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 Less than 6 monthsMore than 6 months Outpatient Day hospital Inpatient psychotherapy

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? Separate PhD, 2010 Medical Care, 2010 Psychotherapy and Psychosomatics, 2009

12. Cluster A  N= 58: one of the largest studies ever  But groups got very small Less than 6 monthsMore than 6 months Outpatient Day hospital Inpatient psychotherapy No time constrains Outpatient Day hospital Inpatient psychotherapy

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 Less than 6 monthsMore than 6 months Outpatient Day hospital Inpatient psychotherapy No time constrains Outpatient Day hospital Inpatient psychotherapy

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

17. But no significant results in cluster B…  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…

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. Still inconclusive cost effectiveness…  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

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

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

25. 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. 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: 1.Short-term inpatient psychotherapy (first choice) 2.Short-term day hospital psychotherapy 3.Sub-optimal treatment options are: long-term out patient, long term day hospital and long-term inpatient  Cluster B PD: 1.Outpatient psychotherapy (first choice) 2.Day hospital psychotherapy 3.Sub-optimal treatment option is: Inpatient psychotherapy 29