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Cost-effectiveness of psychotherapy for cluster C personality disorders: a decision-analytic model in the Netherlands |
Soeteman DI, Verheul R, Meerman AM, Ziegler U, Rossum BV, Delimon J, Rijnierse P, Thunnissen M, Busschbach JJ, Kim JJ |
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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 This study examined the cost-effectiveness of short- and long-term out-patient, in-patient, and day hospital psychotherapy for patients with cluster C personality disorders. The authors concluded that short-term day hospital psychotherapy and short-term in-patient psychotherapy were the most cost-effective strategies. The best option depended on the economic perspective and the cost-effectiveness threshold used. The cost-effectiveness methods were valid and should ensure the validity of the authors’ conclusions. Type of economic evaluation Cost-utility analysis, cost-benefit analysis Study objective This study examined the cost-effectiveness of short- and long-term out-patient, in-patient, and day hospital psychotherapy for adult patients with cluster C personality disorders. Interventions Five psychotherapy modalities were considered: long-term out-patient, long-term day hospital, long-term in-patient, short-term day hospital, and short-term in-patient treatment. Out-patient treatment was long-term only and consisted of up to two sessions per week of individual or group psychotherapy for more than six months. Day hospital and in-patient treatment consisted of psychotherapy combined with sociotherapy, nonverbal therapies, or both for one to five days per week. Short-term therapy was for up to six months and long-term therapy was for more than six months. In-patients resided in the treatment centre for five days each week. Location/setting Netherlands/in-patient and out-patient setting. Methods Analytical approach:The analysis was based on a Markov cohort model, with a five-year time horizon. The authors stated that both a societal and a payer perspective were considered.
Effectiveness data:The clinical data were from a published real-life non-randomised trial of 448 participants at six centres; the Study on Cost-Effectiveness of Personality disorder TREatment (SCEPTRE) trial (Bartak, et al. 2010, see ‘Other Publications of Related Interest’ below for bibliographic details). There were 96 patients in the long-term out-patient group, 85 patients in the short-term day hospital group, 103 patients in the long-term day hospital group, 63 patients in the short-term in-patient group, and 101 patients in the long-term in-patient group. The relapse rates were the key input for the model. Patients were followed-up for up to 42 months and data beyond the trial duration were extrapolated by averaging the last two observations from the values and holding those values constant over the last 1.5 years of the model. Baseline differences between groups were taken into account, using the multiple propensity score.
Monetary benefit and utility valuations:The utility values were from the sample of patients enrolled in the clinical trial and were derived using the European Quality of life (EQ-5D) instrument and Dutch tariffs.
Measure of benefit:Quality-adjusted life-years (QALYs) and recovered patient-years were the summary benefit measures. A 1.5% annual discount rate was applied to the QALYs.
Cost data:The payer perspective included the direct medical costs of primary treatment and health care following discharge, while the societal perspective also included the direct non-medical costs of lost productivity due to time spent in treatment and the indirect costs of future lost productivity due to the disorder. The resource quantities were from the trial, while the unit costs were from the hospital finance departments for staff salaries, equipment, buildings, and departmental overheads. A micro-costing approach was used to calculate the cost of a treatment session or an in-patient day. Productivity losses were calculated using questionnaires and the friction-cost method, based on official net incomes. All costs were in Euros (EUR) and were discounted at an annual rate of 4%. The price year was 2007.
Analysis of uncertainty:A probabilistic sensitivity analysis was carried out, using second-order Monte Carlo simulation, with predefined probability distributions for the model inputs. Cost-effectiveness acceptability curves were generated. Results From a societal perspective, the five-year projected costs were EUR 89,411 with short-term day hospital, EUR 89,936 with long-term out-patient, EUR 91,620 with short-term in-patient, EUR 105,940 with long-term day hospital, and EUR 119,946 with long-term in-patient therapy. The percentage of patients recovered was 46.8% with short-term day hospital, 31.3% with long-term out-patient, 49.0% with short-term in-patient, 49.8% with long-term day hospital, and 43.7% with long-term in-patient therapy. The QALYs were 3.44 with short-term day hospital, 3.30 with long-term out-patient, 3.57 with short-term in-patient, 3.49 with long-term day hospital, and 3.49 with long-term in-patient.
