Cost effectiveness of strategies in

behaviour medicine – A review

Presenter : Sarin Dominic

Chairperson : Mr. M.A. Tripati

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 Outline of the presentation
➔ Introduction

➔ Focus areas of behaviour medicine interventions

➔ Financial efficacy analysis and it's components

➔ Aspects of cost effectiveness analysis in behavior medicine
➔ Researches on cost effectiveness in behaviour medicine
➔ Critical evaluation of cost effectiveness analysis
➔ Conclusion

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 Keywords
Behavior medicine: An interdisciplinary field concerned with the
integration of behavioral, psychosocial, and biomedical science
knowledge relevant to the understanding of health and illness, and
the application of this knowledge to prevention, diagnosis,
treatment, and rehabilitation. (Handbook of Behaviour Medicine,
2010)

Cost effectiveness: The degree to which something is effective or

productive in relation to its cost (Oxford Dictionary).

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 Introduction
Thoughts, feelings, and moods can have a significant effect on the
onset of some diseases, the course of many, and the management
of nearly all.

Many visits to the doctor are occasioned by psychosocial distress.

The predominant approach in medicine is to treat people with

physical and chemical treatments that neglect the mental,
emotional, and behavioral dimensions of illness.

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This critical mismatch between the psychosocial health needs of
people and the usual medical response leads to frustration,
ineffectiveness, and wasted health care resources.

By helping patients manage not just their disease but also common
underlying needs for psychosocial support, coping skills, and sense
of control, health outcomes can be significantly improved.

Does these interventions bring about the desired health outcomes

and are they cost effective ?

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 Focus areas of behaviour medicine
interventions
● Psychological conditions secondary to illness
● Somatic presentations of psychological dysfunction
● Psychophysiological disorders
● Physical symptoms responsive to behavioral interventions
● Somatic complications associated with behavioral factors
● Psychological presentations of organic problems

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● Prevention of physical and psychological complications from
stressful medical procedures
● Behavioral risk factors for disease/injury/disability
● Problems of health care providers and health care systems
● Preventive counseling and health education

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 Opportunity cost problem and
Managed Health Care
● Health care resources are limited, and there is constant
pressure to spend more on attractive new treatments or
diagnostic procedures.

● Without containment, it is likely that the health care bill will

dominate the economy'and limit the opportunity to develop
other sectors.

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● Successful lobbying to obtain reimbursement for a specific
service may necessarily mean that another service is excluded.

● Hence inorder to find application a service should demonstrate

that it is effective and financially efficacious

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 Financial efficacy analysis and it's
components

Cost-benefit:  Refers to financial gain resulting from a certain

expenditure

Cost-effectiveness:  Refers more to gains or outcomes that

cannot be easily converted into monetary units (Yates 1985).

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Cost-off-set: Refers to the reduction in utilization (and therefore
cost) of one service as a result of providing service in another area.
(Cummings, 1991)

Cost-containment:  Refers to more general efforts to reduce costs

and might include such strategies as cost-offset or reducing the
number of sessions by stopping at some optimal point in
the treatment process ( Kerns, 1993)

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Type of Compares With
Analysis
Cost- Monetary value of Health effects: clinically
effectiveness resources used based
(death rate; blood pressure)

Cost-utility Monetary value of Health effects: preference

resources used based
(health-related quality of life)

Cost-benefit Monetary value of Monetary value: resources

resources used saved or created
Cost-offset Monetary value of Monetary value: costs (i.e.,
resources used health care) reduced by the
intervention
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 Cost effectiveness analysis

An economic study design in which consequences of different

interventions are measured using outcomes, usually in ‘natural’
units (for example, life-years gained, deaths avoided etc..)(National
Institute for Health and Clinical Excellence, 2009)

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 Aspects of cost effectiveness analysis in
behavior medicine

Perspective of analysis
● The results of cost-effectiveness analysis may depend on
perspective
– Societal

