Measuring the cost effectiveness of mindfulness - CMRP ...

Measuring the cost effectiveness of
mindfulness - challenges and opportunities
Rhiannon Tudor Edwards and Lucy Bryning
Mindfulness in Society Conference
Monday 25 th March – Chester
Centre for Health
Economics and Medicines
Evaluation
Bangor University

Challenges and Opportunities
How do we measure the costs and
benefits of mindfulness-based
therapies compared to usual care, in
different clinical and social settings,
so that mindfulness-based therapies
can compete for scarce resources
with new drugs, health and social
care services?

Health Economist – cynic?
“What is a cynic? A man who knows
the price of everything and the value
of nothing”. Oscar Wilde
In fact…. The health economist
strives to place a value on
everything…sometimes reflected by
prices.

Health Economics – the cheerful
face of the dismal science
– Economics is usually a rather doom laden subject, and in
this respect is linked indirectly with medicine through the
observation that the only two things in life that are certain
are death and taxes.
– We are not defeatist prophets of doom and gloom,
obsessed with death and taxes, but active and creative
workers for improvement, concerned to improve the
quality of people’s lives to the maximum feasible extent
Alan Williams was Professor of
Economics at York University for over
40 years.
(Alan Williams (Ed) Health and Economics.
Basingstoke: Macmillan 1987.p1 and p11)

Archie Cochrane on Health
Economics
“Allocations of funds and facilities are nearly
always based on the opinions of senior
consultants, but, more and more, requests for
additional facilities will have to be based on
detailed arguments with ‘hard evidence’ as to
the
gain to be expected from the patients’ angle and
the cost. Few can possibly object to this.” (p82)
Archibald Leman Cochrane (1909–1988)
was a Scottish doctor and pioneer of evidence
based medicine.
Cochrane AL. Effectiveness and efficiency:
random reflections on health services. London:
Nuffield Provincial Hospitals Trust, 1972.

Health Economics in 30
Seconds!
Economics is the study of scarcity and choice
Health Economics is the application of economic
principles to health care and other societal activities that
promote health
The Basis of Health Economics
Demand for healthcare is infinite
Resources are scarce
Choices are necessary
Prioritisation is required
Costs and benefits must be measured and compared

1.0
0.0
Measuring Health Outcomes
QALYs
QUANTITY OF LIFE (Years)
Quality-
Adjusted Life
Years-Gained
Without
Program
With
Program
Death Death

Is economic evaluation in touch
with society's health values?
Health funding is increasingly based on the results of
economic evaluation. But current methods fail to consider
all society's health objectives and are too complex for policy
makers to use
Cost effectiveness analysis is increasingly aligned with the
biostatistical desire for a single primary outcome in design
efficient trials.
For complex interventions, in particular, several
health outcomes will be important, not just
QALYs.
Proposes cost consequence analysis instead of
QALYs
(J Coast, Is economic evaluation in touch with society's
health values? BMJ 2004;329:1233)
Jo Coast, Professor of Health
Economics, Birmingham University

Measuring Health Related Quality of Life
Versus Measuring Capability in Old Age
EQ-5D Questionnaire, EuroQol Group
http://www.euroqol.org/eq-5d.html
ICECAP O Questionnaire, Coast & Flynn
http://www.birmingham.ac.uk/research/activity/mds
/projects/HaPS/HE/ICECAP/ICECAP-O/index.aspx

im Pugh
eech leaves

Costs of Depression
High levels of depression are costing
the country almost £11bn a year in
lost earnings, in demands on the
health service and in prescribing
drugs to tackle the problem
(Independent 2011)

NICE guidance on Depression
THE NICE GUIDELINE ON THE TREATMENT AND
MANAGEMENT OF DEPRESSION IN ADULTS (2009)
National Clinical Practice Guideline 90
National Collaborating Centre for Mental Health
commissioned by the National Institute for Health
& Clinical Excellence

Depression and Mindfulness
Mindfulness-based cognitive therapy (MBCT) was
developed with a specific focus on preventing
relapse/recurrence of depression (Segal et al.,
2002).
MBCT is derived from mindfulness-based stress
reduction, a programme with proven efficacy in
ameliorating distress in people with chronic
disease (Baer, 2003; Kabat-Zinn, 1990), and CBT
for acute depression (Beck et al., 1979), which
has demonstrated efficacy in preventing
depressive relapse/recurrence (Hollon et al.,
2005).
Coping strategies for early warning signs of
relapse/recurrence (Williams, J.M., et al., 2008).

