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Cost-effectiveness Analysis of a Rural Telemedicine Collaborative Care Intervention for Depression
Jeffrey M. Pyne, MD;
John C. Fortney, PhD;
Shanti Prakash Tripathi, MS;
Matthew L. Maciejewski, PhD;
Mark J. Edlund, MD, PhD;
D. Keith Williams, PhD
Arch Gen Psychiatry. 2010;67(8):812-821. doi:10.1001/archgenpsychiatry.2010.82
Context Collaborative care interventions for depression in primary care settings are clinically beneficial and cost-effective. Most prior studies were conducted in urban settings.
Objective To examine the cost-effectiveness of a rural telemedicine-based collaborative care depression intervention.
Design Randomized contolled trial of intervention vs usual care.
Setting Seven small (serving 1000 to 5000 veterans) Veterans Health Administration community-based outpatient clinics serving rural catchment areas in 3 mid-South states. Each site had interactive televideo dedicated to mental health but no psychiatrist or psychologist on site.
Patients Among 18 306 primary care patients who were screened, 1260 (6.9%) screened positive for depression; 395 met eligibility criteria and were enrolled from April 2003 to September 2004. Of those enrolled, 360 (91.1%) completed a 6-month follow-up and 335 (84.8%) completed a 12-month follow-up.
Intervention A stepped-care model for depression treatment was used by an off-site depression care team to make treatment recommendations via electronic medical record. The team included a nurse depression care manager, clinical pharmacist, and psychiatrist. The depression care manager communicated with patients via telephone and was supported by computerized decision support software.
Main Outcome Measures The base case cost analysis included outpatient, pharmacy, and intervention expenditures. The effectiveness outcomes were depression-free days and quality-adjusted life years (QALYs) calculated using the 12-Item Short Form Health Survey standard gamble conversion formula.
Results The incremental depression-free days outcome was not significant (P = .10); therefore, further cost-effectiveness analyses were not done. The incremental QALY outcome was significant (P = .04) and the mean base case incremental cost-effectiveness ratio was $85 634/QALY. Results adding inpatient costs were $111 999/QALY to $132 175/QALY.
Conclusions In rural settings, a telemedicine-based collaborative care intervention for depression is effective and expensive. The mean base case result was $85 634/QALY, which is greater than cost per QALY ratios reported for other, mostly urban, depression collaborative care interventions.
Author Affiliations: Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System and South Central Mental Illness Research, Education, and Clinical Center (Drs Pyne and Fortney) and Departments of Psychiatry (Drs Pyne, Fortney, and Edlund and Mr Tripathi) and Biostatistics (Dr Williams), University of Arkansas for Medical Sciences, Little Rock; and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center and Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina (Dr Maciejewski).
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