Posttraumatic stress disorder (PTSD), anxiety, and depression

Transcription

1 Cost-Effectiveness of Collbortive Cre for Depression nd PTSD in Militry Personnel Tr A. Lvelle, PhD; Mllik Kommreddi, MPH; Lis H. Jycox, PhD; Brdley Belsher, PhD; Michel C. Freed, PhD; nd Chrles C. Engel, MD, MPH Posttrumtic stress disorder (PTSD), nxiety, nd depression re common conditions in the US militry. Prevlence estimtes of postdeployment PTSD nd depression rnge from 13% to 18%, nd 28% of service members report severe symptoms of PTSD, nxiety, or depression. 1,2 These problems cuse suffering nd impirment nd contribute to militry ttrition, bsenteeism, misconduct, nd sick-cll visits. 3,4 Despite this, less thn hlf of the serving militry personnel ffected receive militry mentl helth services, which re often not timely or dequte. 5,6 The militry hs ttempted to better integrte mentl helth services into primry cre, nd the first Army integrtion pproch begn in ,8 Access to nd qulity of mentl helth services for militry personnel hs remined recurring public policy concern, however. 1,9 To ddress this, the Institute of Medicine hs clled for helth system level interventions to increse ccess to nd continuity of mentl helth services in militry nd vetern popultions. 10 Collbortive cre is n empiriclly supported method of extending nd improving the rech, qulity, nd outcomes of cre for common helth conditions. 11,12 In more thn 80 rndomized trils, collbortive cre models hve demonstrted improved outcomes mong ptients with depression nd nxiety, depression-relted suicidl idetion, 15 depression nd other chronic helth conditions (eg, dibetes, sthm), 16 nd chronic pin. 17,18 As of Jnury 1, 2017, the Medicre fee schedule now reimburses for the delivery of collbortive cre. Recently, the first rndomized controlled tril (RCT) of centrlly ssisted collbortive telecre (CACT) for PTSD nd depression within the Militry Helth System (MHS) ws completed. 19,20 The STepped Enhncement of PTSD Services Using Primry Cre (STEPS-UP) tril compred CACT with the Army s preexisting progrm integrting behviorl helth in primry cre. CACT ws effective in reducing the severity of PTSD nd depressive symptoms in ctive militry personnel using primry cre, dding to the evidence supporting the use of collbortive cre tretment models for mentl illness in rnge of settings nd popultions. 20 However, no prior reserch ABSTRACT OBJECTIVES: Collbortive cre is n effective pproch for treting posttrumtic stress disorder (PTSD) nd depression within the US Militry Helth System (MHS), but its cost-effectiveness remins unstudied. Our objective ws to evlute the costs nd cost-effectiveness of centrlly ssisted collbortive telecre (CACT) versus optimized usul cre (OUC) for PTSD nd depression in the MHS. STUDY DESIGN: A rndomized tril compred CACT with OUC. Routine primry cre screening identified ctive-duty service members with PTSD or depression. Eligible prticipnts (N = 666) were rndomized to CACT or OUC nd ssessed t 3, 6, nd 12 months. OUC ptients could receive cre mngement nd incresed behviorl helth support. CACT ptients could receive these services plus stepped psychosocil tretment nd routine centrlized tem monitoring. METHODS: Qulity-djusted life-yers (QALYs) were derived from the 12-Item Short Form Helth Survey. Clims nd cse mngement dt were used to estimte costs. Cost-effectiveness nlyses were conducted from societl perspective. RESULTS: Dt from 629 ptients (320 CACT nd 309 OUC) with sufficient follow-up were nlyzed. CACT ptients gined 0.02 QALYs (95% CI, to 0.03) reltive to OUC ptients. Twelve-month costs, including productivity, were $987 (95% CI, $3056 to $5030) higher for CACT versus OUC. CACT ws estimted to cost $49,346 per QALY gined compred with OUC over 12 months. There is 58% probbility tht CACT is cost-effective t $100,000/QALY threshold. CONCLUSIONS: Despite its higher costs, CACT ppers to be cost-effective strtegy reltive to OUC for mnging PTSD nd depression in the MHS. Am J Mng Cre. 2018;24(2):91-98 THE AMERICAN JOURNAL OF MANAGED CARE VOL. 24, NO. 2 91

