Advertisement

Journal of General Internal Medicine

, Volume 18, Issue 6, pp 432–441 | Cite as

Cost-effectiveness of a primary care depression intervention

  • Jeffrey M. PyneEmail author
  • Lathryn M. Rost
  • Mingliang Zhang
  • D. Keith Williams
  • Jeffrey Smith
  • John Fortney
Original Articles

Abstract

OBJECTIVE: To determine the incremental cost-effectiveness of a quality improvement depression intervention (enhanced care) in primary care settings relative to usual care.

DESIGN: Following stratification, we randomized 12 primary care practices to enhanced or usual care conditions and followed patients for 12 months.

SETTING: Primary care practices located in 10 states across the United States.

PATIENTS/PARTICIPANTS: Two hundred eleven patients beginning a new treatment episode for major depression.

INTERVENTIONS: Training the primary care team to assess, educate, and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year.

MEASUREMENTS AND MAIN RESULTS: Cost-effectiveness was measured by calculating incremental (enhanced minus usual care) costs and quality-adjusted life years (QALYs) derived from SF-36 data. The mean incremental cost-effectiveness ratio in the main analysis was $15,463 per QALY. The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from $11,341 (using geographic block variables to control for pre-intervention service utilization) to $19,976 (increasing the cost estimates by 50%) per QALY.

CONCLUSIONS: This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation.

