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Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder

Administration and Policy in Mental Health and Mental Health Services Research volume 49, pages 429–439 (2022)Cite this article

Abstract

Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n = 541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P = 0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P = 0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services.

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References

  • Abraham, K. M., Yosef, M., Resnick, S. G., & Zivin, K. (2017). Competitive employment outcomes among veterans in VHA therapeutic and supported employment services programs. Psychiatric Services, 68(9), 938–946.

    Article  Google Scholar 

  • Amick, M. M., Meterko, M., Fortier, C. B., Fonda, J. R., Milberg, W. P., & McGlinchey, R. E. (2018). The deployment trauma phenotype and employment status in veterans of the wars in Iraq and Afghanistan. Journal of Head Trauma Rehabilitation, 33(2), E30-e40. https://doi.org/10.1097/htr.0000000000000308

    Article  Google Scholar 

  • Baller, J. B., Blyler, C. R., Bronnikov, S., Xie, H., Bond, G. R., Filion, K., & Hale, T. (2020). Long-term follow-up of a randomized trial of supported employment for SSDI beneficiaries with mental illness. Psychiatric Services, 71(3), 243–249. https://doi.org/10.1176/appi.ps.201800554

    Article  PubMed  Google Scholar 

  • Bond, G. R., Campbell, K., & Drake, R. E. (2012). Standardizing measures in four domains of employment outcomes for individual placement and support. Psychiatric Services, 63(8), 751–757. https://doi.org/10.1176/appi.ps.201100270

    Article  PubMed  Google Scholar 

  • Davis, L. L., Kyriakides, T. C., Suris, A., Ottomanelli, L., Drake, R. E., Parker, P. E., Mueller, L., Resnick, S. G., Toscano, R., Blansett, C. M., McCall, K. P., & Huang, G. D. (2018a). Veterans individual placement and support towards advancing recovery: Methods and baseline clinical characteristics of a multisite study. Psychiatric Rehabilitation Journal, 41(1), 55–66. https://doi.org/10.1037/prj0000250

    Article  PubMed  Google Scholar 

  • Davis, L. L., Kyriakides, T. C., Suris, A. M., Ottomanelli, L. A., Mueller, L., Parker, P. E., Resnick, S. G., Toscano, R., Scrymgeour, A. A., & Drake, R. E. (2018b). Effect of evidence-based supported employment vs transitional work on achieving steady work among veterans with posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 75(4), 316–324. https://doi.org/10.1001/jamapsychiatry.2017.4472

    Article  PubMed  PubMed Central  Google Scholar 

  • Davis, L. L., Leon, A. C., Toscano, R., Drebing, C. E., Ward, L. C., Parker, P. E., Kashner, T. M., & Drake, R. E. (2012). A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder. Psychiatric Services, 63(5), 464–470. https://doi.org/10.1176/appi.ps.201100340

    Article  PubMed  Google Scholar 

  • Department of Veterans Affairs. Your healthcare costs. Retrieved September 8, 2021, from https://www.va.gov/health-care/about-va-health-benefits/cost-of-care/.

  • Dixon, L., Hoch, J. S., Clark, R., Bebout, R., Drake, R., McHugo, G., & Becker, D. (2002). Cost-effectiveness of two vocational rehabilitation programs for persons with severe mental illness. Psychiatric Services, 53(9), 1118–1124. https://doi.org/10.1176/appi.ps.53.9.1118

    Article  PubMed  Google Scholar 

  • Drake, R., Bond, G., & Becker, D. (2012). Individual Placement and Support: An evidence-based approach to supported employment. Oxford University Press.

  • Drake, R. E., Frey, W., Bond, G. R., Goldman, H. H., Salkever, D., Miller, A., Moore, T. A., Riley, J., Karakus, M., & Milfort, R. (2013). Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work. American Journal of Psychiatry, 170(12), 1433–1441. https://doi.org/10.1176/appi.ajp.2013.13020214

    Article  Google Scholar 

  • Drake, R. E., & Wallach, M. A. (2020). Employment is a critical mental health intervention. Epidemiology and Psychiatric Sciences, 29(e178), 1–3.

    Google Scholar 

  • Efron, B., & Tibshirani, R. (1993). An introduction to the bootstrap. Chapman & Hall.

    Book  Google Scholar 

  • Frank, R. G. (2013). Helping (some) SSDI beneficiaries with severe mental illness return to work. American Journal of Psychiatry, 170, 1379–1381. https://doi.org/10.1176/appi.ajp.2013.13091176

    Article  Google Scholar 

  • Frederick, D. E., & VanderWeele, T. J. (2019). Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support. PLoS ONE, 14(2), e0212208. https://doi.org/10.1371/journal.pone.0212208

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., Elbogen, E., & Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107. https://doi.org/10.1016/j.janxdis.2015.02.003

    Article  PubMed  Google Scholar 

  • Health Economics Resource Center. (March 30, 2020). Validity of MCA data. Retrieved December 16, 2020, from https://vaww.herc.research.va.gov/include/page.asp?id=managerial-cost-accounting#valid.

