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
Worse
‘Equal’
Better
Higher N ? Y
Lower
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
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

13. 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

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: ParametersEI 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

23. Vocational Model: Results

24. Homicide Model: Structure

25. Homicide Model: ParametersEI 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

26. Homicide Model: Results

27. Suicide Model: Structure

28. Suicide Model: ParametersEI 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

29. Suicide Model: Results

30. 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

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
£36,632
£17,427
£27,029

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:

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 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

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-UpEI 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)

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)

51. 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