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Cognitive-behavioural therapy for health anxiety in a genitourinary medicine clinic: randomised controlled trial |
Seivewright H, Green J, Salkovskis P, Barrett B, Nur U, Tyrer P |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective was to examine the clinical and economic impact of cognitive-behavioural therapy (CBT) in patients aged 16 to 65 years, with high health anxiety, in a genitourinary medicine clinic. CBT improved the clinical outcomes, although the additional costs were not offset by savings on health care consultations. Overall, the study was well conducted and reported, which enhances the validity of the authors’ conclusions. However, this was a pilot study, which needs confirmation in a larger clinical trial. Type of economic evaluation Cost-effectiveness analysis Study objective The objective was to examine the clinical and economic impact of cognitive-behavioural therapy (CBT) in patients aged 16 to 65 years with high health anxiety and hypochondria in a genitourinary medicine clinic. Interventions Sessions of CBT, supplemented by a booklet, were compared with a single assessment interview followed by ordinary care. Methods Analytical approach:This economic evaluation was based on a single study with a one-year time horizon. The authors stated that the perspective of the health service provider was adopted.
Effectiveness data:The clinical data were derived from a randomised controlled trial, which was carried out at a single institution, which was the King’s Mill Hospital (Sutton-in-Ashfield, Nottinghamshire). Patients suffering from high health anxiety were identified between April 2002 and February 2005. High anxiety was defined as 20 or more points on the Health Anxiety Inventory (HAI). At the end of the selection process, 23 patients were enrolled in the CBT group and 26 patients in the control group. Follow-up took place after three months, six months, and one year. The assessments were not masked, but self-ratings were used to assess anxiety, depression and social functioning. Statistical analyses were carried out to take into account both the potential impact of baseline confounding factors and the issue of missing follow-up data.
Monetary benefit and utility valuations:Not relevant.
Measure of benefit:The summary benefit measure was the improvement in HAI score.
Cost data:The analysis included the costs of CBT (time spent by therapists and the relevant overheads), primary care contacts, out-patient visits, in-patient stays, and attendances at the accident and emergency department. The resource use data was collected, after the one-year follow-up, from patient medical records by staff, who were unaware of the treatment allocation. These items were costed using Personal Social Services Research Unit and National Health Service Reference Costs. All costs were in UK pounds sterling (£) for the financial year 2004 to 2005.
Analysis of uncertainty:A deterministic univariate sensitivity analysis was carried out on the cost of the intervention, which was varied by plus and minus 50% of its baseline value. Results The mean total costs per patient were £911 in the CBT group and £634 in the control group. This difference was not statistically significant. The reduction in other service costs of £150 did not completely offset the cost of CBT, which was £427 for an average of 4.3 sessions, making CBT more expensive overall.
Patients in the CBT group experienced statistically significant improvements in HAI scores, compared with those in the control group (mean difference: 6.60, p=0.001).
The incremental cost per unit reduction in HAI score with CBT over the comparator was £33.
Changes in the cost of the intervention affected these findings, with the cost differences ranging from £63 to £490 and the incremental cost-effectiveness ratios ranging from £8 to £59 per unit. Authors' conclusions The authors concluded that CBT, for patients with high health anxiety, in a genitourinary medicine clinic, improved their clinical outcomes, although the additional costs of the therapy were not offset by the savings on health care consultations. CRD commentary Interventions:The rationale for the selection of the comparators was clear in that the new intervention was compared against the usual care in the authors’ setting.
Effectiveness/benefits:Extensive information on the methods of the primary study was provided. The inclusion and exclusion criteria, methods of sample selection, details of the randomisation procedure and follow-up, methods used to impute missing data, use of other statistical tests, and types of clinical endpoints used were all reported. The small size of the sample was justified as this was a pilot study. In general, the clinical analysis was well conducted and reported. The benefit measure was disease-specific, which means that direct comparisons with the benefits of other health care interventions will not be possible.
Costs:The analysis of costs was consistent with the viewpoint. A breakdown of the cost items was given. The quantities of resources used were reported for all items, but the unit costs were not reported. The sources of costs were reported and were appropriate for the UK. Other details of the economic analysis, such as the price year and the use of statistical analyses, were reported.
Analysis and results:The use of an incremental approach to combine the costs and benefits of the two strategies was appropriate. The issue of uncertainty was not extensively addressed as the analysis considered only variations in the cost of the intervention. The study findings were clearly presented. The authors highlighted the limitations of their study, which mainly related to the small sample size and the unmasked assessment of the clinical results. This should be considered as a pilot study, which needs confirmation in a larger clinical trial.
Concluding remarks:Overall, the study was well conducted and reported, which enhances the validity of the authors’ conclusions. However, this was a pilot study, which needs confirmation in a larger clinical trial. Funding Supported by grants from the Sir Jules Thorn Charitable Trust, and North Nottinghamshire Research & Development. Bibliographic details Seivewright H, Green J, Salkovskis P, Barrett B, Nur U, Tyrer P. Cognitive-behavioural therapy for health anxiety in a genitourinary medicine clinic: randomised controlled trial. British Journal of Psychiatry 2008; 193(4): 332-337 Other publications of related interest Hakkaart-Van Roijen L, Van Straten A, Al M, et al. Cost-utility of brief psychological treatment for depression and anxiety. Br J Psychiatry 2006;188:323-9.
Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007;164:91-9. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Aged; Anxiety Disorders /economics /therapy; Cognitive Therapy /economics /methods; Female; Humans; Male; Middle Aged; Treatment Outcome; Young Adult AccessionNumber 22008102156 Date bibliographic record published 31/03/2009 Date abstract record published 03/06/2009 |
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