Mindfulness in many different
Hokusai says
Hokusai says look carefully.
He says pay attention, notice.
He says keep looking, stay curious.
He says there is no end to seeing
settings
He says look forward to getting old.
He says keep changing,
you just get more who you really are.
He says get stuck, accept it, repeat
yourself as long as it is interesting.
He says keep doing what you love….
He says don't be afraid.
Don't be afraid.
Love, feel, let life take you by the hand.
Let life live through you.
By Roger Keyes

Tim Pugh
Beach blooms

Origins…
“MBCT was developed by Zindel Segal, Mark
Williams, and John Teasdale in the interest of
discovering a cost-effective treatment approach
that would significantly reduce relapse and
recurrence of depression” (Segal et al., 2002)
“The preventative effect of MBCT was achieved
for an average investment of less than 5 hr of
instructor time per patient, suggesting that
offering a group skills-based training program to
recovered depressed patients may be a costefficient
strategy for prevention” (Teasdale et al.,
2000, p.8)

MBCT to Prevent Relapse in
Recurrent Depression
Relapsing depression – a major social and economic problem
Economic analysis- broad perspective covering NHS + productivity
losses
Setting –Primary care, England
Costs – UK £ unit costs 2005/06, converted to $ 2006
Participants – 3 or more episodes of depression
Intervention – MBCT compared with enhanced usual care (antidepressant
medication): 8 week course with support to taper ADM
Intervention group 61; control group 62 (no power given)
15 month follow up; utility weights based on SF-36/SF-6D
Findings- MBCT as effective in terms of relapse prevention as ADM.
Adherence to MBCT 85%. No cost difference between groups. 25%
MBCT group still taking ADM. MBCT reduced residual symptoms.
Sensitivity analyses – with and without imputation of missing data,
no effect on findings
Kuyken W, Byford S, Taylor RS, Watkins E, Holden E, White K, Barrett B, Byng R, Evans A, Mullan E, Teasdale JD. J Consult
Clin Psychol. 2008 Dec;76(6):966-78. doi: 10.1037/a0013786.

Cost Effectiveness of MBCT for
Patients with Medically Unexplained
Symptoms
Medically unexplained symptoms are common
Economic analysis- societal/ healthcare perspective
Setting – primary care, Netherlands
Costs – Standardized Dutch unit prices 2010
Intervention – 8 x 2.5 hour group sessions of MBCT, with 45 mins
home practice per day
Intervention group 55; control group 41 (no power given)
9 month follow up; utility weights based on SF-36/SF-6D
Findings - Incremental cost effectiveness ratio (ICER) €56,000 per
QALY
Sensitivity analyses
Hiske van Ravesteijn, Janneke Grutters, Tim olde Hartman, Peter Lucassen, Hans Bor, Chris van Weel, Gert Jan van der

My Thoughts for Future Cost-
effectiveness Studies…
MBCT relating to depression- antidepressants are
low cost. Need to fully capture any change in
contacts with health and social services, need to
capture impacts to wider economy e.g., employment
and family caring roles
MBCT and other conditions- need to measure HRQoL
for the calculation of QALYs or DALYs allowing
comparison with other psychological
interventions/services
For all studies of cost-effectiveness of MBCT:
1. Length of follow up
2. Choice of outcome measures

Beech Stars
Tim Pugh

A Tenovus funded Health
Economics PhD
Evaluating the current state of health
economics research on mindfulness
Investigating the true cost of
delivering mindfulness
Pilot trial exploring the costeffectiveness
of mindfulness in a
Cancer setting

Micro Costing of Delivering
Mindfulness Classes
Survey sent to 18 mindfulness teachers
– Detailing costing of resources required
during delivery of MBSR/MBCT course
– Various settings and client groups
– Takes into account training/supervision of
teacher and other factors
Creating a framework for the costing of
Mindfulness
– To inform implementation and health
economic evaluations

Trial Overview
A pilot randomised control trial
– NHS Ethics & R&D approval from BCUHB
– Recruitment Dec 2012 – Dec 2013
– Two MBCT-Ca courses currently running
with three more planned
– Random allocation (1:1) to receive
MBCT-Ca or a waiting list control
condition (both groups continue with
treatment as usual)

Measuring Costs and Outcomes
7 questionnaires exploring participant
health and wellbeing (3 time points)
– EQ-5D primary outcome measure
Additional qualitative interviews
– Exploring quality of life and assessing the
health economic toolkit
Service use interviews
– conducted taking a multi-agency
perspective

What Will This Trial Tell Us?
Our trial will:
Provide information on the costs of
running mindfulness courses for the future
Provide lessons for how to design a
definitive, fully powered trial of
mindfulness with cancer patients for the
future
Teach us more about how to measure
outcomes of mindfulness in a meaningful
way for future economic evaluations

Scallop
clusters
Tim Pugh
www.bangor.ac.uk/healtheconomics
r.t.edwards@bangor.ac.uk l.bryning@bangor.ac.uk