Bowen Chung MD, Adjunct Staff, RAND, Assistant Professor, Geffen School of Medicine, UCLA

Michael Ong, MD, PhD

Associate Professor, Geffen School of Medicine, UCLA

Kenneth Wells, MD, MPH Senior Scientist, RAND

Weill Professor of Psychiatry, David Geffen School of Medicine at UCLA

January 23, 2013

Comparative Cost Analysis of Depression Care Interventions in

Community Partners in Care

Presenter Disclosures

No financial conflicts of interest to report

Acknowledgements

• RAND: Paul Koegel, Cathy Sherbourne • UCLA: Michael McCreary, Esmeralda Pulido, Lingqi Tang, Lily Zhang,

Susan Ettner • Healthy African American Families: Loretta Jones, Felica Jones • QueensCare Health and Faith Partnership: Elizabeth Dixon • Behavioral Health Services: James Gilmore •  Funders: National Institute of Mental Health, California Community

Foundation, Robert Wood Johnson Foundation, UCLA Clinical and Translational Science Institute

Goals for talk • Explain rationale for Community Partners in Care (CPIC) • Describe CPIC interventions and 6 & 12 month client

outcomes

• Review comparative cost analysis of the CPIC interventions from a societal perspective

• Feedback on several questions related to the cost analysis

Background

•  Depression a leading cause of disability worldwide •  Disparities exist in access, quality, outcomes of care for depression •  Collaborative care for depression in primary care improves outcome especially for African Americans and Latinos relative to whites

% recovered from depression at 5 years

Depression QI Interventions Reduce Long-Term Outcome Disparities (Partners in Care)

Community Context

•  Under-resourced communities have limited provider availability and limited implementation of Quality Improvement (QI) programs for depression.

•  Multiple services sectors support safety-net populations, but have little or no formal role in depression care or QI.

•  Healthcare reform prioritizes medical homes, accountable care organizations and patient-centered care but the role of community agencies as partners is unclear.

���Community Partners in Care

•  Community partnered participatory research and rigorous science •  Group-randomized trial at program level (n=95) of 2 approaches to

implement evidence-based QI toolkits for depression across diverse community-based agencies: Resources for Services (RS) and Community Engagement and Planning (CEP) in 2 communities, Hollywood and South Los Angeles

•  Primary outcomes •  poor mental health quality of life (MCS-12≤40) •  poor mental health (PHQ8≥10 + MCS-12≤40 + MHI-5<56)

•  Client measures at baseline, 6, 12 months

Interventions Resources for Services (RS) • Expert team conducted culturally competent outreach to programs • Offered 24 one-hour webinars and primary care site visits • Provided 22 webinars and 1 site visit • Study directly funded team/trainings Community Engagement and Planning (CEP) • 4-5 months of collaborative planning: biweekly meetings to review toolkits, plan trainings, build networks/agreements and capacity to co-lead; develop written plan; $15K for trainings

•  Team implementation of 174 trainings over 192 hours (conferences, webinars, on-site consultation)

•  Innovations: Resiliency classes, “Village Clinic”

Resources for Services

Community Engagement & Planning

Objective of cost analysis���sub-study

To determine the comparative cost-effectiveness from a societal perspective of 2 approaches (RS &CEP) to disseminate depression quality improvement on clients health and mental health outcomes

Sampling - Client • Approached: 4,649 •  Screened: 4,440 (95.5%) •  Eligible: 1,322 of 4,440 (29.8%)

– Criteria: PHQ-8≥10, Age≥18 years, reliable phone number •  Enrolled: 1,246 of 1322 (94.3%) • Completed baseline: 981 of 1,246 (78.7% of enrolled) • Completed 6 month: 759 of 1093 (69.4% eligible for follow-up) • Completed either baseline or 6 month: 1018 (81.7% of enrolled)

Screened Clients Reflected��� Diversity of Communities���

(N = 4,440, mean age 47 years)

