More Related Content Similar to Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON Similar to Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON (20) More from HMO Research Network More from HMO Research Network (20) Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON1. Incremental cost-effectiveness of
preventing depression in at-risk
adolescents
John Dickerson, MS
May 1, 2012
18th Annual HMO Research Network Conference,
Seattle, WA
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
2. Frances L. Lynch, PhD
John F. Dickerson, MS
Greg Clarke, PhD
V Robin Weersing, PhD
William Beardslee, MD
Lynn DeBar, PhD
Tracey RG Gladstone, PhD
David Brent MD
Tami Mark, PhD
Giovanna Porta, MS
Judy Garber, PhD
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
3. Acknowledgements
Boston Pittsburgh
Rachel Ammirati Yuan Brustoloni Satish Iyengar
Jim Cooney Brian McKain Nadine Melhem
Kate Ginnis Deena Palenchar Tim Pitts
Mary Kate Little Jennifer Spendley Ebony West
Ellen Murachver Nathan Wigham Jamie Zelazny
Shula Ponet
Phyllis Rothberg
Carol Tee
Portland
Nashville
Kristina Booker
Alison Firemark
Mary Jo Coiro Beth Donaghey Bobbi Jo Yarborough
Laurel Duncan Liz Ezell Stephanie Hertert
Jocelyn Carter Wendi Marien Sue Leung
Rachel Swan Matt Morris Tracy O’Connor
Brandyn Street Sarah Frankel Kevin Rogers
Katie Gallerani Christian Webb Jane Wallace
Mi Wu
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
4. Adolescent Depression
Point prevalence rates of 3-8%
Average age of first onset = 15 years
Lifetime prevalence rate of depression by end of
adolescence = 25%
Relapse rate of 40% within 2 years; 75% within 5 years
Symptoms of depression in adolescence are associated
with risk for full-blown disorder
Most cases of recurrent adult depression have initial
onsets during adolescence
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
5. Consequences of Adolescent Depression
– Short Term
Difficulties in relationships
Impaired school and work performance
Increased risk for teen pregnancy
Increased risk for substance abuse
Reduced quality of life
Higher rates of suicide attempts
Higher health care costs
Greater use of school and other social services
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
6. Consequences of Adolescent Depression
– Long Term
Poor functional outcomes in adulthood
Reduced quality of life
Higher rates of suicide attempts
More psychiatric and medical hospitalizations
Lower educational attainment
More time out of work
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
7. Risk Factors for Depression
Parental Depression
Increases risk of youth depression by 40%
Sub-syndromal Depression symptoms
Symptoms but not meeting diagnostic criteria
Increases risk of youth depression by 30%
Previous Episodes of Depression
(Weisz et al. 2006; Birmaher & Brent 2007; TADS Team 2004; NICE 2008)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
8. Parental Depression
Strongest risk factor for depression in youth
4X greater risk of depression in children of depressed
parents
Amongst adolescents seeking services for depression
most have parents with current mood disorders
More internalizing and externalizing disorders,
cognitive delays, academic and social difficulties
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
9. Treatment of Adolescent Depression
Evidence for pharmacotherapy and psychotherapy
(interpersonal psychotherapy, cognitive-behavioral psychotherapy)
Only 25% of youth who meet depression criteria
receive any type of treatment
50-60% of those treated in controlled research
studies show improvement
Current clinical practice fails to alleviate the majority
of the disease burden associated with depression
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
10. Prevention and Mental Health
Clinical resources focused on current crises
Researchers and clinicians trained in pathology-
based models
Insurance and health care systems designed to
provide treatment of disease, prevention is typically
less well funded
Most insurance does not currently cover
prevention services for mental health
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
11. Studies evaluating prevention interventions
Multiple RCT have demonstrated that it is possible
to prevent depression episodes using
psychotherapeutic interventions including CB
approaches
In particular, two studies have demonstrated that
a CB Prevention intervention can reduce the risk
of depression episodes in youth of depressed
parents (Clarke et al. 2001; Lynch et al. 2005; Garber et al. 2010)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
12. Prevention of Depression (POD) Study
Specific Aims
To test the efficacy of a cognitive-behavioral (CB)
program for preventing depression in at-risk
adolescents, across 4 sites
To explore possible moderators
To examine cost-effectiveness of program
compared to TAU
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
13. Inclusion Criteria
At least one biological parent had a current and/or
past depressive episode
Adolescents (13-17 years old) had
Current subsyndromal symptoms of depression [CES-D > 20]
A history of a diagnosed depressive disorder
Or both
Both a selective and indicated sample
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
14. Exclusion Criteria
Neither parent nor the teen could be bipolar or
schizophrenic
Teens could not
currently meet criteria for MDD or dysthymia
currently be taking any anti-depressant medication
have received cognitive-behavioral therapy
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
15. Study Design
RCT
4 sites (Nashville, TN; Boston, MA;
Pittsburgh PA; Portland OR)
Adolescents aged 13-17 years
At-risk for depression
316 youth participated in study
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
16. POD Prevention Program
• Cognitive therapy approach
• Groups ranged in size from 3 to 10
• Mixed gender, expected 60-80% female
• 8 weekly Acute sessions, 90 minute per session
• 6 monthly Continuation sessions, also 90 min’s
• Parent group: weeks 1 and 8 (variable
attendance)
• Led by Master’s level therapists
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
17. Methods
Participants assessed at baseline, 3, and 9
months blind to intervention status
Randomized to either CBP or UC
All participants could initiate or continue any
health care services, non-health services (e.g.,
school, social services)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
18. Clinical Outcome Measures
Schedule for Affective Disorders and
Schizophrenia for School- Age Children
(KSADS) Present and Lifetime Version (Kaufman et al. 1997)
Clinical Global Impression Scale (CGI) -
Improvement (Guy 1976)
Child Depression Rating Scale (CDRS) –Revised
(Poznanski et al. 1994; Brent et al. 2008).
