Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

1054 — Cost Effectiveness Analysis of Rural Telemedicine Collaborative Care Intervention for Depression

Pyne JM (CeMHOR) , Fortney J (CeMHOR), Tripathi S (UAMS, Dept. of Pyschiatry), Williams DK (UAMS), Edlund M (CeMHOR)

Objectives:
We adapted the collaborative care model for depression using telemedicine (e.g., telephone, interactive video, electronic medical records) to support antidepressant therapy initiated by PC providers in small rural practices. The Telemedicine Enhanced Antidepressant Management (TEAM) collaborative care intervention was implemented by offsite personnel and utilized telemedicine technologies. One of the objectives of this study was to determine the cost-effectiveness of the TEAM intervention relative to usual care.

Methods:
Seven VISN 16 CBOCs participated in the study. CBOCs were included if they treated 1,000 to 5,000 unique veterans, had no on-site psychiatrists, and had interactive video equipment. Matched CBOCs were randomized to receive the intervention or usual care. 395 patients were enrolled. Telephone research interviews were conducted at baseline, 6-and 12-months. Effectiveness was tested using an intent-to-treat analysis. Cost-effectiveness was assessed from the perspective of VA. Cost included intervention, encounter, and medication costs. Quality adjusted life years (QALYs) were calculated using the Quality of Well Being Scale.

Results:
Intervention patients had significantly higher total VA costs than usual care patients ($1,083, p<0.01) and significantly higher QALYs (0.0174, p=0.03). The incremental cost effectiveness ratio for the intervention was $62,191 per QALY. Intervention costs averaged $794 per patient. In order for the cost-effectiveness ratio to be less than the common threshold of $50,000 per QALY, the incremental intervention cost would need to be less than $870.

Implications:
Using the commonly cited cost-effectiveness threshold of $50,000 per QALY, the TEAM intervention is less cost-effective than this threshold. Adjusting the common threshold for inflation, the cost effectiveness ratio is near the upper limit. Our findings suggest that collaborative care for depression is less cost-effective for rural VA patients than patients in other sectors.

Impacts:
Future research should focus on improving the effectiveness of telemedicine interventions and/or lowering cost. The cost of the TEAM intervention could be lowered by streamlining the off-site depression care team or by providing better informatics support to the nurse care manager to improve their efficiency. The effectiveness of the TEAM intervention could be improved by targeting common comorbidities such as pain, anxiety, and substance abuse and providing access to telephone-based psychotherapy.