Early intervention services the economic case
Download
1 / 51

Early Intervention Services: The Economic Case - PowerPoint PPT Presentation


  • 122 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Early Intervention Services: The Economic Case' - debra


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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


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?



What type of evidence
What Type of Evidence?

Randomised controlled trials

Long-term follow-up observational studies

Decision models


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





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




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 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





Vocational model parameters
Vocational Model: Parameters

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




Homicide model parameters
Homicide Model: Parameters

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




Suicide Model: Parameters

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





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 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 18-Month Follow-Up

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




Conclusions from leo study
Conclusions from LEO Study 18-Month Follow-Up

  • 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 18-Month Follow-Up

  • 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? 18-Month Follow-Up

  • 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 18-Month Follow-Up

  • 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


ad