1. Cost-effectiveness in the quest to convince the outside world Dr. Jan Busschbach De Viersprong Erasmus MC www.vispd.nl

2. 2 Should we employ cost effectiveness research in personality disorder?  The obligatorily favourable arguments… –State-of-the-art research –Legitimise reimbursement  But cost effectiveness is not widely present…. –What stops us?

3. 3 Arguments not to employ cost effectiveness research…  It has already been shown.. –We know that psychotherapy is cost effective in PD  The methods are unfavourable for psychotherapy –The outcome measures (QALYs) are not sensitive for changes in personality  It is not important –It does not matter in reimbursement decisions  It is complex… –An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis using a societal perspective….

4. 4 Arguments not to employ cost effectiveness research…  It has already been shown.. –We know that psychotherapy is cost effective in PD  The methods are unfavourable for psychotherapy –The outcome measures (QALYs) is not sensitive for changes in personality  It is not important –It does not matter in reimbursement decisions  It is complex… –An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….

5. 5 Elements of cost effectiveness…

6. 6 Productivity losses in months per year

7. 7 But does that tell us: …how competitive is psychotherapy in PD?  What is de cost effectiveness of psychotherapy in PD? –Compared to treatment in oncology… –Compared to dialysis… –Compared to osteoporosis treatment …  Cost per health gain –Like cost per kilometre in cars  Outcome health: QALY –Quality Adjusted Life Years –Makes outcome in health care comparable –Both survival & quality of life

8. 8 Car league table

9. 9 QALY league table

10. 10 Is there already evidence of cost effectiveness?

11. 11 White raven  The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial. –Palmer, S., K. Davidson, et al. (2006). –J Personal Disord 20(5): 466-81  Outpatient psychotherapy for BPD: The cost-effectiveness of schema- focused therapy versus transference-focused psychotherapy –Thea van Asselt, Josephine Giesen-Bloo –University of Maastricht –This ISSPD conference  Modelling the cost-effectiveness of psychotherapy in personality disorders, long term inpatient versus short term inpatient –Djøra Soeteman et al. –Viersprong –This ISSPD conference

12. 12  John Brazier, Prof in Health Economics –Leading institute, University of Sheffield –Psychological therapies […] for borderline personality disorder: a systematic review and preliminary economic evaluation –January, 2007  On the basis of an extensive review  Converted all existing evidence into a health economic model –“The results for [psychotherapy] are promising, though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.” Cumulative evidence can be classified as “a promise”

13. 13 Arguments not to employ cost effectiveness research…  It has already been shown.. –We know that psychotherapy is cost effective in PD  The methods are unfavourable for psychotherapy –The outcome measures (QALYs) are not sensitive for changes in personality  It is not important –It does not matter in reimbursement decisions  It is complex… –An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….

14. 14 Are the methods unfavourable for psychotherapy?  Cost effectiveness focuses on costs –Psychotherapy is labour intensive and thus expensive  Cost effectiveness uses generic outcomes: QALY –Quality Adjusted Life Years (QALYs) Are not sensitive –The changes caused by psychotherapy are subtle Functional changes Relations Enjoyment of life –But is that an argument against QALYs?

15. 15 QALY  Quality Adjusted Life Years  Area under the curve

16. 16 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….. Suspected: Not sensitive for PD The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs

17. 17 But the EQ-5D is sensitive in PD….

18. 18 Cost effectiveness is already employed in metal health  Schizophrenia –"Schizophrenia"[Mesh] AND "Cost-Benefit Analysis"[Mesh] –307 Hits in PubMed  Depression –"Depression"[Mesh] AND "Cost-Benefit Analysis"[Mesh] –104 Hits

19. 19 Arguments not to employ cost effectiveness research…  It has already been shown.. –We know that psychotherapy is cost effective in PD  The methods are unfavourable for psychotherapy –The outcome measures (QALYs) are not sensitive for changes in personality  It is not important –It does not matter in reimbursement decisions  It is complex… –An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….

20. 20 Car league table

21. 21 Is cost effectiveness important?  Indeed other factor are also important: –Burden of disease –Budget impact Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

22. 22 Burden of Disease and Budget Impact are imbedded in cost effectiveness  Burden of disease –In term of cost Uses same cost prises estimates –In term of quality of life Uses same generic quality of life estimates EQ-5D  Budget impact –Uses same cost prises estimates –Plus estimates of prevalence

23. 23 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders. 2007 in press. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005

24. 24 Cost of illness Soeteman, et al. Journal of Clinical Psychiatry, 2007 in press

25. 25 Cost effectiveness becomes more important

26. 26 Reimbursement of pharmaceuticals in Australia

27. 27 Arguments not to employ cost effectiveness research…  It has already been shown.. –We know that psychotherapy is cost effective in PD  The methods are unfavourable for psychotherapy –The outcome measures (QALYs) are not sensitive for changes in personality  It is not important –It does not matter in reimbursement decisions  It is complex… –An incremental cost effectiveness ratio from a probabilistic Markov Model with a multiple sensitivity analysis….

28. 28 Models can be complex…. As it tries to model real life…..

29. 29 Model of Soeteman et al, ISSPD conference The Hague

30. 30 We want both costs and effects…. Bad effectsGood effects Low costs (savings) High costs Good Better SUPER ! Forget it ! Difficult…

31. 31 Multiple sensitivity analysis Bad effectsGood effects Low costs (savings) High costs Good Better SUPER ! Forget it ! Difficult…

32. 32  John Brazier, Prof in Health Economics –Leading institute, University of Sheffield –January, 2007  On the basis of an extensive review  Converted all existing evidence into a health economic model –“The results for [psychotherapy] are promising, though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.” Psychological therapies […] for borderline personality disorder: a systematic review and preliminary economic evaluation

33. 33 Cost effectiveness plane, Brazier, 2007 Good Better SUPER ! Not so good… Forget it !

34. 34 Cost effectiveness threshold, Brazier, 2007 Our uncertainty about the cost effectiveness is not (further) determined by willingness to pay, but by the uncertainty of our own research results

35. 35 Arguments to employ cost effectiveness research…  We should research whether psychotherapy is cost effective in PD –It has already been shown..  The methods are favourable for psychotherapy –The methods are unfavourable for psychotherapy…  It is important –It does not matter in reimbursement decisions…  It is complex… –It is not of our psychotherapeutic world –It is more the outside world…

36. Let convince the outside world, before the outside world convinces us…..

37. 37 Hopeful, but incomplete  Psychotherapy appears to have a beneficial impact on a variety of costs […in…] borderline personality disorder. –Reviews of Gabbert et al., AJP, 1997 –Note: no integration with effects  "Until […] there is conclusive evidence of the efficacy and the cost-effectiveness of long-term psychotherapy, restraint needs to be exercised in administering such therapy [in personality disorder]." –Dutch Health Council, 2001  The results for [psychotherapy] are promising, though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area. –Brazier, 2007