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J Affect Disord. 2019 Jan 1;242:244-254. doi: 10.1016/j.jad.2018.08.024. Epub 2018 Aug 9.

The cost-utility of stepped-care algorithms according to depression guideline recommendations - Results of a state-transition model analysis.

Author information

1
Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands. Electronic address: jmeeuwissen@trimbos.nl.
2
Department of Epidemiology, Unit Health Technology Assessment, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands; Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
3
Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Department of Epidemiology and Biostatistics and Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, The Netherlands.
4
Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands; Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Program for Mood Disorders, Pro Persona Mental Health Care, Nijmegen, The Netherlands.
5
Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands.
6
Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
7
Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam, The Netherlands.
8
Department of Epidemiology, Unit Health Technology Assessment, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands.

Abstract

BACKGROUND:

Evidence-based clinical guidelines for major depressive disorder (MDD) recommend stepped-care strategies for sequencing evidence-based treatments conditional on treatment outcomes. This study aims to evaluate the cost-effectiveness of stepped care as recommended by the multidisciplinary clinical guideline vis-à-vis usual care in the Netherlands.

METHODS:

Guideline-congruent care as described in stepped-care algorithms for either mild MDD or moderate and severe MDD was compared with usual care in a health-economic state-transition simulation model. Incremental costs per QALY gained were estimated over five years from a healthcare perspective.

RESULTS:

For mild MDD, the cost-utility analysis showed a 67% likelihood of better health outcomes against lower costs, and 33% likelihood of better outcomes against higher costs, implying dominance of guideline-congruent stepped care. For moderate and severe MDD, the cost-utility analysis indicated a 67% likelihood of health gains at higher costs following the stepped-care approach and 33% likelihood of health gains at lower costs, with a mean ICER of about €3,200 per QALY gained. At a willingness to pay threshold of €20,000 per QALY, the stepped-care algorithms for both mild MDD and moderate or severe MDD is deemed cost-effective compared to usual care with a greater than 95% probability.

LIMITATIONS:

The findings of our decision-analytic modelling are limited by the accuracy and availability of the underlying evidence. This hampers taking into account all individual differences relevant to optimise treatment to individual needs.

CONCLUSIONS:

It is highly likely that guideline-congruent stepped care for MDD is cost-effective compared to usual care. Our findings support current guideline recommendations.

KEYWORDS:

Clinical decision-making; Clinical guideline; Depressive disorder; State-transition model; Stepped care; Treatment algorithm

PMID:
30216769
DOI:
10.1016/j.jad.2018.08.024
[Indexed for MEDLINE]

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