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Cost-effectiveness of an Improving Access to Psychological Therapies service

  • Clara Mukuria (a1), John Brazier (a1), Michael Barkham (a2), Janice Connell (a1), Gillian Hardy (a2), Rebecca Hutten (a3), Dave Saxon (a3), Kim Dent-Brown (a3) and Glenys Parry (a4)...

Abstract

Background

Effective psychological therapies have been recommended for common mental health problems, such as depression and anxiety, but provision has been poor. Improving Access to Psychological Therapies (IAPT) may provide a cost-effective solution to this problem.

Aims

To determine the cost-effectiveness of IAPT at the Doncaster demonstration site (2007–2009).

Method

An economic evaluation comparing costs and health outcomes for patients at the IAPT demonstration site with those for comparator sites, including a separate assessment of lost productivity. Sensitivity analyses were undertaken.

Results

The IAPT site had higher service costs and was associated with small additional gains in quality-adjusted life-years (QALYs) compared with its comparator sites, resulting in a cost per QALY gained of £29 500 using the Short Form (SF-6D). Sensitivity analysis using predicted EQ-5D scores lowered this to £16 857. Costs per reliable and clinically significant (RCS) improvement were £9440 per participant.

Conclusions

Improving Access to Psychological Therapies provided a service that was probably cost-effective within the usual National Institute for Health and Clinical Excellence (NICE) threshold range of £20 000-30 000, but there was considerable uncertainty surrounding the costs and outcome differences.

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Copyright

Corresponding author

Clara Mukuria, Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. Email: c.mukuria@sheffield.ac.uk

Footnotes

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Declaration of interest

None.

Footnotes

References

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3 Sainsbury Centre for Mental Health. The Economic and Social Costs of Mental Illness. Sainsbury Centre for Mental Health, 2003.
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Cost-effectiveness of an Improving Access to Psychological Therapies service

  • Clara Mukuria (a1), John Brazier (a1), Michael Barkham (a2), Janice Connell (a1), Gillian Hardy (a2), Rebecca Hutten (a3), Dave Saxon (a3), Kim Dent-Brown (a3) and Glenys Parry (a4)...
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eLetters

IAPT probably not cost effective and a gamble too far for the NHS

Ahmed S Huda, Consultant
10 April 2013

The authors are to be congratulated on an important paper. Given the current NHS spending envelope it is critical we focus on cost- effective interventions. The authors on their actual measured outcome SF-6D clearlyshowed <50% chance of IAPT being cost effective at the maximum NIICE threshold of 30,0000 pounds/QALY. Even on their projected i.e. non-measured EQ-5D measure the CEAC at the 30,000 pounds/QALY threshold the probability is only 53%. Given that this is only achieved using a much less robust method ( projected rather than actually measured) and that NHS finances are in a parlous state this is anunacceptable gamble. The implications are clear.1. There should be no further expansion of IAPT.2. Unless there is a demonstrated large increase in cost-effectiveness of IAPT we may have to consider decommissioning (taking into account exit costs).Once again I congratulate the authors for bravely publishing these resultsdespite the implications.

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Conflict of interest: None declared

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Common sense and health economics

Andrew J. Amos, Psychiatric Registrar
10 April 2013

Mukuria and colleagues (BJP, 202:220-227) cost-effectiveness analysisof the Improving Access to Psychological Therapies (IAPT) programme perfectly illustrates the need to apply common sense to the interpretationof statistical results. Leaving aside the fact that the authors failed to accommodate for the selective attrition of IAPT patients with worse depression scores (on the PHQ-9), it is inconsistent to report that the average cost of IAPT patients was higher than comparators, that there wereno statistically significant differences in QALYs between the groups, and that it is likely that IAPT was cost-effective. The authors also do not adequately explain why a relatively greater increase in the measure used to calculate QALYs (SF-6D) for the comparator group did not also lead to agreater increase in QALYs for the comparator group. That is, over the 8 month trial, the IAPT group's SF-6D scores increased from 0.61 to 0.66, while the comparator group's scores increased from 0.63 to 0.69 (a higher score indicating greater health utility). Despite the relatively greater improvement on the SF-6D for the comparator group, after transformation toQALYs the authors report that there has been a relatively greater improvement in the QALYs of the IAPT group. Without clarification, this point would seem to invalidate the author's conclusions.

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Conflict of interest: None declared

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IAPT is probably not cost-effective

Paul McCrone, Professor of Health Economics
05 March 2013

The recent economic evaluation of an Improving Access to Psychological Therapies (IAPT) service conducted by Mukuria and colleagues(BJP, 202:220-227) is a welcome addition to the evidence base pertaining to this programme. This was a non-randomised comparison but it appears that the authors have used appropriate methods to control for differences between areas. A casual reading of the abstract conclusion would lead one to assume that IAPT is likely to be cost-effective. Indeed, the cost per QALY is below the upper threshold used by NICE, and below the lower threshold in a sensitivity analysis where the EQ5D was used. However, the cost per QALY is somewhat misleading. The most useful results from this study are the cost-effectiveness acceptability curves shown in Figure 2. Here it is revealed that at the NICE upper threshold of 30,000 pounds per QALY there is something like a 38% likelihood that IAPT is cost-effective,increasing to just over 50% if the EQ5D is used to generate QALYs. If the lower threshold is used then there is even less chance that IAPT is cost-effective. The overall conclusion of this paper should be based on Figure 2 and it should be that on the basis of this study IAPT was probably not cost-effective.

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Conflict of interest: None declared

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