65%

85%

16%

50%

23%

39%

28%

54%

MAJORITY OF DEPRESSION CONTACTS WERE NOT IN PRIMARY OR MENTAL HEALTH

7%

27%

27%

27%

Other data sources •  Provider and administrator survey data – baseline, 6, and 12 month •  Provider and administrator training data – baseline, 6, and 12 month •  Costs estimated from

•  CMS: DRG codes and payments for inpatient stays •  Food, Venue, Materials, CEUs – project invoices •  Medications: WHO DDD Index, Micromedex, Redbook •  AMA: CPT codes and payments for medical and mental health procedures •  National Bureau of Labor Statistics: wages for non-healthcare

sector providers – participant time, travel time, preparation time

•  Costs adjusted to 2010 using consumer price index

Key Assumptions •  BLS Wage classifications were an accurate reflection of the job title •  Minimum wage is a reasonable dollar amount to value client

opportunity costs •  Although we had individual at baseline, we didn’t 6 and 12 months, so

– we just used baseline – but 70 % unemployment – up 40% + unemployements in south LA – we didn’t think this was a bad assumption.

•  Client, provider, administrator travel time: 1 hour roundtrip

Key Assumptions •  Cost estimates of venue for similar interventions based on per

person costs of similar events •  Intervention staff – 15 or 30 minute prep time for meetings •  Services use estimate

•  Healthcare – output – moderate to severe complexity •  Mental Health – 30 min for a med visit, 45-50 minutes for

therapy, case management 45 minutes •  Social Services – case management 45 minutes •  Parks and recreation – Total annual budget / annual visitors •  Churches – 1 hour for a pastoral counseling visit •  Substance use – 45 -50 minutes for counseling

Analysis •  6 and 12 month outcomes •  Intent to treat, comparative effectiveness study •  Independent variable: intervention status •  Adjusted for baseline status of dependent variable and co-variates •  Weighted to eligible sample •  Imputation for missing data •  Adjustment for clustering of clients within programs for client data •  2-sided test with p<.05 for statistical significance •  Costs – analytic samples participating at baseline, 6, and 12 months

•  Not currently weighted for sampling or adjusted for clustering

RS CEP

Poor Mental Health Related Quality of Life* 51%

44%

Mental Wellness* 34% 46% Poor Mental Health* 37% 29% Good physical health and activity* 13% 19% ≥ 2 risk factors for homelessness* 39% 29% Any hospitalizations for alcohol, drugs, mental health* 10.5% 5.8% ≥ 4 hospital nights* 5.8% 2.1% *p<0.05 Poor Mental Health Quality of Life, MCS12 < 40 Mental Wellness, Yes to 1 item in last 4 weeks about: 1. Feeling peaceful and calm 2. Being a happy person 3. Having energy Poor Mental Health, Yes to all: MCS12 < 40, PHQ-8≥ 10, MHI-5≥ 56 Good Physical Health and Activity, Yes to all health limits: 1. Moderate activity, 2. Stairs, 3. Physical activity Risk factors for homelessness, ≥ 2 nights homeless, food insecurity, eviction, severe financial crisis

CPIC 6 Month Outcomes

CPIC 6 Month Outcomes RS CEP

Total outpatient contacts for depression across sectors (mean)

23 22

Any mental outpatient visits 54% 54% Took antidepressant, >=2 months 39% 32% # MH outpatient visits received medication advice (mean)*

11 5

Any primary care visit 29% 29% >= 2 visits for depression* 62% 80%

Faith-based visit 60% 57% >=3 faith-based visits for depression, if any (n=125)*

42% 64%

*p<0.05

Percent Poor Mental Health Quality of Life at 6 and 12 months

Perc

ent (

%)

p=0.07

Service Use Costs by Sector���at baseline, 6 & 12 months -

unadjusted Sector Baseline 6 Month 1 year

RS CEP RS CEP RS CEP Primary Care $796 $870 $835 $792 $662 $677 Mental Health $701 $779 $789 $651 $570 $510 Substance Abuse $1442 $2059 $1047 $1382 $537 $549 Faith Based $350 $306 $315 $255 $326 $271 Social and Community $403 $414 $321 $297 $183 $225

Costs, in dollars, include all client service use costs (hospitalizations for ADM, stayed in a residential treatment for substance abuse, ER visit, self-help for mental health problem, hotline for ADM problem, mental health outpatient visit, outpatient substance abuse services, primary care visit, social services, religious services, park services, met with case manager, other services for depression).