2 TAKEAWAY POINTS Centrlly ssisted collbortive telecre is cost-effective strtegy reltive to usul cre for treting posttrumtic stress disorder nd depression in the Militry Helth System (MHS). These findings re consistent with those of previous studies tht hve investigted the use of similr models of cre in rnge of helthcre settings nd popultions, but this is the first study to demonstrte vlue in militry helthcre setting. Results indicte tht investments in behviorl helth integrtion nd infrstructure in primry cre my provide good vlue for helthcre systems similr to the MHS, which is lrge integrted helthcre system serving pproximtely 9.5 million eligible beneficiries. hs shown whether collbortive cre pproch to treting PTSD nd depression is cost-effective in the MHS, n importnt question given tht the militry spends more thn $50 billion nnully on helthcre for its nerly 10 million beneficiries. 21 The objective of this study ws to evlute the cost-effectiveness of treting ptients with PTSD nd depression using CACT compred with optimized usul cre (OUC) in the MHS. METHODS Tril Design nd Tretment Protocol The RCT study design hs been published elsewhere in detil. 19 Briefly, between Februry 2012 nd September 2013, routine clinicl screening in 18 Army primry cre clinics t 6 militry instlltions identified ctive-duty service members with 1) PTSD, depression, or both, nd 2) ccess to Internet nd emil. Ptients were excluded if they hd current lcohol dependence, ctive suicidl idetion in the prior 2 months, plnned geogrphic reloction within 6 months, or current duties in the prticipting clinic. 20 Eligible prticipnts (N = 666) were rndomized to OUC (n = 334) or CACT (n = 332) to tret their symptoms for up to 12 months fter enrollment. OUC ptients received the stndrd integrted mentl helth pproch for Army primry cre clinics, which included incresed ccess to mentl helth specilists nd follow-up monitoring from nurse cre mnger who trcked ptients progress nd provided sttus updtes to primry cre clinicins. 8 CACT ptients received the stndrd OUC services plus 1) stepped psychosocil tretment nd 2) routine monitoring by centrl mentl helth tem with centrlized ptient symptom registry. Nurse cre mngers who worked with CACT ptients lso received dditionl trining in behviorl ctivtion, problem solving, nd motivtionl interviewing to provide dditionl support to ptients. 20 The study ws pproved by ll ffilited institutionl reserch review bords. Helth Outcome Assessment We used dt from ptient surveys dministered t bseline nd 3-, 6-, nd 12-month follow-ups to ssess the primry outcomes of depression nd PTSD, s well s helth-relted qulity of life (QOL) nd Intervention Costs other secondry helth outcomes. We ssessed the severity of PTSD nd depression symptoms using the PTSD Dignostic Scle 22,23 (PDS) nd the Hopkins Symptom Checklist depression items (HSCL-20). 24 We ssessed QOL using the 12-Item Short Form Helth Survey (SF-12). 25 We derived qulity-djusted life-yers (QALYs) from the Short-Form Six-Dimension utility index (SF-6D). 26 Depression-free dys (DFDs) were derived from the scored HSCL-20, 27 nd PTSD-free dys (PFDs) were derived from the PDS. Both rms of the study followed protocols tht instructed the use of weekly cselod review clls between nurse coordintors nd stff psychitrists to review prticipting ptients progress, s well s regulr cse mngement clls between the nurse coordintor nd the ptient nd other phone, emil, or text messge contcts s needed. An electronic cse mngement system ws used to trck ll contcts nd cselod review clls. Nurse coordintors in ech intervention rm lso underwent trining nd eduction sessions. To estimte the cost of ech of these intervention components, we multiplied the estimted hourly wge of ech prticipting stff member (nurse coordintor nd/or stff psychitrist) by the number nd verge durtion of ech contct or trining session, estimted from cse mngement system dt nd interviews with nurse coordintors t ech site. The CACT rm lso included centrlized mngement tem tht coordinted intervention ctivities throughout the 12-month study period, composed of hlf-time dministrtive ssistnt, full-time psychologist, nd hlf-time nurse coordintor. We estimted