TY - JOUR
KW - Adult
KW - Cost-Benefit Analysis
KW - Depression/therapy
KW - Depressive Disorder/therapy
KW - Humans
KW - Prospective Studies
KW - Quality-Adjusted Life Years
KW - Costs and Cost Analysis
KW - Delivery of healthcare, integrated
KW - depressive disorder
AU - C. Brettschneider
AU - D. Heddaeus
AU - M. Steinmann
AU - M. Harter
AU - B. Watzke
AU - H. H. Konig
A1 - 
AB - BACKGROUND: Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression. METHODS: This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered. RESULTS: We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained). CONCLUSIONS: We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual. TRIAL REGISTRATION: NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.
AD - Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20251, Hamburg, Germany. c.brettschneider@uke.de.; Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20251, Hamburg, Germany.; Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20251, Hamburg, Germany.; Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20251, Hamburg, Germany.; Institute of Psychology, Clinical Psychology and Psychotherapy Research, University of Zurich, Binzmühlestrasse 14, Box 16, CH-8050, Zürich, Switzerland.; Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20251, Hamburg, Germany.
BT - BMC psychiatry
C5 - Financing & Sustainability; Healthcare Disparities; Measures
CP - 1
DO - 10.1186/s12888-020-02829-0
IS - 1
JF - BMC psychiatry
LA - eng
M1 - Journal Article
N2 - BACKGROUND: Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression. METHODS: This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered. RESULTS: We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained). CONCLUSIONS: We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual. TRIAL REGISTRATION: NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.
PY - 2020
SN - 1471-244X; 1471-244X
SP - 427
T1 - Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression - a cluster-randomized trial
T2 - BMC psychiatry
TI - Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression - a cluster-randomized trial
U1 - Financing & Sustainability; Healthcare Disparities; Measures
U2 - 32859177
U3 - 10.1186/s12888-020-02829-0
VL - 20
VO - 1471-244X; 1471-244X
Y1 - 2020
Y2 - Aug 28
ER -