Cost-effectiveness Analysis of a Rural Telemedicine Collaborative Care Intervention for Depression

CONTEXT: Collaborative care interventions for depression in primary care settings are clinically beneficial and cost-effective. Most prior studies were conducted in urban settings. OBJECTIVE: To examine the cost-effectiveness of a rural telemedicine-based collaborative care depression intervention. DESIGN: Randomized controlled trial of intervention vs usual care. SETTING: Seven small (serving 1000 to 5000 veterans) Veterans Health Administration community-based outpatient clinics serving rural catchment areas in 3 mid-South states. Each site had interactive televideo dedicated to mental health but no psychiatrist or psychologist on site. Patients Among 18 306 primary care patients who were screened, 1260 (6. 9%) screened positive for depression; 395 met eligibility criteria and were enrolled from April 2003 to September 2004. Of those enrolled, 360 (91. 1%) completed a 6-month follow-up and 335 (84. 8%) completed a 12-month follow-up. Intervention A stepped-care model for depression treatment was used by an off-site depression care team to make treatment recommendations via electronic medical record. The team included a nurse depression care manager, clinical pharmacist, and psychiatrist. The depression care manager communicated with patients via telephone and was supported by computerized decision support software. MAIN OUTCOME MEASURES: The base case cost analysis included outpatient, pharmacy, and intervention expenditures. The effectiveness outcomes were depression-free days and quality-adjusted life years (QALYs) calculated using the 12-Item Short Form Health Survey standard gamble conversion formula. RESULTS: The incremental depression-free days outcome was not significant (P =. 10) ; therefore, further cost-effectiveness analyses were not done. The incremental QALY outcome was significant (P =. 04) and the mean base case incremental cost-effectiveness ratio was 85 634/QALY. Results adding inpatient costs were 111 999/QALY to 132 175/QALY. CONCLUSIONS: In rural settings, a telemedicine-based collaborative care intervention for depression is effective and expensive. The mean base case result was 85 634/QALY, which is greater than cost per QALY ratios reported for other, mostly urban, depression collaborative care interventions.