Page 94 - The efficacy and effectiveness of psychological treatments for eating disorders - Elske van den Berg

94 Chapter 4
BMI <15 or did not offer inpatient care. When comparing the BMI increase of 2.75 (SD = 1.9) during CBT-E with 2.77 (SD = 1.81) of the Fairburn anorexia nervosa outpatient study, which included patients with a slightly higher BMI, findings appear similar (Fairburn et al., 2013). The present CBT-E finding of 47.1% of patients reach- ing healthy weight, also corresponds with 38.8% found in the considerable more intensive inpatient study of Dalle Grave (Dalle Grave et al., 2013). In the Fairburn study (Fairburn et al., 2013), 61% of treatment completers reached BMI ≥ 18.5, within an outpatient setting; at the same time, attrition rate in the Fairburn study was high- er, probably because patients dropped out when they needed hospitalization. The 19.7% robust remission rate in the CBT-E period appears to be in line with the 17% and 8.8% respectively in the Turner and Byrne studies (Turner et al., 2015; Byrne et al., 2011), although slightly different definitions were used across the studies.
There are two possible explanations for the higher treatment costs in the CBT-E cohort compared with TAU: first, the higher outpatient costs appear to be related to the lower attrition rate, with more outpatients completing the recommended number of sessions. Secondly, the higher admission rate led to higher inpatient costs. At the same time, total costs of CBT-E treatment still contrast well with internationally reported average treatment costs (Stuhldreher et al. 2015). The found lower attrition rate is of note because anorexia nervosa treatments are known for their high drop- out rates and thus the lower attrition rate could be related to high acceptability of CBT-E. The CBT-E focus on engaging may pay off here, because therapists are able to commit more outpatients to complete their treatment. The comparatively higher admission rate in the CBT-E cohort may be related to staff members still mastering CBT-E Underweight in order to treat severely underweight patients on an outpatient basis, combined with available inpatient facilities at hand.
Limitations
Due to absence of follow up data, longer term effect were not examined. The five year time frame of this study, although in line with similar studies (Turner et al., 2015; Byrne et al., 2011), may be a confounding variable. The analyses however suggested that there was no change in both the key patient characteristics and program leader- ship and / or financing system. Additional societal and potential concurrent health costs were not measured and valued; as little knowledge is available on direct treat- ment costs of anorexia nervosa, the purpose in this study was establishing direct costs. Finally, therapist fidelity was not systematically assessed during the CBT-E period, rather, to monitor and enhance CBT-E adherence, audiotaped sessions were reviewed during intervision.