the cost of these services using the slry of ech stff member. All wge estimtes were bsed on the Generl Schedule py scle. 20 Other Costs We used clims dt to ssess the other (nonintervention) helthcre resources utilized within nd outside of the MHS through the 12-month study period. These dt contin informtion on medictions, inptient stys, emergency deprtment visits, outptient tests nd procedures, outptient visits, nd telephone contcts. Utiliztion ws recorded within the MHS nd outside the MHS when reimbursed by TRICARE. For services provided within the MHS, costs were estimted from the given estimted full service cost, which includes resources used nd estimted overhed; for services nd medictions provided outside of the MHS, costs were estimted from the totl mount reimbursed by TRICARE. We excluded ny services, such s certin telephone contcts, tht were recorded in clims dt but lredy ccounted for in our nlysis s n intervention component. Helthcre costs borne by the ptient, including co-pys for services, were not included. 92 FEBRUARY

3 1 column Cost-Effectiveness of Collbortive Cre We used survey dt from 3-, 6-, nd 12-month follow-ups to estimte productivity costs over the course of the 12-month study. At ech survey time point, we sked prticipnts if they hd missed n entire workdy or prt of workdy due to mentl or physicl helth problem in the previous 28 dys. We extrpolted the stted number of lost workdys to cover the full period since the previous survey nd estimted productivity costs by multiplying the estimted number of lost workdys by dily personnel cost. We estimted personnel costs from the slries reported t the study bseline plus fringe benefits. Sttisticl Anlysis We included ptients who received the intervention nd hd t lest 1 follow-up intervl of both survey dt nd cost dt in the primry economic evlution nlytic popultion. We excluded ptients who did not receive ny intervention or received the intervention but did not hve both cost nd survey dt. For ptients included in the nlysis, we imputed missing 12-month cumultive QALY, utiliztion, nd cost dt using the fully conditionl specifiction pproch. 28 Imputtion models included vilble mesures of cost nd utiliztion; demogrphic nd socil chrcteristics, including ge, rce, gender, slry, mritl sttus, nd eduction; nd clinicl chrcteristics, including SF-12 scores nd depression nd/or PTSD sttus. Imputtions were performed within ech tretment rm. Five imputtions were creted, nd results from ech imputtion were pooled using the rules outlined by Rubin. 29 Specificlly, we defined point estimtes s the verge of those from the 5 imputed dtsets. The vrince of the estimte ws derived from both the within-imputtion nd between-imputtion vrinces, where the former is the verge of the vrinces of point estimtes from the 5 imputed dtsets. Ctegoricl dt re reported s frequencies nd were compred using χ 2 or Fisher s exct test sttistics. Continuous demogrphic vribles re reported s mens nd SDs nd were compred with t test sttistics. Continuous cost nd utiliztion dt re reported s mens; the sttisticl significnce of the difference in mens between the 2 groups ws evluted using 95% CI. Cost ctegories lso report medin vlues. All nlyses were performed in SAS 9.4 (SAS Institute, Inc; Cry, North Crolin). Cost-Effectiveness Anlysis We exmined the cost-effectiveness of CACT versus OUC over the 12-month study period. In our bse cse nlysis, we included ll intervention costs, other helthcre costs pid for by the MHS or TRICARE within nd outside of the MHS, nd productivity costs. The primry outcome ssessed ws the incrementl cost-effectiveness rtio (ICER) in dollrs per QALY gined, which ws the difference in men totl costs between the 2 tretment rms over the 12-month study period divided by the difference in men QALYs. We converted ll costs to 2014 US dollrs for nlysis. Probbility Intervention Is Cost-Effective FIGURE. Cost-Effectiveness Acceptbility Curve 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 50, , , ,000 CACT indictes centrlly ssisted collbortive telecre; CEA, cost-effectiveness nlysis; ICER, incrementl cost-effectiveness rtio; OUC, optimized usul cre; QALY, qulity-djusted life yer. To crete the cceptbility curves, we creted 1000 bootstrpped replictions of ech of our multiply imputed dtsets. We re-rn the CEA in ech of these dtsets nd clculted the proportion of ICERs (CACT vs OUC) tht fell below commonly cited cost-effectiveness thresholds between $0/QALY nd $200,000/ QALY. At ech threshold, proportions from ech of our multiply imputed dtsets were combined using Rubin s rules. 