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Incremental benefits and cost of coordinated anxiety learning and management for anxiety treatment in primary care

Published online by Cambridge University Press:  13 December 2011

J. M. Joesch ,
C. D. Sherbourne ,
G. Sullivan ,
M. B. Stein ,
M. G. Craske  and
P. Roy-Byrne
J. M. Joesch*
Affiliation:
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP), Seattle, WA, USA
C. D. Sherbourne
Affiliation:
Rand Corporation, Santa Monica, CA, USA
G. Sullivan
Affiliation:
Department of Psychiatry and VA South Central Mental Illness Research, Education, and Clinical Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
M. B. Stein
Affiliation:
Departments of Psychiatry and Family and Preventive Medicine, University of California, La Jolla, CA, USA
M. G. Craske
Affiliation:
Departments of Psychology and Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
P. Roy-Byrne
Affiliation:
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP), Seattle, WA, USA
*
*Address for correspondence: J. M. Joesch, Ph.D., Department of Psychiatry and Behavioral Sciences, University of Washington Medical Center, Box 359911, Seattle, WA 98104-2499, USA. (Email: joesch@uw.edu)
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Abstract

Background

Improving the quality of mental health care requires integrating successful research interventions into ‘real-world’ practice settings. Coordinated Anxiety Learning and Management (CALM) is a treatment-delivery model for anxiety disorders encountered in primary care. CALM offers cognitive behavioral therapy (CBT), medication, or both; non-expert care managers assisting primary care clinicians with adherence promotion and medication optimization; computer-assisted CBT delivery; and outcome monitoring. This study describes incremental benefits, costs and net benefits of CALM versus usual care (UC).

Method

The CALM randomized, controlled effectiveness trial was conducted in 17 primary care clinics in four US cities from 2006 to 2009. Of 1062 eligible patients, 1004 English- or Spanish-speaking patients aged 18–75 years with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) and/or post-traumatic stress disorder (PTSD) with or without major depression were randomized. Anxiety-free days (AFDs), quality-adjusted life years (QALYs) and expenditures for out-patient visits, emergency room (ER) visits, in-patient stays and psychiatric medications were estimated based on blinded telephone assessments at baseline, 6, 12 and 18 months.

Results

Over 18 months, CALM participants, on average, experienced 57.1 more AFDs [95% confidence interval (CI) 31–83] and $245 additional medical expenses (95% CI $–733 to $1223). The mean incremental net benefit (INB) of CALM versus UC was positive when an AFD was valued ⩾$4. For QALYs based on the Short-Form Health Survey-12 (SF-12) and the EuroQol EQ-5D, the mean INB was positive at ⩾$5000.

Conclusions

Compared with UC, CALM provides significant benefits with modest increases in health-care expenditures.

Keywords

Anxiety disorderscollaborative careincremental benefits and costprimary care
Type
Original Articles
Information
Psychological Medicine , Volume 42 , Issue 9 , September 2012 , pp. 1937 - 1948
Copyright
Copyright © Cambridge University Press 2011

