costeffectiveness of cognitive behaviour therapy versus talking and usual care for depressed older people in primary care

1、 Holmanetal.BMCHealthServicesResearch2011,11:33 :/ biomedcentral /1472-6963/11/33RESEARCH ARTICLEOpenAccessCost-effectivenessofcognitivebehaviourtherapyversustalkingandusualcarefordepressedolderpeopleinprimarycareAmandaJHolman1,MarcASerfaty 1,2*,BaptisteELeurent1,MichaelBKing1AbstractBackground:Whil

2、stevidencesuggestscognitivebehaviourtherapy(CBT)maybeeffectivefordepressedolderpeopleinaprimarycaresetting,fewstudieshaveexamineditscost-effectiveness.Theaimofthisstudywastocomparethecost-effectivenessofcognitivebehaviourtherapy(CBT),atalkingcontrol(TC)andtreatmentasusual(TAU),deliveredinaprimarycar

3、esetting,forolderpeoplewithdepression.Methods:Costdatageneratedfromasingleblindrandomisedcontrolledtrialof204peopleaged65yearsormorewereofferedonlyTreatmentasUsual,orTAUplusuptotwelvesessionsofCBToratalkingcontrolispresented.TheBeckDepressionInventoryII(BDI-II)wasthemainoutcomemeasurefordepression.D

4、irecttreatmentcostswerecomparedwithreductionsindepressionscores.Cost-effectivenessanalysiswasconductedusingnon-parametricbootstrapping.Theprimaryanalysisfocussedonthecost-effectivenessofCBTcomparedwithTAUat10monthsfollowup.Results:Completecostdatawereavailablefor198patientsat4and10monthfollowup.Ther

5、ewerenosignificantdifferencesbetweengroupsinbaselinecosts.Themajorityofhealthservicecontactsatfollowupweremadewithgeneralpractitioners.FewercontactswithmentalhealthserviceswererecordedinpatientsallocatedtoCBT,thoughthesedifferenceswerenotsignificant.Overalltotalperpatientcosts(includinginterventionc

6、osts)weresignificantlyhigherintheCBTgroupcomparedwiththeTAUgroupat10monthfollowup(difference427,95%CI:56-787,p0.001).ReductionsinBDI-IIscoresweresignificantlygreaterintheCBTgroup(difference3.6points,95%CI:0.7-6.5points,p=0.018).CBTisassociatedwithanincrementalcostof120peradditionalpointreductioninBD

7、Iscoreanda90%probabilityofbeingconsideredcost-effectiveifpurchasersarewillingtopayupto270perpointreductionintheBDI-IIscore.Conclusions:CBTissignificantlymorecostlythanTAUaloneorTAUplusTC,butmoreclinicallyeffective.Basedoncurrentestimates,CBTislikelytoberecommendedasacost-effectivetreatmentoptionfort

8、hispatientgroupifthevalueplacedonaunitreductioninBDI-IIisgreaterthan115.TrialRegistration:Identifier:ISRCTN18271323Backgroundhospitalandoutpatientmedicalservices3-5,evenafterDepression in older people is common, frequently adjustmentshavebeenmadefordemographic,socioeco-missed and undertrea

9、ted 1. Within the community it nomic and functional status, and co-morbidity 5-7often becomes a chronic disorder with up to 74% of Depressed patients are also more likely to end up inpeopleremainingdepressedoneyearafterdetection2. nursing homes 8. All of this places an increasedDepression is associa

10、ted with an increase in the use of demandonhealthandsocialcareresources9ofwhicholderpeoplearetraditionallyhighusers.Cognitive Behaviour Therapy (CBT) is a clinicallyeffectiveandrecommendedtreatmentfordepressivedis-order in adults of all ages and is associated with*Correspondence:mserfatymedsch.ucl.a

11、c.uk1ResearchDepartmentofMentalHealthSciences,UniversityCollegeMedicalSchool,London,UKFulllistofauthorinformationisavailableattheendofthearticle2011Holmanetal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense( ://licen

12、ses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. Holmanetal.BMCHealthServicesResearch2011,11:33Page2of9 :/ biomedcentral /1472-6963/11/33continuedimprovementovertime10.OlderpeopleinMethodsparticular tend to be high utilisers of m

13、edical services The study was conducted in a primary care setting inand service demands increase with clinical depression NorthLondonbetweenApril2004andSeptember2007.7,11. CBT is effective for depressed older people in a The inclusion criteria were (1) a primary diagnosis ofprimary care setting 12.

14、However, few studies have depressive disorder obtainedfromtheGeriatric Mentalassessed whether psychological interventions such as StateandHistoryandEtiologySchedule15.(2)ascoreCBTarecosteffectivefordepressedolderpeopletreated of 14 or higher on the BDI-II 16 (3) sufficient com-inaprimarycaresetting.

