Cost Effectiveness of a Home Support Program for Depression in Black Elders

描述(由申请人提供)： 本申请涉及广泛的挑战领域(05)比较有效性研究和具体挑战主题，05-MH-102*：心理健康干预的成本效益。我们提议一项为期两年的计划，增加成本和结果部分，使我们能够对我们目前资助的随机对照试验(NIMH R01MH079814)进行成本效益分析，该试验测试了一种新的为期10次的家庭干预措施，以治疗老年社区居住的非裔美国人的抑郁症。这项干预被称为BTB(BTB)，由训练有素的社会工作者与参与者会面，以确定护理管理方面的问题，进行转介和联系，提供抑郁教育，制定量身定制的行动计划，以实现已确定的行为目标，提高对愉快活动的参与度，并教授管理日常压力源(如深呼吸)的减压技巧。BTB采用随机两组实验设计(治疗与等待名单对照)，所有参与者接受两次抑郁症状筛查(PHQ-9和5)以确定研究资格，随机分配，然后在4个月后根据主要研究结果(PHQ-9抑郁严重程度、生活质量、功能能力)进行评估。在4个月时，等待名单对照组接受全部的BTB，然后在8个月时对所有研究参与者进行重新评估，以评估治疗组的治疗效果的维持情况，以及等待名单对照组在4个月时是否表现出与治疗组类似的改善。BTB嵌入了一个高级中心，公园中心(CIP)，让他们的机构工作人员作为抑郁症筛查者和干预者。要将BTB转化为老年中心提供的抑郁症计划，关键是要了解其成本、结果和成本效益。对抑郁症的家庭支持计划的经济评估是不存在的，这些计划针对老年非裔美国人，可以由社区机构训练有素的工作人员提供。我们建议的研究的具体目标是：1.计算由受过该计划培训的高级中心工作人员提供BTB的成本；2.从社会的角度计算BTB的成本效益，采用两个相关的结果衡量标准：每质量调整生命年的成本(QALY；Euro-QOL 5D vs.HUI2和HU13健康效用衡量标准)，以及抑郁症状的每次减少成本。成本效益将被衡量为：在4个月时，将BTB和对照组之间的成本增量差除以治疗和控制期之间的卫生效用差额(以QALYs衡量)，对于前4个月接受BTB并观察另外4个月的参与者的次级样本，在8个月时除以。将进行单变量和概率敏感性分析，以确定8个月时BTB的增量成本效益，并将有助于确定住院和门诊医疗和药物成本变化时模型的稳健性。我们还提出了探索性的目标：a)检查Euro-QOL 5D工具(EQ-5D)和卫生实用程序指数(HUI2与HUI3)的结果之间的关系，以提供初步建议，以确定哪种工具最适合BTB人群的成本效益；b)探索BTB的成本效益是否在既定的阈值范围内；以及c)探索这些阈值在应用于社会行为项目时的应用。这项为期两年的计划与最初试验的03-04年(为期5年)重叠，因此我们的建议是可行的，并可在母研究的结构/时间表内完成。成本分析将涉及参与者的子集(n=122/192)，我们将能够收集这些参与者的QALY度量。这项研究有可能对经济评估科学产生重大影响，通过比较不同的效用指数对目标人群的敏感性，通过提供由老年中心提供的抑郁症计划的成本和成本效益进行转化研究，通过将覆盖决定与充分的科学证据联系起来，为存在心理健康差异的服务不足的群体提供治疗和成本效益的卫生政策。由于老年非裔美国人中老年抑郁症的患病率很高，对BTB进行经济评估对于改善这一弱势群体的生活具有巨大的潜力。公共卫生声明-BTB我们建议对老年非裔美国人老年人的家庭支持抑郁症计划进行经济评估。我们的研究将通过比较与老年非裔美国人抑郁人口的敏感性的效用指数，通过转换研究使社区组织能够提供服务，以及通过将覆盖决定与充分的成本效益科学证据联系起来，为经济评估科学做出贡献。

DESCRIPTION (provided by applicant): This application addresses the broad Challenge Area (05) Comparative Effectiveness Research and specific Challenge Topic, 05-MH-102*: Cost Effectiveness of Mental Health Interventions. We propose a two year initiative to add a cost and outcome component which will enable us to perform a cost effectiveness analysis of our currently funded randomized controlled trial (NIMH R01MH079814) "Treating Depression in Older African Americans") that tests a novel 10- session home-based intervention to treat depression in older community-dwelling African Americans. The intervention, referred to as Beat the Blues (BTB), involves trained social workers who meet with participants to identify care management concerns, make referrals and linkages, provide depression education, develop tailored action plans to accomplish identified behavioral goals and enhance engagement in pleasurable activities, and teach stress reduction techniques for managing daily stressors (e.g., deep breathing). BTB uses a randomized two-group experimental design (treatment vs. wait-list control) in which all participants are screened twice for depressive symptoms (PHQ-9 >5) to determine study eligibility, randomly assigned, and then evaluated at 4 months on main study outcomes (PHQ-9 depression severity, quality of life, functional ability). At 4 months, the wait-list control group receives BTB in its entirety, and then all study participants are reassessed at 8 months to evaluate the maintenance of treatment effects for the treatment group, and whether the wait-list control group demonstrates similar improvements as the treatment group at 4 months. BTB is embedded in a senior center, Center in the Park (CIP) involving their agency