van der Aa Hilde P A, van Rens Ger H M B, Bosmans Judith E, Comijs Hannie C, van Nispen Ruth M A
Department of Ophthalmology and the Amsterdam Public Health Research Institute, VU University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, HV, The Netherlands.
Department of Ophthalmology, Elkerliek Hospital, Wesselmanlaan 25, 5707, Helmond, HA, The Netherlands.
BMC Psychiatry. 2017 Aug 1;17(1):280. doi: 10.1186/s12888-017-1437-5.
A stepped-care program was found effective in preventing depressive and anxiety disorders in older adults with vision impairment. However, before a decision can be made about implementation, the cost-effectiveness of this program should be investigated. Therefore, we aimed to compare the cost-effectiveness of stepped-care versus usual care within low vision rehabilitation.
An economic evaluation from a societal perspective was performed alongside a multicenter randomized controlled trial. Data were collected by masked assessors during 24 months. Included were 265 older adults with vision impairment and subthreshold depression and/or anxiety. They were randomly assigned to stepped-care plus usual care (n = 131) or usual care alone (n = 134). Stepped-care comprised 1) watchful waiting, 2) guided self-help based on cognitive behavioral therapy, 3) problem solving treatment, and 4) referral to a general practitioner. Costs were based on direct healthcare costs and indirect non-healthcare costs. Main outcome measures were quality-adjusted life years (QALYs) and the cumulative incidence of major depressive, dysthymic and/or anxiety disorders. Secondary outcomes were symptoms of depression and anxiety.
Based on intention-to-treat, significant differences were found in the incidence of depressive/anxiety disorders (mean difference 0.17; 95% CI 0.06 to 0.29) and symptoms of anxiety (mean difference 1.43, 95% CI 0.10 to 2.77) in favor of stepped-care versus usual care; no significant difference was found for QALYs and symptoms of depression. Societal costs were non-significantly lower in the stepped-care group compared with the usual care group (mean difference: -€877; 95% confidence interval (CI): -8039 to 5489). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 95% or more at a willingness-to-pay of €33,000 per disorder prevented. The probability that stepped-care was cost-effective compared to usual care was 59% or more for a ceiling ratio of 0 €/QALY and increased to 65% at 20000 €/QALY.
This economic evaluation shows that stepped-care is dominant to usual care, with a probability of around 60%, due to its clinical superiority and its modest cost savings. However, it depends on the willingness-to-pay of decision makers whether or not stepped-care is considered cost-effective compared with usual care.
identifier: NTR3296 , date: 13-02-2012.
一项逐步护理计划被证明在预防视力受损的老年人患抑郁症和焦虑症方面有效。然而，在决定是否实施该计划之前，应调查其成本效益。因此，我们旨在比较低视力康复中逐步护理与常规护理的成本效益。
从社会角度进行经济评估，并同时开展一项多中心随机对照试验。数据由经过培训的评估人员在24个月内收集。纳入了265名患有视力障碍且有亚阈值抑郁和/或焦虑的老年人。他们被随机分配到逐步护理加常规护理组（n = 131）或仅常规护理组（n = 134）。逐步护理包括：1）观察等待；2）基于认知行为疗法的引导式自助；3）问题解决疗法；4）转诊至全科医生。成本基于直接医疗成本和间接非医疗成本。主要结局指标为质量调整生命年（QALY）以及重度抑郁、心境恶劣和/或焦虑症的累积发病率。次要结局为抑郁和焦虑症状。
基于意向性分析，发现逐步护理组与常规护理组相比，抑郁/焦虑症发病率（平均差异0.17；95%可信区间0.06至0.29）和焦虑症状（平均差异1.43，95%可信区间0.10至2.77）存在显著差异，支持逐步护理；QALY和抑郁症状方面未发现显著差异。逐步护理组的社会成本与常规护理组相比无显著降低（平均差异：-877欧元；95%置信区间（CI）：-8039至5489）。成本效益可接受性曲线显示，每预防一种疾病支付意愿为33000欧元时，成本效益概率为95%或更高。对于上限比率为0欧元/QALY，逐步护理与常规护理相比具有成本效益的概率为59%或更高，在20000欧元/QALY时升至65%。
这项经济评估表明，由于其临床优势和适度的成本节约，逐步护理比常规护理更具优势，概率约为60%。然而，与常规护理相比，逐步护理是否被认为具有成本效益取决于决策者的支付意愿。
标识符：NTR3296，日期：2012年2月13日。