– Administrative

– Individual

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 Comparators

A "comparator" is the alternative to which a new treatment is

compared
Usual comparators are
– Low-cost alternative

– Different intensities of treatment

– Care provided by alternative providers

– No-treatment control group

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 Measures of effectiveness

● Behavioral outcomes
● Absenteeism
● disability days
● institutional confinement
● ability to perform activities of daily living
● restriction in usual activities
● life expectancy
● quality of life

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 QALY
● Stands for quality-adjusted life-year

● Measure of disease burden, including both the quality and the

quantity of life lived

● Integrate mortality and morbidity

● Can be added together and estimated over multiple patients

and multiple years.

● Includes prognosis and preferences for health outcomes

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 Clinical significance

Whether treatment produces benefits from the perspective of the

clinician or the patient ?

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 Accounting for costs

Considers all resources required for the intervention and for the
comparator.
Costs can be two types
● Direct costs : It includes all costs of treatment and any costs
associated with caring for side effects of treatment.
● Indirect costs : It include patient time required for therapy-,
income lost because a family member offers home care, and
morbidity and mortality cost associated with reduced
productivity due to disability or premature death.

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 Discounting costs and outcomes
Health is expected to be valued and preferred earlier in life in the
same manner as money and should therefore be discounted in
a similar manner (Weinstein & Stason, 1977).

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 Time horizon and modeling
● The time horizon concept simply refers to how long after the
intervention Costs and outcomes are evaluated.

● Modeling uses estimates of the probability of each possible

health outcome to calculate future costs and health
consequences of the intervention.

● Probability estimates are derived from epidemiological research.

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 Sensitivity analysis

● Actual health care costs are often hard to identify

● Effect sizes from multiple studies of a very similar intervention

may vary widely.

● Sensitivity analysis examines how the results of the cost-

effectiveness analysis would change if these estimated values
were allowed to vary between a realistic upper and lower
bound.

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Researches on cost effectiveness in
behaviour medicine

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 Preparation for Surgery
Patients typically feel anxious when facing hospitalization and invasive
medical procedures such as surgery. This anxiety can be maladaptive
if it leads to panic and a disintegration of normal coping.(Horne,1994)

Specific interventions include providing relevant information to the

patient and teaching appropriate postsurgical exercises, relaxation
procedures, distractive techniques, and techniques to enhance control

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Jacobs (1988) using biofeedback training before surgery for adults,
reduced hospital days by 72% and postoperative outpatient visits by 63%.

Anderson (1987) examined the effects of information and coping

preparation on patients presented for cardiac surgery.
● Patients were randomized to information, coping preparation and control
groups
● Self-report questionnaires indicated that both experimental groups were
significantly less anxious and fearful than control patients and
postoperatively experienced less emotional distress.
● Nursing staffs reported a 33% lower incidence of postoperative
hypertension in the experimental groups compared to control patients.

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Devine and Cook (1983) reviewed 49 controlled experiments that
used psychoeducational preparation prior to surgery, and they
reported an average of 1.31 fewer days in hospital for those
patients compared to those who received standard medical
management

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 Smoking cessation
Several researches has shown that smoking becomes one among
the causative factor for various physical illness and bings about
huge health costs.

Psychologists, as part of a multidisciplinary team, have aided

smokers in cessation by developing individually tailored plans
(including a specific date, time, and place to stop), by listing all the
factors that prompt the person to smoke, and by producing counter
steps to prevent relapse (Erfurt,1992)

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Cummings et al. (1989) found that Single-session, short duration
(average of 4 min), physician-initiated counseling was estimated to
increase the cessation rate by 3%. The cost-effectiveness was
calculated at $705 to $988 per year of life saved for men and $1,204
to $2,508 per year of life saved for women.

Krumholz et al. (1993) conducted a nurse-managed smoking

cessation intervention programme who had had myocardial infarction
and found that there was a $20,000 cost-savings per year of life.