  • Hoffmann, H., Jäckel, D., Glauser, S., Mueser, K., & Kupper, Z. (2014). Long-term effectiveness of supported employment: Five-year follow-up of a randomized controlled trial. American Journal of Psychiatry, 171, 1183–1190.

    Article  Google Scholar 

  • Knapp, M., Patel, A., Curran, C., Latimer, E., Catty, J., Becker, T., Drake, R. E., Fioritti, A., Kilian, R., Lauber, C., Rössler, W., Tomov, T., van Busschbach, J., Comas-Herrera, A., White, S., Wiersma, D., & Burns, T. (2013). Supported employment: Cost-effectiveness across six European sites. World Psychiatry, 12(1), 60–68. https://doi.org/10.1002/wps.20017

    Article  PubMed  PubMed Central  Google Scholar 

  • Knapp, M., & Wong, G. (2020). Economics and mental health: The current scenario. World Psychiatry, 19(1), 3–14. https://doi.org/10.1002/wps.20692

    Article  PubMed  PubMed Central  Google Scholar 

  • Kulka, M., & Bond, G. (2013). A randomized controlled trial of evidence-based supported employment: Nonvocational outcomes. Journal of Vocational Rehabilitation, 38, 91–98.

    Article  Google Scholar 

  • Marshall, T., Goldberg, R. W., Braude, L., Dougherty, R. H., Daniels, A. S., Ghose, S. S., George, P., & Delphin-Rittmon, M. E. (2014). Supported employment: Assessing the evidence. Psychiatric Services, 65(1), 16–23. https://doi.org/10.1176/appi.ps.201300262

    Article  PubMed  Google Scholar 

  • Modini, M., Tan, L., Brinchmann, B., Wang, M. J., Killackey, E., Glozier, N., Mykletun, A., & Harvey, S. B. (2016). Supported employment for people with severe mental illness: Systematic review and meta-analysis of the international evidence. British Journal of Psychiatry, 209(1), 14–22. https://doi.org/10.1192/bjp.bp.115.165092

    Article  Google Scholar 

  • Mueller, L., Wolfe, W. R., Neylan, T. C., McCaslin, S. E., Yehuda, R., Flory, J. D., Kyriakides, T. C., Toscano, R., & Davis, L. L. (2019). Positive impact of IPS supported employment on PTSD-related occupational-psychosocial functional outcomes: Results from a VA randomized-controlled trial. Psychiatric Rehabilitation Journal, 42(3), 246–256. https://doi.org/10.1037/prj0000345

    Article  PubMed  PubMed Central  Google Scholar 

  • O’Brien, B. J., & Briggs, A. H. (2002). Analysis of uncertainty in health care cost-effectiveness studies: An introduction to statistical issues and methods. Statistical Methods in Medical Research, 11(6), 455–468. https://doi.org/10.1191/0962280202sm304ra

    Article  CAS  PubMed  Google Scholar 

  • Phibbs, C., Barnett, P., Fan, A., Harden, C., King, S., & Scott, J. (2010). Research guide to decision support system national cost extracts. Health Economics Resource Center of Health Service R&D Services, Department of Veterans Affairs.

  • Pogoda, T. K., Levy, C. E., Helmick, K., & Pugh, M. J. (2017). Health services and rehabilitation for active duty service members and veterans with mild TBI. Brain Injury, 31(9), 1220–1234. https://doi.org/10.1080/02699052.2016.1274777

    Article  PubMed  Google Scholar 

  • Ramsey, S., Willke, R., Briggs, A., Brown, R., Buxton, M., Chawla, A., Cook, J., Glick, H., Liljas, B., Petitti, D., & Reed, S. (2005). Good research practices for cost-effectiveness analysis alongside clinical trials: The ISPOR RCT-CEA Task Force report. Value in Health, 8(5), 521–533. https://doi.org/10.1111/j.1524-4733.2005.00045.x

    Article  PubMed  Google Scholar 

  • Salkever, D. (2013). Social costs of expanding access to evidence-based supported employment: Concepts and interpretive review of evidence. Psychiatric Services (Washington, DC), 64(2), 111–119. https://doi.org/10.1176/appi.ps.201100499

    Article  Google Scholar 

  • Schein, J., Houle, C., Urganus, A., Cloutier, M., Patterson-Lomba, O., Wang, Y., King, S., Levinson, W., Guérin, A., Lefebvre, P., & Davis, L. L. (2021). Prevalence of post-traumatic stress disorder in the United States: A systematic literature review. Current Medical Research and Opinion. https://doi.org/10.1080/03007995.2021.1978417 Epub ahead of print.

    Article  PubMed  Google Scholar 

  • Suijkerbuijk, Y. B., Schaafsma, F. G., van Mechelen, J. C., Ojajärvi, A., Corbière, M., & Anema, J. R. (2017). Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database of Systematic Reviews, 9(9), CD011867. https://doi.org/10.1002/14651858.CD011867.pub2

    Article  Google Scholar 

  • US House Committee on Veterans’ Affairs. Testimony of Anthony Campinell, Ph.D., Director, Therapeutic and Supported Employment Programs. Veterans Health Administration, U.S. Department of Veterans Affairs. https://archives-veterans.house.gov/witness-testimony/anthony-campinell-phd.