Key words

cost-benefit analysis depression quality of life primary health care 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 Projected to 2020. Cambridge, Mass: Harvard University Press; 1996.Google Scholar
  2. 2.
    Henry JA. Debits and credits in the management of depression. Br J Psychiatry. 1993;(suppl):33–9.Google Scholar
  3. 3.
    Schurman R, Kramer P, Mitchell J. The hidden mental health network: treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry. 1985;42:89–94.PubMedGoogle Scholar
  4. 4.
    Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994;56:136–41.PubMedGoogle Scholar
  5. 5.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–31.PubMedCrossRefGoogle Scholar
  6. 6.
    Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.PubMedGoogle Scholar
  7. 7.
    Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53:913–9.PubMedGoogle Scholar
  8. 8.
    Goldberg HI, Wagner EH, Fihn SD, et al. Arandomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines? Jt Comm J Qual Improv. 1998;24:130–42.PubMedGoogle Scholar
  9. 9.
    Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109–15.PubMedCrossRefGoogle Scholar
  10. 10.
    Lin EH, Simon GE, Katon WJ, et al. Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry. 1999;156:643–5.PubMedGoogle Scholar
  11. 11.
    Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Schulberg HC, Block MR, Madonia MJ, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000;9:345–51.CrossRefGoogle Scholar
  13. 13.
    Wells K, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care. JAMA. 2000;283:212–20.PubMedCrossRefGoogle Scholar
  14. 14.
    Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. (see comments). Arch Fam Med. 2000;9:700–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Rost KM, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial of the QuEST intervention. J Gen Intern Med. 2001;16:143–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press, Inc.; 1996:425.Google Scholar
  17. 17.
    Williams JW, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58–67.PubMedCrossRefGoogle Scholar
  18. 18.
    Rost K, Nutting P, Smith J, Werner J. Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression. Gen Hosp Psychiatry. 2000;22:66–77.PubMedCrossRefGoogle Scholar
  19. 19.
    Depression Guideline Panel. Depression in Primary Care: Detection and Diagnosis. Rockville, Md: Agency for Health Care Policy and Research; 1993:1.Google Scholar
  20. 20.
    Depression Guideline Panel. Depression in Primary Care: Treatment of Major Depression. Rockville, Md: Agency for Health Care Policy Research (AHCPR); 1993:2.Google Scholar
  21. 21.
    Depression Guideline Panel. Treatment of Major Depression: Detection and Diagnosis. Rockville, Md: Agency for Health Care Policy Research (AHCPR); 1993:1.Google Scholar
  22. 22.
    Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomized trial of ongoing treatment in primary care. BMJ. 2002;325:934–40.PubMedCrossRefGoogle Scholar
  23. 23.
    Zimmerman M, Coryell W. The validity of a self-report questionnaire for diagnosing major depressive disorder. Arch Gen Psychiatry. 1988;45:738–40.PubMedGoogle Scholar
  24. 24.
    Brazier J, Usherwood T, Harper R, Thomas K. Deriving a preference-based single index from the UK SF-36 Health Survey. J Clin Epidemiol. 1998;51:1115–28.PubMedCrossRefGoogle Scholar
  25. 25.
    Ganiats T, Browner D, Kaplan R. Comparison of two methods of calculating Quality-adjusted Life Years. Qual Life Res. 1996;5:162–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Wolff N, Helminiak TW, Tebes JK. Getting the cost right in cost-effectiveness analyses. Am J Psychiatry. 1997;154:736–43.PubMedGoogle Scholar
  27. 27.
    Schoenbaum M, Unutzer J, Sherbourne C, et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. JAMA. 2001;286:1325–30.PubMedCrossRefGoogle Scholar
  28. 28.
    World Health Organization. Composite International Diagnostic Interview, Version 2.0. Geneva, Switzerland: World Health Organization; 1996.Google Scholar
  29. 29.
    Duan N. Smearing estimate: a non-parametric retransformation method. JASA 1983;78:605–10.Google Scholar
  30. 30.
    Efron B. Better bootstrap confidence intervals. JASA 1987;82:171–85.Google Scholar
  31. 31.
    Briggs AH, Wonderling DE, Mooney CZ. Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation. Health Econ. 1997;6:327–40.PubMedCrossRefGoogle Scholar
  32. 32.
    Anderson JP, Bush JW, Chen M, Dolenc D. Policy space areas and properties of benefit-cost/utility analysis. JAMA. 1986;255:794–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Hunink MGM, Bult JR, de Vries J, Weinstein MC. Uncertainty in decision models analyzing cost-effectiveness: the joint distribution of incremental costs and effectiveness evaluated with a nonparametric bootstrap method. Med Decis Making. 1998;18:337–46.PubMedCrossRefGoogle Scholar
  34. 34.
    Simon GE, Katon WJ, VonKorff M, et al. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Am J Psychiatry. 2001;158:1638–44.PubMedCrossRefGoogle Scholar
  35. 35.
    Simon GE, Manning WG, Katzelnick DJ, Pearson SD, Henk HJ, Helstad CS. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry. 2001;58:181–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making. 1998;18:68S-80S.CrossRefGoogle Scholar
  37. 37.
    Kaplan RM, Anderson JP. The general health policy model: an integrated approach. In: Spilker B. ed. Quality of Life and Pharmaceoeconomics in Clinical Trials. Philadelphia, Pa: Lippincott-Raven; 1996:309–21.Google Scholar
  38. 38.
    Lave J, Frank R, Schulberg H, Kamlet M. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998;55:645–51.PubMedCrossRefGoogle Scholar
  39. 39.
    Revicki DA, Brown RE, Keller MB, Gonzales J, Culpepper L, Hales RE. Cost-effectiveness of newer antidepressants compared with tricyclic antidepressants in managed care settings. J Clin Psychiatry. 1997;58:47–58.PubMedGoogle Scholar
  40. 40.
    Kamlet MS, Paul N, Greenhouse J, Kupfer D, Frank E, Wade M. Cost utility analysis of maintenance treatment for recurrent depression. Control Clin Trials. 1995;16:17–40.PubMedCrossRefGoogle Scholar
  41. 41.
    Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med. 1998;60:143–9.Google Scholar
  42. 42.
    Forder J, Kavanagh S, Fenyo A. A comparison of the cost-effectiveness of sertraline versus tricyclic antidepressants in primary care. J Affect Disord. 1996;38:97–111.PubMedCrossRefGoogle Scholar
  43. 43.
    Bombardier C, Ware J, Russell IJ, Larson M, Chalmers A, Read JL. Auranofin therapy and quality of life in patients with rheumatoid arthritis: results of a multicenter trial. Am J Med. 1986;81:565–78.PubMedCrossRefGoogle Scholar
  44. 44.
    Azimi N, Welch H. The effectiveness of cost-effectiveness analysis in containing costs. J Gen Intern Med. 1998;13:664–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Kaplan RM, Bush JW. Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol. 1982;1:61–80.CrossRefGoogle Scholar
  46. 46.
    Laupacis A, Feeny D, Detsky A, Tugwell P. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J. 1992;146:473–81.Google Scholar
  47. 47.
    Kaplan RM, Anderson JP. A General Health Policy Model: update and applications. Health Serv Res. 1988;23:203–35.PubMedGoogle Scholar
  48. 48.
    Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ. 1996;313:275–83.PubMedGoogle Scholar
  49. 49.
    Kaplan RM. Value judgment in the Oregon Medicaid Experiment. Med Care. 1994;32:975–88.PubMedCrossRefGoogle Scholar
  50. 50.
    Patrick DL, Sittampalam Y, Somerville SM, Carter WB, Bergner M. A cross-cultural comparison of health state values. Am J Public Health. 1985;75:1402–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Ritter PL, Stewart AL, Kaymaz H, Sobel DS, Block DA, Lorig KR. Self-reports of health care utilization compared to provider records. J Clin Epidemiol. 2001;54:136–41.PubMedCrossRefGoogle Scholar
  52. 52.
    Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry. 2001;58:55–61.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Jeffrey M. Pyne
    • 1
    • 2
    Email author
  • Lathryn M. Rost
    • 4
  • Mingliang Zhang
    • 2
  • D. Keith Williams
    • 3
  • Jeffrey Smith
    • 4
  • John Fortney
    • 1
    • 2
  1. 1.Received from the HSRD Center for Mental Healthcare and Outcomes ResearchCentral Arkansas Veterans Healthcare SystemLittle Rock
  2. 2.the Department of PsychiatryUniversity of Arkansas for Medical SciencesLittle Rock
  3. 3.Department of BiometryUniversity of Arkansas for Medical SciencesLittle Rock
  4. 4.the Department of Family MedicineUniversity of Colorado Health Sciences CenterDenver

Personalised recommendations