### CBT costs £176/session at Maudsley Hospital (one of trial centres). This translates to CBT not being cost effective when a QALY is valued at £30,000 in healthcare costs

#### Posted by tkindlon on 23 Feb 2014 at 02:37 GMT

This paper (1) says:
"The cost per hour of therapy was £110 for CBT and £100 for APT and GET"
and
"The healthcare costs per QALY gained for CBT and GET compared to SMC were below the cost-effectiveness threshold of £30,000. The cost of CBT would need to increase by 45% and GET by 22% for the cost per QALY to reach £30,000."

That is to say, the threshold for CBT to be cost-effective is £159.50 per hour of therapy.

As Ed Jackson has pointed out (2), the actual cost being charged at Maudsley Hospital, London (one of the centres for the CBT Trial itself) is £176 per session (pp.41, 3). In the PACE Trial, there was one session of 90 minutes and the other 14 sessions were of 50 minutes (4). This translates to average session length of 52.67 minutes if all the sessions are attended, slightly more if not all the sessions are attended. The £176 per session at Maudsley Hospital is quoted for 20 sessions. If all the sessions are attended, this would mean an average session length of 52 minutes. If fewer were attended, it would be slightly more. If one uses the figure of 52 minutes, that translates to CBT costing £203.08 per hour, a lot more than the threshold for CBT to be cost effective where a QALY is valued at £30,000. If one uses a more conservative figure of a session lasting 60 minutes on average, then it costs £176 per hour and is still not cost effective.

I thought I would highlight again an analysis promised in the statistical plan (5): "The estimated costs of APT, GET and CBT will be increased and decreased by 50% to see how sensitive the costs, cost-effectiveness and cost-utility findings are to these variables." Increasing the cost by 50% using such a sensitivity analysis, which wasn't explicitly reported in the cost effectiveness paper itself, CBT would not be cost effective. Such an analysis seems particularly relevant given the quoted cost of CBT in Maudsley Hospital.

References:

1. McCrone P1, Sharpe M, Chalder T, Knapp M, Johnson AL, Goldsmith KA, White PD. Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis. PLoS One. 2012;7(8):e40808. doi: 10.1371/journal.pone.0040808. Epub 2012 Aug 1.

2. Jackson Ed: Additional analyses from statistical analysis plan and trial's protocol should also be released.
http://www.plosone.org/an...

3. National Services Directory. A guide to our specialist mental health services for adults across the United Kingdom. April 2012 - March 2013 https://www.national.slam...

4. Burgess M, Chalder T. PACE manual for therapists. Cognitive behaviour therapy for CFS/ME. http://www.pacetrial.org/... .

5. Walwyn R, Potts L, McCrone P, Johnson AL, DeCesare JC, Baber H, Goldsmith K, Sharpe M, Chalder T, White PD. A randomised trial of adaptive pacing therapy, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome (PACE): statistical analysis plan. Trials. 2013 Nov 13;14:386. doi: 10.1186/1745-6215-14-386

Competing interests declared: I assist the Irish ME/CFS Association in a voluntary capacity

### RE: CBT costs £176/session at Maudsley Hospital (one of trial centres). This translates to CBT not being cost effective when a QALY is valued at £30,000 in healthcare costs

#### spjupmc replied to tkindlon on 24 Feb 2014 at 05:53 GMT

It has now been said a number of times that we did not report the results of our sensitivity analysis regarding the cost of therapy. The paper states the following: "The healthcare costs per QALY gained for CBT and GET compared to SMC were below the cost-effectiveness threshold of £30,000. The cost of CBT would need to increase by 45% and GET by 22% for the cost per QALY to reach £30,000. Therapy costs for APT would need to fall 35% for APT to have a cost per QALY compared to SMC of £30,000." If a 45% increase in CBT costs mean the the threshold is reached then clearly a 50% increase means it is exceeded.

Competing interests declared: Author

### RE: RE: CBT costs £176/session at Maudsley Hospital (one of trial centres). This translates to CBT not being cost effective when a QALY is valued at £30,000 in healthcare costs

#### tkindlon replied to spjupmc on 24 Feb 2014 at 21:41 GMT

I accept that the paper gave useful information in this case (which I quoted in the comment above). I pointed out that the paper did not explicitly say it was less than the 50% increase the Analysis Plan said would be looked at. I think it is useful to put the required increases in context e.g. of what was set in the Analysis Plan as the sensitivity analysis.

With regard to another analysis, the paper said, "however, sensitivity analyses revealed that the results were robust for alternative assumptions."* One might possibly then hope or expect it be reported that, with these particular estimates, the results are not robust for alternative assumptions, but such language was not used in the paper.

But my main point in the comment above is to point out the real world cost of CBT at Maudsley Hospital.

* Which I have pointed out elsewhere (http://www.plosone.org/an...) wasn't true for the two alternative assumptions in the statistical plan.

No competing interests declared.

### RE: RE: RE: CBT costs £176/session at Maudsley Hospital (one of trial centres). This translates to CBT not being cost effective when a QALY is valued at £30,000 in healthcare costs

#### spjupmc replied to tkindlon on 25 Feb 2014 at 07:09 GMT

Dear Tom

I see what you mean now and am happy to clarify the sensitivity analyses. I will post a new comment because I suspect there are only a few bothering to read our thread!

Regarding the SLaM and Barts figures I strongly suspect that these are charges/prices that these Trusts make to other Trusts or to private patients. As such they are very unlikely to be true costs. (As an economist I am interested in costs not charges - boring difference but crucial.) Can you send me the details from Barts so I can look into this some more?

BW

Paul

Competing interests declared: Author