Bowen Chung MD, Adjunct Staff, RAND, 	Assistant Professor, Geffen School of Medicine, UCLA		Michael Ong, MD, PhD 	Associat...
Presenter Disclosures	No financial conflicts of interest to report
Acknowledgements	• RAND: Paul Koegel, Cathy Sherbourne	• UCLA: Michael McCreary, Esmeralda Pulido, Lingqi Tang, Lily Zhang...
Goals for talk		• Explain rationale for Community Partners in Care (CPIC)		• Describe CPIC interventions and 6 & 12 month ...
Background	•  Depression a leading cause of disability worldwide		•  Disparities exist in access, quality, outcomes of car...
% recovered from depression at 5 years	Depression QI Interventions Reduce Long-Term OutcomeDisparities (Partners in Care)
Community Context	•  Under-resourced communities have limited provider availabilityand limited implementation of Quality I...
Community Partners in Care 	•  Community partnered participatory research and rigorous science	•  Group-randomized trial a...
Interventions		Resources for Services (RS)	• Expert team conducted culturally competent outreach to programs	• Offered 24 ...
Resources forServicesCommunityEngagement Planning
Objective of cost analysissub-study	To determine the comparative cost-effectiveness from asocietal perspective of 2 approa...
Sampling - Client	• Approached: 4,649 	• Screened: 4,440 (95.5%) 	• Eligible: 1,322 of 4,440 (29.8%) 	– Criteria: PHQ-8≥10...
Screened Clients ReflectedDiversity of Communities(N = 4,440, mean age 47 years)	65%	85%	16%	50%	23%	39%	28%	54%
MAJORITY OF DEPRESSION CONTACTS WERENOT IN PRIMARY OR MENTAL HEALTH7%	27%	27%	27%
Other data sources	•  Provider and administrator survey data – baseline, 6, and 12 month		•  Provider and administrator tr...
Key Assumptions	•  BLS Wage classifications were an accurate reflection of the job title	•  Minimum wage is a reasonable dol...
Key Assumptions	•  Cost estimates of venue for similar interventions based on perperson costs of similar events	•  Interve...
Analysis	•  6 and 12 month outcomes	•  Intent to treat, comparative effectiveness study	•  Independent variable: intervent...
RS	 CEP	Poor Mental Health Related Quality of Life*	 51%		44%		Mental Wellness*	 34%	 46%	Poor Mental Health*	 37%	 29%	Go...
CPIC 6 Month Outcomes	RS	 CEP	Total outpatient contacts for depression acrosssectors (mean)	23	 22	Any mental outpatient v...
Percent Poor Mental HealthQuality of Life at 6 and 12 months	Percent(%)	p=0.07
Service Use Costs by Sectorat baseline, 6  12 months -unadjusted	Sector	 Baseline	 6 Month	 1 year	RS	 CEP	 RS	 CEP	 RS	 C...
Start-up Costs by Sector	Sector	 RS	 CEP	Primary Care	$5,315 $27,363Mental Health	$5,592 $33,010Substance Abuse	$4,584 $34...
Preliminary RS  CEP Differences in Mean Cost of Services ($) and SF-6Dat baseline, 6  12 months -unadjusted	Baseline	 6 Mo...
Next Steps	•  Completing 12 month outcomes analysis	•  Sensitivity analyses of different approaches to costing client time...
Implications	•  Community engagement around evidence-based practicesmay address multiple disparities by linking healthcare...
Questions	• How do we capture the differences in the benefits capturedby the MCS-12, but not overall SF-12 in the QALY’s?	•...
• How do we magnify the effects over the population ofpeople who may have received some sort of treatment fromthese agenci...
ThankYou to Our Funders!
Presenters and Contact Information	Bowen Chung, MD	Adjunct Scientist, RAND Corporation	Assistant Professor, Department of ...