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References

Brazier, JE, Roberts, J (2004). The estimation of a preference-based measure of health from the SF-12. Medical Care 42, 851–859.CrossRefGoogle ScholarPubMed
Butler, M, Kane, RL, McAlpine, D, Kathol, RG, Fu, SS, Hagedorn, H, Wilt, TJ (2008). Integration of Mental Health/Substance Abuse and Primary Care. Evidence Reports/Technology Assessments, No. 173. Agency for Healthcare Research and Quality (US): Rockville, MD.Google Scholar
Campbell-Sills, L, Norman, SB, Craske, MG, Sullivan, G, Lang, AJ, Chavira, DA, Bystritsky, A, Sherbourne, CD, Roy-Byrne, P, Stein, MB (2009). Validation of a brief measure of anxiety-related severity and impairment: the Overall Anxiety Severity and Impairment Scale (OASIS). Journal of Affective Disorders 112, 92–101.CrossRefGoogle ScholarPubMed
Craske, MG, Rose, RD, Lang, AJ, Welch, SS, Campbell-Sills, L, Sullivan, G, Sherbourne, CD, Bystritsky, A, Stein, MB, Roy-Byrne, PP (2009). Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings. Depression and Anxiety 26, 235–242.CrossRefGoogle ScholarPubMed
Craske, MG, Stein, MB, Sullivan, G, Sherbourne, CD, Bystritsky, A, Rose, RD, Lang, AJ, Welch, SS, Campbell-Sills, L, Golinelli, D, Roy-Byrne, P (2011). Disorder specific impact of CALM treatment for anxiety disorders in primary care. Archives of General Psychiatry 68, 378–388.CrossRefGoogle ScholarPubMed
Derogatis, LR (1993). Brief Symptom Inventory (BSI). Administration, Scoring, and Procedures Manual, 3rd edn. National Computer Systems: Minneapolis, MN.Google Scholar
DuPont, RL, Rice, DP, Miller, SL, Shiraki, SS, Rowland, CR, Harwood, HJ (1996). Economic costs of anxiety disorders. Anxiety 2, 167–172.3.0.CO;2-L>CrossRefGoogle ScholarPubMed
Greenberg, PE, Sisitsky, T, Kessler, RC, Finkelstein, SN, Berndt, ER, Davidson, JR, Ballenger, JC, Fyer, AJ (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry 60, 427–435.CrossRefGoogle ScholarPubMed
Grosse, SD (2008). Assessing cost-effectiveness in healthcare: history of the $50 000 per QALY threshold. Expert Review of Pharmacoeconomics and Outcomes Research 8, 165–178.CrossRefGoogle ScholarPubMed
Hazen, AL, Walker, JR, Eldridge, GD (1996). Anxiety sensitivity and treatment outcome in panic disorder. Anxiety 2, 34–39.3.0.CO;2-D>CrossRefGoogle ScholarPubMed
Hoch, JS, Briggs, AH, Willan, AR (2002). Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis. Health Economics 11, 415–430.CrossRefGoogle Scholar
Katon, W, Robinson, P, Von Korff, M, Lin, E, Bush, T, Ludman, E, Simon, G, Walker, E (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry 53, 924–932.CrossRefGoogle ScholarPubMed
Katon, W, Roy-Byrne, PP, Russo, J, Cowley, D (2002). Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Archives of General Psychiatry 59, 1098–1104.CrossRefGoogle ScholarPubMed
Katon, W, Russo, J, Sherbourne, CD, Stein, MB, Craske, MG, Fan, M-Y, Roy-Byrne, P (2006). Incremental cost-effectiveness of a collaborative care intervention for panic disorder. Psychological Medicine 36, 353–363.CrossRefGoogle ScholarPubMed
Katon, W, Von Korff, M, Lin, E, Simon, G, Walker, E, Unützer, J, Bush, T, Russo, J, Ludman, E (1999). Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Archives of General Psychiatry 56, 1109–1115.CrossRefGoogle ScholarPubMed
Katon, W, Von Korff, M, Lin, EH, Walker, ED, Simon, GE, Bush, TM, Robinson, P, Russo, J (1995). Collaborative management to achieve treatment guidelines. Impact on depression in primary care. Journal of the American Medical Association 273, 1026–1031.CrossRefGoogle ScholarPubMed
Katzelnick, DJ, Simon, GE, Pearson, SD, Manning, WG, Helstad, CP, Henk, HJ, Cole, SM, Lin, EH, Taylor, LH, Kobak, KA (2000). Randomized trial of a depression management program in high utilizers of medical care. Archives of Family Medicine 9, 345–351.CrossRefGoogle ScholarPubMed