staff as depression screeners and interventionists. Essential to translating BTB as a depression program for delivery by senior centers, is an understanding of its cost, outcomes, and cost effectiveness. Economic evaluations of home support programs for depression which target older African Americans and can be delivered by trained staff of a community-based agency are non- existent. The specific aims of our proposed study are to: 1. Calculate the cost of delivering BTB by senior center staff trained in the program; 2. Calculate the cost effectiveness of BTB from a societal perspective that employs two relevant outcome measures: cost per quality adjusted life year (QALY; Euro-QOL 5D vs. HUI2 and HU13 health utility measures), and cost per reduction in depression symptoms. Cost-effectiveness will be measured as the average incremental difference between cost of BTB and the control group divided by the difference in health utility (measured as QALYS) between treatment and control periods at 4 months, and at 8 months for the subsample of participants who receive BTB for the first 4 months and are observed for another 4 months. Univariate and probabilistic sensitivity analyses will be conducted to determine the incremental cost effectiveness of BTB at 8 months, and will aid in determining the robustness of the model when inpatient and outpatient medical and medication costs are varied. We also propose exploratory aims to: a) examine relationship between results of Euro-QOL 5D instrument (EQ-5D) and Health Utilities Index (HUI2 vs. HUI3) to inform preliminary recommendations as to which instrument is best suited for cost effectiveness in the BTB population; b) explore whether the cost effectiveness of BTB falls within established thresholds, and c) explore the application of these thresholds when applied to social-behavioral programs. This two year initiative overlaps with years 03-04 (of 5 years) of the original trial such that our proposal is feasible and can be accomplished within the structure/timeline of the parent study. The cost analyses will involve a subset (n=122/192) of participants for which we will be able to collect QALY measures. This study has potential for making a major impact on the science of economic evaluation by comparing different utility indices for their sensitivity with the target population, translational research by providing cost and cost effectiveness of a depression program for delivery by a senior center, and health policy by linking coverage decisions to adequate scientific evidence of treatment and cost effectiveness for an underserved group for whom mental health disparities persist. As the prevalence of late-life depression among older African Americans is high, an economic evaluation of BTB has great potential for improving the lives of this vulnerable population. Public Health Statement - BTB We propose an economic evaluation of a home support depression program for older African Americans elders. Our study will contribute to the science of economic evaluation by comparing utility indices for sensitivity with an older African American depressed population, translational research to enable delivery by a community organization, and health policy by linking coverage decisions to adequate scientific evidence of cost effectiveness.