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Economic Evaluation of Treatment for Externalizing Disorders in Adolescents Connecting Mental Health and Economics

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Economic Evaluation of Treatment for Externalizing Disorders in Adolescents Connecting Mental Health and Economics Omslag - Werkbestand - Saskia Schawo.indd 2-3 30-10-2019 12:22:12 Economic Evaluation of Treatment for Externalizing Disorders in Adolescents Connecting mental health and economics Saskia Schawo Binnenwerk werkbestand Saskia.indd 1 28-10-2019 12:38:51 Colofon Cover photo: Saskia Schawo; lay-out: Carolien Laro Lay-out Rutger van Aken | persoonlijkproefschrift.nl Print Ridderprint BV | www.ridderprint.nl ©2019 Saskia Jana Schawo, Roterdam, The Netherlands All rights reserved. No part of this work may be reproduced, stored in a retrieval database or published in any form, without prior writen permission of the author. Binnenwerk werkbestand Saskia.indd 2 28-10-2019 12:38:51 Economic Evaluation of Treatment for Externalizing Disorders in Adolescents Connecting mental health and economics Economische evaluatie van behandelingen voor externaliserende problematiek in adolescenten De brug slaan tussen mentale gezondheid en economie Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Roterdam op gezag van de rector magnifcus Prof.dr. R.C.M.E. Engels en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op vrijdag 20 december 2019 om 11.30 uur door Saskia Jana Schawo geboren te Bonn, Duitsland Binnenwerk werkbestand Saskia.indd 3 28-10-2019 12:38:52 Promotiecommissie: Promotor: Prof.dr. W.B.F. Brouwer Overige leden: Prof.mr.dr. S.M.A.A. Evers Prof.dr. N.J.A. van Exel Dr. G.A. de Wit Copromotor: Dr. L. Hakkaart-van Roijen Binnenwerk werkbestand Saskia.indd 4 28-10-2019 12:38:52 Contents Chapter 1 Introduction 7 Chapter 2 Probabilistic Markov Model Estimating Cost Efectiveness 21 of Methylphenidate Osmotic-Release Oral System Versus Immediate-Release Methylphenidate in Children and Adolescents: Which Information is Needed? Chapter 3 The Cost-Efectiveness of Family/Family-based Therapy for 63 Treatment of Externalizing Disorders, Substance Use Disorders and Delinquency: A Systematic Review Chapter 4 Framework for Modeling the Cost-efectiveness of Systemic 109 Interventions Aimed to Reduce Youth Delinquency Chapter 5 Value of Information Analysis Applied to Systemic Interventions 131 Aimed to Reduce Juvenile Delinquency Chapter 6 Clinicians’ Views on Therapeutic Outcomes of Systemic 153 Interventions and on the Ability of the EQ-5D to Capture these Outcomes Chapter 7 The Search for Relevant Outcome Measures for Cost-utility 165 Analysis of Systemic Interventions in Adolescents with Substance Use Disorder and Delinquent Behavior: A Systematic Literature Review Chapter 8 Obtaining Preference Scores for an Abbreviated Self-Completion 209 Version of the Teen-Addiction Severity Index (ASC T-ASI) to Value Therapy Outcomes of Systemic Family Interventions: a Discrete Choice Experiment Chapter 9 Discussion 239 Summary 255 Samenvating 258 List of publications 260 PhD portfolio 262 Curriculum vitae 265 Dankwoord 266 Binnenwerk werkbestand Saskia.indd 5 28-10-2019 12:38:52 Binnenwerk werkbestand Saskia.indd 6 28-10-2019 12:38:52 Chapter 1 Introduction Binnenwerk werkbestand Saskia.indd 7 28-10-2019 12:38:52 Chapter 1 Mental health Mental disorders are common [1-3]. In the Netherlands, lifetime prevalence of one or more mental disorders in adults has been found to be 42.7% [2]. Being afected by a mental disorder can result in a high disease burden, both for the afected individuals as well as for their environment and society [4-7]. For the patient, this burden primarily relates to the quality of life losses related to mental disorders, which can be substantial [8-10]. For the patients’ environment, mental health problems may lead to disturbed personal relationships, stress, and strain on caregivers [11, 12]. The societal burden related to mental disorders includes aspects like the high health care costs of treating mental disorders [13,14, 6], losses of productivity due to absenteeism and reduced working capacity [15, 16], as well as pressure on sectors such as social care, education and criminal justice [17-19]. Due to these broad impacts of mental disorders at several levels and in diferent sectors, specifying the overall burden of the disorders is a complex and challenging task. Externalizing mental disorders in adolescents The multifaceted and substantial impact of mental disorders also holds for externalizing mental disorders in adolescents. Externalizing disorders are mental disorders, like Atention-Defcit-Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Antisocial Personality Disorder, which are outwardly directed and therefore, by defnition, do not only afect the patient, but also his or her environment. These disorders are therefore associated with a