschbach, Verheul

19. Favorable results in Borderline • Additional CBT is not cost effective • Schema focus is cost effective • Out patient is cost effective • Day hospital also, with high willingness to pay

20. Why not general accepted? • Only three studies • Cost effectiveness is not all that counts… • Other issues • Burden of disease • Prevalence • Budget impact • Own influence on health • Perceived own influence • Consensus in the field

21. Burden of disease Willingness to pay is function of burden

22. € 80.000 € 60.000 € 40.000 € 20.000 € 0 Costs/QALY versus Burden of disease X X X X X Burden of disease

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

24. Need to demonstrate Burden • 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….. • Burden often demonstrated in technical terms • Disease specific questionnaire results, jargon • But we need comparisons with (somatic) diseases • Generic measures • EuroQol EQ-5D • Health Utility Index • SF-6D

25. Burden is considerable Soeteman et al. Assessment of the burden of disease among inpatients in specialized units that provide psychotherapy. Psychiat Serv. 2005 Sep;56(9):1153-5

26. Prevalence • Prevalence relates to: • Budget impact • The higher the budget impact, the more risk avers policy makers become • Burden • “If it is so common: why don’t I see al that misery?” • Own influence on disease • “If it is common, others seem to deal with it…” • “So why paying for treatment?” • Being enthusiastic about a high prevalence…. • ….might not be such a good idea • And… in fact we do not know the prevalence of people that need treatment…

27. Orphan drugs • Pompe disease • Classical form: € 300.000 – 900.000 per QALY • Non classical form: up to € 15.000.000 per QALY • If maximum = € 80.000 • Ration is almost 1:200 • Low cost effectiveness but… • High burden • Low prevalence • Little own influence on disease • High consensus in the field • Coalition patient, industry, doctors and media • Low perceived incertainty

28. What can we do now? • We can claim cost effectiveness • But 3 state-of-the-art cost effectiveness analysis in Borderline • More research is on its way • We can claim a high burden • But investigation in the burden of disease is limited • Be restrictive with proclaiming high prevalence • Are all those people patients in need of treatment? • What is the prevalence of patient in need of treatment? • Try to find consensus in the field

29. Can we improve cost effectiveness? • Research into cost effective components of therapy • Like adding CBT (See Palmer, 2005) • What is the added value of for instance ‘drama therapy’ • Research in the amount of therapy needed • Volume drives costs • See Soeteman et al, / Bartak et al.

30. Stop rules We seem to know when a therapy is needed But do we know when to stop? If all the ‘potential’ of the patient is reached?

31. Within social health insurance • Reasonable stop rules might be: • When no progress is made anymore • When the patient is comparable with the general population • > 5 – 10% • For this we need to monitor the patient • ….frequently during therapy • Looks like Routine Outcome Measure • but with a high frequency • Monitor progress • Monitor position patients / normal population

32. Michael Lambert N = 400 Kim de Jong et al in press Erasmus MC Monitoring reduces the number of treatments

33. …and gives better results Feed back Non feed back

34. Conclusion Cost effectiveness in Borderline is on the break of establishment We should ‘carefully’ claim cost effectiveness and a high burden We are in need of research into Cost effectiveness Burden of disease Research focus on dosages Number of sessions, length of treatment Monitoring can be of help here We should be careful with Statements about high prevalence