29 The proportion of ICERs (CACT vs OUC) tht fell below ech benchmrk CEA threshold represented the probbility tht CACT would be considered cost-effective compred with OUC t tht threshold nd would be considered the preferred intervention. In ll remining cses, we considered OUC to be the preferred intervention t ech threshold. We rn 6 sensitivity nlyses to exmine the impct of ssumptions used in our bse cse nlysis. We generted cost-effectiveness cceptbility curves to show the probbility tht either CACT or OUC would be considered the preferred intervention t rnge of cost-effectiveness thresholds (Figure). 29 RESULTS Study Smple Willingness to Py Threshold ($/QALY) CACT OUC Among the 666 ptients enrolled in the study, 629 ptients were ssigned to n intervention rm (320 CACT nd 309 OUC) nd hd t lest 1 follow-up intervl ech of cost dt nd helth outcome dt. A totl of 553 ptients nswered the survey t ll 4 time points. Full 12-month cost nd helth outcome dt were vilble for 459 ptients, nd multiple imputtion ws used to generte full QALY nd cost dt for the remining 170 ptients (27% of full nlytic smple). Ptients were well mtched between study rms, with no sttisticlly significnt differences mong them. The mjority of ptients in ech rm were mle (~80%) nd mrried (63%), nd men ges were 31 nd 32 yers in the CACT nd OUC rms, respectively (Tble 1). 26,30,31 THE AMERICAN JOURNAL OF MANAGED CARE VOL. 24, NO. 2 93

4 TABLE 1. Sociodemogrphic Chrcteristics Twelve-Month Helth Outcomes CACT (n = 320) OUC (n = 309) As reported in Engel et l, the primry PTSD nd depression outcomes exmined s prt of the overll RCT showed smll to moderte, but sttisticlly significnt, improvements over 12 months in the CACT group compred with the OUC group. 20 These improvements were mesured by the PDS ( 2.53 lower scores for CACT vs OUC; 95% CI, 4.47 to 0.59) nd HSCL-20 scores ( 0.26; 95% CI, 0.41 to 0.11). 20 Significnt improvements were lso observed in the CACT P for Difference Bseline Chrcteristics Age (yers), men ± SD (n) ± 7.48 (320) ± 7.79 (309).23 Mle, n (%) 255 (79.69) 254 (82.20).42 Mrried, n (%) 202 (63.13) 195 (63.11).85 Highest level of eduction, n (%).58 High school or GED 106 (33.13) 104 (33.66) Some college 150 (46.88) 134 (43.37) College or grdute degree 64 (20.00) 71 (22.98) Rce, n (%).92 White, non-hispnic 154 (48.13) 148 (47.90) Africn Americn, non-hispnic 78 (24.38) 70 (22.65) Hispnic 55 (17.19) 55 (17.80) Other, non-hispnic 33 (10.31) 36 (11.65) Annul slry (individul), n (%).64 <$30, (33.44) 90 (29.13) $30,000-$59, (54.69) 181 (58.58) $60,000-$99, (10.94) 35 (11.32) $100,000 2 (0.63) 1 (0.32) Workdys missed in previous month due to mentl or physicl helth problem, men dys ± SD (n) Entire workdys 1.58 ± 3.25 (315) 1.99 ± 4.91 (305).23 Prtil workdys 2.95 ± 4.20 (315) 3.45 ± 5.29 (305).19 Qulity of life (SF-12), men summry scores ± SD (n) Mentl helth ± 9.34 (317) ± (309).06 Physicl helth ± (317) ± (309).16 SF-6D utility scores ± 0.10 (315) 0.56 ± 0.11 (308).88 Bseline screening, n (%) PTSD (86.25) 261 (84.47).53 Depression (67.19) 194 (62.78).25 PTSD nd depression 186 (58.13) 165 (53.40).23 CACT indictes centrlly ssisted collbortive telecre; GED, Generl Eductionl Development; OUC, optimized usul cre; PTSD, posttrumtic stress disorder; SF-6D, Short-Form Six-Dimension utility index; SF-12, 12-Item Short Form Helth Survey. Bseline survey sked prticipnts if they hd missed n entire workdy or prt of workdy in pst 4 weeks due to physicl or mentl helth problem. group versus OUC for the 12-month secondry RCT outcomes of physicl symptom severity nd mentl helth relted QOL, but not for other secondry helth outcomes of suicidlity, pin intensity nd interference, lcohol