Kessler, RC (2000). Posttraumatic stress disorder: the burden to the individual and to society. Journal of Clinical Psychiatry 61 (Suppl. 5), 4–12, discussion 13–14.Google Scholar
Kessler, RC, Berglund, P, Demler, O, Jin, R, Merikangas, KR, Walters, EE (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 593–602.CrossRefGoogle ScholarPubMed
Kessler, RC, McGonagle, KA, Zhao, S, Nelson, CB, Hughes, M, Eshleman, S, Wittchen, HU, Kendler, KS (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry 51, 8–19.CrossRefGoogle ScholarPubMed
Koenker, R, Hallock, KF (2001). Quantile regression: an introduction. Journal of Economic Perspectives 15, 143–156.CrossRefGoogle Scholar
Lave, JR, Frank, RG, Schulberg, HC, Kamlet, MS (1998). Cost-effectiveness of treatments for major depression in primary care practice. Archives of General Psychiatry 55, 645–651.CrossRefGoogle ScholarPubMed
Machlin, SR, Carper, K (2007 a). Expenses for Hospital Inpatient Stays, 2004. Statistical Brief No. 164. Agency for Healthcare Research and Quality: Rockville, MD.Google Scholar
Machlin, SR, Carper, K (2007 b). Expenses for Office-Based Physician Visits by Specialty, 2004. Statistical Brief No. 166. Agency for Healthcare Research and Quality: Rockville, MD.Google Scholar
Mendlowicz, MV, Stein, MB (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry 157, 669–682.CrossRefGoogle ScholarPubMed
Nixon, RM, Wonderling, D, Grieve, RD (2010). Non-parametric methods for cost-effectiveness analysis: the central limit theorem and the bootstrap compared. Health Economics 19, 316–333.CrossRefGoogle ScholarPubMed
Olfson, M, Fireman, B, Weissman, MM, Leon, AC, Sheehan, DV, Kathol, RG, Hoven, C, Farber, L (1997). Mental disorders and disability among patients in a primary care group practice. American Journal of Psychiatry 154, 1734–1740.CrossRefGoogle Scholar
Rabin, R, de Charro, F (2001). EQ-5D: a measure of health status from the EuroQol Group. Annals of Medicine 33, 337–343.CrossRefGoogle ScholarPubMed
Rollman, BL, Belnap, BH, Mazumdar, S, Houck, PR, Zhu, F, Gardner, W, Reynolds, CF 3rd, Schulberg, HC, Shear, MK (2005). A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care. Archives of General Psychiatry 62, 1332–1341.CrossRefGoogle ScholarPubMed
Rost, K, Nutting, P, Smith, JL, Elliott, CE, Dickinson, M (2002). Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. British Medical Journal 325, 934–937.CrossRefGoogle ScholarPubMed
Roy-Byrne, PP, Craske, MG, Stein, MB, Sullivan, G, Bystritsky, A, Katon, W, Golinelli, D, Sherbourne, CD (2005). A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Archives of General Psychiatry 62, 290–298.CrossRefGoogle ScholarPubMed
Roy-Byrne, P, Craske, MG, Sullivan, G, Rose, RD, Edlund, MJ, Lang, AJ, Bystritsky, A, Welch, SS, Chavira, DA, Golinelli, D, Campbell-Sills, L, Sherbourne, CD, Stein, MB (2010). Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. Journal of the American Medical Association 303, 1921–1928.CrossRefGoogle ScholarPubMed
Roy-Byrne, P, Katon, W, Cowley, D, Russo, J (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry 58, 869–876.CrossRefGoogle ScholarPubMed
Russell, LB, Gold, MR, Siegel, JE, Daniels, N, Weinstein, MC (1996). The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine. Journal of the American Medical Association 276, 1172–1177.CrossRefGoogle ScholarPubMed
Shaw, JW, Johnson, JA, Coons, SJ (2005). US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Medical Care 43, 203–220.CrossRefGoogle ScholarPubMed
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, G (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (Suppl. 20), 22–33.Google ScholarPubMed
Simon, GE, Ludman, E, Rutter, CM (2009). Incremental benefit and cost of telephone care management and telephone psychotherapy for depression in primary care. Archives of General Psychiatry 66, 1081–1089.CrossRefGoogle ScholarPubMed
Simon, GE, Von Korff, M, Rutter, CM, Wagner, E (2000). Randomized trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. British Medical Journal 320, 550–554.CrossRefGoogle ScholarPubMed