15、mandofEnglishtouseCBTtechniques; and(4)iftak-Boweretal(2000)conductedananalysis ofthecost- inganantidepressant,astabledoseofmedicationforateffectivenessofCBTfordepressioninpeopleofallages, least8weekspriortorandomization.Informedconsentcomparing CBT with non-directive counselling and was obtained fr

16、om all participants. Full details on theusualgeneral practitioner care13. Bothnon-directive designandmethodsemployedintheclinicaltrial,whichcounselling and CBT were associated with a reduction adhered to the CONSORT guidelines, have beenin depressive symptoms at four months, but this was reportedinS

17、erfatyetal,(2009)12.not sustained through till 12 months follow up. Therewere no significant differences in direct costs (drugs, The interventionoutpatientservices,inpatientservices,protocoltherapy, Patients allocated to CBT or TC were offered up totravelcosts),productionlosses,orsocietalcostsbetwee

18、n twelvesessionswithatherapistaccreditedbytheBritishthethreetreatmentsateitherfouror12months.How- Association of Behavioural andCognitive Psychothera-ever,closeranalysisofthedatashowedpatientsreceiv- pists. Within theconstraints of thenumberofsessionsingusualgeneralpractitionercarealonerecordedmore

19、available, the patient and the therapist collaborativelyGP consultations, greater use of antidepressants, and agreewhentherapyshouldterminate.TheTCwasusedmore psychiatric referrals. Untzer et al (2000) rando- to control for the main non-specific effects of therapy,mised 1,801 depressed primary care

20、patients aged over and is most comparable to a befriending service. All60 to usual care by their primary care doctor or colla- patientsreceivedusualcareasmanagedbytheirgeneralborative care. The cost of the intervention was about practitioner. The project was approved by the ethics370 ($670; 550) per

21、 patient over 12 months which committeeofCamdenandIslingtonCommunityHealthwassubstantiallylessthanayearsworthofanti-demen- ServicesTrustandsupportedbytheNorthCentralLon-tiadrugs(approximately1,000)14.donResearchConsortium,LRECreference03/37.We present a cost-effectiveness analysis based on arandomis

22、ed controlled trial of three treatments, Treat- Health service utilisationment as Usual (TAU), TAU plus CBT or TAU plus a Data on health service use was accessed via generaltalking control, for older people with depression pre- practicemedicalrecordsandcollectedusingamodifiedsenting in primary care

23、12. This design was used to version of the Client Service Receipt Inventory (CSRI)balanceknownandunknownfactorswhichmaypredict 17.Datawerecollectedforthreemonthperiodsprioroutcome and aimed to take into account the effects of toall follow up points: baseline, 4monthpost baseline“non-specific”factors

24、 intherapy, including face-to-face and10monthpostbaseline.contactwithanotherperson,warmthandempathy. ForDirect treatment costs associated with the interven-the purpose of this paper we will refer to the three tion, as well as community health service costs wereinterventionsasTAU,CBTorTC,whileacknowl

25、edging included munityhealthcareincludedcontactswiththelattertwowereprovidedinadditiontoTAU.GPs, practice and district nurses, health visitors, psy-chiatrists,clinicalpsychologists,occupationaltherapists,physiotherapists,communitypsychiatricnursesandgen-eral counsellors. All prescribed medication wa

26、sAimsHealth Economics ObjectiveFirst, to compare the average costs of care associated recorded.Dataspecificallyforantidepressantmedicationwith CBT, a Talking Control (TC) or Treatment as isprovidedindetailinSerfatyetal(2009)12.Nosig-Usual(TAU)forolderpeoplewithdepression.Secondly, nificant differenc

27、es at baseline or during the course ofto estimate the cost-effectiveness of CBT plus TAU thetrialwereobservedandimipraminedoseequivalentscomparedwithTAUaloneforolderpeoplewithdepres- weresimilar inall 3groups. Data relating to collectingsion using the change in Beck Depression Inventory-II of prescr

28、iptions or medication compliance were not(BDI-II) score at the trial end point. The analysis was available. However, as antidepressant prescribing wasconductedfromtheperspectiveoftheUKDepartments similaracrossgroups,itislikelythatthecostsofmedi-ofHealthandSocialServices.cationwerebalanced. Holmaneta

29、l.BMCHealthServicesResearch2011,11:33Page3of9 :/ biomedcentral /1472-6963/11/33Althoughitwouldhavebeenhelpfultoobtaininforma- thenumberofsessionsattendedbyeachpatient.Datafortiononindirectcostssuchasproductionlosses,patient thenumberoftherapysessionswascontinuousandnor-time,andcaregivertimeandburden

