An attempt to summarise some of the main outcomes, excluding the QALY analysis.
Differences in Overall Costs and Totals
Table 3: Service costs at baseline and follow-up.
Total Health Costs:
"
SMC patients had significantly lower healthcare costs than those receiving APT, CBT and GET."
"
Controlling for baseline, healthcare costs after randomisation were significantly lower for SMC than for APT (difference £840, 95% CI £637 to £1117), CBT (difference £904, 95% CI £613 to £1205) and GET (difference £829, 95% CI £534 to £1165). The differences between the APT, CBT and GET groups were small and non-significant."
Total Societal costs (consists of: healthcare, informal care and lost employment/production costs)
Differences between CBT, GET and SMC "were not statistically significant."
"
Societal costs (i.e. healthcare, informal care and lost production costs) were significantly lower for patients allocated to CBT compared to APT (difference £2607, 95% CI £432 to £5585). Other differences were not statistically significant."
There is, however, a difference between the totals, even if it is not significant. CBT and GET show (statistically
insignificant) total societal savings. It seems that it is this (insignificant) difference from SMC that the cost benefit analysis is partly based on.
This is all very confusing because some of the cost benefit analysis is based primarily on societal costs/savings (the difference between CBT/GET and SMC.) So, even though health care costs are greater for CBT/GET than for SMC, and there is no 'significant' difference for societal costs between CBT/GET and SMC, the costs per QALY gained, and costs per patient improved, are considered worth the costs. (I'll try and get my head around this later.)
For CBT and GET there are overall health
costs, not
savings, and so the societal
savings are made up of purely out of informal care and lost employment/production costs.
For Total Societal Costs, there would be very little cost benefit, if any, for CBT and GET, if the 'informal care' costs had not been included. So, in Table 3, I think the 'informal care' costs, alone, make GET better than SMC. CBT is still slightly better than SMC without informal care costs included.
It seems to me that including these 'informal care' costs was optional, just as excluding welfare benefits was optional, so they were very handily included by the authors to make their case.
If they hadn't been included, then I
think they might not have been able to say that CBT and GET are significantly more cost effective than SMC, but I'm not certain about that.
So it looks like the whole basis of the paper, could rest entirely on the informal care costs.
Very clever.
Informal Care costs
"
Informal care costs were substantial for each group and significantly lower after receiving CBT and GET when compared to APT and SMC."
Lost employment.
Lost employment 'days' are given in Table 2, and lost employment 'costs' are given in Table 3.
The paper says that CBT and GET did not improve employment prospects:
"
There was no clear difference between treatments in terms of lost employment."
I don't understand this because the differences between the changes for SMC vs CBT and SMC vs GET for employment costs, look highly substantial. The unadjusted figures are a relative saving of £1157 for CBT and £711 for GET. (Savings compared to the SMC control group).
Note that there were lost employment
improvements in the CBT, GET
and SMC groups, but the differences between CBT/GET and SMC were not significant, so CBT/GET did not improve outcomes.
Lost Production costs
I think the paper says that lost production costs are the same as lost employment costs:
"
The human capital approach was used with the value of lost work-time to society assumed to be reflected by national mean age and gender-specific wage rates and combined with the lost employment data to generate lost production costs."
I think there was no difference between groups, apart from between APT and CBT. All it says about production costs is:
"
Lost production costs were significantly higher for APT compared to CBT (difference £1279, 95% CI £141 to £2772)."
Table 4: Welfare Benefits and Other Financial Payments
http://www.plosone.org/article/info...RI=info:doi/10.1371/journal.pone.0040808.t004
Note that these figures are
not included in the cost effectiveness evaluations.
I think they are the only cost data in the paper that are excluded from the final analysis.
For the overall differences, for welfare
and private 'benefits' taken as a whole, I
think there were no significant difference between CBT/GET vs SMC, although it's not very clear what exactly they mean by 'benefits' in the following text:
"
However, with the exception of a difference between CBT and APT, there were no significant differences in either lost work time or benefits between the treatments during follow up. In fact, benefits increased across all four treatments."
Income Benefits:
The proportion of participants claiming Income Benefits increased in every therapy group.
Looking at the unadjusted figures, compared with SMC, CBT made no significant difference to income benefits claims, and GET increased numbers on income benefits slightly, but I don't know if it is a significant difference. So there is little difference between SMC, CBT and GET.
The text says:
"
Relatively few patients were in receipt of income-related benefits or payments from income protection schemes and differences between groups were not substantial."
Illness/disability benefits:
The proportion of participants claiming illness/disability benefits increased in each therapy group.
Compared with SMC, CBT/GET resulted in a relatively lower increase in numbers on illness/disability benefits, by my rough estimation using the unadjusted figures, of about 12/13 percentage points lower increase for CBT/GET than for SMC.
Although, this doesn't tally with the text of the paper, so maybe I've got something wrong here:
"
Receipt of benefits due to illness or disability increased slightly from baseline to follow-up (Table 4). Patients in the SMC group had the lowest level of receipt at baseline but the figures at followup were similar between groups."
They seem to be looking at absolute numbers claiming benefits in each group, rather than the relative changes in numbers claiming benefits in each group over time. So they completely fail to comment on the relative changes in illness/disability benefits. I don't understand this. Maybe there's no statistical significance but that sort of minor detail doesn't usually stop them from making outlandish claims of success.
So for Illness/disability benefits, there were absolute increases for CBT and GET, but relative lower increases for CBT/GET than for SMC.
Income protection schemes or private pensions:
The proportion of participants claiming for income protection schemes or private pensions were higher in every therapy group.
CBT and GET resulted in relative increases, compared with SMC, (but I don't know if they are statistically significant increases), in payments from income protection schemes or private pensions. (Roughly 4 to 6 percentage points more participants made claims in the CBT and GET groups, compared with SMC, using the unadjusted figures.)
Keeping in mind that at least one of the authors works for an insurance company, the paper avoids
commenting on the increase in payments from income protection schemes and private pensions, as a result of CBT and GET:
"
Relatively few patients were in receipt of income-related benefits or payments from income protection schemes and differences between groups were not substantial."
(Note, that they do not say that the differences were not 'significant'. Crafty!)
So, in all benefits categories, there was an absolute increase in the proportion of participants making claims, in each of the therapy groups.
For both 'income-related benefits' and 'income protection schemes or private pensions', the increases in claimants for CBT/GET are higher (worse) than for SMC, but they just say that the differences were not 'substantial'. They don't say that the differences are not significant.
For illness/disability benefits, there was a lower increase in the CBT/GET groups in relation to the SMC group. The paper doesn't seem to comment about whether the differences are significant in this category.
For the
overall differences, for
all welfare and private 'benefits', taken as a whole, the paper seems to assert that there were no significant difference between CBT/GET vs SMC, although it's not very clear what
exactly they mean by 'benefits' in the following text:
"
However, with the exception of a difference between CBT and APT, there were no significant differences in either lost work time or benefits between the treatments during follow up. In fact, benefits increased across all four treatments."
Interestingly, there is no separate data specifically about 'private medical insurance' claims. I don't know if they collected it. If they did, then the data can't have been good because they didn't include it.
Well, that's my lot for now. When I look at it again, I might find that I've made some major mistakes.
I haven't yet worked out how QALYs relate to the above info.