Early intervention services the economic case
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Early Intervention Services: The Economic Case. Paul McCrone, 1 A-La Park, 2 Martin Knapp 1,2 1 Institute of Psychiatry, King’s College London, 2 PSSRU, London School of Economics. Background. Deinstutionalisation in UK started in 1980s and is largely complete

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Early intervention services the economic case

Early Intervention Services: The Economic Case

Paul McCrone,1 A-La Park,2 Martin Knapp1,2

1 Institute of Psychiatry,King’s College London,

2 PSSRU,London School of Economics


Early intervention services the economic case

Background

  • Deinstutionalisation in UK started in 1980s and is largely complete

  • Community mental health teams (CMHTs) developed often using case-management techniques

  • In 2001 the government stating that specialist teams should be provided throughout England

    • Assertive community treatment (ACT)

    • Crisis resolution (CRT)

    • Early intervention (EI)

  • Are these services a good investment?


Early intervention in psychosis services

Early Intervention in Psychosis Services

  • Intervening early is encouraged in other clinical areas (e.g. cancer, heart disease)

  • Onset of psychosis frequently not recognised

  • Duration of untreated psychosis (DUP) can be up to 2 years

  • Longer DUP is associated with poorer outcome

  • EI services provide rapid care using a multidisciplinary team approach

  • Varied interventions

    • Medication

    • Psychological therapies

    • Vocational support

  • EI is generally time limited (around 3 years in England)


Why consider cost effectiveness

Why Consider Cost-Effectiveness?

  • Increasing number of studies evaluating EI services

  • New services clearly require scarce resources and therefore economic evaluation is essential

  • Are the extra costs of EI offset by reduced costs elsewhere in the system?

  • Is EI cost-effective?


Early intervention services the economic case

Interpretation of Results from Economic Evaluations

Outcomes

Costs


What type of evidence

What Type of Evidence?

Randomised controlled trials

Long-term follow-up observational studies

Decision models


Early intervention services the economic case

Decision Models

  • A way of assessing costs and cost-effectiveness

  • Alternative or supplementary to trial

  • Advantages:

    • Results can be produced quickly

    • Models can be adapted to aid generalisability

    • Allows a focus on certain key parameters of interest

  • Disadvantages

    • Models are by definition an abstraction from reality

    • Data are required for probabilities and costs and these are not always available


Initial model

Initial Model


Early intervention services the economic case

Base Case Model (EI subtree)


Early intervention services the economic case

Base Case Model (SC subtree)


Data required for model

Data Required for Model

  • Probabilities

    • clinical trials (LEO)

    • audit data (Worcestershire and Northumberland EI services)

    • routine data (28-day readmission rates)

    • expert judgement

  • Costs

    • existing economic studies of EI

    • economic studies in other areas

    • non-economic studies


Base case data probabilities

Base Case Data: Probabilities

D = default probability


Early intervention services the economic case

Base Case Data: Costs


Early intervention services the economic case

Base-Case 1-Year Costs


Sensitivity analyses 1

Sensitivity Analyses (1)

  • Key parameters increased/decreased by 50%

    • probability of initial formal admission

    • probability of initial informal admission

    • probability of readmission

    • probability of remaining with EI team/CMHT


Sensitivity analyses results 1

Sensitivity Analyses: Results (1)

Std care

EI


Sensitivity analyses 2

Sensitivity Analyses (2)

  • Probabilistic sensitivity analysis

    • all parameters varied simultaneously

    • Monte Carlo analysis

    • data drawn from parameter distributions

    • 100,000 resamples

    • cost distributions generated


Probabilistic sensitivity analyses 1 year costs

Probabilistic Sensitivity Analyses (1-Year costs)


Early intervention services the economic case

Impact of EI on Vocational Outcomes


Vocational model structure

Vocational Model: Structure


Vocational model parameters

Vocational Model: Parameters

Sources: Garety et al, 2006; Perkins & Rinaldi, 2002; Major et al, 2010


Vocational model results

Vocational Model: Results


Homicide model structure

Homicide Model: Structure


Homicide model parameters

Homicide Model: Parameters

Sources: Nielssen & Large, 2008; Home Office, 2004


Homicide model results

Homicide Model: Results


Suicide model structure

Suicide Model: Structure


Early intervention services the economic case

Suicide Model: Parameters

Sources: Melle et al, 2006; Robinson et al, 2010, McDaid & Park, 2010; Platt et al, 2006


Suicide model results

Suicide Model: Results


Summary of savings

Summary of Savings


Long term model

Long-Term Model


Scenarios for long term model

Scenarios for Long-Term Model

  • Scenario 1. Readmission rates are constant throughout all the 48 cycles for both EI (12%) and standard care (20%).

