Cost-Effectiveness of Stepped Care Versus Stratified Care for Pediatric Anxiety Disorders: A Pilot Evaluation in...

Anxiety disorders are common in children and adolescents, but constrained resources limit access to cognitive-behavioral therapy (CBT). Stepped and stratified care models offer different ways to organize care. Stepped care starts with lower-resource CBT and escalates when needed, whereas stratified care matches CBT format to patient complexity from the outset. Economic evidence comparing these models remains scarce. We conducted a pilot economic evaluation alongside an RCT of 51 youths with anxiety disorders to examine the feasibility of health-economic evaluation and generate preliminary cost-effectiveness estimates. Participants were randomized to stepped care (guided internet-delivered CBT [iCBT] with escalation to in-person CBT if needed, n = 25) or stratified care (baseline allocation to guided iCBT or in-person CBT with escalation to in-person CBT if needed, n = 26). Health outcomes and costs from the healthcare and societal perspectives were collected over 6 months, with the base case analysis estimating the change in utility scores. Incremental cost-effectiveness ratios (ICERs) were estimated using non-parametric bootstrapping. Stratified care yielded greater, though not statistically significant, health gains than stepped care and was dominant from the societal perspective. From the healthcare perspective, the AUC-derived quality-adjusted life years (QALY) sensitivity analysis yielded an ICER of USD 6,878 per QALY gained, although estimates remained uncertain given the small pilot sample. Subgroup analyses by age, sex, and treatment response generally supported these patterns while highlighting heterogeneity. These findings support the feasibility of conducting economic evaluations of care models in routine youth mental health care, but larger trials are needed to provide more precise cost-effectiveness estimates and inform service-delivery policy.