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Ellen et al. (2006) compared smoking outcomes for pregnant
women
● 105 women were randomized to receive either usual care or an
intervention conducted in the prenatal clinic consisting of 1.5 h
of counseling plus telephone follow-up.
● At follow-up, 28.3% and 9.4% of participants in the
experimental intervention and 9.6% and 3.8% of patients in
usual care were abstinent at end of pregnancy and 6 months
post-partum, respectively.
● Cost of the intervention was $56 per patient and cost to
produce a non-smoker at end of pregnancy was $299.

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 Somatizing patients
Somatizing patients can account for between 30 to 60% of all
outpatient physician visits

Because the patient is highly invested in finding a physiological

explanation, the search for the “right” physician is repeated as the
patient seeks further professional opinions, resulting in
considerable cost to both the patient and the health care system.

A large amount of research has strongly suggested that cost-

savings to health care systems can be obtained by treating
patients who somatize their complaints by psychological strategies
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Smith et al. (1986) specifically targeted patients who met the criteria
for somatization disorder.
● Thirty-eight patients were randomly assigned to either a
treatment or control group. 
● Intervention consisted of assessment of each patient followed by
recommendations to treating physicians related to case
management.
● Following intervention, the quarterly health care costs decreased
by 53% compared to the control group.

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Hellman et al. (1990) found that six months after, group treatment
in patients with psychophysiological symptoms, patients who had
previously been identified as high utilizers of primary care services
reported decreased psychological distress and discomfort from
physical symptoms as well as fewer physician visits. They
estimated a net savings of $3900 in the first six months alone.

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 Chronic pain rehabilitation
Chroic pain is a highly disabling condition that affect the quality of
life significantly.
Remediated through surgery, medications and psychosocial
interventions
Psychosocial interventions includes relaxation, hypnosis,
biofeedback, altering relevant cognitions, family or group therapy.

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Peters et al. (1992) evaluated a New Zealand multimodal pain
control program
● Results demonstrated that 68% of inpatients and 61% of
outpatients had increased activity and exercise and decreased
reliance on pain medication.
● Short-term (12-month) cost-savings were $132,180 for the 18
inpatients and $60,590 for the 18 outpatients.
● Longer term (5-year) cost-savings estimates that were based
on patients returning to active employment were $660,900 for
the inpatients and $304,450 for the outpatients.

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 Systemic and chronic illness
Lorig et al (1993) followed participants in an arthritis self-
management group
● A 12 hour class with a significant relaxation training was provided.
● After four years she found a 43% decrease in visits to physicians,
a 20% decrease pain, and a significant increase in patients’ sense
of self-efficacy.
● These improvements were found despite an actual increase in
physical disability over time, as the disease progressed.
Nevertheless, at a cost of $54 per person for the group, the
adjusted four year savings were $648 for persons with rheumatoid
arthritis and $189 per person for those with osteoarthritis.
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Schlesinger (1983) tracked 2,000 patients (over a 3-year period)
who had been diagnosed with four chronic diseases: ischaemic
heart disease, hypertension, diabetes, and airflow limitation
disease.
● One group of 700 patients was provided with psychotherapy of
variable duration, whereas the remaining 1,300 patients were
used as controls.
● Outcome measurements indicated both improvements in
mental health status and a reduction in medical use.
● The average medical–surgical cost per patient for those who did
not receive psychotherapy was $950, compared with $570 for
those who did receive psychotherapy—a 40% reduction.
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Hamilton et al.(1993) examined patients with primary
hypertension to study the effects of a behavioral–educational
intervention on adherence to their therapeutic regimen.

In contrast to control participants, patients in the intervention group

showed significantly higher adherence

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Edurado et al. (2011) conducted a study to evaluate the cost-
effectiveness of supervised exercise therapy in Heart failure
patients under the perspective of the Brazilian Public Healthcare
System.
● Exercise therapy showed small reduction in hospitalization and
mortality at a low cost, an incremental cost-effectiveness ratio of
Int$26,462/quality-adjusted life year.
● Results were more sensitive to exercise therapy costs, standard
treatment total costs, exercise therapy effectiveness, and
medications costs.

