Cost-effectiveness of Interventions for
Michael Schoenbaum,1* Jeanne Miranda,2
Cathy Sherbourne,3 Naihua Duan,4 Kenneth Wells5
1Ph.D., RAND, Arlington,
2Ph.D., UCLA-NPI, Los Angeles, CA, USA
3Ph.D., RAND, Santa Monica, CA, USA
4Ph.D., UCLA-NPI Center for Community Health, Los Angeles,
5M.D., M.P.H., UCLA-NPI, Los Angeles, CA and RAND, Santa Monica,
* Correspondence to: Michael Schoenbaum, Ph.D., RAND, 1200 South Hayes
Street, Arlington, VA 22202, USA
Tel.: +1-703-413 1100 ext. 5426
Fax: +1-703-413 8111
Source of Funding: This work was funded by the John D. and Catherine
T. MacArthur Foundation, the Agency for Healthcare Research and Quality (R01-HS08349),
and NIMH (5R01MH57992).
Depression is a leading cause of disability, but
treatment rates are low, particularly for minority patients. We
estimate societal cost-effectiveness of two quality improvement
interventions for depression, separately for Latino and White patients.
Matched primary care clinics were randomized to usual care or to
one of two quality improvement interventions for depression, one
facilitating medication management ("QI-Meds") and the
other psychotherapy ("QI-Therapy"). The study involved
398 Latino and 778 White patients with depression, in 46 clinics
in 6 organizations. Relative to usual care, the estimated cost per
quality-adjusted life year (QALY) for Latinos was $6,100 or less
under QI-Therapy, well within the range of usual medical practice;
but $90,000 or more in QI-Meds. For Whites, estimated costs per
QALY were around $30,000 under both interventions, towards the upper
end of usual medical practice. Both interventions increased labor
supply for Latinos and Whites, by around one work month over two
Context: Depression is a leading cause of disability worldwide,
but treatment rates are low, particularly for minority patients.
Objective: To estimated societal cost-effectiveness of two interventions
to improve care for depression in primary care, examining Latino and white
Methods: Intent-to-treat analysis of data from a group-level controlled
trial, in which matched primary care clinics in the US were randomized
to usual care or to one of two interventions designed to increase the
rate of effective depression treatment. One intervention facilitated medication
management (``QI-Meds'') and the other psychotherapy ("QI-Therapy'');
but patients and clinicians could choose the type of treatment, or none.
The study involved 46 clinics in 6 non-academic, managed care organizations;
181 primary care providers; and 398 Latino and 778 White patients with
current depression. Outcomes are health care costs, quality-adjusted life
years (QALY), depression burden, employment, and costs per QALY, over
24 months of follow-up.
Results: Relative to usual care, QI-Therapy resulted in significantly
fewer depression burden days for Latinos and increased days employed for
white patients. Average health care costs increased $278 in QI-Meds and
$161 in QI-Therapy for Latinos, and by $655 in QI-Meds and $752 in QI-Therapy
for whites, relative to usual care. The estimated cost per QALY for Latinos
was $6,100 or less under QI-Therapy, but $90,000 or more in QI-Meds. For
Whites, estimated costs per QALY were around $30,000 under both interventions.
Conclusions: Latinos benefit from improved care for depression,
and the cost is less than that for white patients. Diverse patients are
likely to benefit from improving care for depression in primary care.
Received 1 October 2003; accepted 10 March 2004
Copyright © 2004 ICMPE