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TABLE 106HEALTH ECONOMICS EVIDENCE

Study ID and countryIntervention detailsStudy population
Setting
Study design – data source
Study typeCosts: description and values
Outcomes: description and values
Results: cost effectivenessComments
Internal validity (Yes/No/NA)
Industry support
BURNS 1999 (UK700) UKIntervention:
ICM; caseload 10–15

Comparator:
Standard case management (SCM); caseload 30–35
Patients aged 18–65 years, with psychotic illness of at least 2 years and a history of repeated hospital admissions (at least two, one within the past 2 years). Exclusion criteria: organic brain damage or primary diagnosis of substance misuse

Community

Data source of effect size measures and resource use: multicentre
RCT (four sites); randomisation stratified by centre.

Economic analysis n = 667:
ICM 335
SCM 332
Cost-minimisation analysisCosts:
Direct medical: case managers, hospital (inpatient, outpatient, day care, A&E), primary care (GPs, nurses), medication Direct non-medical: accommodation, prison and police custody, social and non-statutory services

Total costs per patient (mean, SD):
ICM £24,553 (£23,408)
SCM £22,704 (£22,000)
Difference £1,849 (p = 0.29, 95%CI − £1,605 to £5,304)
Non-significant difference between groups

Primary outcome: number of days in hospital for psychiatric problems

Number of days in hospital per patient (mean, sd):
ICM 73.5 (124.2)
SCM 73.1 (111.2)
Difference 0.4 (p = 0.97, 95% CI − 17.4 to 18.1)
Non-significant difference between groups

Also: non-significant differences in secondary outcome measures (clinical status, quality of life, unmet needs, social disability, patient satisfaction).
ICM and SCM were similar in terms of both costs and benefitsPerspective: all service-providing sectors
Currency: UK £
Cost year: 1997/98
Discounting: 6%
Time horizon: 24 months
Analysis based on intention-to-treat
Internal validity: 25/2/8
FORD 1995 UKIntervention:
ICM; maximum case load 15

Comparator:
Standard psychiatric services
Patients with psychotic illness and either a recent inpatient admission, impairment in social functioning, problems in compliance with medication / treatment regimes, or problems in receiving necessary multi-agency care. Exclusion criteria: primary diagnosis of learning difficulty, alcohol/drug dependency or organic psychosis

Community

Data source of effect size measures and resource use: RCT;
ICM n = 39
Control n = 38
Cost-consequences analysisCosts:
Direct service costs: psychiatric services (inpatient, outpatient, CPN, other), medical inpatient and outpatient, case management, GPs, other primary care, day services, residential care, social worker, other social services

Total mean costs per patient (95% CI):
ICM £21,759 (£16,450 to £27,067); control £8,604 (£5,574 to £11,633)
Total median costs per patient:
ICM £19,620; control £5,691
Costs in ICM group significantly higher than costs in the control group (p < 0.05)

Outcomes:
Clinical symptoms measured using the BPRS; social functioning measured using the Life Skills Profile (LSP); patients’ quality of life measured using the Lehman Quality of Life Interview

Non-significant differences in outcomes between groups
Not applicablePerspective: all publicly financed services
Currency: UK £
Cost year: 1990/91
Discounting: not necessary
Time horizon: 18 months
Internal validity: 18/3/14
FORD 2001 UKIntervention 1:
Team providing intensive case management (caseload maximum 15 clients) for 5 years (ICM1)

Intervention 2:
Team providing ICM (caseload maximum 15 clients) for 18 months, then amalgamated with local CPNs, retaining case management culture but with responsibility for more clients (ICM2)

Intervention 3:
Team providing intensive case management (caseload maximum 15 clients) for 18 months, then disbanded and patients transferred to other services (ICM3)
Patients with severe mental illness

Community
Data source of effect size measures & resource use: multi-site prospective cohort study

Follow-up at 18 months: n = 128
ICM1 45
ICM2 47
ICM3 36

Follow-up at 5 years: n = 120 (all live subjects included)
ICM1 43
ICM2 47
ICM3 30
Cost-consequences analysisCosts:
Direct medical: inpatient care, outpatient care, day care, ICM, CPN
Direct non-medical: social worker, residential care
Mean annualised costs per patient (mean, SD):
At 0–18 months:
ICM1: £10,974 (£9,039)
ICM2: £13,132 (£11,949)
ICM3: £12,654 (£11,549)
Non-significant difference between groups
At 18 months – 5 years:
ICM1: £13,734 (£10,820)
ICM2: £11,037 (£13,603)
ICM3: £5,742 (£7,007)
Significant differences between groups after controlling for severity of mental health problems (p = 0.015)

Outcomes:
Clinical outcomes measured using the BPRS; social functioning measured using the LSP

