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Economic evaluation of psychotherapy for personality disorders:

Economic evaluation of psychotherapy for personality disorders: burden of disease, cost-effectiveness, and value of information and implementation Dj ø ra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam

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Economic evaluation of psychotherapy for personality disorders:

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  1. Economic evaluation of psychotherapy for personality disorders: burden of disease, cost-effectiveness, and value of information and implementation Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Center for Health Decision Science, Boston, MA Boston, December 2, 2009

  2. Efficient health care provision • Three questions need to be addressed: - Which treatments are cost-effective and should be adopted? (reimbursement decision); - Is it worthwhile to conduct additional research (research decision); - Is it cost-effective to implement treatments into clinical practice (implementation decision). 2

  3. Reimbursement decision 3

  4. Reimbursement decision Necessity Effectiveness Cost-effectiveness Reimbursement decision

  5. Reimbursement decision: 3 criteria • Necessary care • How severe is the disease? • Effectiveness • Is treatment effective? • Cost-effectiveness • Are the effects worth the costs? 5

  6. Reimbursement decision: criterion 1 • Necessity: how severe is the disease? • Is it a common disease? (prevalence) • Does the patient suffers? (individual burden) • What are the costs? (economic burden)

  7. Prevalence • Prevalence in the general population: 13,5% • Verheul et al., 1999 • Treatment seeking: 19,1% • in the year prior to interview • Andrews et al., 2001 • 422.285 patients in the Netherlands • Prevalence x population x treatment seekers • 13,5% x 16.377.153 x 19,1%

  8. General population HIV infected pt Schizophrenia outpatients (treated with neuroleptics) Type II diabetes Parkinson’s disease Lung cancer Personality disorders Rheumatic disease Pt with renal failure on heamodialysis Major depressive disorder 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 EQ-5D score Individual burden Soeteman et al., 2008 The burden of disease in personality disorders: diagnosis-specific quality of life. Journal of Personality Disorders, 22, 259-268

  9. Relation between funding and burden Pronk et al., 2004 Outpatient drug policy by clinical assessment rather than financial constraints. Eur J Health Econom, 5, 274-277 9

  10. Mean annual costs per patient € 12,000 € 10,000 € 8,000 Total costs Costs (€) € 6,000 Direct Indirect € 4,000 € 2,000 € - Personality disorders Schizophrenia Depression Generalized anxiety disorder Economic burden Soeteman et al., 2008 The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69, 259-265

  11. Total societal costs • Health care utilization € 3,12 billion • Productivity losses € 0,24- € 3,60 billion • Criminal justice resources € 0,27 billion • Total annual costs € 3,6- € 7,0 billion (conservative estimate not included e.g., costs of non-treatment seekers, intergenerational transfer) +

  12. Reimbursement decision: criterion 1 • Necessary care • Highly prevalent • Low quality of life • High societal costs

  13. Reimbursement decision: criterion 2 • Necessary care • Highly prevalent • Low quality of life • High societal costs • Effectiveness • Is treatment effective?

  14. Evidence for effectiveness

  15. Reimbursement decision: criterion 2 • Necessary care • Highly prevalent • Low quality of life • High societal costs • Effectiveness • Psychotherapeutic treatments are effective

  16. Reimbursement decision: criterion 3 • Necessary care • Highly prevalent • Low quality of life • High societal costs • Effectiveness • Psychotherapeutic treatments are effective • Cost-effectiveness • Are the effects worth the costs?

  17. Current evidence?

  18. Current evidence ‘a promise’ Brazier et al., 2007 • John Brazier, Prof. of Health economics. • University of Sheffield • Psychological therapies […] for borderline personality disorder: a systematic review and preliminary economic evaluation • Integrating existing evidence in health economic model • “The results are promising [for psychotherapy], though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.”

  19. First (!) state-of-the-art cost-effectiveness study from the Netherlands • RCT Van Asselt et al., 2008 (BJP) • Compared Transference-Focused Psychotherapy and Schema-Focused Therapy for borderline PD • % recovered after 4 years • SFT: 52.3% • TFP: 28.6% • Treatment costs • SFT: € 12,946 • TFP: € 10,876 • Total costs over 4 years • SFT: € 37,826 • TFP: € 46,795

  20. 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

  21. Cluster C PD

  22. 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

  23. Model structure • Markov model: 5-year time horizon 25

  24. Different costs

  25. Total costs over 5 years

  26. Effect over 5 years

  27. Costs per QALY

  28. Uncertainty 30

  29. CEAC

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

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

  32. Conclusion • Cluster C PD • Cost-effective treatment strategies are: • Short-term inpatient psychotherapy (first choice) • Short-term day hospital psychotherapy • Sub-optimal treatment options are: • Long-term day hospital and long-term inpatient

  33. Reimbursement decision: 3 criteria • Necessary care • Highly prevalent • Low quality of life • High societal costs • Effectiveness • Psychotherapeutic treatments are effective • Cost-effectiveness • Cost-effective treatment strategies for cluster C PD are available

  34. Research decision 36

  35. Decision uncertainty • Uncertainty in cost-effectiveness • Current information on costs and effects is imperfect 37

  36. EVPI Population expected value of perfect information 38

  37. EVPPI • EVPI for parameter groups 39

  38. Implementation decision 40

  39. EVPIM • Population expected value of perfect implementation 41

  40. Efficient health care provision • Recommendations based on three questions • Based on currently available evidence: short-term inpatient psychotherapy is the most cost-effective choice (at threshold value of €40,000 per QALY) • Before implementing this cost-effective treatment strategy into clinical practice, further research is valuable especially when prioritizing information on treatment costs and transition probabilities. 42

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