Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial

Abstract

BackgroundIt is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU).MethodsA single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective.ResultsOf the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI –2.81; 95% CI –5.11 to –0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group.ConclusionsRCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care.Trial registrationThe trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036Electronic supplementary materialThe online version of this article (10.1186/s12916-019-1253-5) contains supplementary material, which is available to authorized users.

Cognitive behavior therapy for health anxiety: systematic review and meta-analysis of clinical efficacy and health economic outcomes

“…The criteria for response corresponded to a reduction in health anxiety of 19-29%. Three studies of remission were based on cutoff scores on a psychometric instrument [60][61][62], and one was based on a clinical diagnosis of DSM-IV hypochondriasis [63]. The pooled responder rate was 66% (k = 7, 95% CI: 55-78), the pooled remission rate was 48% (k = 5, 95% CI: 28-67) and the pooled rate of clinically significant improvement was 51% (k = 7, 95% CI: 45-57).…”

“…Due to the scarcity of studies and different methods used we did not pool cost-effectiveness estimates using meta-analysis. Six RCTs reported health economic outcomes in terms of costeffectiveness and cost-utility [56,60,61,68,70,71], see Table 4. Three of these were based in Sweden and concerned therapist-guided Internet-delivered CBT and other minimal-contact CBT formats.…”

“…Cost-effectiveness and cost-utility of cognitive behavior therapy for health anxiety. [61] Note that the probability of cost-effectiveness (or cost-utility) at the willingness to pay level of zero is a sensitivity analysis of (cognitive behavior therapy vs. comparator) net costs only. Only studies that assessed indirect costs relating to productivity losses are here reported as using a societal perspective.…”

Preventing relapse with personalized smart‐messaging after cognitive behavioural therapy: A proof‐of‐concept evaluation

“…An exploratory observational design was applied to data from a randomized controlled trial of remotely delivered CBT for health anxiety versus usual care among high service utilizers (Morriss et al , ). The 79 participants randomized to CBT were offered 5–15 sessions delivered via either videoconferencing ( n = 54) or the telephone ( n = 14); 11 did not attend any sessions.…”

“…If potential participants consented to contact, independent researchers then carried out a telephone screening for health anxiety severity and service use. Researchers conducted follow‐up assessments by telephone, videoconference, in person, or by email depending on participant preference (See Morriss et al , for more details).…”