1 Interactive Introduction Cost Effectiveness and Psychotherapy Jan J. v. Busschbach, Ph.D. Psychotherapeutic Centrum ‘De Viersprong’, Halsteren – Department of Medical Psychology and Psychotherapy, Erasmus MC –

2 Psychotherapy or cancer treatment Symptoms of illnessPsycho Chemo Additional Survival0 years0.5 year Quality of life0.5   0.5 Days benefit / patient10 year0.5 year Costs of treatment € € Savings (medical)5.000 €0 € Savings (productivity)5.000 €0 €

3 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 Issues in health economics

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

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: € –3 mouths = 91.3 day –91.3 x 210 = 19, € Effect –Assume quality of life increase of 0.25 –Over 10 year Cost / QALY –19, / (10 x 0.25) = 7, € 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

ABC Utility of Health Egalitarian Concerns

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 – »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