This project will determine the cost of low- and high-intensity interventions for depression. The project will also compare the costs of the interventions and determine whether they save money for the health system or society in general, since people who recover from chronic depression may require less public support because they will need to see a doctor less and will be able to work more. The low-intensity approach is called Resources for Services. Under this approach, we give providers and agencies technical assistance on how to (1) screen for depression, and (2) educate patients around depression and their treatment options, which include cognitive behavioral therapy and medication. We also train providers and agencies to deliver these treatments. The high-intensity approach is called Community Engagement and Planning, which calls for adapting depression-care materials to agency networks and providing intensive, in-person trainings, conferences and site visits.

1. Bowen Chung MD, Adjunct Staff, RAND,
Assistant Professor, Geffen School of Medicine, UCLA
Michael Ong, MD, PhD
Associate Professor, Geffen School of Medicine, UCLA
Kenneth Wells, MD, MPH
Senior Scientist, RAND
Weill Professor of Psychiatry, David Geffen School of Medicine at UCLA
January 23, 2013
Comparative Cost Analysis of
Depression Care Interventions in
Community Partners in Care

2. Presenter Disclosures
No financial conflicts of interest to report

3. Acknowledgements
• RAND: Paul Koegel, Cathy Sherbourne
• UCLA: Michael McCreary, Esmeralda Pulido, Lingqi Tang, Lily Zhang,
Susan Ettner
• Healthy African American Families: Loretta Jones, Felica Jones
• QueensCare Health and Faith Partnership: Elizabeth Dixon
• Behavioral Health Services: James Gilmore
• Funders: National Institute of Mental Health, California Community
Foundation, Robert Wood Johnson Foundation, UCLA Clinical and
Translational Science Institute

4. Goals for talk
• Explain rationale for Community Partners in Care (CPIC)
• Describe CPIC interventions and 6 & 12 month client
outcomes
• Review comparative cost analysis of the CPIC interventions
from a societal perspective
• Feedback on several questions related to the cost analysis

5. Background
• Depression a leading cause of disability worldwide
• Disparities exist in access, quality, outcomes of care for depression
• Collaborative care for depression in primary care improves outcome
especially for African Americans and Latinos relative to whites

6. % recovered from depression at 5 years
Depression QI Interventions Reduce Long-Term Outcome
Disparities (Partners in Care)

7. Community Context
• Under-resourced communities have limited provider availability
and limited implementation of Quality Improvement (QI)
programs for depression.
• Multiple services sectors support safety-net populations, but have
little or no formal role in depression care or QI.
• Healthcare reform prioritizes medical homes, accountable care
organizations and patient-centered care but the role of
community agencies as partners is unclear.

8. Community Partners in Care
• Community partnered participatory research and rigorous science
• Group-randomized trial at program level (n=95) of 2 approaches to
implement evidence-based QI toolkits for depression across diverse
community-based agencies: Resources for Services (RS) and
Community Engagement and Planning (CEP) in 2 communities,
Hollywood and South Los Angeles
• Primary outcomes
• poor mental health quality of life (MCS-12≤40)
• poor mental health (PHQ8≥10 + MCS-12≤40 + MHI-556)
• Client measures at baseline, 6, 12 months

9. Interventions
Resources for Services (RS)
• Expert team conducted culturally competent outreach to programs
• Offered 24 one-hour webinars and primary care site visits
• Provided 22 webinars and 1 site visit
• Study directly funded team/trainings
Community Engagement and Planning (CEP)
• 4-5 months of collaborative planning: biweekly meetings to review
toolkits, plan trainings, build networks/agreements and capacity to co-
lead; develop written plan; $15K for trainings
• Team implementation of 174 trainings over 192 hours
(conferences, webinars, on-site consultation)
• Innovations: Resiliency classes, “Village Clinic”

10. Resources for
Services
Community
Engagement
Planning

11. Objective of cost analysis
sub-study
To determine the comparative cost-effectiveness from a
societal perspective of 2 approaches (RS CEP) to
disseminate depression quality improvement on clients
health and mental health outcomes

