More than cost-effectiveness? Applying a second-stage filter to improve policy decision making.

BACKGROUND: Apart from cost-effectiveness, considerations like equity and acceptability may affect health-care priority setting. Preferably, priority setting combines evidence evaluation with an appraisal procedure, to elicit and weigh these considerations. OBJECTIVE: To demonstrate a structured approach for eliciting and evaluating a broad range of assessment criteria, including key stakeholders' values, aiming to support decision makers in priority setting. METHODS: For a set of cost-effective substitute interventions for depression care, the appraisal criteria were adopted from the Australian Assessing Cost-Effectiveness initiative. All substitute interventions were assessed in an appraisal, using focus group discussions and semi-structured interviews conducted among key stakeholders. RESULTS: Appraisal of the substitute cost-effective interventions yielded an overview of considerations and an overall recommendation for decision makers. Two out of the thirteen pairs were deemed acceptable and realistic, that is investment in therapist-guided and Internet-based cognitive behavioural therapy instead of cognitive behavioural therapy in mild depression, and investment in combination therapy rather than individual psychotherapy in severe depression. In the remaining substitution pairs, substantive issues affected acceptability. The key issues identified were as follows: workforce capacity, lack of stakeholder support and the need for change in clinicians' attitude. CONCLUSIONS: Systematic identification of stakeholders' considerations allows decision makers to prioritize among cost-effective policy options. Moreover, this approach entails an explicit and transparent priority-setting procedure and provides insights into the intended and unintended consequences of using a certain health technology. PATIENT CONTRIBUTION: Patients were involved in the conduct of the study for instance, by sharing their values regarding considerations relevant for priority setting.

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare.

BACKGROUND: The majority of patients with major depressive disorder (MDD) have comorbid mental conditions. OBJECTIVES: Since most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD). METHODS: The Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort. RESULTS: A total of 34,713 patients had MDD as a primary diagnosis over the period 2000-2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes. CONCLUSIONS: Psychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.

The clinical effectiveness of an algorithm-guided treatment program for depression in specialized mental healthcare: A comparison with efficacy trials.

BACKGROUND: Doubts exist on whether effects found in randomized controlled trials (RCTs) are directly generalizable to daily clinical practice. This study aimed (a) to investigate the effectiveness of treatment options within an algorithm-guided treatment (AGT) program for depression and compare their effectiveness with outcomes of efficacy trials and (b) to assess the relation between treatment continuity and outcomes. METHODS: This naturalistic study linked treatment data from January 2012 to November 2014 from a Dutch mental healthcare provider, to routine outcome monitoring (ROM) data (N = 351). Effectiveness of the treatment options (pharmacotherapy, psychotherapy and their combination) was compared to the efficacy reported in the meta-analyses. We included treatment continuity as binary variable "early terminators versus completers of the recommended number of treatment sessions". RESULTS: Remission rates for psychotherapy (38% [95% CI: 32-45]), pharmacotherapy (31% [95% CI: 22-42]) and combination therapy (46% [95% CI: 19-75]) were respectively lower, comparable, and comparable to those reported in the meta-analyses. Similarly, response rates were respectively lower (24% [95% CI: 19-30]), lower (21% [95% CI: 13-31]), and comparable (46% [95% CI: 19-75]) to meta-analyses results. A similar share of early terminators and completers achieved remission and response. LIMITATIONS: A substantial proportion of patients had incomplete ROM data after data linkage. Limited set of patient characteristics to check for selection bias. CONCLUSIONS: Despite the more heterogeneous patient population in clinical practice, the effectiveness of an AGT program, emphasizing strict guideline adherence, approached that found in RCTs. A fixed number of treatment sessions may not suit all individual patients.

Patients' and clinicians' perspectives on relevant treatment outcomes in depression: qualitative study.

BACKGROUND: Although symptomatic remission is considered the optimal outcome in depression, this is not always achieved. Furthermore, symptom indicators do not fully capture patients' and clinicians' perspectives on remission. Broader indicators of (partial) remission from depression should be considered. AIMS: To investigate relevant outcomes of depression treatment in specialist care from patients' and clinicians' perspectives and to investigate whether these perspectives differ from each other. METHOD: Three focus groups with 11 patients with depression and seven semi-structured interviews with clinicians were conducted exploring their perspectives on remission. All interviews were audio-recorded and transcribed verbatim. We analysed the transcripts thematically using the phenomenologist approach. RESULTS: Independently, both patients and clinicians perceived the following outcomes relevant: restoring social functioning and interpersonal relations, regaining quality of life and achieving personal goals. All clinicians emphasised symptom reduction and satisfaction with treatment as relevant outcomes, whereas the former was not an obvious theme in patients. Unlike clinicians, patients made a clear distinction between treatment outcomes in first versus recurrent/chronic depression. CONCLUSIONS: Classically defined study outcomes based on symptom resolution only partly reflect issues considered important by patients and clinicians in specialist depression treatment. Incorporating patients' and clinicians' perspectives in the development of measurable end-points makes them more suitable for use in trials and subsequent translation to clinical practice. Furthermore, evaluating patients' perspectives on treatment outcomes helps in the development of tailored interventions according to patients' needs.

Public attitudes toward people with intellectual disabilities: a cross-cultural study.

This study investigated attitudes toward people with intellectual disabilities among the general Hong Kong Chinese population and compared these to a White British sample, using the Community Living Attitudes Scale-Mental Retardation form (CLAS-MR; D. Henry, C. Keys, F. Balcazar, & D. Jopp, 1996 ). As predicted, attitudes among the Hong Kong Chinese public (n = 149) were less favorable than the British sample (n = 135). The former were less opposed to the exclusion of people with intellectual disabilities, less likely to view them as similar to themselves and more in favor of sheltering such individuals. Of all demographic variables examined, ethnicity was the strongest predictor of attitudes, although it only accounted for a small part of the variance in attitudes. The results are discussed in terms of policy implementation and additional research.