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Value based Health Care for Depression and Anxiety
Matthias Rose
Department of Psychosomatic MedicineCenter for Internal Medicine and DermatologyCharité Universitätsmedizin Berlin, Germany
Department of Quantiative Health SciencesUniversity of Massachusetts, USA
Symposium Value Based Health Care
Basel September 2018
Key numbers
▪ Mental disorders among the 10
diseases accounting for the
most years lived with
disability
▪ Depressive disorders account
for nearly 81 million years
▪ Anxiety disorders account for
nearly 27 million years
▪ Together, the economic burden
is upwards of $210 billion in the
US alone
Vos et al. The Lancet 2013
Disease BurdenGlobal Burden of Disease Study
Outcome Measurement
query Sep, 19th 2018
National Standardization
▪ As part of effort to
integrate mental health
into primary care, routine
outcome monitoring is used
for all patient visiting a
behavioral health provider
▪ Over 50,000 surveys now
administered monthly
▪ National initiative for routine
outcomes monitoring across the
mental health spectrum
▪ Data feed back for clinical care
as well as benchmarking
▪ Supported by health plans
▪ As part of effort to expand
access to psychotherapy,
routine outcome monitoring
established
▪ Demonstrated substantial
cost-effectiveness of
program and is now the
model for many system-wide
efforts worldwide
Veteran’s Affairs and
Military Health System (US) Stichting Benchmark (NL) IAPT (UK)
International
Standardization
ICHOM Approach
After outcomes and measures are defined, a similar
process was followed to identify and define an
accompanying set of case-mix factors
ICHOM Approach
Depression & Anxiety Group
Anne Crocker, Douglas Mental Health
University Institute; McGill University
Lucie Langford*
Alain Lesage, University of Montréal
David M. Clark, Oxford University
Dave Smithson*, Anxiety UK
Maria Kangas, Centre for Emotional Health,
Macquarie University
Edwin de Beurs, Stichting
Benchmark GGZ
Paul Emmelkamp, University
of Amsterdam
Erik Hedman,
Karolinska Institutet
Lee Baer, Harvard Medical School;
Massachusetts General Hospital
Kelly Woolaway-Bickel, Department of
the U.S. Army; Office of the Surgeon
General
Paul A. Pilkonis, University of Pittsburgh
Harold A. Pincus, Columbia University
Cathy Sherbourne, The RAND
CorporationDoris M. Mwesigire,
Makerere University
Sandra Nolte, Alexander
Obbarius & Matthias Rose,
Charité Universitätsmedizin
BerlinToshi A. Furukawa, Kyoto
University
Roberta Alvarenga Reis,
Universidade Federal do Rio
Grande do SulGraciela Rojas, University of Chile
Vikram Patel, Centre for
Chronic Conditions and
Injuries; Public Health
Foundation of India
Standardset Depression & Angst
Paul A. PilkonisUniversity of Pittsburgh
Working
Towards Agreement
ICHOM Methods
13th/14th
Call 2
June Jul Aug Sept Oct Nov Dec
Launch of ICHOM Standard Set for
Depression & Anxiety at ICHOM conference
Outcome domains
Call 3 Call 4 Call 5 Call 6Kick-off
meeting
Outcome measures
Risk factor domains
Risk factor measures
Scope
Prepare for launch and publication
Call 1
Jan
Transition to implementation
17th 1st 22nd 16th 14th 4th26th
Promote adoption
Inclusion Criteria
Psychopharmacotherapy
Psychotherapy
Lifestyle Interventions, Self-
guided help
Other Forms of Therapy
Patient population
Large variation across
conditions
Large variation across
conditions and treatments
Mortality
Disease Symptoms
Disease Burden
Health-related Quality of Life
Main Diagnosis: bipolar and
schizophrenic disorders as well
as other mental disorders (e.g.
