Incremental cost-effectiveness of a collaborative care intervention for panic disorder
Department of Psychiatry, University of California, San Diego, San Diego, California, United States Psychological Medicine
(Impact Factor: 5.94).
04/2006; 36(3):353-63. DOI: 10.1017/S0033291705006896
Panic disorder is a prevalent, often disabling, disorder among primary-care patients, but there are large gaps in quality of treatment in primary care. This study describes the incremental cost-effectiveness of a combined cognitive behavioral therapy (CBT) and pharmacotherapy intervention for patients with panic disorder versus usual primary-care treatment.
This randomized control trial recruited 232 primary-care patients meeting DSM-IV criteria for panic disorder from March 2000 to March 2002 from six primary-care clinics from university-affiliated clinics at the University of Washington (Seattle) and University of California (Los Angeles and San Diego). Patients were randomly assigned to receive either treatment as usual or a combined CBT and pharmacotherapy intervention for panic disorder delivered in primary care by a mental health therapist. Intervention patients had up to six sessions of CBT modified for the primary-care setting in the first 12 weeks, and up to six telephone follow-ups over the next 9 months. The primary outcome variables were total out-patient costs, anxiety-free days (AFDs) and quality adjusted life-years (QALYs).
Relative to usual care, intervention patients experienced 60.4 [95% confidence interval (CI) 42.9-77.9] more AFDs over a 12-month period. Total incremental out-patient costs were 492 US dollars higher (95% CI 236-747 US dollars ) in intervention versus usual care patients with a cost per additional AFD of 8.40 US dollars (95% CI 2.80-14.0 US dollars ) and a cost per QALY ranging from 14,158 US dollars (95% CI 6,791-21,496 US dollars ) to 24,776 US dollars (95% CI 11,885-37,618 US dollars ). The cost per QALY estimate is well within the range of other commonly accepted medical interventions such as statin use and treatment of hypertension.
The combined CBT and pharmacotherapy intervention was associated with a robust clinical improvement compared to usual care with a moderate increase in ambulatory costs.
Available from: Harm Van Marwijk
- "In addition, Katon's study  did not involve a care manager, who was responsible for the largest part of the additional costs in our study. None of the costeffectiveness studies   used a stepped component in collaborative care. All studies were North American and since there are important differences between European and North American health care systems, these studies cannot be generalized without consideration. "
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: Generalized anxiety and panic disorder are a burden on society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective.
: The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life.
: The average annual direct medical costs in the collaborative stepped care group were 1,854 Euro (95% CI, 1,726 to 1,986) compared to € 1,503 (95% CI, 1,374 to 1,664) in the care as usual group. The average quality of life years (QALY's) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6,965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more.
: The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken.
: trialregister.nl, Netherlands Trial Register NTR107
Available from: Margarita Alegria
- "and assign it to the number of face-to-face sessions each patient completed. For telephone sessions, we assign half the price of regular psychologist/social worker visits ($68.32) as it was done in Katon et al. 2006. 13 Given the lack of publicly available data on the cost of this type of therapy, we follow the previous literature and price telephone sessions at half the value of regular sessions. "
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ABSTRACT: Rising mental health costs have brought with them the pressing need to identify cost-effective treatments. Identifying cost-effective treatments for depression among Latinos is particularly relevant given substantial disparities in access to depression treatment for Latinos compared to non-Latino whites.
Available from: Lee Martinez
- "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".
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