Jolanda A C Meeuwissen1, Talitha L Feenstra2, Filip Smit3, Matthijs Blankers4, Jan Spijker5, Claudi L H Bockting6, Anton J L M van Balkom7, Erik Buskens8. 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.
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.
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