personality disorders, substance
abuse)
Age < 18 years
DepressionDepressive Adaptive / Adjustment
Disorder
Major depressive disorderDepressive Disorder - NOS
Dysthymia
AnxietyGeneral Anxiety DisorderPhobic disorder
Panic disorderPost-Traumatic Stress Disorder
Treatment options Outcomes
Incl
ud
e
Constructs within the VBHC Framework
• Symptoms1
a. depression b. anxiety• Participation1
a. work b. social
• Functional status1
• Quality of Life1
• Length of inpatient stay
• Time to Symptom relief• Time to participation
• Time to achieve sufficient
functional status
• Medication side effects
• Side effects of other treatment (e.g. memory loss due to ECT)
• Suicide rate
• Sustainability of symptom relief,
participation and functional status1
• Recurrence of disease
• Emergency visits
• Need for medication
• Symptom shift
• Medication side effects (e.g. dyskinesia, physical dependency)
• Therapy induced dependency
• Secondary gain
Survival
Degree of health achieved or maintained
Time to recovery and return to normal activities
Disutility of the care or treatment process
Sustainability of health /recovery and nature of recurrences
Long-term consequences of therapy
Tier 1
Health status
achieved or
retained
Tier 2
Process of
Recovery
Tier 3
Sustainability
of health
DOMAIN SUGGESTED OUTCOMES
Obbarius et al.
Qual of Life Res 2017
From Construct to Instrument
From Construct to InstrumentCategory Domains Covered
PHQ SWLS CGI BDI BSI HRSQIDS-
SRWSAS
Q-LES-
QMADR-S
Symptom
Burden
Suicidal Thoughts
Depressed Mood and Thoughts
Insomnia
Other Symptoms
Functional Functional Functional Functional Status Status Status Status Overall Functional Status
Quality of Life Health-related Quality of Life
Practical
Considerations
# questions 10 5 3 21 53 or 18 21 16 5 16 10
# citations 3301 7739 1853 14693 3954 18278 689 396 870 6079
Year published 1999 1985 1976 1961 1983 1960 2003 2002 1993 1979
Cost None None None Yes Yes None None ? ? None
Translations 79 28 ? 46 3 13 46 ? 64 42
Light Focus Moderate Focus Heavy Focus
PHQ Patient Health Questionnaire BSI Brief Symptom Inventory WSAS Work and Social Adjustment Scale
SWLSSatisfaction with Life Scale
HRSHamilton Rating Scale
Q-LES-QQuality of Life Enjoyment and Satisfaction
Questionnaire
CGIClinical Global Impression
QIDS-SRQuick Inventory of Depressive
SymptomatologyMADR-S
Montgomery-Asberg Depression Rating Scale
BDI Beck Depression Inventory
From Construct to Instrument
number of available translations
psychometric soundness
comprehensiveness
available royalty free
Items
Items
CaseMix
Variables
Items
TreatmentVariables
Items
Outcomes
Items
Outcomes
Time Points
Standard Metric
Item Bank - Depression
Representative Samples
Item Location
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feelingdepressed feeling
guilty
lost ofinterest
suicidalideation
feelingdown
happy
relaxed
difficultiesconcentrate
populationmean ±±±±
standard deviation
high30 40 50 60 70 80 90
lowTheta ΘΘΘΘ
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Patients with Depression7 Clinical Sites / 12 Health
Centers total n > 33,000
Wahl et al. J Clin Epi 2014
Item Bank - Depression
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Questionnaire B
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11 establishedinstruments
feelingdepressed feeling
guilty
lost ofinterest
suicidalideation
feelingdown
happy
relaxed
difficultiesconcentrate
30 40 50 60 70 80 90 Theta ΘΘΘΘhighlow
Wahl et al. J Clin Epi 2014
Standardized Metric
GAD-7 and PHQ-9 Conversion Tables
Promis Metric
Conclusion
Conclusion
However, if an instrument oriented measurementis standardized this would prevent to improve methodsin the future
II
I ICHOM provides the prerequisite to learnfrom large data sets
One way to avoid this is an agreement on the constructs with common metrics
III
Vielen Dank
Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, 2008, s.a. SGB V, §23
Relevance of the Patients’ Perspective in Germany
Parking Lot
45
Standardized Metric
BDI
5
20
1961
60
WHO-5
50
30
70
Depression
50
HADS
10
8
3
1983 1998 2012
Cut-OffDepression
MeanRepresentative
Sample55
60
65
70
Theta ΘΘΘΘ
10
15
25 75
40
20
5
12
Beck Depression Inventory
Well-Being Index
Hospital AnxietyDepression Scale
Phenotype of Depressivity
Hasselmann et al. Multiple Sclerosis Journal 2016
Treatment approaches
covered
▪ Psychopharmacotherapy
▪ Psychotherapy
▪ Lifestyle interventions
▪ Self-guided help
▪ Other forms of therapy
© 2015 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM a s the source so that this
organization can continue its work to define more standard outcome sets.