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
19. Clinical Effects for the CEA
Depression Free Days (DFD)
Quality-adjusted Life Years (QALY)
Used clinical data at each assessment
Use linear interpolation between clinical
time points
Summed over 9 months
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
20. Cost Data
Comprehensive costs of interventions, usual
care across service sectors, parent time costs
Collected concurrent with trial
Sources of data
Interviews with study personnel
Study activity and financial records
Child and Adolescent Services Assessment (CASA)
Parent and youth report
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
21. Types of Cost Included
• Interventions
– CBP
– Including training and supervision
• Usual Care health care
General medical and mental health specialty
• Comprehensive services outside Health
Including school, social services, juvenile justice
• Family costs
Time, travel
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
22. Valuation of resources
Study financial records
• Estimated cost of Usual Care services
• Unit costs from large databases including MEPS,
Marketscan Claims Databases, Previous Studies
(Lynch et al. 2005; Lynch et al. 2011; Domino et al. 2008)
• Parent and participant reported costs for outside
health and other costs
• Estimated parent time costs using human capital
approach
• All resources in 2009 $
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
23. Statistical Analyses
Analyses were intention-to-treat basis
Hypotheses tests from based on group variable in OLS regression
models
Bootstrapping with a single model with 1000 replications
(BCa; Thompson et al. 2000; O’Brien & Briggs 2002; O’Brien et al. 1994).
Net benefit regression framework to estimate
Cost Effectiveness Acceptability Curve (CEAC)
Examine differential CE for subgroups indicated by primary clinical analyses
(Hoch et al. 2005)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
24. Analyses
Main
All randomized youth
Sensitivity
Alternative QALY weights
Removal of outliers
Sub-group analyses
Based on clinical moderation analyses
Youth whose parents were actively depressed at baseline
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
25. Missing Data
Complete clinical outcome and health services data on 87%
of participants
Multiple imputation with chained equations (Royston 2004; Royston
2005) using STATA
Assumed missing at random
Included all non-missing values at all time points and
baseline demographics in the models
Created five imputation datasets (Little & Rubin 2002)
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
26. Table 1 – Sample Description
CBP TAU p
Adolescents (N=316) n=159 n=157
Age 14.8 (1.5) 14.8 (1.3) .66
Female 93 (58.5%) 92 (58.6%) .98
Caucasian 129 (82.7%) 125 (80.6%) .64
Latino/Hispanic 10 (6.3%) 11 (7.1%) .78
CES-D (entry qualifying score) 18.5 (9.1) 18.8 (9.6) .83
Children’s Depression Rating Scale -
28.6 (8.0) 29.1 (8.5) .52
Revised
Household Income 81 (52.3%) 96 (63.6%) .045
27. Incremental Differences in Clinical
Outcomes at 9 months
CBP group had:
13 more DFDs (p=.008)
0.022 more QALYs (p=.008)
DFD increased over time for both
groups
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
28. Table 3. Service Use thru 9 months
% with any use Mean use (SD)
CBP TAU CBP TAU
Inpatient Mental Health Days 1.9 1.3 33.3 (46.5) 11.0 (9.9)
Inpatient Alcohol or Drug Days 1.3 0 24.0 (28.3)
Counseling or Medication Visits 29.6 27.4 11.3 (17.3) 9.1 (14.3)
Day Hospital Days 0.6 0 106 (--)
Alcohol or Drug Treatment Visits 1.3 0.6 8.5 (6.4) 33.0 (--)
Crisis Services 2.5 0.6 24.0 (34.5) 2.0 (--)
Medical doctor visits 6.3 11.5 2.1 (1.5) 1.8 (1.1)
Emergency Room Visits 1.9 1.3 1 (--) 2.5 (2.1)
5.7 5.1
Days of Antidepressant Medication 110.9 (78.7) 126.0 (86.5)
3.1 1.9
Days of Stimulant Medication 105.6 (74.2) 61.0 (30.0)
Days of Other Psych Medication 0.0 1.3 73.0 (70.4) 153.0 (--)
ANY School Services 20.1 22.9 29.1 (61.1) 44.9 (105.2)
Juvenile correction contact 1.3 3.2 10.0 (2.8) 5.2 (7.3)
29. Table 4. Cost (2009 USD) thru 9 months
CBP TAU CBP TAU
Non-Protocol Costs
% with Any Cost/
Mean Cost (SD) 52.1 50.3 882 (3,285) 740 (2,021)
Family Costs 38.2 36.9 55 (170) 109 (470)
Intervention Costs
CBP Program Costs 277 (108)