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Comparative Cost Analysis of Depression Care Interventions in Community Partners in Care

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This project will determine the cost of low- and high-intensity interventions for depression. The project will also compare the costs of the interventions and determine whether they save money for the health system or society in general, since people who recover from chronic depression may require less public support because they will need to see a doctor less and will be able to work more. The low-intensity approach is called Resources for Services. Under this approach, we give providers and agencies technical assistance on how to (1) screen for depression, and (2) educate patients around depression and their treatment options, which include cognitive behavioral therapy and medication. We also train providers and agencies to deliver these treatments. The high-intensity approach is called Community Engagement and Planning, which calls for adapting depression-care materials to agency networks and providing intensive, in-person trainings, conferences and site visits.

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Comparative Cost Analysis of Depression Care Interventions in Community Partners in Care

  1. 1. Bowen Chung MD, Adjunct Staff, RAND, Assistant Professor, Geffen School of Medicine, UCLA Michael Ong, MD, PhD Associate Professor, Geffen School of Medicine, UCLA Kenneth Wells, MD, MPH Senior Scientist, RAND Weill Professor of Psychiatry, David Geffen School of Medicine at UCLA January 23, 2013 Comparative Cost Analysis ofDepression Care Interventions inCommunity Partners in Care
  2. 2. Presenter Disclosures No financial conflicts of interest to report
  3. 3. Acknowledgements • RAND: Paul Koegel, Cathy Sherbourne • UCLA: Michael McCreary, Esmeralda Pulido, Lingqi Tang, Lily Zhang,Susan Ettner • Healthy African American Families: Loretta Jones, Felica Jones • QueensCare Health and Faith Partnership: Elizabeth Dixon • Behavioral Health Services: James Gilmore • Funders: National Institute of Mental Health, California CommunityFoundation, Robert Wood Johnson Foundation, UCLA Clinical andTranslational Science Institute
  4. 4. Goals for talk • Explain rationale for Community Partners in Care (CPIC) • Describe CPIC interventions and 6 & 12 month clientoutcomes • Review comparative cost analysis of the CPIC interventionsfrom a societal perspective • Feedback on several questions related to the cost analysis
  5. 5. Background •  Depression a leading cause of disability worldwide •  Disparities exist in access, quality, outcomes of care for depression •  Collaborative care for depression in primary care improves outcome especially for African Americans and Latinos relative to whites
  6. 6. % recovered from depression at 5 years Depression QI Interventions Reduce Long-Term OutcomeDisparities (Partners in Care)
  7. 7. Community Context •  Under-resourced communities have limited provider availabilityand limited implementation of Quality Improvement (QI)programs for depression. •  Multiple services sectors support safety-net populations, but havelittle or no formal role in depression care or QI. •  Healthcare reform prioritizes medical homes, accountable careorganizations and patient-centered care but the role ofcommunity agencies as partners is unclear.
  8. 8. Community Partners in Care •  Community partnered participatory research and rigorous science •  Group-randomized trial at program level (n=95) of 2 approaches toimplement evidence-based QI toolkits for depression across diversecommunity-based agencies: Resources for Services (RS) andCommunity Engagement and Planning (CEP) in 2 communities,Hollywood and South Los Angeles •  Primary outcomes •  poor mental health quality of life (MCS-12≤40) •  poor mental health (PHQ8≥10 + MCS-12≤40 + MHI-556) •  Client measures at baseline, 6, 12 months
  9. 9. Interventions Resources for Services (RS) • Expert team conducted culturally competent outreach to programs • Offered 24 one-hour webinars and primary care site visits • Provided 22 webinars and 1 site visit • Study directly funded team/trainings Community Engagement and Planning (CEP) • 4-5 months of collaborative planning: biweekly meetings to reviewtoolkits, plan trainings, build networks/agreements and capacity to co-lead; develop written plan; $15K for trainings •  Team implementation of 174 trainings over 192 hours(conferences, webinars, on-site consultation) •  Innovations: Resiliency classes, “Village Clinic”
  10. 10. Resources forServicesCommunityEngagement Planning
  11. 11. Objective of cost analysissub-study To determine the comparative cost-effectiveness from asocietal perspective of 2 approaches (RS CEP) todisseminate depression quality improvement on clientshealth and mental health outcomes