  • VA Information Resource Center, VIReC. (September, 2008). VIReC Research User Guide: VHA pharmacy prescription data (2nd ed.). VIReC. Retrieved December 16, 2020, from www.virec.research.va.gov.

  • VA Mental Health Services. (November 2014). Public Report. Retrieved December 16, 2020, from https://www.mentalhealth.va.gov/docs/Mental_Health_Transparency_Report_11-24-14.pdf.

  • Veterans Health Administration Department of Veterans Affairs. (October 20, 2019). Retrieved December 16, 2020, from www.va.gov/health/aboutvha.asp.

  • Veterans Health Administration. Psychosocial Rehabilitation and Recovery Services, VHA Directive 1163, August 13, 2019. Retrieved September 27, 2021.

  • Vogt, D., Smith, B. N., Fox, A. B., Amoroso, T., Taverna, E., & Schnurr, P. P. (2017). Consequences of PTSD for the work and family quality of life of female and male U.S. Afghanistan and Iraq War veterans. Social Psychiatry and Psychiatric Epidemiology, 52(3), 341–352. https://doi.org/10.1007/s00127-016-1321-5

    Article  PubMed  Google Scholar 

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Acknowledgements

The investigators acknowledge the excellent support of the VA West Haven Cooperative Studies Program Coordinating Center and excellent technical assistance provided by Judy Burt and Teddy Bishop at the Tuscaloosa VA Medical Center.

Clinical Trial Registration

This study assessed the cost-effectiveness of interventions for individuals who had participated in a randomized controlled trial. clinicaltrials.gov Identifier: NCT01817712.

Standards of Reporting

This study reports results of a cost-effectiveness analysis consistent with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Statement.

Funding

This work was supported by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service Project IIR 15-342. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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Authors and Affiliations

  1. Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Ave (151H), Hines, IL, 60141, USA

    Kevin T. Stroupe, Neil Jordan & Lishan Cao

  2. Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA

    Kevin T. Stroupe

  3. Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Neil Jordan

  4. Birmingham VA Medical Center, Birmingham, AL, USA

    Joshua Richman & Stefan G. Kertesz

  5. Westat, Rivermill Commercial Center, 85 Mechanic Street, Suite C3-1, Lebanon, NH, 03766, USA

    Gary R. Bond

  6. Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Building 9, Office 218, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA

    Terri K. Pogoda

  7. Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA

    Terri K. Pogoda

  8. Research and Development Service, Tuscaloosa VA Medical Center-Psychiatry, 3701 Loop Rd, Tuscaloosa, AL, 35404, USA

    Lori L. Davis

  9. Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL, USA

    Lori L. Davis

  10. Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA

    Joshua Richman

  11. Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA

    Stefan G. Kertesz

  12. West Haven Cooperative Studies Program Coordinating Center, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT, 06516, USA

    Tassos C. Kyriakides

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  1. Kevin T. Stroupe
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Contributions

Conceptualization: LLD, TCK; Methodology: KTS, NJ, JR; Formal analysis and investigation: JR, LC; Writing—original draft preparation: KTS, NJ, GRB, TKP; Writing—review and editing: KTS, NJ, JR, GRB, TKP, LC, SGK, TCK, LLD; Funding acquisition: LLD, TCK, KTS, NJ, JR, GRB, TKP, SGK; Resources: LLD; Supervision: LLD, KTS, NJ.

Corresponding author

Correspondence to Kevin T. Stroupe.

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Conflict of interest

Stefan Kertesz reports receipt of royalty income from UpToDate, Inc. related to a chapter on homeless health care. The authors have no conflict of interests to disclose that pertain to the subject of this manuscript or study. Stefan Kertesz attests to ownership in stock from Thermo Fisher Scientific and Zimmer Biomet. He attests to past ownership of stock in CVS Caremark, sold in 2020.

Ethical Approval

This study was approved by the Birmingham, Hines, and Tuscaloosa Veterans Health Administration Institutional Review Boards. This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed Consent

All participants provided informed consent for the original randomized controlled trial (RCT). The current study was a cost-effectiveness analysis that used data from the original RCT linked to national Veterans Health Administration databases to obtain information on healthcare costs. The original RCT was funded by the Department of Veterans Affair Cooperative Studies Program. Separate funding for the cost-effectiveness analysis was obtained from the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service. As noted above, the current cost-effectiveness study was approved by the Birmingham, Hines, and Tuscaloosa Veterans Health Administration Institutional Review Boards (IRBs). The cost-effectiveness study used only retrospective data and obtained waivers of consent from the IRBs.

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Stroupe, K.T., Jordan, N., Richman, J. et al. Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder. Adm Policy Ment Health 49, 429–439 (2022). https://doi.org/10.1007/s10488-021-01173-z

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