The incremental analysis showed that long-term out-patient, long-term day hospital, and long-term in-patient psychotherapy were strongly dominated, as they were less effective and more expensive than another modality, with short-term day hospital therapy as the reference strategy. From the perspective of society, the incremental cost per recovered patient-year, for short-term in-patient therapy, was EUR 2,637 and from the payer perspective it was EUR 9,874, while the incremental cost per QALY gained was EUR 16,570 from the societal perspective and EUR 66,302 from the payer perspective.
The probabilistic analysis confirmed that short-term in-patient psychotherapy had the highest probability of being cost-effective, regardless of the societal willingness to pay for a QALY, while the probability of being cost-effective was negligible for both long-term day hospital and long-term in-patient therapy. From a societal perspective, the cost-effectiveness acceptability frontier showed that above a threshold of EUR 16,570 for a QALY, short-term in-patient psychotherapy was the best strategy, but short-term day hospital therapy was the preferred strategy below this threshold. From the perspective of the payer, this threshold was EUR 66,302. Authors' conclusions The authors concluded that short-term day hospital psychotherapy and short-term in-patient psychotherapy were the most cost-effective strategies. The best option depended on the economic perspective and the cost-effectiveness threshold used. CRD commentary Interventions:The selection of the comparators was based on the interventions in the SPECTRE trial (Bartak, et al. 2010). A few patients were assigned to short-term out-patient psychotherapy, but this was not recommended and was excluded from the comparison.
Effectiveness/benefits:A published clinical trial was used for the clinical inputs. The authors pointed out the advantages of a trial of clinical practice, despite the lack of randomisation. It should have represented the real clinical patterns and allowed a very detailed collection of clinical and economic data. A relatively large number of patients were involved and a statistical approach was used to ensure the baseline comparability of the groups and to account for potential selection bias. The analysis was appropriately based on intention-to-treat. The trial participants also supplied the utility values, which were elicited using the validated EQ-5D instrument. QALYs were an appropriate benefit measure as they capture the impact of the disease on quality of life, which is a relevant dimension of health in patients with cluster C personality disorders.
Costs:A broad range of costs was included and they were consistent with the perspectives. The methods used to calculate the indirect cost were reported, but the cost items were not reported for other categories. The resource quantities were directly from the clinical trial, in which the data were collected prospectively and in detail. The price year, discount rate, and a currency conversion from EUR to US dollars were reported. The data sources were given and most of the costs were based on hospital charges. The costs were varied in the sensitivity analysis.
Analysis and results:The authors presented extensive details of the model outcomes and an incremental approach was appropriately used to synthesise the costs and benefits of the alternative strategies. This allowed the exclusion of inferior (dominated) strategies. An appropriate probabilistic approach was used to investigate the uncertainty. The methods and results of this probabilistic analysis were clearly presented. Discounting was carried out in accordance with Dutch guidelines. The authors stated that the analysis was based on treatment-seeking patients and was, therefore, not applicable to non-treatment seekers. The analysis appears to have been specific to the Dutch context and cannot easily be transferred to other settings.
Concluding remarks:The cost-effectiveness methodology was valid and should ensure the validity of the authors’ conclusions. Funding Supported by the Trustfonds of the Erasmus University, Netherlands. Bibliographic details Soeteman DI, Verheul R, Meerman AM, Ziegler U, Rossum BV, Delimon J, Rijnierse P, Thunnissen M, Busschbach JJ, Kim JJ. Cost-effectiveness of psychotherapy for cluster C personality disorders: a decision-analytic model in the Netherlands. Journal of Clinical Psychiatry 2011; 72(1): 51-59 Other publications of related interest Bartak A, Spreeuwenberg MD, Andrea H, et al. Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study. Psychotherapy and Psychosomatics 2010; 79(1): 20-30. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Aged; Ambulatory Care /economics /methods; Cluster Analysis; Cost-Benefit Analysis; Day Care, Medical /economics /methods; Decision Support Techniques; Diagnostic and Statistical Manual of Mental Disorders; Female; Health Care Costs /statistics & Hospitalization /economics; Humans; Intention to Treat Analysis; Length of Stay /economics; Male; Middle Aged; Models, Statistical; Netherlands; Personality Disorders /diagnosis /economics /therapy; Practice Guidelines as Topic; Psychiatric Status Rating Scales; Psychotherapy /economics /methods; Quality-Adjusted Life Years; numerical data AccessionNumber 22011000424 Date bibliographic record published 16/03/2011 Date abstract record published 25/05/2011 |
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