  12. 12. Sampling - Client • Approached: 4,649 • Screened: 4,440 (95.5%) • Eligible: 1,322 of 4,440 (29.8%) – Criteria: PHQ-8≥10, Age≥18 years, reliable phone number • Enrolled: 1,246 of 1322 (94.3%) • Completed baseline: 981 of 1,246 (78.7% of enrolled) • Completed 6 month: 759 of 1093 (69.4% eligible for follow-up) • Completed either baseline or 6 month: 1018 (81.7% of enrolled)
  13. 13. Screened Clients ReflectedDiversity of Communities(N = 4,440, mean age 47 years) 65% 85% 16% 50% 23% 39% 28% 54%
  14. 14. MAJORITY OF DEPRESSION CONTACTS WERENOT IN PRIMARY OR MENTAL HEALTH7% 27% 27% 27%
  15. 15. Other data sources •  Provider and administrator survey data – baseline, 6, and 12 month •  Provider and administrator training data – baseline, 6, and 12 month •  Costs estimated from •  CMS: DRG codes and payments for inpatient stays •  Food,Venue, Materials, CEUs – project invoices •  Medications: WHO DDD Index, Micromedex, Redbook •  AMA: CPT codes and payments for medical and mental health procedures •  National Bureau of Labor Statistics: wages for non-healthcare sector providers – participant time, travel time, preparation time •  Costs adjusted to 2010 using consumer price index
  16. 16. Key Assumptions •  BLS Wage classifications were an accurate reflection of the job title •  Minimum wage is a reasonable dollar amount to value clientopportunity costs •  Although we had individual at baseline, we didn’t 6 and 12 months, so– we just used baseline – but 70 % unemployment – up 40% +unemployements in south LA – we didn’t think this was a badassumption. •  Client, provider, administrator travel time: 1 hour roundtrip
  17. 17. Key Assumptions •  Cost estimates of venue for similar interventions based on perperson costs of similar events •  Intervention staff – 15 or 30 minute prep time for meetings •  Services use estimate •  Healthcare – output – moderate to severe complexity •  Mental Health – 30 min for a med visit, 45-50 minutes fortherapy, case management 45 minutes •  Social Services – case management 45 minutes •  Parks and recreation –Total annual budget / annual visitors •  Churches – 1 hour for a pastoral counseling visit •  Substance use – 45 -50 minutes for counseling
  18. 18. Analysis •  6 and 12 month outcomes •  Intent to treat, comparative effectiveness study •  Independent variable: intervention status •  Adjusted for baseline status of dependent variable and co-variates •  Weighted to eligible sample •  Imputation for missing data •  Adjustment for clustering of clients within programs for client data •  2-sided test with p.05 for statistical significance •  Costs – analytic samples participating at baseline, 6, and 12 months •  Not currently weighted for sampling or adjusted for clustering
  19. 19. RS CEP Poor Mental Health Related Quality of Life* 51% 44% Mental Wellness* 34% 46% Poor Mental Health* 37% 29% Good physical health and activity* 13% 19% ≥ 2 risk factors for homelessness* 39% 29% Any hospitalizations for alcohol, drugs, mental health* 10.5% 5.8% ≥ 4 hospital nights* 5.8% 2.1% *p0.05 Poor Mental Health Quality of Life, MCS12 40 Mental Wellness,Yes to 1 item in last 4 weeks about: 1. Feeling peaceful and calm 2. Being a happy person 3. Having energy Poor Mental Health,Yes to all: MCS12 40, PHQ-8≥ 10, MHI-5≥ 56 Good Physical Health and Activity, Yes to all health limits: 1. Moderate activity, 2. Stairs, 3. Physical activity Risk factors for homelessness, ≥ 2 nights homeless, food insecurity, eviction, severe financial crisis CPIC 6 Month Outcomes
  20. 20. CPIC 6 Month Outcomes RS CEP Total outpatient contacts for depression acrosssectors (mean) 23 22 Any mental outpatient visits 54% 54% Took antidepressant, =2 months 39% 32% # MH outpatient visits received medication advice(mean)* 11 5 Any primary care visit 29% 29% = 2 visits for depression* 62% 80% Faith-based visit 60% 57% =3 faith-based visits for depression, if any(n=125)* 42% 64% *p0.05
  21. 21. Percent Poor Mental HealthQuality of Life at 6 and 12 months Percent(%) p=0.07
  22. 22. Service Use Costs by Sectorat baseline, 6 12 months -unadjusted Sector Baseline 6 Month 1 year RS CEP RS CEP RS CEP Primary Care $796 $870 $835 $792 $662 $677Mental Health $701 $779 $789 $651 $570 $510Substance Abuse $1442 $2059 $1047 $1382 $537 $549Faith Based $350 $306 $315 $255 $326 $271Social andCommunity $403 $414 $321 $297 $183 $225Costs, in dollars, include all client service use costs (hospitalizations for ADM, stayed in a residential treatment for substance abuse, ER visit,self-help for mental health problem, hotline for ADM problem, mental health outpatient visit, outpatient substance abuse services, primarycare visit, social services, religious services, park services, met with case manager, other services for depression).
