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 Worse ‘Equal’ Better Higher N ? Y Lower 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 Parameter EI Standard Care Formal admission (first cycle) 0.23 0.44 Informal admission (first cycle) 0.25 Discharge to CMHTs (all cycles) 0.10 NA Remain with EI team (first cycle) 0.42 (D) Formal admission (subsequent cycles) 0.06 0.13 Informal admission (subsequent cycles) 0.07 CMHT treatment (subsequent cycles) 0.80 (D) Remain with EI team (subsequent cycles) 0.78 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

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 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

Homicide Model: Structure

Homicide Model: Parameters 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

Suicide Model: Structure

Suicide Model: Parameters 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

Summary of Savings Year 1 Years 2-5 Year 6-10 Per person (£) Services -5,777 -2,408 -60 Productivity -2,052 -1,912 Intangibles -314 -628 Total -4,774 -2,600 By sector (£m) NHS -39.1 -16.0 Other public sector -0.8 -0.6 -0.4 -14.2 -13.2 Intangible -2.2 -4.3 -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 £36,632 £17,427 £27,029

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 SC (standard care) 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 EI SC Baseline Inpatient days 52.3 44.0 Inpatient costs 8989 7573 Total costs 9747 8256 18-month follow-up 35.5 54.9 6103 9442 Other costs 5332 4544 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

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