title: Cost-effectiveness of depression case management in small practices.
abstract: BACKGROUND
  Case management undertaken by healthcare assistants in small primary care practices is effective in improving depression symptoms and adherence in patients with major depression.
  
  
  OBJECTIVE
  To evaluate the cost-effectiveness of depression case management by healthcare assistants in small primary care practices.
  
  
  METHODS
  Cost-effectiveness analysis on the basis of a pragmatic randomised controlled trial (2005-2008): practice-based healthcare assistants in 74 practices provided case management to 562 patients with major depression over 1 year. Our primary outcome was the incremental cost-effectiveness ratio (ICER) calculated as the ratio of differences in mean costs and mean number of quality-adjusted life-years (QALYs). Our secondary outcome was the mean depression-free days (DFDs) between the intervention and control group at 24-month follow-up. The study was registered at the International Standard Randomised Controlled Trial Number Registry: ISRCTN66386086.
  
  
  RESULTS
  Intervention v. control group: no significant difference in QALYs; significantly more DFDs (mean: 373 v. 311, P<0.01); no significant difference in mean direct healthcare costs (€4495 v. €3506, P = 0.16); considerably lower mean indirect costs (€5228 v. €7539, P = 0.06), resulting in lower total costs (€9723 v. €11 045, P = 0.41). The point estimate for the cost-utility ratio was €38 429 per QALY gained if only direct costs were considered, and 'dominance' of the intervention if total costs were considered. Yet, regardless of decision makers' willingness to pay per QALY, the probability of the intervention being cost-effective was never above 90%.
  
  
  CONCLUSIONS
  In small primary care practices, 1 year of case management did not increase the number of QALYs but it did increase the number of DFDs. The intervention was likely to be cost-effective.
authors.affiliation: Institute of General Practice and Family Medicine, Friedrich-Schiller-University/Jena University Hospital, Bachstr. 18, D-07743 Jena, Germany. jochen.gensichen@med.uni-jena.de
authors.forename: Jochen
authors.initials: J
authors.lastname: Gensichen
authors.forename: Juliana J
authors.initials: JJ
authors.lastname: Petersen
authors.forename: Michael
authors.initials: M
authors.lastname: Von Korff
authors.forename: Dirk
authors.initials: D
authors.lastname: Heider
authors.forename: Steffen
authors.initials: S
authors.lastname: Baron
authors.forename: Jochem
authors.initials: J
authors.lastname: König
authors.forename: Antje
authors.initials: A
authors.lastname: Freytag
authors.forename: Christian
authors.initials: C
authors.lastname: Krauth
authors.forename: Ferdinand M
authors.initials: FM
authors.lastname: Gerlach
authors.forename: Hans-Helmut
authors.initials: HH
authors.lastname: König
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019090:Case Management / Q000191:economics*; D003362:Cost-Benefit Analysis; D003865:Major Depressive Disorder / Q000191:economics* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics*; D008875:Middle Aged; D011320:Primary Health Care / Q000191:economics*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D011795:Surveys and Questionnaires; D055815:Young Adult