Abstract
Background: To our knowledge, adjustment for baseline imbalances in costs has never been performed in trial-based cost-effectiveness analyses.
Methods: We used data from a clinical trial performed in the Netherlands comparing two outpatient psychotherapies: schema-focused therapy (SFT) versus transference-focused psychotherapy (TFP). Costs were assessed with a cost interview. Outcome was the proportion of recovered patients measured with the Borderline Personality Disorder Severity Index (BPDSI-IV). We used three methods to adjust the costs for baseline differences: (i) mean difference adjustment, calculating total costs after baseline by adjusting the difference between groups with the difference of the mean baseline costs; (ii) delta adjustment, calculating the individual differences between patient baseline and the subsequent measurements (concerning incremental costs, this is the same as mean difference adjustment); and (iii) regression-based adjustment, adjusting total costs with a regression model, with total costs as the dependent variable and baseline costs as the independent variable.
Results: Mean baseline costs were €3339 for SFT and €4238 for TFP, a mean difference of €899. Total unadjusted follow-up costs were €30 822 for SFT and €36 812 for TFP. The fraction of recovered patients was 45% for SFT and 24% for TFP. Cost-effectiveness acceptability curves show that mean difference and delta adjustments are different from the regression-based methods.
Conclusions: Although the routine starting point of an analysis should always be an unadjusted analysis of the cost effectiveness, a baseline difference between treatment groups should be adjusted for. This should be done by reported patient characteristics or, when these are not sufficiently present, by baseline costs as a substitute. This adjustment should be carried out most preferably with a regression-based method.
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References
Pocock SJ, Assmann SE, Enos LE, et al. Subgroup analysis, covariate adjustment and baseline comparisons in clinical trial reporting: current practice and problems. Stat Med 2002 Oct 15; 21 (19): 2917–30
Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med 2001 Apr 17; 134 (8): 657–62
Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001 Apr 17; 134 (8): 663–94
Kleinbaum DG. Logistic regression: a self-learning text. Chapter 7. New York: Springer-Verlag, 1994
Richardson G, Manca A. Calculation of quality adjusted life years in the published literature: a review of methodology and transparency. Health Econ 2004 Dec; 13 (12): 1203–10
Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial-based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Econ 2005 May; 14 (5): 487–96
Briggs AH, Wonderling DE, Mooney CZ. Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation. Health Econ 1997 Jul-Aug; 6 (4): 327–40
Efron B, Tibshirani RJ. An introduction to the bootstrap. London: Chapman & Hall, 1993
Fenwick E, Byford S. A guide to cost-effectiveness acceptability curves. Br J Psychiatry 2005 Aug; 187: 106–8
Giesen-Bloo J, van Dyck R, Spinhoven P, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006 Jun; 63 (6): 649–58
Arntz A, van den Hoorn M, Cornelis J, et al. Reliability and validity of the borderline personality disorder severity index. J Personal Disord 2003 Feb; 17 (1): 45–59
Bland JM, Altman DG. Some examples of regression towards the mean. BMJ 1994 Sep 24; 309 (6957): 780
Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemiology, the essentials, chapter 2. 2nd ed. Baltimore (MD): Williams & Wilkins, 1988
Barber J, Thompson S. Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy 2004 Oct; 9 (4): 197–204
Oostenbrink JB, Bouwmans CAM, Koopmanschap MA, et al. Manual for cost research: methods and unit-prices for economic evaluations in health care – actualized version [in Dutch]. Diemen: College voor Zorgverzekeringen, 2004
Fenwick E, O’Brien BJ, Briggs A. Cost-effectiveness acceptability curves: facts, fallacies and frequently asked questions. Health Econ 2004 May; 13 (5): 405–15
Joffe MM, Rosenbaum PR. Invited commentary: propensity scores. Am J Epidemiol 1999; 150 (4): 327–33
Severens JL, Mulder J, Laheij RJ, et al. Precision and accuracy in measuring absence from work as a basis for calculating productivity costs in the Netherlands. Soc Sci Med 2000; 51 (2): 243–9
van den Brink M, van Den Hout WB, Stiggelbout AM, et al. Self-reports of health-care utilization: diary or questionnaire? Int J Technol Assess Health Care 2005; 21 (3): 298–304
Oostenbrink JB, Al MJ. The analysis of incomplete cost data due to dropout. Health Econ 2005; 14: 763–76
Acknowledgements
The clinical trial and economic evaluation were financially supported by the Dutch Healthcare Insurance Board (CVZ Grant OG 97-002). There are no financial relationships between the authors and the sponsor. Publication of the study results was not contingent on the sponsor’s approval or censorship of the manuscript. The authors have no conflicts of interest that are directly relevant to the content of this study.
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van Asselt, A.D.I., van Mastrigt, G.A.P.G., Dirksen, C.D. et al. How to Deal with Cost Differences at Baseline. Pharmacoeconomics 27, 519–528 (2009). https://doi.org/10.2165/00019053-200927060-00007
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DOI: https://doi.org/10.2165/00019053-200927060-00007