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

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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

  • 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?

  • 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?


Interpretation of Results from Economic Evaluations

Outcomes

Costs


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


Initial Model


Base Case Model (EI subtree)


Base Case Model (SC subtree)


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

D = default probability


Base Case Data: Costs


Base-Case 1-Year Costs


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)

Std care

EI


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)


Impact of EI on Vocational Outcomes


Vocational Model: Structure


Vocational Model: Parameters

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


Vocational Model: Results


Homicide Model: Structure


Homicide Model: Parameters

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


Homicide Model: Results


Suicide Model: Structure


Suicide Model: Parameters

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


Suicide Model: Results


Summary of Savings


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

£17,427

£27,029

£36,632


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)

  • 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)

  • 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)

  • 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

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


Use of Services 0-6 months


Use of Services 12-18 months


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

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


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 2


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

  • 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?

  • 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

  • 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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