30、,thiswasnotpossi- mallydistributedandthereforetestedusinganunpairedble for ethical reasons. The bulk ofthe CSRI was col- t-test. There wasnosignificant difference between thelectedthroughconsultation withGPrecords. Inclusion meannumberofsessionsattendedforCBT(meanSD,ofothercostswouldhaveentailedfurt

31、herdatacollection 7.094.41sessions) orTC(meanSD,7.584.56ses-from avulnerable group ofpatients already burdened sions)(p=0.52).Totalcostsarepresentedasacumula-withhavingtocompleteanumberofratingscales.The authors believed there was no reason why CBTshouldaffecttheuseofacutehospitalcareservices,andtiv

32、etotalofhealthservicecostsandinterventioncosts.Statistical Analysismoreover,therewasconcernthatanyunderlyingdiffer- Althoughdetailedresourceusedatawerecollected,theencesinfunctionalitybetweenpatientgroupsmayresult samplesizewascalculatedonthebasisofexpectedclin-indifferencesinhospitalutilisation,and

33、thereforeintro- icaloutcomesandnotonthecostanalysisandreportedduceunnecessaryvariancetothecosts.Whiletherewas in Serfaty et al 12. The cost analysis was based onnorationaleforincludinghospitalutilisationintheana- patients with complete cost-data only, given very littlelysis,thesedatawereavailableand

34、providedanopportu- wasmissing(n=6/204,3%).Ascostswerenotnormallynitytoassessthereasonsforadmissionandwhetherthe distributed, analysis of variance (ANOVA) was per-decisiontoexcludethesecostswasappropriate.formedonlog-transformed costdata.Asdatahadonlybeencollectedforthreemonthspriortoeachfollowupperi

35、od (at 4 and 10 months), the gaps were estimatedUnit costsCosts are presented from the perspective of the UK asaproportion ofthecostsincurred duringthesubse-Departments of Health and Social Services, in 2008 quent follow up periods. The primary analysis was ofvalues (Table 1).Patient-level costs wer

36、ecalculated by total costs at the trial end point (10 months), but wemultiplying frequency of contacts with health service alsoreportcostsat4monthsfollow up.Asub-analysisproviderswithunitcostsfromUnitCostsofHealthand was conducted for mental health services using a chi-SocialCare2008 18.Intervention

37、costswerebasedon squared test (including visits to psychiatrists, clinicalpsychologists, occupational therapists, community psy-chiatricnurseandcounsellors).Around90%ofpatientsdidnotuseanymentalhealthservices,thereforeneithera t-test, nor a non-parametric test such as KruskallWallis,couldbeusedonthe

38、continuousvariable“num-ber of contacts”, hence the variable was dichotomised.Baseline costs were examined for differences betweengroups,butwerenotusedtoadjusttheresults.EffectivenesswasdefinedasthechangeinBDI-IIfrombaselinetofollowup.Astherewerenosignificantdiffer-encesbetweengroupsonhealth-relatedq

39、ualityoflife,wedidnotperform acost-effectiveness analysis using thisoutcomemeasure.Multiply-imputedvaluesgeneratedfortheeffectivenessanalysis(Serfatyetal.,2009)wereusedinthecase ofmissing BDI-II follow-up values. Outcomesdataweremissing for13%and18%ofthepatients at4and 10months respectively, with no

40、difference acrossarms. Webasedouranalysis ontheimputed outcomesdatausedfortheeffectivenesstrial12.Outcomeswereimputed using multiple imputation 19, using the icecommandinSTATAtogenerate5setsofimputedvalues.Table1UnitCosts(2008)CommunityHealthUnit ReferenceCost (PSSRUUnitCosts2008)ServicesGPcontact36

41、22Perclinicconsultationlasting11.7minutesphonecall7.1minsPhonedGPforadviceGPhomevisitsPracticenurse58homevisit23.4minsPerconsultation11Phonedpracticenurse6.72datanotavailable.setasaproportionaccordingtoGPtimeconsult:phonevisitDistrictnurseHealthVisitor26Perhomevisit16.533perhourincquals;Assume30mins

42、session.Psychiatrist10641PercontracthourClinicalPerprofessionalchargeablehour.psychologistOccupationalTherapist66Averagecostforaonetoonecontact.Physiotherapist4232Averagecostforaonetoonecontact.CommunityPsychiatricnurseNursespecialist(community).Perhour(includingqualifications)Counsellor/IndivTherap

43、ist40Perhourofclientcontact.Counsellingservicesinprimarymedicalcare.Cost-effectiveness analysisWeperformedanincrementalcost-effectivenessanalysis(CEA) comparing CBT with both TC and TAU, calcu-latingtheincrementalcost-effectivenessratios(ICER),i.e. the difference in average costs divided by the diff

