Cost-effectiveness of treatments for major depression in primary care practice.

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.

Health-related physical function and quality of well-being prior to and following cardiomyoplasty. A preliminary report.

OBJECTIVE: The purpose of this study was to obtain preliminary data regarding the effects of cardiomyoplasty on health-related physical function and quality of well-being. EXPERIMENTAL DESIGN: Quasi-experimental with repeated measures. Patients were interviewed prior to surgery, with post-surgical follow-up interviews at 6 weeks, 6 months, and 12 months. SETTING: Interviews were usually conducted by telephone with patients who were at home at the time of data collection. PATIENTS OR PARTICIPANTS: Four patients receiving cardiomyoplasty at Allegheny General Hospital in Pittsburgh, Pennsylvania. INTERVENTIONS: Patients received cardiomyoplasty between November 1992 and April 1993. Cardiomyoplasty using the right latissimus dorsi muscle was performed on the first patient. A left muscle-wrap was performed on the subsequent three patients. MEASURES: Self-reported function and well-being were measured using the Sickness Impact Profile (SIP), the Quality of Well-Being Scale (QWB), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Patient responses on the SF-36 demonstrated general improvement in cardiomyoplasty survivors. Results on the QWB and SIP are mixed. CONCLUSIONS: Due to the small, incomplete sample and lack of any comparison group, extreme caution must be used in drawing any clinical conclusions from this preliminary data. Future randomized clinical trials of cardiomyoplasty need to include quality of life and health-related physical function as dependent variables. Further psychometric study is necessary which compares the usefulness of these various methods for assessing the value of outcomes for patients with end-stage heart disease.

Recommendations of the Panel on Cost-effectiveness in Health and Medicine.

OBJECTIVE: To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users. CONSENSUS PROCESS: The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists. CONCLUSIONS: The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ¿rule of reason,¿ balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.

Economic cost of home-based care for ventilator-assisted individuals: a preliminary report.

STUDY OBJECTIVE: To measure the direct and indirect costs of maintaining a ventilator-assisted individual (VAI) at home. DESIGN: A cross-sectional survey was conducted of primary family caregivers of VAIs residing in 37 states. SETTING: Surveys were delivered to the homes of VAIs. PARTICIPANTS: Two hundred seventy-seven (19.7%) of 1,404 primary family caregivers of patients who were ventilator-dependent and who were living at home. Interventions. None. MEASURES: Participants received the modified Katz Index and an investigator-developed Home Ventilator Care Cost and Utilization Survey (HVCCUS). RESULTS: Total cost of care was determined by summing total direct medical and nonmedical costs of home care and lost wages. Using LPN rates for private duty care, the average total cost of care was estimated to be $7,642 per month (median=$5,406). Using RN rates for private duty care, the average total cost of home care was estimated to be $8,596 per month (median=$5,911). Variation with VAI characteristics is discussed. CONCLUSIONS: Home care of VAIs is a labor-intensive and an economically costly undertaking. The development of policies and programs to support home placement requires additional investigation regarding factors affecting the cost-effectiveness of various placement settings, as well as the ability and/or willingness of family members to accept the cost and responsibility of home care.

Cost utility analysis of maintenance treatment for recurrent depression.

This paper presents a cost-utility analysis of three maintenance treatments for recurrent depression: interpersonal therapy (IPT-M), imipramine drug therapy (Drug), and a combination of the two. We base our analysis on the results of the University of Pittsburgh's Controlled Clinical Trial of Maintenance Therapies for Recurrent Depression. We construct a Markovian state-transition model to incorporate clinical effectiveness into cost and quality-of-life impacts; we assign empirical values to the parameters of this model; and we then use Monte Carlo analysis to compare the relative cost effectiveness of the different maintenance treatments. For the patients who met the eligibility standards for the study, Drug maintenance treatment is cost-effective in the strongest sense of the term compared to either a placebo group or IPT-M: it both improves expected lifetime health (measured in quality-adjusted life years, or QALYs) and reduces direct medical costs. This is true even when relatively severe side effects of the drug are considered. Compared to the placebo group, IPT-M and the combination of IPT-M and Drug each improve expected lifetime health, although in neither case are expected direct medical costs reduced. Still, the cost of the resulting health improvements, under $5000/QALY, are very reasonable. A similar conclusion holds comparing Drug and IPT-M to IPT-M alone. All of the above conclusions are quite robust to sensitivity analyses.

