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

Worse ‘Equal’ Better

Higher N N ?‘Equal’ N ? YLower ? Y Y

Co s

ts

Outcomes

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

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

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

Base-Case 1-Year Costs

£14394

£9422

0

5000

10000

15000

EI Standard care

Exp

ecte

d c

ost

s (£

s)

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)

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

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)

0

0.02

0.04

0.06

0.08

0.1

0.12

1-year cost (£s)

Pro

bab

ilit

y

EI

SC

Impact of EI on Vocational Outcomes

Vocational Model: Structure

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

Vocational Model: Results

7111

5024

0

1000

2000

3000

4000

5000

6000

7000

8000

EI SC

Annu

al c

ost (

2008

/9 £

s)

Homicide Model: Structure

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

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)

Suicide Model: Structure

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

Suicide Model: Results

1376

459

0

200

400

600

800

1000

1200

1400

1600

EI SC

Annu

al c

ost (

2008

/9 £

s)

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

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

0

20000

40000

60000

80000

100000

120000

Scenario 1 Scenario 2 Scenario 3

Co

st (

£s)

EI

SC

£36,632 £27,029£17,427

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

52.3

35.5

44.0

54.9

0

10

20

30

40

50

60

Baseline 18m FU

EI

SC

Use of Services 0-6 months

0

10

20

30

40

50

60

70

80

90

100

%EI

SC

Use of Services 12-18 months

0

10

20

30

40

50

60

70

80

%EI

SC

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)

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

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

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

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