(Cost-)Effectiveness of Psychotherapy
for Personality Disorders
Jan van Busschbach
Prof. Dr. J. van Busschbach
Department of Medical Psychology and Psychotherapy
Erasmus MC
PO Box 2040
3000 CA Rotterdam
+31 10 7043807 (direct: 7044306)
[email protected]
Jan van Busschbach, Roel Verheul,
Anna Bartak, Djora Soeteman, Helene
Andrea, Janine van Manen
An different mindset:
Comparing “dosages”
 Usually ...
– Comparison between theoretical orientation of therapy
 Typically ...
– Amount of therapy is keep constant
– Little differences
• Nonspecific factors seems to drive treatment success
 This assumes ...
– amount of therapy is relevant
 Amount of therapy relates to costs
 Yet ...
– Relation between costs and effects is rarely investigated
SCEPTRE
 Study on Cost-Effectiveness of Personality Disorder
Treatment
 Start: March 2003
 6 clinics
SCEPTRE
 About 900 patient with PD
 Followed over 3 years
 Dosages compared
– Outpatient, day-hospital and inpatient psychotherapy
– Shorter than or equal to 6 months, longer than 6 months
 Clusters
– A; N = 58
– B; N = 241
– C; N = 466
 Naturalistic design
Selection bias
 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”
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
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)
Is the super covariate valid?
Psychotherapy and
Psychosomatics, 2009
Separate PhD, 2010
Medical Care, 2010
Cluster A: one of the largest studies ever
Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach,
Verheul, Stijnen, & Emmelkamp, (in press). Effectiveness of outpatient, day hospital, and inpatient
psychotherapeutic treatment for patients with cluster A personality disorder. Under review
But assumptions are not met in cluster A
Assumptions met in:
 3 groups in cluster B
– Inpatient
– Day-hospital
– Outpatient
 5 groups in cluster C
–
–
–
–
–
Short-term inpatient
Long-term inpatient
Short-term day-hospital
Long-term day-hospital
Long-term out-patient
Results cluster B
Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach,
Verheul, Stijnen, & Emmelkamp. Effectiveness of outpatient, day hospital, and inpatient
psychotherapeutic treatment for patients with cluster B personality disorder. Psychotherapy and
Psychosomatics, in press
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…
Results cluster C
Corrected rsults C
GSI - Difference score
Treatment
group
Long
outpatient
Short day
hospital
Long day
hospital
Short day
hospital
-0.0770
Long day
hospital
-0.1278
-0.0508
Short inpatient
0.3035
0.3805**
0.4313**
Long inpatient
-0.0030
0.0740
0.1247
* p < 0.05 ** p < 0.01 *** p < 0.001
Short
inpatient
-0.3065*
Propensity escore in cluster C
 Better effects of short-term inpatient psychotherapy
remain significant
 Assumptions propensity score are met
– Results maintain
 But costs could still make a difference…
Conclusions: effects
 No comparison possible in cluster A
– But psychotherapy seems to work
– Inpatient / day hospital seems better
 Non difference in B (after correction)
– But costs can be decisive ….
 Cluster C
– Favorable results for short-term inpatient psychotherapy
– Expect to dominates long in-patient
– But is short-term inpatient worth the costs?
• Compared to long day hospital / short day hospital
QALY
 Health economics addresses the efficient allocation
of health care resources
 For instance
– Psychotherapy “long” versus “short”
– “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)
QALY
 Quality Adjusted Life Years
 Area under the curve
1
Adjusment factor QALY
0,9
0,8
0,7
0,6
Co-morbidity
With psychotherapy
No psychotherapy
0,5
0,4
0,3
0,2
0,1
0
0
10
20
30
40
Life years
20
50
60
70
80

MOBILITY
– I have no problems in walking about
– I have some…….
– I am confined to bed
EQ-5D

SELF-CARE
– I have no problems with self-care
– I have some problems…..
– I am unable…
The EuroQol EQ-5D is
specially designed to
measure the quality of
life index for QALYs

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…..
21
Burden of disease: EQ-5D
Normal population
HIV
Schizophrenia (treated)
Diabetes II
Parkinson
Lung cancer
Personality disorder
Rheumatic disease
Heamodialysis
Major depression
0
0,2
0,4
0,6
0,8
Soeteman et al. Journal of Personality Disorders, 2008;22:259-68 .
Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
22
1
Markov model Cluster B
Soeteman, Verheul, Delimon, Meerman, Van den Eijnden, Rossum, Ziegler,
Thunnissen, Busschbach, Kim. Cost-effectiveness of psychotherapy for cluster B
personality disorders. British Journal of Psychiatry 2010;196:396–403.
Costs and effects in Cluster B
Much difference
Little difference
Much difference
Interested in both costs and effect
High costs
Forget it!
Good
Better
Less effective
Difficult…
More effective
Superb!
Low costs (savings)
25
Sensitivity analysis
High costs
Forget it!
Good
Better
Less effective
Difficult…
More effective
Superb!
Low costs (savings)
26
Cost-effectiveness plane
€ 250,000
Good
€ 200,000
long out
€ 150,000
Cost
short day
long day
short in
€ 100,000
long in
€ 50,000
Better
€0
2.8
2.9
3.0
3.1
3.2
3.3
QALYs
27
3.4
3.5
3.6
3.7
3.8
Acceptability curve
1
Probability cost-effective
0.9
0.8
0.7
Long outpatient
0.6
Short day hospital
Long day hospital
0.5
Short inpatient
0.4
Long inpatient
0.3
0.2
0.1
0
Societal WTP for a QALY (€)
28
Cluster B
Out /
Day /
in – patient
Cluster B
Out /
Day /
in – patient
Cluster C
Soeteman, Verheul, Meerman, Rossum, Delimon, Rijnierse, Thunnissen, Busschbach, & Kim.
Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical
Psychiatry (in press).
31
Cluster C
32
Conclusion
 Cost-effective treatment strategies are:
 Cluster C PD:
– Short-term inpatient psychotherapy (first choice)
– Short-term day hospital psychotherapy
 Sub-optimal treatment options are:
– 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
33
Dutch Council for Public Health and
Health Care (RvZ, 2006)
34
Definition “recovered patient”
 Clinically significant change:
(Jacobson and Truax, 1991)
–
–
–
–
Recovered: statistically reliable  + ends up within normal limits
Improved: statistically reliable , but ends still dysfunctional
Unchanged: no statistically reliable 
Relapsed or deteriorated: statistically reliable  in the opposite
direction
 General Symptom Index (BSI/SCL-90)
35
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(Cost-)Effectiveness of Psychotherapy for