Cost-Effectiveness of Psychotherapy (for Personality Disorders) Prof. dr. Jan van Busschbach

1. Cost-Effectiveness of Psychotherapy (for Personality Disorders)Prof. dr. Jan van Busschbach

2. Cost-Effectiveness of Psychotherapy Cost effectiveness analyses in psychotherapy are scarce Especially in long term treatment Irrespectivelly of the books that appeared Results might are favorable Strong arguments towards insurers But they might give undesirable answers There will be winners and loserss

3. Nonspecific factors • Most effectivenss research... • Compairs theoretical orientation of therapy • Little differences • Nonspecific factors seems to drive treatment success

4. Comparing “dosages” • Typically ... • Amount of therapy is keep constant • This assumes ... • amount of therapy is relevant • Relation costs and effects is rarely investigated Illustration of the 'dose-effect' relationship showing the majority of improvement happens early in therapy (Howard et al, 1996)

5. SCEPTRE • Study on Cost-Effectiveness of Personality Disorder Treatment • Start: March 2003 • 6 clinics

6. SCEPTRE • About 900 patient with PD • Followed over 3 years • Dosages compared • Clusters • A; N = 58 • B; N = 241 • C; N = 466

7. Naturalistic design • No randomisation • Difficult when dosages differ • Not seen as big problem in health econics • Economist hardly randomize • Randomization jeopardizes generalisabilty • Inclusion; exclusion is strict • Interference in clinical process • Randomization of disappointment • Use co-variance analysis • The standard economic design

8. In need of a super covariate • Question to clinician: • “What are the important variables for treatment allocation?” • Answer: • “Everything is important!” • How to control for everything? • “We are in need of a super covariate”

9. Correction for selection bias • Propensity score • A sophisticated co-variance analysis • Combines several co-variates • To correct for baseline differences • If successful • Results can be interpreted as an RCT • Several checks on validity • Often used in • (health) economics • Epidemiology

10. Super Covariate: the propensity score • Age • Sex • Diagnosis (SIDP-IV) • Baseline GSI • Motivation • Measures of pathology • DAPP-BQ; SIPP; OQ-45 • Quality of life (EQ-5D)

11. Can super covariate fly? Psychotherapy and Psychosomatics, 2009 Separate PhD, 2010 Medical Care, 2010

12. N= 58: one of the largest studies ever But groups got very small Cluster A

13. Cluster A raw results: Day hospital and inpatient seem best

14. But assumptions are not met in cluster A

15. Assumptions were met when using… • 3 groups in Cluster B • 5 groups in Cluster C

16. Cluster B: Again day hospital and inpatient seem best…

17. Differences diminish till P = 0.06 After correction with the propensity score Complicates conclusions Assumptions of propensity score are met Effect are reduces after correction But costs could make the difference… But no significant results in cluster B…

18. Results cluster C

19. Results hold in Cluster C • Short inpatient better than • Short day hospital • Long day hospital • Long inpatient psychotherapy

20. Winner and losers • Short term inpatient is better that long term inpatient • In cluster C • When incorporating cost argument • Short term inpatient dominates long term patient • Better and cheaper • In cluster C • At de Vierspong • Closing long term inpatient treatment for cluster C • Expanding short term inpatient treatment for cluster C

21. Non difference in Cluster B (after correction) Between outpatient, day hospital and inpatient But costs can be decisive …. Cluster C Favorable results for short-term inpatient psychotherapy It is reasonable to assume that short inpatient dominates long in-patient But is short-term inpatient worth the additional costs…? compared to long day hospital / short day hospital Still inconclusive cost effectiveness…

22. QALY • Health economics compare the efficient allocation of health care resources • For instance: • Psychotherapy Short Inpatient versus Day Hospital • 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)

23. Quality Adjusted Life Years (QALY) 1.00 X 0.00 0.5 x 80 = 40 QALYs 80 40 Life years 23 • Example • Blindness • Time trade-off value is 0.5 • Life span = 80 years • 0.5 x 80 = 40 QALYs

24. QALY • Quality Adjusted Life Years • Area under the curve

25. 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

26. Sensitivity EQ-5D

27. Cost per QALY in Cluster B High cost effectiveness ratio compared to out-patient

28. Cost effectiveness Cluster C Favorable cost effectiveness ratio compared to Short Day Hospital Soeteman DI, Verheul R, Meerman AMMA, Rossum BV, Delimon J, Rijnierse P, Thunnissen M, Busschbach JJV, & Kim JJ. Cost-effectiveness of psychotherapy for cluster C personality disorders: a decision-analytic model in the Netherlands. Journal of Clinical Psychiatry 2011 Jan;72(1):51-9

29. Conclusion cost effectiveness • Cluster C PD: • Short-term inpatient psychotherapy (first choice) • Short-term day hospital psychotherapy • Sub-optimal treatment options are: • long-term out patient, • 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 29