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The Cost-Effectiveness of a Collaborative Care Approach to Treating Depression and PTSD in the
Military
Tara Lavelle, PhD
Assistant Professor, Tufts Medical Center Institute for Clinical Research and Health Policy Studies
Adjunct Researcher, The RAND CorporationJune 26, 2016
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Collaborators:• Mallika Kommareddi, MS, Lisa H. Jaycox, PhD, Charles
C. Engel, MD, MPH (RAND Corporation)
• Bradley Belsher, PhD, Michael C. Freed, PhD
• Uniformed Services University of the Health Sciences & Deployment Health Clinical Center at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
Funding: • Department of Defense Deployment Related Medical
Research Program award (Grant DR080409)
2
Acknowledgements
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1/10 military
personnel have mental health diagnosis
3
1/5 returning from
combat receive diagnosis of PTSD
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Treatment
4
– Medication
– Clinical follow-up
– Therapy
But…
– Less than half receive mental health services
– Often not timely or adequate
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New Approach: Centrally Assisted Collaborative Telecare (CC)
Case management team
Specialists Patient PCP
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New Approach: Centrally Assisted Collaborative Telecare (CC)
6
• 12-month RCT: CC vs. Optimized Usual Care (UC)
• Clinically effective
• What is cost and is it cost-effective?
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Cost-effectiveness analysis
Incremental cost-effectiveness ratio
Effect: Quality Adjusted Life Year (QALY)
–Range: 0-1
Cost new treatment -Cost current treatment
Effect new treatment -Effect current treatment
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CEA Perspective
Societal
Health sector
Caregiver timeWorkProductivity
Family quality of life
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Cost-effectiveness: health sector
Health care
Work
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Cost-effectiveness: societal perspective
Health care
Work
10
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METHODS
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12-month health outcomes
Quality of Life
• SF-12
Survey measurements:
• Baseline, 3-months, 6-months, and 12-months
Patient QALYs
• SF-6D
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12-month costs
Intervention:
• Centralized management team
• Weekly case management team calls
• Contacts between nurse coordinator and patient
Other costs:
• Health Care: Outpatient, inpatient, medications
• Productivity: Lost work days
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RESULTS
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Baseline Characteristics (n=666)
80%
67% 70%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Male Married Education > HighSchool
RaceWhite
UC
CC
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Cost-effectiveness: health sector
Health care
Work
16
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12-month outcomes
Health Outcomes
• Patient QALYs
Costs
• Intervention
• Inpatient, outpatient, medications
17
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0.5
0.51
0.52
0.53
0.54
0.55
0.56
0.57
0.58
0.59
0.6
UC CC
QA
LYs
12-month Patient QALYs
18
CC > UC0.02
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12-month outcomes
Health Outcomes
• Patient QALYs
Costs
• Intervention
• Inpatient, outpatient, medications
19
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$0
$2,000
$4,000
$6,000
$8,000
$10,000
Usual care
STEPS-UP
UC
CC
12 month health care costs
20
Total 12-month costsCC > UC$2200
~$1800
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Cost-effectiveness: health care perspective
21
$110,000 per QALY
∆ QALYs
0.02
∆ Cost
$2200
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What is considered cost-effective?
Country specific
• USA:
–No explicit threshold
–$50,000- $100,000/QALY most commonly cited in literature
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Cost-effectiveness: societal perspective
Health care
Work
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12-month outcomes
Health Outcomes
• Patient QALYs
Costs
• Intervention
• Inpatient, outpatient, medications
• Lost work days
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12 month costs
25
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
Usual Care
STEPS-UP
UC
CC
Productivity costsUsual care> STEPS-UP
$1200
12 month costsSTEPS-UP > Usual care
$1000
Total 12-month costsSTEPS-UP > Usual care
$2200
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Cost-effectiveness: societal perspective
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$50,000 per QALY
∆ QALYs
0.02
∆ Cost
$1000
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Perspective ∆ Cost ∆ QALY ICER
Health System $2200 0.02 $110,000 per QALY
Societal $1000 0.02 $50,000 per QALY
Results were sensitive to our decision to include productivity costs…
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Limitations
• Claims data: Military health system and TRICARE
– No other third party payers
– No out of pocket costs
• 12-month time horizon
• SF-6D not sensitive to mental health outcomes
• Did not include impact on other family members
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Conclusions
• CC cost-effective approach to treating PTSD and depression in the MHS
• Consistent with CEA of other collaborative care models
• Increased health care integration promotes efficiency and value, major goals of the Affordable Care Act
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Thank You
Questions/Comments
30