Problems with expanding Medicaid for the uninsured.

Many proposals for financing health care for the uninsured recommend expanding the Medicaid program. They often advocate extending Medicaid to all those under the poverty level and standardizing program benefits. However, the proposals have ignored important problems that must be resolved if the plans are to be successfully implemented, the most serious being the fiscal impacts that such proposals would have on states. The current Medicaid matching formula fails to reflect either the size of a state's Medicaid program or its ability to pay for it. As a result, the proportional fiscal effort that expansion proposals would require of states would greatly exceed that required of the federal government. Additionally, the fiscal impact would vary widely and have little relationship to a state's current Medicaid program generosity. Besides fiscal problems, significant differences exist between Medicaid and private plans in the areas of benefits, cost sharing, managed care, cost containment, and provider payment. Under a national system of health care, these differences would limit program economies, and create problems with perceived equity, continuity of care, and migration effects.

Risk perception and the value of safety.

This paper examines the relationship between perceived risk and willingness-to-pay (WTP) for increased safety from technological hazards in both conceptual and empirical terms. A conceptual model is developed in which a given household's WTP for risk reductions is a function of traditional socioeconomic variables (i.e., income and base level of risk) and perceived characteristics of the hazards (i.e., dread, knowledge, and exposure). Data to estimate the model are obtained through a combined contingent valuation and risk perception survey that considers 10 technological hazards, five of which are well-defined (e.g., death rates are known and the risks are relatively common) and five are less well-defined. Econometric results, using TOBIT estimation procedures, support the importance of both types of variables in explaining WTP across all 10 hazards. When the risks are split into two groups, the results show that WTP for well-defined hazards is most influenced by perceived personal exposure, while WTP for less well-defined risks is most influenced by levels of dread and severity.

Economic aspects of patterns of mental health care: cost variation by setting.

The paper examines the evidence regarding the extent to which differences exist in health and mental health status of psychiatric patients treated in the specialty mental health, general medical, and informal care sectors. Differences in types of patients treated in the three sectors are important to identify since there are dramatic differences in the average costs of treatment. We use data from the Baltimore Epidemiological Catchment Area Survey to estimate a statistical model of treatment setting choice. Our results suggest that there is little support for attributing major differences in treatment costs across sectors to differences in the health and mental health status of patients.

Determining provider choice for the treatment of mental disorder: the role of health and mental health status.

This article specifies and estimates a model of provider choice for mental health services. Three types of providers are identified: specialty mental health providers, general medical providers, and informal providers. Specific attention is paid to the role of health and mental health status in determining provider choice. The model is estimated using a multinomial logit approach applied to a sample of 2,800 respondents to the Baltimore Epidemiological Catchment Area Survey. The results are largely consistent with the previous work of Wells et al. (1982), suggesting that health and mental health status play an important role in the decision to seek care but have little effect on the type of provider chosen. The results also reveal that 22 percent of individuals obtaining mental health care did so through the informal care sector. One exemplary benefit design simulation is performed using the estimation results.

Direct costs and expenditures for mental health care in the United States in 1980.

Estimates of direct costs and expenditures for mental health care in 1980 are presented in this analysis. Besides estimates for the specialty mental health sector, the general medical sector, and the human service sector (schools and the criminal justice system), the authors include transportation costs and expenditures for transfer payments. They obtained a low total estimate of $19.2 billion and a high total estimate of $22 billion. Comparisons with previous estimates indicate an annual growth rate in real costs for mental health care of about 1.7 percent since 1971.