misuse, nd physicl QOL. 20 We found tht over the 12-month follow-up, QALYs, s derived from the SF-6D, were 0.60 for CACT versus 0.59 for OUC, with nonsignificnt 0.02 QALY (95% CI, to 0.03) gin for CACT reltive to OUC. DFDs nd PFDs lso did not differ significntly between groups (Tble 2). Twelve-Month Costs Compred with ptients rndomized to OUC, ptients in the CACT rm of the study received significntly more intervention resources, including cre mngement contcts (7.25 vs 3.74) nd other s needed contcts (3.97 vs 1.06) during the study period (P <.05 for difference in both) (Tble 2). Ptients in CACT were lso reviewed more frequently in cselod review clls (9.9 times over the 12-month study period vs 1.5 times for OUC ptients; P <.05), nd CACT nurse coordintors received more trining nd eduction (Tble 2). These resources, plus 12 months of centrl ssistnce, resulted in $1754 higher intervention costs for ptients in the CACT rm compred with the OUC rm over the 12-month study period ($2743 vs $989; P <.05). The utiliztion of other helthcre resources did not differ significntly between study rms, with the exception of nonintervention-relted telephone contcts, which were significntly more common in the CACT intervention rm (6.0 vs 4.3 in the OUC rm) (Tble 2). However, ptients in the CACT rm hd 3.0 fewer lost workdys (95% CI, 13.1 to 7.0) compred with ptients in OUC, equting to $1255 (95% CI, $3961 to $1451) productivity gin for CACT versus OUC. Adding up intervention costs, other helthcre costs, nd productivity costs cross both CACT nd OUC, totl 12-month costs were $987 (95% CI, $3056 to $5030) higher in CACT compred with OUC over the study period ($23,125 vs $22,138) (Tble 3). Cost-Effectiveness In the primry cost-effectiveness nlysis, CACT ws estimted to cost $49,346 per QALY gined compred with OUC (Tble 4). At US willingness to py (WTP) cost-effectiveness threshold of $100,000/ 94 FEBRUARY

5 Cost-Effectiveness of Collbortive Cre QALY, there is 58% probbility tht CACT is the preferred intervention (Figure). This likelihood increses t higher WTP thresholds (74% t $200,000/QALY) nd decreses t lower WTP thresholds (46% t $50,000/QALY). Excluding productivity costs incresed the cost of CACT reltive to OUC, resulting in rtio of $112,081/QALY (Tble 4). Similrly, hlving the number of ptients followed by centrlized mngement incresed the rtio to $110,089/QALY. Other sensitivity nlyses resulted in more fvorble ICERs for CACT reltive to OUC (Tble 4). DISCUSSION The MHS is sizble federl helth system with budget nerly s lrge s tht of the Veterns Helth Administrtion. The MHS invests hevily in behviorl helth integrtion nd infrstructure in primry cre, 32 ensuring tht this study is timely. We hve estimted tht CACT costs $49,346/QALY gined nd hs 58% probbility of being cost-effective t $100,000/QALY WTP threshold compred with OUC. These results were bsed on 12-month improvements in the PTSD nd depression outcomes observed s prt of the overll RCT for CACT versus OUC nd 0.02 (95% CI, to 0.03) gin in QALYs. CACT hd significntly higher intervention costs ($1754) over the 12-month period of intervention nd follow-up. Totl 12-month costs were $987 (95% CI, $3056 to $5030) higher in the CACT versus the OUC rm of the study when intervention costs, other helthcre costs, nd productivity costs were considered. Cost-effectiveness estimtes pper robust to ssumptions regrding the imputtion of missing dt, high-cost outliers, nd OUC intervention costs. These results re sensitive to the size of the ptient cselod hndled by the centrl ssistnce tem used to support CACT. In contrst to ptient-level tretments (eg, the cost-effectiveness nlysis [CEA] of mediction or psychotherpy), CACT is systems-level intervention requiring multidisciplinry tem with centrlized dministrtive nd clinicl support. Significnt reserch suggests tht depression nd nxiety outcomes improve when primry cre bsed collbortive cre TABLE Month Helth Service Use, Lost Workdys, nd Helth Outcomes, by Intervention Arm Intervention service utiliztion, men per ptient Cselod review clls (n) Cse mngement contcts (n) Other emil, text, or