12. Sampling - Client
• Approached: 4,649
• Screened: 4,440 (95.5%)
• Eligible: 1,322 of 4,440 (29.8%)
– Criteria: PHQ-8≥10, Age≥18 years, reliable phone number
• Enrolled: 1,246 of 1322 (94.3%)
• Completed baseline: 981 of 1,246 (78.7% of enrolled)
• Completed 6 month: 759 of 1093 (69.4% eligible for follow-up)
• Completed either baseline or 6 month: 1018 (81.7% of enrolled)

13. Screened Clients Reflected
Diversity of Communities
(N = 4,440, mean age 47 years)
65%
85%
16%
50%
23%
39%
28%
54%

14. MAJORITY OF DEPRESSION CONTACTS WERE
NOT IN PRIMARY OR MENTAL HEALTH
7%
27%
27%
27%

15. Other data sources
• Provider and administrator survey data – baseline, 6, and 12 month
• Provider and administrator training data – baseline, 6, and 12 month
• Costs estimated from
• CMS: DRG codes and payments for inpatient stays
• Food,Venue, Materials, CEUs – project invoices
• Medications: WHO DDD Index, Micromedex, Redbook
• AMA: CPT codes and payments for medical and mental health
procedures
• National Bureau of Labor Statistics: wages for non-healthcare
sector providers – participant time, travel time, preparation time
• Costs adjusted to 2010 using consumer price index

16. Key Assumptions
• BLS Wage classifications were an accurate reflection of the job title
• Minimum wage is a reasonable dollar amount to value client
opportunity costs
• Although we had individual at baseline, we didn’t 6 and 12 months, so
– we just used baseline – but 70 % unemployment – up 40% +
unemployements in south LA – we didn’t think this was a bad
assumption.
• Client, provider, administrator travel time: 1 hour roundtrip

17. Key Assumptions
• Cost estimates of venue for similar interventions based on per
person costs of similar events
• Intervention staff – 15 or 30 minute prep time for meetings
• Services use estimate
• Healthcare – output – moderate to severe complexity
• Mental Health – 30 min for a med visit, 45-50 minutes for
therapy, case management 45 minutes
• Social Services – case management 45 minutes
• Parks and recreation –Total annual budget / annual visitors
• Churches – 1 hour for a pastoral counseling visit
• Substance use – 45 -50 minutes for counseling

18. Analysis
• 6 and 12 month outcomes
• Intent to treat, comparative effectiveness study
• Independent variable: intervention status
• Adjusted for baseline status of dependent variable and co-variates
• Weighted to eligible sample
• Imputation for missing data
• Adjustment for clustering of clients within programs for client data
• 2-sided test with p.05 for statistical significance
• Costs – analytic samples participating at baseline, 6, and 12 months
• Not currently weighted for sampling or adjusted for clustering

19. RS
CEP
Poor Mental Health Related Quality of Life*
51%
44%
Mental Wellness*
34%
46%
Poor Mental Health*
37%
29%
Good physical health and activity*
13%
19%
≥ 2 risk factors for homelessness*
39%
29%
Any hospitalizations for alcohol, drugs, mental health*
10.5%
5.8%
≥ 4 hospital nights*
5.8%
2.1%
*p0.05
Poor Mental Health Quality of Life, MCS12 40
Mental Wellness,Yes to 1 item in last 4 weeks about: 1. Feeling peaceful and calm 2. Being a happy person 3. Having energy
Poor Mental Health,Yes to all: MCS12 40, PHQ-8≥ 10, MHI-5≥ 56
Good Physical Health and Activity, Yes to all health limits: 1. Moderate activity, 2. Stairs, 3. Physical activity
Risk factors for homelessness, ≥ 2 nights homeless, food insecurity, eviction, severe financial crisis
CPIC 6 Month Outcomes

20. CPIC 6 Month Outcomes
RS
CEP
Total outpatient contacts for depression across
sectors (mean)
23
22
Any mental outpatient visits
54%
54%
Took antidepressant, =2 months
39%
32%
# MH outpatient visits received medication advice
(mean)*
11
5
Any primary care visit
29%
29%
= 2 visits for depression*
62%
80%
Faith-based visit
60%
57%
=3 faith-based visits for depression, if any
(n=125)*
42%
64%
*p0.05

