early intervention services: the economic case paul mccrone, 1 a-la park, 2 martin knapp 1,2 1...
TRANSCRIPT
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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
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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?
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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)
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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?
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Interpretation of Results from Economic Evaluations
Worse ‘Equal’ Better
Higher N N ?‘Equal’ N ? YLower ? Y Y
Co s
ts
Outcomes
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What Type of Evidence?
Randomised controlled trials
Long-term follow-up observational studies
Decision models
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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
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Initial Model
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Base Case Model (EI subtree)
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Base Case Model (SC subtree)
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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
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Base Case Data: Probabilities
Parameter EI Standard
Care
Formal admission (first cycle) 0.23 0.44
Informal admission (first cycle) 0.25 0.23
Discharge to CMHTs (all cycles) 0.10 NA
Remain with EI team (first cycle) 0.42 (D) NA
Formal admission (subsequent cycles) 0.06 0.13
Informal admission (subsequent cycles) 0.06 0.07
CMHT treatment (subsequent cycles) NA 0.80 (D)
Remain with EI team (subsequent cycles) 0.78 NA
D = default probability
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Base Case Data: Costs
Parameter Cost
EI input over 2 months £388
Standard community services over 2 months £233
Formal admission (61 days) £10492
Informal admission (33 days) £5871
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Base-Case 1-Year Costs
£14394
£9422
0
5000
10000
15000
EI Standard care
Exp
ecte
d c
ost
s (£
s)
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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
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Sensitivity Analyses: Results (1)
0
2000
4000
6000
8000
10000
12000
14000
16000
Probformal
adm (EI)
Probinfomaladm (EI)
RR (EI) Probformal
adm (stdcare)
Probinfomal
adm (stdcare)
RR (stdcare)
Ex
pe
cte
d 1
-ye
ar
co
st
(£s
)
Low estHigh est
Std care
EI
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Sensitivity Analyses (2)
• Probabilistic sensitivity analysis– all parameters varied simultaneously– Monte Carlo analysis– data drawn from parameter distributions– 100,000 resamples– cost distributions generated
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Probabilistic Sensitivity Analyses (1-Year costs)
0
0.02
0.04
0.06
0.08
0.1
0.12
1-year cost (£s)
Pro
bab
ilit
y
EI
SC
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Impact of EI on Vocational Outcomes
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Vocational Model: Structure
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Vocational Model: Parameters
Parameter EI SC
Employment 0.36 0.27
Education 0.20 0.065
Not economically active 0.44 0.67
Full employment (if employed) 0.58 0.52
Wage rate £5.80
Lost productivity costs/year £9744
Sources: Garety et al, 2006; Perkins & Rinaldi, 2002; Major et al, 2010
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Vocational Model: Results
7111
5024
0
1000
2000
3000
4000
5000
6000
7000
8000
EI SC
Annu
al c
ost (
2008
/9 £
s)
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Homicide Model: Structure
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Homicide Model: Parameters
Parameter EI SC
Homicide rate 0.011% 0.17%
Lifetime cost of homicide
physical and emotional
lost productivity
service costs
£1.72 million
59%
31%
10%
Annual cost of homicide
year 1
subsequent years
£54,079
£50,260
Sources: Nielssen & Large, 2008; Home Office, 2004
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Homicide Model: Results
6
92
0
10
20
30
40
50
60
70
80
90
100
EI SC
Annu
al c
ost (
2008
/9 £
s)
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Suicide Model: Structure
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Suicide Model: Parameters
Parameter EI SC
Suicide rate 1.3% 4.0%
Lifetime cost of suicide
physical and emotional
lost productivity
service costs
£1.6 million
69%
29%
3%
Annual cost of suicide
year 1
subsequent years
£34,412
£33,442
Sources: Melle et al, 2006; Robinson et al, 2010, McDaid & Park, 2010; Platt et al, 2006
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Suicide Model: Results
1376
459
0
200
400
600
800
1000
1200
1400
1600
EI SC
Annu
al c
ost (
2008
/9 £
s)
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Summary of SavingsYear 1 Years 2-5 Year 6-10
Per person (£) (£) (£)
Services -5,777 -2,408 -60
Productivity -2,052 -1,912
Intangibles -314 -628
Total -5,777 -4,774 -2,600
By sector (£m) (£m) (£m)
NHS -39.1 -16.0 0
Other public sector -0.8 -0.6 -0.4
Productivity 0 -14.2 -13.2
Intangible 0 -2.2 -4.3
Total -39.9 -32.9 -17.9
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Long-Term Model
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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.
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Eight Year Costs of EI and SC
0
20000
40000
60000
80000
100000
120000
Scenario 1 Scenario 2 Scenario 3
Co
st (
£s)
EI
SC
£36,632 £27,029£17,427
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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
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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
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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
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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
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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%
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Inpatient Days
52.3
35.5
44.0
54.9
0
10
20
30
40
50
60
Baseline 18m FU
EI
SC
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Use of Services 0-6 months
0
10
20
30
40
50
60
70
80
90
100
%EI
SC
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Use of Services 12-18 months
0
10
20
30
40
50
60
70
80
%EI
SC
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Inpatient Use and Costs (2003/4 £s) at Baseline and 18-Month Follow-Up
EI SC
Baseline
Inpatient days 52.3 44.0
Inpatient costs 8989 7573
Total costs 9747 8256
18-month follow-up
Inpatient days 35.5 54.9
Inpatient costs 6103 9442
Other costs 5332 4544
Total costs 11685 14062
95% CI of cost difference -£8128 to £3326)
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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
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Cost-Effectiveness Acceptability Curve 1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Willingness to pay for full vocational recovery by 18 months (£s)
Pro
bab
ilit
y th
at L
EO
in
terv
enti
on
is
mo
re c
ost
-eff
ecti
ve t
han
ro
uti
ne
care
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Cost-Effectiveness Acceptability Curve 2
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 20 40 60 80 100 120 140 160 180 200
Willingnes to pay for one-unit improvement in quality of life (£s)
Pro
bab
ilit
y th
at s
pec
iali
sed
car
e is
mo
re c
ost
-eff
ecti
ve t
han
usu
al c
are
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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
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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
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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)
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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