  • Scenario 2. Readmission rates for EI for the first three years are constant, and then suddenly become the same as for standard care.

  • Scenario 3. Readmission rates for EI after three years gradually become similar to those for standard care.


Eight year costs of ei and sc

Eight Year Costs of EI and SC

£17,427

£27,029

£36,632


Cost effectiveness of ei the leo study

Cost-Effectiveness of EI:The LEO Study

Craig et al (2004) BMJ 329: 1067

Garety et al (2006) Br J Psychiatry 188: 37-45

McCrone et al (2010) Br J Psychiatry 96: 377-382


Methods 1

Methods (1)

  • Lambeth Early Onset (LEO) service

  • Deprived area of inner-London

  • For first episode psychosis or those for with second episode where care was never received

  • Patients identified by screening for possible psychosis

  • Randomised controlled trial conducted including 144 patients (71 to EI, 73 to standard care)

  • Assessments at baseline, 6 months and 18 months

  • Primary outcome measure was relapse and hospitalisation


Methods 2

Methods (2)

  • EI

    • Provided ACT

    • Focus on maximising engagement, psychosocial recovery and relapse prevention

    • 10 staff members (psychiatrists, psychologists, occupational therapists, nurses, healthcare assistants)

    • Interventions included low-dose medication, CBT, family therapy and vocational rehabilitation

  • SC (standard care)

    • CMHTs with no extra training in dealing with first episode psychosis


Methods 3

Methods (3)

  • 6-month service use measured at each assessment with CSRI

  • Data on hospital admissions available for entire follow-up period

  • Service use data combined with unit costs

  • Cost-effectiveness analysis used vocational recovery and quality of life data


Sample

Sample

71 randomised to EI and 73 to SC

Mean age: EI 26 years, SC 27 years

Men: EI 55%, SC 74%

First episode: EI 86%, SC 71%

BME: EI 62%, SC 75%

Employment: EI 19%, SC 18%

Schizophrenia: EI 72%, SC 67%


Inpatient days

Inpatient Days


Use of services 0 6 months

Use of Services 0-6 months


Early intervention services the economic case

Use of Services 12-18 months


Inpatient use and costs 2003 4 s at baseline and 18 month follow up

Inpatient Use and Costs (2003/4 £s) at Baseline and 18-Month Follow-Up

95% CI of cost difference -£8128 to £3326)


Outcomes

Outcomes

Vocational recovery at 18m FU:

EI 33%, SC 21% (p = 0.162)

Quality of life (MANSA): EI 59.3, SC 53.3

(p = 0.025)

EI was dominant – lower costs and better outcomes


Cost effectiveness acceptability curve 1

Cost-Effectiveness Acceptability Curve 1


Early intervention services the economic case

Cost-Effectiveness Acceptability Curve 2


Conclusions from leo study

Conclusions from LEO Study

  • EI resulted in reduced inpatient use

  • Costs were lower for EI (although not significantly)

  • When combined with outcomes, EI is very likely to be cost-effective


Summary

Summary

  • Initial model has demonstrated savings in care costs for EI compared to SC

  • Large savings due to increased employment

  • Small savings due to reduced homicide and suicide

  • Long-term cost savings depend on convergence in readmission rates

  • LEO study revealed lower costs, better outcomes and (therefore) cost-effectiveness


How do findings compare with those from other studies

How do findings compare with those from other studies?

  • Australia - savings of $AUD 7110 (Mihalopoulos et al, 1999)

  • Long-term savings of $AUD 6058 (Mihalopoulos et al, 2009)

  • Canada – EI $2371, SC $2125 (Goldberg et al, 2006)

  • England – 54% fewer bed days (Dodgson et al, 2008)

  • Norway & Denmark – weeks in hospital EI 16.4, SC 15.5 (Larsen et al, 2006)

  • Denmark – inpatient days in year 1 EI 62, SC 79; year 2 EI 27, SC 35; years 3-5 EI 58, SC 71 (Petersen et al, 2005; Bertelsen et al, 2008)

  • Norway – admissions EI 33%, SC 50% (Grawe et al, 2006)

  • Sweden – cost savings of 29% year 1, 55% year 2, 61% year 3 (Cullberg et al, 2006)


Acknowledgements

Acknowledgements

  • Mike Clark

  • David Shiers

  • Swaran Singh

  • Jo Smith

  • Tom Craig

  • Philippa Garety

  • David McDaid

  • Other steering group members

  • IOP/LSE colleagues

  • DH for funding programme


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