particularly wide variety of costs and efects. Symptoms of these disorders range from concentration problems and restlessness or disobedience to aggressive behavior, violence and substance use [20-22]. Patients may experience signifcant impairments in social, academic or occupational functioning [20, 23-25]. This can create high individual and societal burdens, both within and beyond the health care sector. Especially in younger patients, this burden will include aspects such as school performance, criminal activity, disturbed relationships with parents and siblings, and so forth. Several psychotherapeutic and psychosocial interventions for treatment of externalizing disorders exist, including, for example, Functional Family Therapy (FFT), Multisystemic Therapy (MST), Multidimensional Family Therapy (MDFT), Cognitive Behavioral Therapy (CGT), parent training, and community-based interventions [26-29]. Some of these interventions are specifcally directed at improving patients’ interactions with the various systems around them (i.e., parents, siblings, peers, teachers, colleagues, neighbors, ‘society as a whole’). 8 Binnenwerk werkbestand Saskia.indd 8 28-10-2019 12:38:52 Introduction Budget limitations The broad and diverse impacts of externalizing disorders in adolescents and related intervention strategies pose clear challenges for evaluating the (costs and) efects of such interventions. Nonetheless, such evaluations are needed. To date, limited information is available regarding the costs and efects of these interventions. Yet, this information is of high importance for medical and policy decisions concerning preferred treatment and the funding thereof. In recent years, changes in government policy, technological advances, 1 increasing wealth and population ageing have contributed to increasing health care expenditures [30-32]. In the Netherlands, also as a result of changes in government policy, mental health care expenses rose more (+105%) than overall health care expenditures (+49%) [33] between 2000 and 2010. This raises questions regarding the sustainability of such expenditures and growth rates as well as the justifcation of how budgets are spent, given that resources are limited and more spending on (mental) health care has opportunity costs inside and outside the health care sector. Ideally, limited resources would be allocated in the most efcient way, so that they optimally contribute to improving overall health or welfare. However, a lack of information on costs and efects of interventions makes it difcult to provide evidence-based advice to policymakers on which interventions contribute optimally to their goals. Health economic evaluation has become a commonly used tool to inform such policy and budget decisions [34]. Yet, to what extent the classical health economic methodology sufciently and adequately captures the broad costs and efects of mental health interventions in adolescents with externalizing disorders remains a mater of debate. This has been previously highlighted for complex mental health conditions and mental disorders in general by Brazier et al. [35, 36] and Knapp et al. [37]. The lack of information on costs and efects of mental interventions, together with questions concerning the suitability of the common methodology used in economic evaluations to assess these, is at odds with the societal and scientifc relevance of providing more insight into these issues. This is especially the case when policy makers wish to stimulate efective and cost-efective treatments of adolescents with mental disorders (and externalizing disorders in particular). Economic evaluations In health economic analysis costs are compared to the benefts of an intervention. The aim of the analysis, when taking a societal perspective, is to answer the 9 Binnenwerk werkbestand Saskia.indd 9 28-10-2019 12:38:52 Chapter 1 question as to whether the benefts exceed the costs, thus demonstrating that intervention results in an increase in societal welfare. Several types of health economic evaluation exist. Classical cost-beneft analysis (CBA) compares costs and benefts both expressed in monetary units. It directly answers the question whether benefts exceed the costs of the intervention. Whereas CBA is more common in other sectors, it is used less often in health care. There, cost- efectiveness analysis (CEA) is more common. CEA compares costs expressed in monetary units with efects expressed in a unit relevant to the outcome of the intervention (i.e., costs per life year gained, costs per hip fracture avoided, costs per point decrease on some clinical scale, etc.). The advantage of doing this is that such outcomes, which cannot easily be expressed in monetary terms, relate well to the clinical practice and can still be evaluated. Yet, a disadvantage is that CEA uses diverse outcomes across setings, which limits comparability
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