Early Intervention Services: The Economic Case

1. 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

2. 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?

3. 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)

4. 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?

5. Interpretation of Results from Economic Evaluations Outcomes Costs

6. What Type of Evidence? Randomised controlled trials Long-term follow-up observational studies Decision models

7. 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

8. Initial Model

9. Base Case Model (EI subtree)

10. Base Case Model (SC subtree)

11. 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

12. Base Case Data: Probabilities D = default probability

13. Base Case Data: Costs

14. Base-Case 1-Year Costs

15. 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

16. Sensitivity Analyses: Results (1) Std care EI

17. Sensitivity Analyses (2) • Probabilistic sensitivity analysis • all parameters varied simultaneously • Monte Carlo analysis • data drawn from parameter distributions • 100,000 resamples • cost distributions generated

18. Probabilistic Sensitivity Analyses (1-Year costs)

20. Impact of EI on Vocational Outcomes

21. Vocational Model: Structure

22. Vocational Model: Parameters Sources: Garety et al, 2006; Perkins & Rinaldi, 2002; Major et al, 2010

23. Vocational Model: Results

24. Homicide Model: Structure

25. Homicide Model: Parameters Sources: Nielssen & Large, 2008; Home Office, 2004

26. Homicide Model: Results

27. Suicide Model: Structure

28. Suicide Model: Parameters Sources: Melle et al, 2006; Robinson et al, 2010, McDaid & Park, 2010; Platt et al, 2006

29. Suicide Model: Results

30. Summary of Savings

32. Long-Term Model

33. 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.

34. Eight Year Costs of EI and SC £17,427 £27,029 £36,632

36. 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

37. 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

38. 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

39. 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

40. 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%

41. Inpatient Days

42. Use of Services 0-6 months

43. Use of Services 12-18 months

44. Inpatient Use and Costs (2003/4 £s) at Baseline and 18-Month Follow-Up 95% CI of cost difference -£8128 to £3326)

45. 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

46. Cost-Effectiveness Acceptability Curve 1

47. Cost-Effectiveness Acceptability Curve 2

48. 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

49. 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

50. 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)