cost-effectiveness of detection and treatment of anxiety and depression in frequent attenders of the...

Cost-effectiveness of detection and treatment of anxiety and depression in

frequent attenders of the GP

Judith Bosmans, Frans Smits, Veerle Coupé,Jacob Mohrs, Aart Schene, Henk van Weert,

Gerben ter Riet

g.terriet@amc.nl

Frequent Attenders• 90-100th centile of attendance frequency in 4 age categories

for men and women separately

• Somatic, psychological & social problems

• Referral and costs

• Heartsink for (some) GPs

• Why embark on RCTs?

Questions• What would happen if

– We detected and treated all depression and anxiety in:• one-year frequent attenders (1yFA)• two-year frequent attenders (2yFA)

• In terms of– years spent as non-FA without depression or anxiety– quality-adjusted life years

• Compared to– Usual care in Amsterdam SE region, The Netherlands 2007 – 2011– Δ cost strategy x vs usual care / Δ effects strategy x vs usual care

QALY: Quality Adjusted Life Years

Usual care

Strategy x

gained by the intervention

Quality improvement

Quantity improvement

α

α = cost-effectiveness ratio = Δ cost / Δ effect

.

Methods: components of CEAComponent Source or number Comment

States (non)FA; depression, anxiety; success of treatment

See next slide

Transitions Simplifications necessary

Transition probabilities Cohort of 1yFAs from HAG-net-AMC Markov model

Utilities of states Literature; FA anxiety 0.55; nonFA 0.85 0=death; 1=full health

Cycle length 1 year Assess states each yr

Time horizon 5 years

Strategies (treatments) RR={0.90, 0.80, 0.60, 0.00} ± spill-over effects

Costs states Achmea dbase; € 2400 – 12400 per year real

Cost psychotherapy € 500 (NL costs 6 x 80) real

Outcomes Years spent as non-FA without depression or anxiety; QALYs

Uncertainty Monte Carlo simulation; 10,000 x Sample from distributions

Perspective Health care Societal better?

1yFA + depression

2yFA + depression

2yFA + anxiety

2yFA + unknown or no morbidity

2yFA + Tx success

pFA + depression

pFA + anxiety

pFA + unknown or no morbidity

pFA + Tx success

nonFA + depression

nonFA + anxiety

nonFA + unknown or no morbidity

1yFA + depression

1yFA + depression

0.02

0.31

0.10

0.06

0.39

0.12

N=49

Example (1 out of 5 cycles): 1yFA with depression and transition probabilities under usual care

Results: Usual Care

• 70 % percent of 1yFA and 2yFA with depression or anxiety were free of those after one year.

• In pFAs 50% stayed depressed and 60% stayed anxious after one year.

• 1000 1yFAs spent 86% of time in a nonFA state without depression or anxiety (4322/5000 person-years)

Results: 1000 1yFAsTreatment effect

(RR) Δ with usual care

- 330.710/44.1 = - 7.504

Δ with usual care

Interpretation

• Detection and treatment of depression cost- effective at RR <= 0.6, unless spill-over

• Detection and treatment of anxiety not cost-effective, even with spill-over

• Detection and treatment of depression and anxiety cost effective at RR <= 0.6

Cost-effectiveness of detection and treatment of anxiety and depression in

frequent attenders of the GP

Judith Bosmans, Frans Smits, Veerle Coupé,Jacob Mohrs, Aart Schene, Henk van Weert,

Gerben ter Riet

g.terriet@amc.nl

Results: 1000 2yFAsTreatment effect

(RR) Δ with usual care

Δ with usual care

Strengths & limitationsStrengths Limitations

Realistic data for transition probabilities 1 year 5 years

Realistic cost data (Achmea) Limited data to populate the model (N=692, but “zeroes”)

Many scenarios Simplifications: number of states

Effect of spill-over analysed Simplifications: possible transitions not considered

PHQ as the yardstick PHQ as the yardstick

Monte Carlo (uncertainty) Pertinent utility weight literature scarce

Usual care quite good

Confidence intervals were wide