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Prezio et al. (2014) conducted a study to examine the long-term cost-

effectiveness and improvements in diabetes-related complications of a

diabetes education and management intervention

● During a 20-year time horizon, participants who received the

intervention had significantly lower hemoglobin A1c levels, fewer foot

ulcers, and a reduced number of foot amputations in comparison with

a control group receiving usual medical care.

● An incremental cost-effectiveness ratio of $355 per quality-adjusted

life year gained was estimated for intervention participants.

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Rawdin et al. (2014) conducted a study estimating cost-effectiveness
of a weight management programme.
● The programme included elements of physical exercise and dietary
restriction which are designed to help women lose excess weight
gained during pregnancy in the vulnerable postnatal period and
inhibit the development of behaviours which could lead to future
excess weight gain and obesity.
● The baseline results show that the difference in weight between
women who received the weight management programme and
women who received the control intervention was 3.02 kg at six
months and 3.53 kg at fifteen years following childbirth.
● This results in an ICER of £7355 per quality adjusted life year
(QALY) for women who were married at childbirth.
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 Critical evaluation of cost
effectiveness analysis

● Reduces everything to the lowest common denominator: Money

● Ignores the most important outcomes
● Less meaningful if not compared with other treatments
● Sometimes are just rationalizations for funding cuts
(Yates, 1994)

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 Conclusion
● The available data on the financial efficacy of
psychosocial interventions varies in depth, quality, quantity, and
persuasiveness.
● Some of the research provides relatively strong support that
psychosocial interventions can and do provide significant cost-
savings, whereas other conclusions related to cost-savings are
based more on a combination of rational and anecdotal
evidence.

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● Future researches should address these concerns and should
come up with more reliable estimates owing to more reliable
designs and application of methods.

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 References
● Belar, C.D. et al.,(1995). Clinical Health Psychology in
Medical Settings: A Practitioner’s Guidebook, Second
Edition. Washington, D.C.: American Psychological
Association.
● Caudill, M. et al.,(1991). Decreased clinic utilization by
chronic pain patients after behavioral medicine
intervention. Journal of Pain, 45, 334-335.
● John, H., (2003).Cost-Effectiveness and Medical Cost-
Offset Considerations in Psychological Service Provision
Journal of Canadian Psychology, 44:1

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● Kaplan, R. & Groessl, E. (2002). Applications of cost-
effectiveness methodologies in behavioral medicine.
Journal of Consulting Clinical Psycholgy. 70(3):482-93.
● Marnat, G., (1996). Professional psychologists in general
health care settings: A review of the financial efficacy of
direct treatment interventions. Professional Psychology:
Research and Practice, Vol 27(2), , 161-174.
● Sobel, D., Rethinking medicine: improving health
outcomes with cost-effective psychosocial
interventions.Psychosomatic Medicine (Impact Factor:
4.09). USA, 57(3):234-44.

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● Turk, D. and Burwinkle, T.,(2005). Clinical Outcomes, Cost-
Effectiveness, and the Role of Psychology in Treatments for
Chronic Pain Sufferers, Professional Psychology: Research
and Practice, 36 (6): 602– 610
● Yates, B., (1994). Toward the Incorporation of Costs, Cost-
Effectiveness Analysis, and Cost-Benefit Analysis into
Clinical Research Journal of Consulting and Clinical
Psychology, 62 (4): 729-736
● Edurado et al.(2011), Cost-Effectiveness of Supervised
Exercise Therapy in Heart Failure Patients,Value in
health, 14(5) : 100–107

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● Ellen, A. et, al.(2006) Efficacy and cost-effectiveness of
a clinic-based counseling intervention tested in an
ethnically diverse sample of pregnant smokers, Patient
education and counseling, 64(3): 342–349

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Thank you

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