Session number: 1095
Abstract title: The Cost-utility of Depression Screening: Usual Care versus Collaborative Treatment
Author(s):
JE Zeber - Serious Mental Illness Treatment Research & Evaluation Center (SMITREC)
S Vijan - Center for Practice Management & Outcomes Research
M Valenstein - Serious Mental Illness Treatment Research & Evaluation Center (SMITREC)
Objectives: Depressive disorders are common in primary care, cost an estimated $44 billion annually, and cause substantial disability. However, this condition is frequently undiagnosed; even once detected, appropriate treatment is often inadequate. Screening programs are one strategy for increasing detection and treatment, while improving outcomes and quality of life. Yet, in an earlier study, the authors determined that periodic depression screening is not cost-effective, at least under current conditions. In that study, the quality adjusted life-year ratio was $225,467; this figure far exceeds the standard $50,000 threshold for cost-effective procedures. Not surprisingly, the most important variables were detection and treatment initiation rates, plus remission. Fortunately, the 1990s witnessed development of several “enhanced” or collaborative care treatment regimes. These models emphasize an integrative approach to depression care, demonstrating significant improvements in overall treatment. This follow-up study examines the cost-utility of enhanced models compared with usual care in determining favorable conditions for periodic screening.
Methods: A semi-Markov decision analysis model examined lifetime costs and benefits of depression screening in a primary care setting. Parameter estimates were drawn from the published literature and analyses conducted from a health payer perspective. The primary outcome was cost per quality-adjusted life-year (QALY) gained. A hypothetical cohort of 40-year old patients was either screened for depression or received usual care, and individuals were followed until age 90 or death. Three specific treatment approaches (Katon, Wells, and Schulberg) and their parameters were examined in separate models across different screening intervals.
Results: Annual screening yielded incremental cost-utility (C/U) ratios between $83,937 - $107,164 per QALY compared to usual care, still exceeding cost-effective limits. However, values for screening every three years were $47,077 - $58,894. Sensitivity analyses supported hypotheses that cost-effective treatment depends on the aforementioned key variables.
Conclusions: Annual screening for depression remains unlikely as a cost-effective intervention, even with enhanced treatment. However, enhanced models offer evidence that improved treatment could render screening efficient at less frequent intervals.
Impact statement: Integrative or collaborative treatment represents positive approaches in caring for depressed veterans. Each clinic should judiciously examine its own situation regarding influential model parameters prior to making a decision about depression screening.