Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster
Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster
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DOI：
10.1001/jamapsychiatry.2017.3037
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发表时间：
2017-12-01
期刊：
影响因子：
25.8
通讯作者：
Galea, Sandro
中科院分区：
文献类型：
--
作者：
Cohen, Gregory H.;Tamrakar, Shailesh;Galea, Sandro
重要性自然灾害后提供的精神病干预通常解决亚综合征症状表现，但往往仍然不足以减轻慢性创伤后应激障碍（PTSD）的负担。目的模拟比较阶梯式护理病例发现干预（阶梯式护理[SC]）vs中等强度单水平干预（常规护理[UC]）在自然灾害后2年内对治疗效果和增量成本效益的影响。设计、设置和参与者本研究，模拟了2012年10月29日飓风桑迪登陆后4周开始，2年后结束的治疗方案，创建了一个由生活在受飓风桑迪影响的纽约市地区的2 642 713名模拟代理人组成的模型。干预在SC下，病例被转介到认知行为治疗，这是一种循证治疗，旨在通过解决问题和改变思想和行为来改善症状;非病例被转介到心理康复技能，一个循证治疗，旨在减少痛苦，改善应对和功能。根据UC，所有的患者都被称为只有技能的心理Recovery.Main结果和措施的范围SC相比，UC为2年，2年减少的患病率PTSD在整个人口中，2年减少的比例PTSD案件中的初始案件，结果2642713名模拟代理人的PTSD患病率为4.38%（115 751例）和性别（52.6%女性和47.4%男性）和年龄（33.9%年龄在18-34岁之间，49.0%年龄在35-64岁之间，17.1%年龄>= 65岁）的分布与受飓风桑迪影响的纽约市地区的人口估计值相当。阶梯式护理与更大范围相关，在降低全体人群中PTSD患病率方面上级UC：6个月时绝对获益明显（风险差异[RD]，-0.004; 95% CI，-0.004至-0.004），1.25年时改善（RD，-0.015; 95% CI，-0.015至-0.014）。SC的相对获益在6个月时是明确的（风险比，0.905; 95%CI，0.898-0.913），持续获益至1.75年（风险比，0.615; 95%CI，0.609-0.662）。病例中SC的绝对获益更强，在3个月时出现（RD，-0.006; 95% CI，-0.007至-0.005），并在1.5年内增加（RD，-0.338; 95% CI，-0.342至-0.335）。SC在病例中的相对获益与在整个人群中观察到的获益相当。与UC相比，SC的增量成本效益为每避免残疾调整生命年3428.71美元至6857.68美元，每无PTSD日0.80美元至1.61美元。并且完全在成本效益的可接受范围内。应根据基于代理的模型固有的局限性来考虑结果。
IMPORTANCE Psychiatric interventions offered after natural disasters commonly address subsyndromal symptom presentations, but often remain insufficient to reduce the burden of chronic posttraumatic stress disorder (PTSD).OBJECTIVE To simulate a comparison of a stepped care case-finding intervention (stepped care [SC]) vs a moderate-strength single-level intervention (usual care [UC]) on treatment effectiveness and incremental cost-effectiveness in the 2 years after a natural disaster.DESIGN, SETTING, AND PARTICIPANTS This study, which simulated treatment scenarios that start 4 weeks after landfall of Hurricane Sandy on October 29, 2012, and ending 2 years later, created a model of 2 642 713 simulated agents living in the areas of New York City affected by Hurricane Sandy.INTERVENTIONS Under SC, cases were referred to cognitive behavioral therapy, an evidence-based therapy that aims to improve symptoms through problem solving and by changing thoughts and behaviors; noncases were referred to Skills for Psychological Recovery, an evidence-informed therapy that aims to reduce distress and improve coping and functioning. Under UC, all patients were referred only to Skills for Psychological Recovery.MAIN OUTCOMES AND MEASURES The reach of SC compared with UC for 2 years, the 2-year reduction in prevalence of PTSD among the full population, the 2-year reduction in the proportion of PTSD cases among initial cases, and 10-year incremental cost-effectiveness.RESULTS This population of 2 642 713 simulated agents was initialized with a PTSD prevalence of 4.38%(115 751 cases) and distributions of sex (52.6% female and 47.4% male) and age (33.9% aged 18-34 years, 49.0% aged 35-64 years, and 17.1% aged >= 65 years) that were comparable with population estimates in the areas of New York City affected by Hurricane Sandy. Stepped care was associated with greater reach and was superior to UC in reducing the prevalence of PTSD in the full population: absolute benefit was clear at 6 months (risk difference [RD], -0.004; 95% CI, -0.004 to -0.004), improving through 1.25 years (RD, -0.015; 95% CI, -0.015 to -0.014). Relative benefits of SC were clear at 6 months (risk ratio, 0.905; 95% CI, 0.898-0.913), with continued gains through 1.75 years (risk ratio, 0.615; 95% CI, 0.609-0.662). The absolute benefit of SC among cases was much stronger, emerging at 3 months (RD, -0.006; 95% CI, -0.007 to -0.005) and increasing through 1.5 years (RD, -0.338; 95% CI, -0.342 to -0.335). Relative benefits of SC among cases were equivalent to those observed in the full population. The incremental cost-effectiveness of SC compared with UC was $3428.71 to $6857.68 per disability-adjusted life year avoided, and $0.80 to $1.61 per PTSD-free day.CONCLUSIONS AND RELEVANCE The results of this simulation study suggest that SC for individuals with PTSD in the aftermath of a natural disaster is associated with greater reach than UC, more effectiveness than UC, and is well within the range of acceptability for cost-effectiveness. Results should be considered in light of limitations inherent to agent-based models.