Stein, MB, Heimberg, RG (2004). Well-being and life satisfaction in generalized anxiety disorder: comparison to major depressive disorder in a community sample. Journal of Affective Disorders 79, 161–166.CrossRefGoogle Scholar
Stein, MB, Kean, YM (2000). Disability and quality of life in social phobia: epidemiologic findings. American Journal of Psychiatry 157, 1606–1613.CrossRefGoogle ScholarPubMed
Stein, MB, Sherbourne, CD, Craske, MG, Means-Christensen, A, Bystritsky, A, Katon, W, Sullivan, G, Roy-Byrne, PP (2004). Quality of care for primary care patients with anxiety disorders. American Journal of Psychiatry 161, 2230–2237.CrossRefGoogle ScholarPubMed
Stinnett, AA, Mullahy, J (1998). Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Medical Decision Making 18, S68–S80.CrossRefGoogle ScholarPubMed
Sturm, R, Unützer, J, Katon, W (1999). Effectiveness research and implications for study design: sample size and statistical power. General Hospital Psychiatry 21, 277–283.CrossRefGoogle ScholarPubMed
Sullivan, G, Craske, MG, Sherbourne, CD, Edlund, MJ, Rose, RD, Golinelli, D, Chavira, DA, Bystritsky, A, Stein, MB, Roy-Byrne, PP (2007). Design of the Coordinated Anxiety Learning and Management (CALM) study: innovations in collaborative care for anxiety disorders. General Hospital Psychiatry 29, 379–387.CrossRefGoogle ScholarPubMed
Unützer, J, Choi, Y, Cook, IA, Oishi, S (2002 a). A web-based data management system to improve care for depression in a multicenter clinical trial. Psychiatric Services 53, 671–673, 678.CrossRefGoogle Scholar
Unützer, J, Katon, W, Callahan, CM, Williams, JWJ, Hunkeler, E, Harpole, L, Hoffing, M, Della Penna, RD, Noel, PH, Lin, EHB, Arean, PA, Hegel, MT, Tang, L, Belin, TR, Oishi, S, Langston, C (2002 b). Collaborative care management of late-life depression in the primary care setting. Journal of the American Medical Association 288, 2836–2845.CrossRefGoogle ScholarPubMed
Unützer, J, Katon, WJ, Russo, J, Simon, G, von Korff, M, Lin, E, Walker, E, Ludman, E, Bush, T (2003). Willingness to pay for depression treatment in primary care. Psychiatric Services 54, 340–345.CrossRefGoogle ScholarPubMed
Van Ameringen, M, Mancini, C, Farvolden, P (2003). The impact of anxiety disorders on educational achievement. Journal of Anxiety Disorders 17, 561–571.CrossRefGoogle ScholarPubMed
Vannoy, SD, Arean, P, Unützer, J (2010). Advantages of using estimated depression-free days for evaluating treatment efficacy. Psychiatric Services 61, 160–163.CrossRefGoogle ScholarPubMed
Waghorn, GR, Chant, DC (2005). Employment restrictions among persons with ICD-10 anxiety disorders: characteristics from a population survey. Journal of Anxiety Disorders 19, 642–657.CrossRefGoogle ScholarPubMed
Wang, PS, Lane, M, Olfson, M, Pincus, HA, Wells, KB, Kessler, RC (2005). Twelve-month use of mental health services in the United States. Results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 629–640.CrossRefGoogle ScholarPubMed
Ware, JE, Kosinski, M, Keller, SD (1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220–223.CrossRefGoogle ScholarPubMed
Wells, KB (1999). The design of partners in care: evaluating the cost-effectiveness of improving care for depression in primary care. Social Psychiatry and Psychiatric Epidemiology 34, 20–29.CrossRefGoogle ScholarPubMed
Wells, KB, Sherbourne, CD, Schoenbaum, M, Duan, N, Meredith, L, Unützer, J, Miranda, J, Carney, M, Rubenstein, L (2000). Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. Journal of the American Medical Association 283, 212–220.CrossRefGoogle ScholarPubMed
Willan, AR, Lin, DY (2001). Incremental net benefit in randomized clinical trials. Statistics in Medicine 20, 1563–1574.CrossRefGoogle ScholarPubMed
Wittchen, HU (2002). Generalized anxiety disorder: prevalence, burden, and cost to society. Depression and Anxiety 16, 162–171.CrossRefGoogle ScholarPubMed