Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression

Arch Gen Psychiatry. 2010 Aug;67(8):812-21. doi: 10.1001/archgenpsychiatry.2010.82.


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.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Catchment Area, Health
  • Cooperative Behavior
  • Cost-Benefit Analysis / statistics & numerical data*
  • Depressive Disorder / drug therapy
  • Depressive Disorder / economics
  • Depressive Disorder / therapy*
  • Female
  • Health Care Costs / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Patient Care Team / economics
  • Primary Health Care / economics
  • Primary Health Care / methods
  • Quality-Adjusted Life Years
  • Rural Health Services / economics*
  • Rural Health Services / statistics & numerical data
  • Telemedicine / economics*
  • Telemedicine / methods
  • Treatment Outcome
  • United States
  • United States Department of Veterans Affairs / statistics & numerical data