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