phone contcts, s needed (n) Trining nd eduction of nurse coordintors, minutes Totl helthcre utiliztion, men n Inptient hospitliztion (ll) Emergency deprtment visit (ll) Outptient procedure, imging, or test (ll) Outptient visit (ll) Outptient visit (mentl helth specilist) CACT (n = 320) 9.9 ( ) 7.3 ( ) 4.0 ( ) OUC (n = 309) 1.5 ( ) 3.7 ( ) 1.1 ( ) Difference in s 8.4 ( ) 3.5 ( ) 2.9 ( ) ( ) 1.2 ( ) 37.7 ( ) 38.1 ( ) 13.6 ( ) Other telephone contcts b 6.0 ( ) Medictions (ll, including refills) Medictions (mentl helth, including refills) Lost workdys, men Totl lost workdys Helth outcomes, men QALYs Depression-free dys 28.4 ( ) 11.4 ( ) 39.4 ( ) 0.60 ( ) 0.31 ( ) PTSD-free dys c 0.34 ( ) 0.2 ( ) 1.0 ( ) 40.6 ( ) 38.8 ( ) 12.9 ( ) 4.3 ( ) 27.2 ( ) 10.6 ( ) 42.5 ( ) 0.59 ( ) 0.29 ( ) 0.32 ( ) 0.1 ( to 0.2) 0.3 ( 0.1 to 0.6) 2.9 ( 9.4 to 3.6) 0.7 ( 6.0 to 4.5) 0.7 ( 1.9 to 3.3) 1.7 ( ) 1.2 ( 3.0 to 5.4) 0.8 ( 1.5 to 3.2) 3.1 ( 13.1 to 7.0) 0.02 ( to 0.03) 0.02 ( 0.03 to 0.07) 0.03 ( 0.01 to 0.07) CACT indictes centrlly ssisted collbortive telecre; OUC, optimized usul cre; PDS, PTSD Dignostic Scle; PTSD, posttrumtic stress disorder; QALY, qulity-djusted life-yer. Utiliztion is sttisticlly significntly higher for CACT versus OUC t the P =.05 level. b Nonintervention-relted telephone contcts, including specilty cre phone clls, or primry cre phone clls when mde by someone other thn nurse. c PTSD-free dys were derived from the PDS ssessments t ech of the bseline nd follow-up time points, using 2 thresholds. At the lower bound, PDS score of 0 (indicting no symptoms of PTSD) ws used to identify ptients who were completely free of PTSD t tht time point (proportion of PTSD-free dys = 1). A score of 36 or higher (indicting severe symptoms of PTSD) ws used to identify ptients who hd no dys free of PTSD t tht time point (proportion of PTSD-free dys = 0). A liner interpoltion between these 2 extremes ws used to estimte the proportion of dys tht were free of PTSD t ech time point. PTSD-free dys during the yer were estimted for ech ptient s the time-weighted verge of these proportions pplied to the number of dys between time points, using the midwy point s the trnsition between helth sttes, strting t bseline. THE AMERICAN JOURNAL OF MANAGED CARE VOL. 24, NO. 2 95

6 TABLE Month Cost Outcomes Costs Centrlized mngement intervention costs CACT (n = 320) OUC (n = 309) systems pproch is utilized to mximize dherence to existing clinicl prctice guidelines by using cre mnger, vlid nd fesible mesures of clinicl sttus, nd improved ccess to mentl helth specilist consulttion. 12 The STEPS-UP tril results hve now shown tht when centrl ssistnce cpbility is used to improve clinics cpcity to implement, monitor, nd sustin collbortive cre, 20 ptient outcomes improve. However, to utilize collbortive cre resources most efficiently, criticl mss of ptients is required to mke the intervention economiclly fesible. Using hypotheticl scenrio, we show tht if the ptient popultion in our study were reduced by hlf, the per ptient cost of CACT reltive to OUC would increse substntilly due to the dditionl per-ptient costs of centrlized cre, nd the ICER of CACT versus OUC would increse Difference in s $1005 $0 $1005 Other intervention costs (without centrl mngement) $1738 ($1707-$1767) $989 ($974-$1004) Medin $1681 $942 Outptient costs $9322 ($8351-$10,293) $9007 ($7948-$10,066) Medin $6225 $5747 Inptient costs $1675 ($939-$2412) $1288 ($633-$1942) Medin $0 $0 Mediction costs $1083 ($875-$1292) $1298 ($1001-$1594) Medin $529 $471 Productivity costs $8302 ($6631-$9974) $9557 ($7431-$11,682) Medin $3200 $3034 Totl costs $23,125 ($20,574-$25,675) $22,138 ($18,986-$25,290) Medin $15,971 $12,794 $749 ($715-$783) $315 ( $1117 to $1746) $388 ( $598 to $1373) $215 ( $590 to $161) $1255 ( $3961 to $1451) $987 ( $3056 to $5030) CACT indictes centrlly ssisted collbortive telecre; OUC, optimized usul cre; PDS, PTSD Dignostic Scle; PTSD, posttrumtic stress disorder; QALY, qulity-djusted life-yer. Cost is sttisticlly significntly higher for CACT versus OUC t the P =.05 level. from $49,346 to $110,089/QALY. Thus, system plnning to implement CACT would need to crefully project the size of the ptient popultion nd pln centrl resources ccordingly. In ddition, the results were sensitive to our decision to include the monetry vlue of lost workdys due to helth problems s cost input, s recommended by the Second Pnel on Cost-Effectiveness in Helth nd Medicine. 