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(Cost-)Effectiveness of Psychotherapy for Personality Disorders
Jan van Busschbach
Prof. Dr. J. van BusschbachDepartment 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?
Separate PhD, 2010
Medical Care, 2010
Psychotherapy and Psychosomatics, 2009
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 inpatient
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 -0.3065*
* p < 0.05 ** p < 0.01 *** p < 0.001
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)
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QALY
Quality Adjusted Life Years Area under the curve
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 10 20 30 40 50 60 70 80
Life years
Ad
jus
me
nt
fac
tor
QA
LY
Co-morbidity
With psychotherapy
No psychotherapy
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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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Burden of disease: EQ-5D
0 0,2 0,4 0,6 0,8 1
Major depression
Heamodialysis
Rheumatic disease
Personality disorder
Lung cancer
Parkinson
Diabetes II
Schizophrenia (treated)
HIV
Normal population
Soeteman et al. Journal of Personality Disorders, 2008;22:259-68 . Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
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
Much difference
Little difference
Interested in both costs and effect
Less effective More effective
Low costs (savings)
High costs
Good
Better
Superb!
Forget it!
Difficult…
25
Sensitivity analysis
Less effective More effective
Low costs (savings)
High costs
Superb!
Forget it!
Difficult…
26
Good
Better
Cost-effectiveness plane
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Good
Better
Acceptability curve
28
Cluster BOut / Day /in – patient
Cluster BOut / Day /in – patient
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).
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
34
Dutch Council for Public Health and Health Care (RvZ, 2006)
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)