Start-up Costs by Sector Sector RS CEP

Primary Care $5,315 $27,363

Mental Health $5,592 $33,010

Substance Abuse $4,584 $34,798

Homeless $313 $9,679

Social and Community $7,221 $52,851

Costs include all intervention costs associated with participation time, travel time, food, venue, preparation and materials.

Preliminary RS & CEP Differences ���in Mean Cost of Services ($) and SF-6D ���at baseline, 6 & 12 months -unadjusted

Baseline 6 Months 12 Months

CEP RS CEP RS CEP RS

All services $ (SD)*

5496 (6989)

4768 (6536)

3701 (6024)

3668 (5191)

2597 (3904)

2490 (3759)

Healthcare 4814 4030 3247 3176 2109 2013

Non Healthcare

578 655 443 542 416 447

SF-6D (SD) 0.58 (0.102)

0.585 (0.116)

0.626 (0.129)

0.616 (0.129)

0.628 (0.134)

0.624 (0.144)

•  Includes patient time. Healthcare includes primary care, public health, mental health, substance abuse. Non-healthcare includes faith-based, social services, homeless services, community-trusted locations (senior centers, parks and recreation)

Next Steps • Completing 12 month outcomes analysis

•  Sensitivity analyses of different approaches to costing client time, adjusting for outliers in services utilization

•  Estimating individual, client hourly wages by examining baseline client reports of hours worked in last months, last estimated work date, and individual income from non-governmental sources

•  Link services use data from self-reported client data to specific agencies to get more accurate service use costs.

Implications •  Community engagement around evidence-based practices

may address multiple disparities by linking healthcare and community partners into networks that support evidence-based goals •  May meet “Triple Aims”

•  Improved individual experience of care •  Improved health of populations •  Reduced or equal cost ???

Questions

• How do we capture the differences in the benefits captured by the MCS-12, but not overall SF-12 in the QALY’s?

• How do we or should we capture the benefits of improvements in outcomes outside of health like reduced risk factors for homelessness?

• How do we capture the costs of client time (travel, visits, waiting time) in sectors outside of healthcare (e.g. faith-based, social services, senior centers)?

• How do we magnify the effects over the population of people who may have received some sort of treatment from these agencies?

• Since there is no usual care, is it reasonable to compare intervention cost and benefits at 6 and 12 months to baseline?

• Since the SD are greater than the means, our estimates are not precise.

Questions

Thank You to Our Funders!

Presenters and Contact Information Bowen Chung, MD Adjunct Scientist, RAND Corporation Assistant Professor, Department of Psychiatry Harbor-UCLA Medical Center 1000 West Carson Street, Box 498 Torrance, CA 90509 V 310-222-1801 E-mail: bchung@mednet.ucla.edu

Kenneth B. Wells, MD, MPH Senior Scientist, RAND Corporation Well Endowed Professor, Department of Psychiatry Geffen School of Medicine at UCLA Center for Health Services & Society 10920 Wilshire Blvd, Suite 300 Los Angeles, CA 90024 V: 310-794-3728 E-mail: kwells@mednet.ucla.edu

Michael Ong, MD, PhD Associate Professor, Department of Internal Medicine David Geffen School of Medicine at UCLA 10940 Wilshire Blvd, Suite 700 Los Angeles, CA 90024 V 310-794-0154 E-mail: mong@mednet.ucla.edu

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