21. Percent Poor Mental Health
Quality of Life at 6 and 12 months
Percent(%)
p=0.07

22. Service Use Costs by Sector
at baseline, 6 12 months -
unadjusted
Sector
Baseline
6 Month
1 year
RS
CEP
RS
CEP
RS
CEP
Primary Care
$796 $870 $835 $792 $662 $677
Mental Health
$701 $779 $789 $651 $570 $510
Substance Abuse
$1442 $2059 $1047 $1382 $537 $549
Faith Based
$350 $306 $315 $255 $326 $271
Social and
Community
$403 $414 $321 $297 $183 $225
Costs, in dollars, include all client service use costs (hospitalizations for ADM, stayed in a residential treatment for substance abuse, ER visit,
self-help for mental health problem, hotline for ADM problem, mental health outpatient visit, outpatient substance abuse services, primary
care visit, social services, religious services, park services, met with case manager, other services for depression).

23. Start-up Costs by Sector
Sector
RS
CEP
Primary Care
$5,315 $27,363
Mental Health
$5,592 $33,010
Substance Abuse
$4,584 $34,798
Homeless
$313 $9,679
Social and Community
$7,221 $52,851
Costs include all intervention costs associated with participation time, travel time, food, venue, preparation and materials.

24. Preliminary RS CEP Differences
in Mean Cost of Services ($) and SF-6D
at baseline, 6 12 months -unadjusted
Baseline
6 Months
12 Months
CEP
RS
CEP
RS
CEP
RS
All services $
(SD)*
5496
(6989)
4768
(6536)
3701
(6024)
3668
(5191)
2597
(3904)
2490
(3759)
Healthcare
4814
4030
3247
3176
2109
2013
Non
Healthcare
578
655
443
542
416
447
SF-6D (SD)
0.58
(0.102)
0.585
(0.116)
0.626
(0.129)
0.616
(0.129)
0.628
(0.134)
0.624
(0.144)
• Includes patient time. Healthcare includes primary care, public health, mental health, substance
abuse. Non-healthcare includes faith-based, social services, homeless services,
community-trusted locations (senior centers, parks and recreation)

25. Next Steps
• Completing 12 month outcomes analysis
• Sensitivity analyses of different approaches to costing client time,
adjusting for outliers in services utilization
• Estimating individual, client hourly wages by examining baseline
client reports of hours worked in last months, last estimated work
date, and individual income from non-governmental sources
• Link services use data from self-reported client data to specific
agencies to get more accurate service use costs.

26. Implications
• Community engagement around evidence-based practices
may address multiple disparities by linking healthcare and
community partners into networks that support evidence-
based goals
• May meet “Triple Aims”
• Improved individual experience of care
• Improved health of populations
• Reduced or equal cost ???

27. Questions
• How do we capture the differences in the benefits captured
by the MCS-12, but not overall SF-12 in the QALY’s?
• How do we or should we capture the benefits of
improvements in outcomes outside of health like reduced risk
factors for homelessness?
• How do we capture the costs of client time (travel, visits,
waiting time) in sectors outside of healthcare (e.g. faith-based,
social services, senior centers)?

28. • How do we magnify the effects over the population of
people who may have received some sort of treatment from
these agencies?
• Since there is no usual care, is it reasonable to compare
intervention cost and benefits at 6 and 12 months to
baseline?
• Since the SD are greater than the means, our estimates are
not precise.
Questions

29. ThankYou to Our Funders!

30. Presenters and Contact Information
Bowen Chung, MD
Adjunct Scientist, RAND Corporation
Assistant Professor, Department of Psychiatry
Harbor-UCLA Medical Center
1000 West Carson Street, Box 498
Torrance, CA 90509
V 310-222-1801
E-mail: bchung@mednet.ucla.edu
Kenneth B.Wells, MD, MPH
Senior Scientist, RAND Corporation
Well Endowed Professor, Department of Psychiatry
Geffen School of Medicine at UCLA
Center for Health Services Society
10920 Wilshire Blvd, Suite 300
Los Angeles, CA 90024
V: 310-794-3728
E-mail: kwells@mednet.ucla.edu
Michael Ong, MD, PhD
Associate Professor, Department of Internal Medicine
David Geffen School of Medicine at UCLA
10940 Wilshire Blvd, Suite 700
Los Angeles, CA 90024
V 310-794-0154
E-mail: mong@mednet.ucla.edu
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