Cost-Effectiveness of Collaborative Care for Depression in a Primary Care Veteran Population

Department of Health Services, University of Washington Seattle, Seattle, Washington, United States
Psychiatric Services (Impact Factor: 2.41). 06/2003; 54(5):698-704. DOI: 10.1176/
Source: PubMed


This study examined the incremental cost-effectiveness of a collaborative care intervention for depression compared with consult-liaison care.
A total of 354 patients in a Department of Veterans Affairs (VA) primary care clinic who met the criteria for major depression or dysthymia were randomly assigned to one of the two care models. Under the collaborative care model, a mental health team provided a treatment plan to primary care providers, telephoned patients to encourage adherence, reviewed treatment results, and suggested modifications. Outcomes were assessed at three and nine months by telephone interviews. Health care use and costs were also assessed.
A significantly greater number of collaborative care patients were treated for depression and given prescriptions for antidepressants. The collaborative care patients experienced an average of 14.6 additional depression-free days over the nine months. The mean incremental cost of the intervention per patient was $237 US dollars for depression treatment and $519 US dollars for total outpatient costs. A majority of the additional expenditures were accounted for by the intervention. The incremental cost-effectiveness ratio was $24 US dollars per depression-free day for depression treatment costs and $33 US dollars for total outpatient cost.
Better coordination and communication under collaborative care was associated with a greater number of patients being treated for depression and with moderate increases in days free of depression and in treatment cost. Additional resources are needed for effective collaborative care models for depression treatment in primary care.

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    • "We thus expected that implementation of PACT would necessitate an ongoing local quality improvement (QI) process, in addition to top-down mandates and education.11 Local QI innovation, however, can be both idiosyncratic12,13 and expensive.14 "
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    ABSTRACT: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. To describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements. Descriptive. Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.
    Journal of General Internal Medicine 04/2014; 29(S2). DOI:10.1007/s11606-013-2703-y · 3.42 Impact Factor
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    • "Some studies apportioned intervention development costs by patient while others by primary care practice. Some studies reported lower overall costs associated with collaborative models [39,40], some reported no cost difference but improved clinical outcomes [13,28], and others reported improved clinical outcomes at higher costs which were comparable to the costs of treatments for other illnesses [41-43]. "
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    ABSTRACT: With the move to community care and increased involvement of generalist health care providers in mental health, the need for health service partnerships has been emphasised in mental health policy. Within existing health system structures the active strategies that facilitate effective partnership linkages are not clear. The objective of this study was to examine the evidence from peer reviewed literature regarding the effectiveness of service linkages in primary mental health care. A narrative and thematic review of English language papers published between 1998 and 2009. Studies of analytic, descriptive and qualitative designs from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted to examine what service linkages have been used in studies of collaboration in primary mental health care. Findings from the randomised trials were tabulated to show the proportion that demonstrated clinical, service delivery and economic benefits. A review of 119 studies found ten linkage types. Most studies used a combination of linkage types and so the 42 RCTs were grouped into four broad linkage categories for meaningful descriptive analysis of outcomes. Studies that used multiple linkage strategies from the suite of "direct collaborative activities" plus "agreed guidelines" plus "communication systems" showed positive clinical (81%), service (78%) and economic (75%) outcomes. Most evidence of effectiveness came from studies of depression. Long term benefits were attributed to medication concordance and the use of case managers with a professional background who received expert supervision. There were fewer randomised trials related to collaborative care of people with psychosis and there were almost none related to collaboration with the wider human service sectors. Because of the variability of study types we did not exclude on quality or attempt to weight findings according to power or effect size. There is strong evidence to support collaborative primary mental health care for people with depression when linkages involve "direct collaborative activity", plus "agreed guidelines" and "communication systems".
    BMC Health Services Research 04/2011; 11(1):72. DOI:10.1186/1472-6963-11-72 · 1.71 Impact Factor
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    • "One included a veteran population, mainly consisting of males (95%) [27] and one study investigated the collaborative care intervention for patients with major depressive disorder and diabetes mellitus[30]. Seven studies were performed in the United States [23-27,29,30] and one was performed in Chile [28]. All studies fulfilled the criteria for collaborative care and all studies compared collaborative care to care as usual in primary care. "
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    ABSTRACT: The effectiveness of collaborative care for patients with major depressive disorder in primary care has been established. Assessing its cost-effectiveness is important for deciding on implementation. This review therefore evaluates the cost-effectiveness of collaborative care for major depressive disorder in primary care. A systematic search on economic evaluations of collaborative care was conducted in Pubmed and PsychInfo. Quality of the studies was measured with the Cochrane checklist and the CHEC-list for economic evaluations. Cost-effectiveness and costs per depression-free days were reported. 8 studies were found, involving 4868 patients. The quality of the cost effectiveness studies, according to the CHEC-list, could be improved. Generally, the studies did not include all relevant costs and did not perform sensitivity analysis. Only 4 out of 8 studies reported cost per QALY, 6 out of 8 reported costs per depression-free days. The highest costs per QALY reported were $49,500, the highest costs per depression-free day were $24. Although studies did not fulfil all criteria of the CHEC-list, collaborative care is a promising intervention and it may be cost-effective. However, to conclude on the cost-effectiveness, depression research should follow economic guidelines to improve the quality of the economic evaluations.
    BMC Health Services Research 01/2010; 10(1):19. DOI:10.1186/1472-6963-10-19 · 1.71 Impact Factor
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