Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN. METHOD: The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses. RESULTS: Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends. CONCLUSIONS: Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Nutritional status and assessment of patients on home parenteral nutrition: anthropometry, bioelectrical impedance, or clinical judgment?

The optimal method of assessing protein energy nutritional status in patients receiving home parenteral nutrition (HPN) is unknown. We evaluated protein energy nutritional status in 47 outpatients (23 male; 24 female) on HPN by measuring anthropometry, plasma proteins, and lymphocyte counts and compared these with the results of subjective clinical assessment and bioelectrical impedance measurements. Sixteen of the 47 patients (34%) were underweight (body mass index < 5th percentile of the reference) and 21 (45%) were below the 5th percentile of the reference for both triceps skinfold thickness and midarm muscle circumference. Plasma proteins were subnormal in 1-5 patients (2-11%). Lymphocyte counts were subnormal in 19 patients (40%). Clinical assessment classified 23 patients (49%) as well nourished and 24 (51%) as moderately malnourished. Moderately malnourished patients had a significantly lower body mass index than well-nourished patients (P = 0.02). Clinical assessment did not correlate with bioelectrical impedance analysis. Fat-free mass determined by bioelectrical impedance analysis resulted in values up to 9.4 kg lower and 8 kg higher than fat-free mass obtained by anthropometry. Weighing combined with a subjective clinical assessment is sufficient for evaluation of protein calorie nutritional status in patients on HPN.