  23. 23. Start-up Costs by Sector Sector RS CEP Primary Care $5,315 $27,363Mental Health $5,592 $33,010Substance Abuse $4,584 $34,798Homeless $313 $9,679Social and Community $7,221 $52,851Costs include all intervention costs associated with participation time, travel time, food, venue, preparation and materials.
  24. 24. Preliminary RS CEP Differences in Mean Cost of Services ($) and SF-6Dat baseline, 6 12 months -unadjusted Baseline 6 Months 12 Months CEP RS CEP RS CEP RS All services $ (SD)* 5496(6989) 4768(6536) 3701(6024) 3668(5191) 2597(3904) 2490(3759) Healthcare 4814 4030 3247 3176 2109 2013 NonHealthcare 578 655 443 542 416 447 SF-6D (SD) 0.58(0.102) 0.585(0.116) 0.626(0.129) 0.616(0.129) 0.628(0.134) 0.624(0.144) •  Includes patient time. Healthcare includes primary care, public health, mental health, substance abuse. Non-healthcare includes faith-based, social services, homeless services, community-trusted locations (senior centers, parks and recreation)
  25. 25. Next Steps •  Completing 12 month outcomes analysis •  Sensitivity analyses of different approaches to costing client time,adjusting for outliers in services utilization •  Estimating individual, client hourly wages by examining baselineclient reports of hours worked in last months, last estimated workdate, and individual income from non-governmental sources •  Link services use data from self-reported client data to specificagencies to get more accurate service use costs.
  26. 26. Implications •  Community engagement around evidence-based practicesmay address multiple disparities by linking healthcare andcommunity partners into networks that support evidence-based goals •  May meet “Triple Aims” •  Improved individual experience of care •  Improved health of populations •  Reduced or equal cost ???
  27. 27. Questions • How do we capture the differences in the benefits capturedby the MCS-12, but not overall SF-12 in the QALY’s? • How do we or should we capture the benefits ofimprovements in outcomes outside of health like reduced riskfactors for homelessness? • How do we capture the costs of client time (travel, visits,waiting time) in sectors outside of healthcare (e.g. faith-based,social services, senior centers)?
  28. 28. • How do we magnify the effects over the population ofpeople who may have received some sort of treatment fromthese agencies? • Since there is no usual care, is it reasonable to compareintervention cost and benefits at 6 and 12 months tobaseline? • Since the SD are greater than the means, our estimates arenot precise. Questions
  29. 29. ThankYou to Our Funders!
  30. 30. Presenters and Contact Information Bowen Chung, MD Adjunct Scientist, RAND Corporation Assistant Professor, Department of Psychiatry Harbor-UCLA Medical Center 1000 West Carson Street, Box 498 Torrance, CA 90509 V 310-222-1801 E-mail: bchung@mednet.ucla.edu Kenneth B.Wells, MD, MPH Senior Scientist, RAND Corporation Well Endowed Professor, Department of Psychiatry Geffen School of Medicine at UCLA Center for Health Services Society 10920 Wilshire Blvd, Suite 300 Los Angeles, CA 90024 V: 310-794-3728 E-mail: kwells@mednet.ucla.edu Michael Ong, MD, PhD Associate Professor, Department of Internal Medicine David Geffen School of Medicine at UCLA 10940 Wilshire Blvd, Suite 700 Los Angeles, CA 90024 V 310-794-0154 E-mail: mong@mednet.ucla.edu 35

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