44、er-ence in average effects between groups. In order toInterventioncostsCBTsession6624CBTsessionTalkingcontrolsessionSocialworkerassistant Holmanetal.BMCHealthServicesResearch2011,11:33Page4of9 :/ biomedcentral /1472-6963/11/33capturetheuncertaintyaroundtheestimates,1000non- Table2Averagenumberofcont

45、actswithcommunityparametric bootstrap replications were generated from healthservices(overbothfollowupperiods)the sets of multiply imputed data, and mean cost andeffectwereplottedinacosteffectivenessplane.CBTn=67TCn=65TAUn=66Totaln=198Aswedonot know the threshold willingness topayvalue foradditional

46、 effectiveness associated with CBT,theprobabilitythatCBTwillbeconsideredcosteffectivewascalculated forarangeofthreshold values andpre-sentedinacosteffectivenessacceptabilitycurve(CEAC).Datawereanalysed andprepared inStata Version 11(StataCorp,CollegeStation,Tex.),andbootstrappingandcost-effectivenes

47、sanalysiswasundertakeninMSExcel.Ourapriorihypothesisaimedtocomparecostsinrela-tiontoourmainoutcome measure, theBDI-II. Serfatyetal(2009)didnotfindanysignificantdifferenceinEuro-qolscoresbetweengroupsatanytimepoint(changeinEQ-5Dfrombaselinetofollow-up:0.04CBT;0.06TAU)12.Acost-effectivenessanalysisono

48、ursubsidiaryout-comemeasurewouldthereforenotbeappropriate.GPcontacts6.970.282.980.000.556.080.491.351.920.220.400.000.727.170.592.142.950.052.920.001.116.740.452.142.670.122.080.000.79PhonedGPforadviceGPhomevisitsPracticenursePhonedpracticenurseDistrictnurseHealthVisitorPhysiotherapist16

49、.67%p=0.207;10monthspost-baselineCBT11.94%,TC12.31%,TAU13.64%p=0.953).Asthenumbersofpatientsaccessingmentalhealthserviceswasverysmall(tenorlessineachgroup),itmaynothavebeenpossi-ble todetect meaningful differences between the treat-mentgroups.ResultsRecruitment and follow throughHospitalisation and

50、reasons foradmissionThe reasons for hospital admission were varied,although the majority were unplanned emergencyadmissions that were unlikely to have been influencedbythepsychologicalinterventions(e.g.orthopaedicsur-gery). Only one hospital admission was related todepression. Outpatient appointment

51、s were also unre-latedtodepression.Thenumberofinpatientadmissionsdidnotdifferacrossarms,orovertime(overallpropor-tion of admissions: baseline 12%,fourmonths: 10%,10months:13%).Thesefindingssupportedthedecisiontoexclude hospital costs from the analysis as they wouldhaveonlyintroducedasourceofunwanted

52、variationtothecostsdata.Ofthe204participantswhoenteredthestudy,83(40.7%)selfreferred,72(35.3%)werereferredbytheirGPand49(24.0%)wererecruitedthroughGPdatabases.Themajor-itywerefemale(n=162;79.4%),white(n=154;75.5%)and aged 74.1(SD 7.0) years. One hundred and fifty(73.5%)wereantidepressantfreeatbaseli

53、ne.TherewerenodifferencesinanyoftheabovecharacteristicsinthoseallocatedTreatmentasUsual(TAU),TAUplusCBT(n=70),orTAUplusaTalkingControl(n=67).Theavail-abilityofcostdatawashigh.Among204patientsrecruitedintothetrial,198patientshadcompletecostdataat10monthsfollowup(postbaseline).Sixcasesweremissinghavin

54、gallwithdrawnfromthetrialafterbaseline.Average CostsHealth service utilisationMean per patient costs are shown in Table 4 by treat-ment group. Histograms showed cost data was highlyskewed, therefore tests of significance using one wayANOVAs were performed on log-transformed data.Resultsshowednosigni

55、ficantdifferencebetweengroupsinbaselinecosts(p=0.0703).Nodifferenceincommu-nityhealthservicecostswereshownateitherfouror10Themajorityofcommunityhealthservicecontactsweremadewithgeneralpractitioners(85%).Overall,theaver-agenumberofcontactswereverysimilarbetweenCBTandTAUgroups,andlowestintheTCgroup(Ta

56、ble2).Significantdifferencesaretestedbelowinthesectiononaverage costs, where resource counts are multiplied byunitcosts.Table3Averagenumberofcontactswithmentalhealthservices(overbothfollowupperiods)Mental health service usePatientsintheCBTgroupgenerallyreportedfewercon-tacts withmentalhealth services thanpa