Intervention Family costs 314 (200)
Total Intervention Costs 591 (286)
TOTAL COST 1,579 (4,073) 802 (2,126)
30. Table 5: Adjusted cost effectiveness ratios
ICER (95% CI)*
DFD QALY
Full Sample (n=316) 59 35,434
(11 -263) (6,350 – 157,594)
Conservative QALY weight [70%] NA 47,250
(8,706 – 210,125)
Excluding cost outlier (n=315) 34 20,417
(2 – 125) (1,193 – 75,188)
Excluding patients with ANY 20 12,267
(-1– 76) (-751 –45,581)
inpatient utilization (n=308)
Outpatient costs only (n=316) 44 26,618
(7 – 192) (4,063 – 115,461)
Parental depression** Dominated Dominated
No parental depression 14 8,683
(-7 – 42) (-4,157–25,156)
*. bias corrected; **. CBP never preferred for this group.
31. Figure 1. Cost-effectiveness Planes Base Case
CDRS-DFDs -- through month 8
$2,000
Higher cost, better outcome
Higher cost, worse outcome
Incremental Total Cost
$1,000
$0
-$1,000
-$2,000
Lower cost, worse outcome Lower cost, better outcome
-40 -30 -20 -10 0 10 20 30 40
Incremental Change in CDRS-DFD
1000 replications; adjusted for age, baseline costs, race, household income, and gender differences
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
32. Figure 2. Cost-effectiveness acceptability curve base case
QALY (CDRS-DFD-based) at Month 8
100%
Probability Treatment is Cost-Effective
75%
50%
25%
0%
$0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000
Willingness to Pay
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
33. Figure 3. Cost-effectiveness planes by subgroup
No Parental Depression at Baseline Parental Depression at Baseline
$4,000
$4,000
Higher cost, worse outcome Higher cost, worse outcome Higher cost, better outcome
Higher cost, better outcome
$2,000
$2,000
Incremental Total Cost
Incremental Total Cost
$1,000
$1,000
$0
$0
-$1,000
-$1,000
-$2,000
-$2,000
Lower cost, better outcome Lower cost, better outcome
Lower cost, worse outcome
=$4,000
=$4,000
Lower cost, worse outcome
-40 -30 -20 -10 0 10 20 30 40 -40 -30 -20 -10 0 10 20 30 40
Incremental Change in CDRS-DFD Incremental Change in CDRS-DFD
1000 replications; adjusted for age, baseline costs, race, household income, and gender differences 1000 replications; adjusted for age, baseline costs, race, household income, and gender differences
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
34. Figure 4. Cost-effectiveness acceptability curves by subgroup
No Parental Depression at Baseline Parental Depression at Baseline
100%
100%
75%
75%
Probability Treatment is Cost-Effective
Probability Treatment is Cost-Effective
50%
50%
25%
25%
0%
0%
$0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000 $0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000
Willingness to Pay Willingness to Pay
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
35. Preliminary Conclusions
CBP increased DFD and QALYs
CBP significantly more expensive
CBP is very likely to be cost-effective compared to
many medical services currently covered by most
insurance programs
CBP highly cost-effective for youth whose parent’s
depression was in REMISSION at baseline
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
36. Limitations
Did not include productivity costs for youth
Adult literature suggests productivity is the largest cost of depression
Suggests substantial lost time from school
Did not include all family costs
Included typical parent time costs
Did NOT include caregiving time, coordination, other
Methods for calculating QALYs
Followed standard methods, but did not directly measure utility weights
No utility weights in youth available – used adult weights
Weights do not account for comorbidity
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
37. Future Directions
Replication over longer period of time
Clinical outcomes and costs may change over time
Data are collected through 32 months
Need better information on sub-groups
Larger sample could help to understand moderation of clinical and cost
outcomes
May need to adapt interventions for some risk groups
Co-treatment of parent and youth, sequential treatment of parent and youth
Need for Preference Based HRQL in youth
Evidence that depression negatively affects HRQL in youth
No preference based QALY weights for youth
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH