A stepped care program has been deemed more cost-effective than care-as-usual in patients with head and neck cancer or lung cancer who have psychological distress, according to a recent study published in the Journal of Clinical Oncology.
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Stepped care programs involve implementing an effective yet least resource-intensive treatment to psychologically distressed patients with cancer. When necessary, a more resource-intensive treatment is administered as a letter step to improving distress levels. One stepped care program consisting of four steps—watchful waiting for 2 weeks, guided self-help, face-to-face problem-solving therapy, and specialized psychological interventions and/or psychotropic medication—was found to be effective in improving distress levels of patients with head and neck cancer or lung cancer. However, the cost-utility of this program had not been assessed.
Researchers conducted a study to assess the value of the stepped care program compared with care-as-usual in 156 patients with head and neck cancer or lung cancer who have psychological distress. Chosen patients for the study had symptoms of psychological distress, a Hospital Anxiety and Depression Scale distress score > 14, or an anxiety or depression score > 7. Patients were randomly assigned to stepped care or care-as-usual programs and subjected to the steps of either program. To perform incremental cost-utility analyses, the cumulative costs were compared with the number of quality-adjusted life years (QALYs), or depression-free days compared with control care, per patient per treatment group. Intervention costs, direct medical costs, direct non-medical costs, productivity losses, and health-related quality of life data were used to calculate cumulative costs.
Results of the data collection and comparison indicated a mean cumulative cost €3,950 (95% CI, –€8,158 to –€190) lower and mean number of QALYs 0.116 (95% CI, 0.005 to 0.227) higher in the stepped care group than in the care-as-usual group. The stepped care group had a 96% probability that cumulative QALYs were higher and cumulative costs were lower than in the care-as-usual group. To validate the accurateness of this percentage, four more analyses were conducted that showed the stepped care group had an 84-98% probability that cumulative QALYs were higher and a 91-99% probability that cumulative costs were lower than in the care-as-usual group.
Results of this study differ from previous studies in that stepped care reported an improvement in QALYs at lower costs. All other previous studies reported higher costs as a result of stepped care implementation. Researchers suggest that the difference in cost-benefit may be a result of the first two steps of this stepped care (watchful waiting followed by guided self-help when patients did not spontaneously recover after 2 weeks). The steps after these were the source of cost increases, according to the researchers. “When the patient had still not recovered after guided self-help, more resource-intensive care was provided, although in the previous studies, all patients in the intervention group received relatively more resource-intensive care,” they said.
Further research is needed to investigate whether findings are replicable in other groups of patients with cancer as well as on optimal stepped care implementation in routine cancer care, which may differ between different health care systems worldwide.
