(Cost-)Effectiveness of Psychotherapy for Personality Disorders Jan van Busschbach Prof. Dr. J. van...

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Transcript of (Cost-)Effectiveness of Psychotherapy for Personality Disorders Jan van Busschbach Prof. Dr. J. van...

  • Slide 1
  • (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) J.vanbusschbach@erasmusmc.nl
  • Slide 2
  • Jan van Busschbach, Roel Verheul, Anna Bartak, Djora Soeteman, Helene Andrea, Janine van Manen
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  • 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
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  • SCEPTRE Study on Cost-Effectiveness of Personality Disorder Treatment Start: March 2003 6 clinics
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  • 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
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  • 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
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  • 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
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  • 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)
  • Slide 9
  • Is the super covariate valid? Separate PhD, 2010 Medical Care, 2010 Psychotherapy and Psychosomatics, 2009
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  • 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
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  • But assumptions are not met in cluster A
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  • 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
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  • 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
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  • 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
  • Slide 15
  • Results cluster C
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  • Corrected rsults C GSI - Difference score Treatment group Long outpatient Short day hospital Long day hospital Short inpatient Short day hospital -0.0770 Long day hospital -0.1278-0.0508 Short inpatient 0.30350.3805**0.4313** Long inpatient -0.00300.07400.1247-0.3065* * p < 0.05 ** p < 0.01 *** p < 0.001
  • Slide 17
  • 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
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  • 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
  • Slide 19
  • 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)
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  • 20 QALY Quality Adjusted Life Years Area under the curve
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  • 21 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
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  • 22 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders, 2008;22:259-68. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
  • Slide 23
  • 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;196:396403.
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  • Costs and effects in Cluster B Much difference Little difference
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  • Interested in both costs and effect Less effectiveMore effective Low costs (savings) High costs Good Better Superb! Forget it! Difficult 25
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  • Sensitivity analysis Less effectiveMore effective Low costs (savings) High costs Superb! Forget it! Difficult 26 Good Better
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  • Cost-effectiveness plane 27 Good Better
  • Slide 28
  • Acceptability curve 28
  • Slide 29
  • Cluster B Out / Day / in patient
  • Slide 30
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  • Cluster C 31 Soeteman, Verheul, Meerman, Rossum, Delimon, Rijnierse, Thunnissen, Busschbach, & Kim. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (in press).
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  • Cluster C 32
  • Slide 33
  • 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
  • Slide 34
  • 34 Dutch Council for Public Health and Health Care (RvZ, 2006)
  • Slide 35
  • 35 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)