No significant differences in the mean total BPRS or LSP scores at follow-up, after controlling for baseline differences
Not applicablePerspective: health and social services
Currency: UK £
Cost year: 1996/1997
Discounting: not undertaken
Time horizon: 18 months and 5 years
Internal validity: 18/5/12
MARSHALL 1995 UKIntervention:
Case management

Comparator:
Standard care (defined as any care received before the study)
Patients with severe, persistent psychiatric disorder; homeless, or at risk of homelessness, or living in temporary, supported, or poor quality accommodation; coping badly, experiencing social isolation or causing disturbances; not clines of another case-management service

Community

Data source of effect size measures & resource use:
RCT: Case management n = 40
Control n = 40
Dropout rate: 13.7% (11/80)
Cost-consequences analysisCosts:
Direct medical: general and psychiatric care (hospital, day care, home visits, GPs, occupational therapy, medication)
Direct non-medical: local welfare services (day centres, social workers), accommodation, law enforcement agencies, state benefits, supported employment, resources for untoward and non-routine events involving patients

Total weekly cost per patient (mean, 95% CI):
Case management £249 (£215–£288); control £272 (£224–£329)
No significant difference in costs between groups

Outcomes:
Need for psychiatric and social care using a modified version of the MRC Needs for Care Schedule; quality of life in terms of employment status, accommodation, subjects’ own ratings on the Lehman Quality of Life Interview; social behaviour rated by observers with a standardised behaviour scale (REHAB) and by patients with the Social Integration Questionnaire; severity of psychiatric symptoms using the Manchester Scale

No statistically significant differences in outcomes between groups, with the exception of REHAB deviant behaviour score which was significantly better for the case management group
Not applicablePerspective: all service providing sectors
Currency: UK £
Cost year: 1993/1994
Discounting: not needed
Time horizon: 14 months
Analysis based on treatment completers
Study sample found to be far too small to detect large differences in costs
Internal validity: 17/4/14
MUIJEN 1994 UKIntervention:
Community support team with staff acting as case managers

Comparator:
Generic CPN care

Patients aged 18–64 years, with a psychotic disorder (schizophrenia or affective psychosis) lasting more than 2 years and at least two hospital admissions in the previous 2 years. Patients with primary organic disorders excluded.

Community

Data source of effect size measures and resource use:
RCT:
Community support team n = 41
Control n = 41
Cost data at 18 months: Community Support team 32 Control 29
Cost-consequences analysisCosts:
Direct medical: general and mental health care (hospital inpatient + outpatient, day care, healthcare professionals)
Direct non-medical: accommodation and living costs, local social care services (day centres, social workers), law and order services (police, court), education services, employment services, voluntary sector services

Total weekly cost per patient (mean, SD):
Case management £285 (£165)
Control £395 (£269)
Difference in costs: £110, not statistically significant
Driven mainly by a significant difference at 6 months: Case management £277 (£181), control £419 (£355), p < 0.05

Outcomes:
Clinical outcomes measured using the GAS, the Present State Examination (PSE), and the BPRS; social and behavioural functioning using the Social Adjustment Scale (SAS); patient and carer satisfaction

No statistically significant differences in outcomes between groups
Not applicablePerspective: all service-providing sectors
Currency: UK £
Cost year: 1992/1993
Discounting: not needed
Time horizon: 18 months
Analysis based on treatment completers
Internal validity: 18/3/14
RUTTER 2004 UKIntervention:
Internal care management, where the case manager (social worker) is part of the multidisciplinary team

Comparator:
External care management (ECM), where the case manager operates externally to the health-care team
Patients with SMI

Integrated care

Data source of effect size measures and resource use:
RCT:
Internal care management n = 13
ECM n = 13
Cost-effectiveness analysisCosts:
Direct medical: hospital, day care, psychiatrists, psychologists, CPNs, GPs, counselling, medication
Direct non-medical: social workers, day care, accommodation, criminal justice

Total cost per patient (mean, SD):
Internal care management £16,792 (£13,011)
ECM £15,132 (£12,258)
ΔC £1,661 (95%CI −£8,572 to £11,893)

Non-significant difference in costs between groups

Primary outcome:
Number of days spent in hospital

Mean number of days spent in hospital per patient: Internal care management 58.3, ECM 42.4
Non-significant difference in outcomes between groups
There were no significant differences in outcomes or costs between internal care management and ECMPerspective: all service providing sectors
Currency: UK £
Cost year: 1999/2000
Discounting: not necessary
Time horizon: 6 months
Analysis based on intention-to-treat
Internal validity: 18/3/14
Δ

= difference in cost

= difference in cost

From: APPENDIX 14, HEALTH ECONOMICS EVIDENCE TABLES

Cover of Bipolar Disorder
Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care.
NICE Clinical Guidelines, No. 38.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2006.
Copyright © 2006, The British Psychological Society & The Royal College of Psychiatrists.

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