A "reference guide"
contains all the details
to measure in a
standard way the
outcomes
recommended
(available at ichom.org)
Distribution of outcomes and case-mix variables across time
Baseline ( )
▪ Age
▪ Sex▪ Educational level
▪ Living status▪ Social support
▪ Comorbidities
▪ Prior episodes of depression
▪ Duration of symptoms▪ Prior treatment
▪ Outcome expectancy
With treatment ( ) Annual ( )
Case-mix
variables
Outcomes
▪ Symptom burden (PHQ-9,
GAD-7, specific anxiety questionnaires depending
on diagnosis)▪ Medication side effects
▪ Functioning (WHO-DAS
2.0)▪ Work status
▪ Absenteeism
▪ Symptom burden (PHQ-9,
GAD-7, specific phobia questionnaires depending
on diagnosis)▪ Functioning (single item
from PHQ-9)
▪ Medication side effects
▪ Symptom burden (PHQ-9,
GAD-7, specific anxiety questionnaires depending on
diagnosis)▪ Medication side effects
▪ Recurrent episode
▪ Functioning (WHO-DAS)▪ Work status
▪ Absenteeism▪ Overal success of treatment
▪ Global assessment
▪ Current treatment ▪ Living status
▪ Comorbidities▪ Prior and current treatment
▪ Social support ▪ Outcome expectancy
• Proposed in by IsHaket al., 2011
• Team of UCLA psychiatrists, biostatisticians, physicians, etc
• Developed through data analysis of Cedars-Sinai Psychiatric Treatment Outcome Registry
• Consists of composite score of three PROMs
QIDS-SR WSAS Q-LES-Q
Suicidal Thoughts
Depressed Mood and
Thoughts
Insomnia
Other Symptoms
Functional Status
(impairment of work
ability, impairment of
enjoying leisurely
activities, impairment
in maintaining close
relationships, loss of
motivation)
Quality of Life
Number of Questions16 5 16
Number of translations46 ? 64
Measurement Range
Depression
Depression
Depression
Fisher et al. 2014
Fisher et al. 2014
Consent Building Efforts
Anxiety & Depression
Obbarius et al. Quality of Life Res 2017
Choosing the Right Perspective
γ-globulin
creatinine
hemoglobin
fatigue
plasmacytomakidney failure
σύµπτωµα (symptoma)=it falls together with something
Nephrology Hematology
disease specific measures=compilation of health parameters
?
but is not unique to it
… from the instrument to the construct !
Synergies
Physical Function
Pain
Fatigue
Depression
Sleep Issues
Social Function
Dia
bete
s
Hea
rt F
ailu
re
Kne
e &
Hip
Rep
lace
men
t
Dep
ress
ion
CO
PD
Bre
ast C
ance
r
Infla
mm
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isea
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Disease Perspective
modernmetricinstrumentindipendent
self-
repo
rted
he
alth
Disease / ContextSpecific Issues
Composite Score
↑ ↑ ↑ ↑ ↑ ↑ ↑
xycont
ext o
r di
seae
spec
ific
standard tools
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