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Cost-effectiveness [and efficacy] of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics
 
 
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JAIDS June 15 2015
 
Painter, Jacob T PharmD, MBA, PhD; Fortney, John C PhD; Gifford, Allen L MD; Rimland, David MD; Monson, Thomas MD; Rodriguez-Barradas, Maria C. MD; Pyne, Jeffrey M MD
 
"HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care."
 
Collaborative care approaches to depression management in primary care settings have been shown to be cost effective and associated with greater patient satisfaction outcomes.[3, 69] However, HIV clinics may be considered the patient's medical home and may not be located in primary care clinics. Therefore, considering available resources, HIV clinics could obtain depression collaborative care from on-site resources (within the HIV clinic or a nearby primary care clinic) or an off-site collaborative care team used in the HITIDES study. Another alternative is a hybrid team with bothon-site and off-site collaborative care resources but the hybrid team was not tested in this study.
 
"In conclusion, in a specialty physical health clinic this depression collaborative care intervention (HITIDES) was effective and cost-saving. This finding is consistent with other primary care depression collaborative care results in subgroups of patients with expensive physical health comorbidities. Implementation of off-site depression collaborative care programs in specialty care clinics or to targeted patients based on clinical characteristics may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources."
 
Depression is the single most common mental health condition seen in non-mental health settings.[1] Collaborative care for depression is effective [2-13] and cost-effective in adult primary care, [14-21] but many patients are seen outside primary care. It is less clear whether collaborative care for depression is effective in specialty care, few studies have been completed on this topic to date.[22, 23] Even more unclear is whether collaborative care for depression is cost-effective outside of primary care, because the cost profiles of specialty care providers and the services they provide are significantly different from those seen in primary care......To our knowledge this is the first cost-effectiveness analysis of a collaborative care intervention for depression set in a specialty physical healthcare setting.
 
In general, patients were middle-aged, predominantly African-American, single, males with high levels of physical and mental health comorbidity in addition to moderate HIV symptoms.
 
The HITIDES intervention demonstrated improved outcomes and decreased costs compared to usual care over one year. ......The implication of this finding is that a wider roll-out of this intervention in VA HIV clinics could result in improved outcomes and cost savings. Further, given the demographic similarity between VA and non-VA HIV clinics,[70] similar results may be possible in non-VA HIV clinic settings. Since the NHB of the HITIDES intervention is positive then it is cost-effective compared to a "marginally cost-effective" program and should be selected for implementation.
 
HITIDES INTERVENTION DESCRIPTION
 
A more detailed description of the intervention has been published elsewhere.[22] The HITIDES intervention involved collaboration between on-site HIV providers and an off-site HITIDES depression team comprised of a registered nurse depression care manager (DCM), clinical pharmacist, and psychiatrist (J.M.P). The HITIDES depression care support team was located off-site at the Central Arkansas Veterans Healthcare System in Little Rock, AR and met weekly or as needed either in-person or via telephone to discuss patients who were not responding to current depression treatment. All clinical communications with care providers took place in the electronic medical record progress notes. The DCM was solely responsible for communication with patients which was done exclusively via telephone. The HITIDES care team provided treatment suggestions to the clinicians responsible for direct patient care; all treatment decisions were ultimately left to on-site treatment providers.
 
Patients received the following intervention components from the DCM via a telephone encounter:
 
participant education and activation,[39] assessment of treatment barriers and possible resolutions, depression symptom and treatment monitoring, substance abuse monitoring, and instruction in self-management (e.g., encouraging patients to exercise and participate in social activities).[4, 40] The DCM used standardized instruction scripts, which were supported by the Web-based decision support system NetDSS (available at https://www.netdss.net) during these telephone encounters.[41] The intervention used a stepped-care model for depression treatment[2] and specific treatment recommendations were based on the Texas Medication Algorithm Project[42] and the VA/Department of Defense Depression Treatment Guidelines.[43]
 
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Abstract
 
Objective: To examine the cost-effectiveness of the HITIDES intervention. Design: Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care.
 
Setting: Three Veterans Health Administration (VHA) HIV clinics in the Southern US.
 
Subjects: 249 HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care.
 
Intervention: HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines.
 
Main outcome measure(s): Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost effectiveness ratios (ICERs) and net health benefit (NHB). ICER distributions were generated using nonparametric bootstrap with replacement sampling.
 
Results: The HITIDES intervention was more effective and cost-saving compared to usual care in 78% of bootstrapped samples. The intervention NHB was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY. Conclusions: In HIV clinic settings this intervention was more effective and cost-saving compared to usual care. Implementation of off-site depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources.

 
 
 
 
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