Cost-Effectiveness of Internet-Based Cognitive-Behavioral Treatment for Bulimia Nervosa: Results of a Randomized Controlled Trial

Abstract

Objective: To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN.

Methods: This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBT-BN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient out-of-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016.

Results: The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or cost-utility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy.

Conclusions: Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment.

Trial registration: ClinicalTrials.gov identifier: NCT00877786​.

Conflict of interest statement

Potential conflicts of interest: Dr. Bulik is a recipient of a grant from Shire Pharmaceuticals and has served on their Advisory Board. Dr. Marcus is on the Scientific Advisory Board of Weight Watchers International, Inc. Dr. Peat is recipient of a contract from RTI and Shire Pharmaceuticals and has consulted for Sunovion Pharmaceuticals and L.E.K consulting. Dr Watson is supported by a research grant from Shire awarded to UNC-Chapel Hill. Dr. Zerwas has consulted for L.E.K consulting. Dr. Crosby is a statistical consultant for Health Outcomes Solutions. Ms McLagan, Ms Hoffmeier, and Drs Levine, Runfola, Moesnner, Zimmer, Hamer, Marcus, and Crow have no conflicts of interest to declare.

© Copyright 2017 Physicians Postgraduate Press, Inc.

Figures

Figure 1

Bootstrapped cost and effectiveness estimates for face-to-face versus Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN). The plots at the top show the mean differences in costs and effectiveness on the primary outcome measure (Eating Disorder Examination binge and purge abstinence) using 10,000 bootstrap replicates. The plots at the bottom show the mean differences in costs and utility on quality-adjusted life years (QALY) gain using 10,000 bootstrap replicates. Negative cost differences indicate that Internet-based CBT-BN had a lower cost estimate than face-to-face CBT-BN, and positive effectiveness (or utility) estimates indicate that Internet-based CBT-BN had a higher abstinence (or QALY gain) estimate than face-to-face CBT-BN. The quadrants (clockwise from top right) represent the following scenarios for Internet-based CBT-BN compared with face-to-face CBT-BN: (1) more costly and more effective, (2) less costly and more effective (ideal), (3) less costly and less effective, and (4) more costly and less effective. The ellipse indicates the 95% confidence limits.