33 We found tht the higher costs in the CACT rm due to the higher costs of the intervention were diminished somewht once the smller number of dys of missed work ws tken into ccount. Excluding these productivity costs incresed the ICER to $112,081/QALY, showing the importnce of including ll relevnt costs in CEA from societl perspective. The evidence for collbortive cre is robust. Collbortive cre hs been demonstrted to be effective in more thn 80 RCTs in vrious settings, which now include the MHS. 20 Helth economics studies hve lso consistently reported the model to be either cost sving or cost-effective. Although no previous studies hve investigted collbortive cre for mentl illness in the MHS, severl hve investigted the use of similr models of cre in vriety of civilin nd Veterns Affirs helthcre settings nd popultions. These studies produced rnge of estimtes, which re generlly consistent with our results. A systemtic review 34 of 11 cost-effectiveness studies ccompnying RCTs of enhnced primry cre for depression found tht interventions bsed upon collbortive cre/cse mngement resulted in improved outcomes t greter cost, but they were generlly considered to be cost-effective (rnge, $15,463 to $36,467/QALY). Another study 35 tht reviewed existing cost-effectiveness studies of primry cre depression tretments lso found tht collbortive cre interventions re generlly considered to be cost-effective (rnge, cost-sving to $105,819/QALY gined). Vrying results re due to different forms of collbortive cre interventions, different comprtors, nd different study popultions. Limittions The clims dt we used included ll services provided within the MHS nd those reimbursed by TRICARE outside of the MHS. We were not ble to trck other services pid for by non-tricare thirdprty pyers or by the ptient. Previous study findings indicte tht more thn one-fifth of depression tretment expenses re pid for 96 FEBRUARY

7 Cost-Effectiveness of Collbortive Cre TABLE 4. Overll nd Sensitivity Cost-Effectiveness Anlyses Difference in Cost Difference in QALY ICER ($/QALY) % Cost-Effective t $100,000/QALY Overll (n = 629) $987 ( $3056 to $5030) 0.02 ( to 0.03) $49,346 58% Sensitivity Truncting costs t 99th percentile $678 ( $2920 to $4275) 0.02 ( to 0.03) $33,880 65% Excluding productivity costs $2242 ($151-$4332) 0.02 ( to 0.03) $112,081 33% Hlf number ptients in centrlized mngement b $2202 ( $1841 to $6245) 0.02 ( to 0.03) $110,089 40% Alterntive ssumptions regrding OUC intervention costs c $796 ( $3248 to $4839) 0.02 ( to 0.03) $39,780 61% Avilble cse (n = 661) d $726 ( $3865 to $5317) 0.02 ( to 0.03) $36,289 N/A Complete cse (n = 459) e $480 ( $4518 to $5478) 0.02 ( to 0.04) $24,001 68% ICER indictes incrementl cost-effectiveness rtio; N/A, not pplicble; OUC, optimized usul cre; QALY, qulity-djusted life-yer. Truncted ll cost dt t the 99th percentile within tretment rm by cost ctegory nd set higher costs equl to tht threshold. b Hlved the number of ptients we ssumed would be followed by our set number of centrlized mngement stff. c Used dt from nurse coordintor interviews insted of the electronic cse mngement system to estimte intervention costs for OUC ptients. d Restricted our nlyses to only ptients with dt t ech time point. e Restricted our nlyses to only ptients with complete dt through 12 months. out-of-pocket in the civilin popultion, 36 but no estimtes re vilble regrding the expected extent of these expenditures in the militry popultion. In ddition, some study prticipnts left the militry nd becme ineligible for services before the end of the 12-month study. 