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

Saha, Sanjib LU orcid ; Olsson, Elin LU orcid ; Andrén, Per LU orcid ; Gušić, Sabina LU ; Thorsson, Max LU orcid ; Serlachius, Eva LU ; Gerdtham, Ulf-Göran LU orcid and Cervin, Matti LU (2026) In Child Psychiatry and Human Development
Abstract

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... (More)

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.

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author
; ; ; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
epub
subject
in
Child Psychiatry and Human Development
publisher
Kluwer Academic/Human Sciences Press Inc.
external identifiers
  • scopus:105043473510
  • pmid:42374010
ISSN
0009-398X
DOI
10.1007/s10578-026-02050-2
language
English
LU publication?
yes
additional info
© 2026. The Author(s).
id
52f3e6a9-dedc-4627-b7ac-06b52c98d467
date added to LUP
2026-07-03 07:15:42
date last changed
2026-09-01 06:39:10
@article{52f3e6a9-dedc-4627-b7ac-06b52c98d467,
  abstract     = {{<p>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.</p>}},
  author       = {{Saha, Sanjib and Olsson, Elin and Andrén, Per and Gušić, Sabina and Thorsson, Max and Serlachius, Eva and Gerdtham, Ulf-Göran and Cervin, Matti}},
  issn         = {{0009-398X}},
  language     = {{eng}},
  month        = {{06}},
  publisher    = {{Kluwer Academic/Human Sciences Press Inc.}},
  series       = {{Child Psychiatry and Human Development}},
  title        = {{Cost-Effectiveness of Stepped Care Versus Stratified Care for Pediatric Anxiety Disorders : A Pilot Evaluation in Routine Care}},
  url          = {{http://dx.doi.org/10.1007/s10578-026-02050-2}},
  doi          = {{10.1007/s10578-026-02050-2}},
  year         = {{2026}},
}