Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.
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.
J Affect Disord. 2019 Jan 1;242:244-254. doi: 10.1016/j.jad.2018.08.024. Epub 2018 Aug 9.
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.
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.
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.
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.
It is highly likely that guideline-congruent stepped care for MDD is cost-effective compared to usual care. Our findings support current guideline recommendations.
有循证临床指南为重度抑郁症（MDD）推荐了基于治疗结局的序贯证据治疗的分级照护策略。本研究旨在评估荷兰多学科临床指南推荐的分级照护与常规护理相比的成本效益。
在健康经济状态转换模拟模型中，将轻度 MDD 或中重度 MDD 的分级照护算法中描述的与指南一致的护理与常规护理进行了比较。从医疗保健角度计算了五年内每增加一个质量调整生命年（QALY）的增量成本。
对于轻度 MDD，成本效用分析显示，在健康结果更好且成本更低的情况下，有 67%的可能性，在健康结果更好且成本更高的情况下，有 33%的可能性，这意味着与指南一致的分级照护具有优势。对于中重度 MDD，成本效用分析表明，采用分级照护方法的情况下，在成本更高的情况下有 67%的可能性获得健康收益，在成本更低的情况下有 33%的可能性获得健康收益，平均增量成本效益比（ICER）约为每增加一个 QALY 3200 欧元。在每增加一个 QALY 的意愿支付阈值为 20,000 欧元的情况下，轻度 MDD 和中重度 MDD 的分级照护算法与常规护理相比具有成本效益的可能性大于 95%。
我们的决策分析模型的发现受到基础证据的准确性和可用性的限制。这限制了考虑优化治疗以满足个体需求的所有个体差异。
与常规护理相比，与指南一致的 MDD 分级照护极有可能具有成本效益。我们的研究结果支持当前的指南建议。