37 However, loss of MHS services did not differ significntly between the 2 tretment rms, 37 nd we used multiple imputtion to include ll ptients who hd miniml cost nd helth outcome follow-up dt. We were limited to 12-month follow-up period nd were not ble to trck cost or helth outcomes beyond this time. Previous study results hve suggested tht higher up-front intervention costs ssocited with collbortive cre my produce longer-term svings 38 nd tht helth effects my continue to be relized beyond the 12-month mrk, 39 indicting tht our reltively short follow-up time period my hve produced conservtive cost-effectiveness estimtes. Our RCT results found tht the reltive effectiveness of CACT improved over the 12-month period of follow-up. 20 We used the SF-6D conversion of the SF-12 instrument to estimte QALY vlues. This utility conversion includes only 1 mentl helth question nd my be limited in its sensitivity to chnges in mentl helth functioning over time. 40 In ddition, our evlution did not incorporte the impct the intervention my hve hd on the helth of ptients fmily members. Previous reserch hs shown tht mentl helth conditions, including depression, cn hve mesurble impcts on other fmily members. 41 Excluding spillover gins in fmily helth tht my result from tretment my led to underestimtion of the true vlue of interventions. 42 CONCLUSIONS Compred with OUC, use of the CACT costs $49,346/QALY gined for decresing symptoms of PTSD nd depression in ctive-duty service members in the MHS, with 58% probbility of being cost-effective t $100,000/QALY threshold. The results of this study re timely nd show tht stepped collbortive cre pproch my offer n economiclly sustinble wy of improving the qulity nd outcomes of cre for ptients with PTSD nd depression in the militry. n Acknowledgments The uthors would like to thnk Clude Setodji (RAND Corportion) nd Norm Terrin (Tufts Medicl Center) for their sttisticl support, Christine Eibner (RAND Corportion) for instrument development, nd Mhlet Woldetsdik (RAND Corportion) nd Brittny D Cruz (Tufts Medicl Center) for their reserch ssistnce. Author Affilitions: RAND Corportion (TAL, MK, LHJ, CCE), Arlington, VA; Center for the Evlution of Vlue nd Risk in Helth, Institute for Clinicl Reserch nd Helth Policy Studies, Tufts Medicl Center (TAL), Boston, MA; School of Medicine, Tufts University (TAL), Boston, MA; Deprtment of Psychitry, Uniformed Services University of the Helth Sciences (BB, MCF, CCE), Bethesd, MD; Deployment Helth Clinicl Center t the Defense Centers of Excellence for Psychologicl Helth nd Trumtic Brin Injury (BB, MCF), Bethesd, MD. Source of Funding: This study ws supported by Deprtment of Defense Deployment Relted Medicl Reserch Progrm wrd (Grnt DR080409). The wrd ws joint wrd to the Henry M. Jckson Foundtion for the Advncement of Militry Medicine, Inc (wrd W81XWH ), Reserch Tringle Institute (wrd W81XWH ), nd RAND Corportion (wrd W81XWH ). The sponsor hd no role in the study design; in the collection, nlysis, nd interprettion of dt; in the writing of the report; or in the decision to submit the rticle for publiction. The views expressed in this rticle re those of the uthors nd do not necessrily represent the views of the Deprtment of Defense, Uniformed Services University of the Helth Sciences, Ntionl Institutes of Helth, or ny other gency or orgniztion public or privte. Author Disclosures: The uthors report no reltionship or finncil interest with ny entity tht would pose conflict of interest with the subject mtter of this rticle. Authorship Informtion: Concept nd design (TAL, LHJ, BB, MCF, CCE); cquisition of dt (TAL, LHJ, BB); nlysis nd interprettion of dt (TAL, MK, BB, MCF, CCE); drfting of the mnuscript (TAL, MK, LHJ, MCF, CCE); criticl revision of the mnuscript for importnt intellectul content (TAL, LHJ, MCF, CCE); sttisticl nlysis (MK); provision of ptients or study mterils (BB, MCF); obtining funding (LHJ, MCF, CCE); dministrtive, technicl, or logistic support (TAL, MK, BB, MCF, CCE); nd supervision (TAL). Address Correspondence to: Tr A. Lvelle, Tufts Medicl Center, 800 Wshington St, Boston, MA Emil: tlvelle@tuftsmediclcenter.org. THE AMERICAN JOURNAL OF MANAGED CARE VOL. 24, NO. 2 97

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N Engl J Med. 2016;374(19): doi: /NEJMp Full text nd PDF t 98 FEBRUARY