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Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study)

  • Lene Halling Hastrup (a1), Christian Kronborg (a2), Mette Bertelsen (a3), Pia Jeppesen (a4), Per Jorgensen (a3), Lone Petersen (a1), Anne Thorup (a5), Erik Simonsen (a5) and Merete Nordentoft (a5)...

Abstract

Background

Information about the cost-effectiveness of early intervention programmes for first-episode psychosis is limited.

Aims

To evaluate the cost-effectiveness of an intensive early-intervention programme (called OPUS) (trial registration NCT00157313) consisting of enriched assertive community treatment, psychoeducational family treatment and social skills training for individuals with first-episode psychosis compared with standard treatment.

Method

An incremental cost-effectiveness analysis of a randomised controlled trial, adopting a public sector perspective was undertaken.

Results

The mean total costs of OPUS over 5 years (€123683, s.e. = 8970) were not significantly different from that of standard treatment (€148751, s.e. = 13073). At 2-year follow-up the mean Global Assessment of Functioning (GAF) score in the OPUS group (55.16, s.d. = 15.15) was significantly higher than in standard treatment group (51.13, s.d. = 15.92). However, the mean GAF did not differ significantly between the groups at 5-year follow-up (55.35 (s.d. = 18.28) and 54.16 (s.d. = 18.41), respectively). Cost-effectiveness planes based on non-parametric bootstrapping showed that OPUS was less costly and more effective in 70% of the replications. For a willingness-to-pay up to €50000 the probability that OPUS was cost-effective was more than 80%.

Conclusions

The incremental cost-effectiveness analysis showed that there was a high probability of OPUS being cost-effective compared with standard treatment.

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Copyright

Corresponding author

Lene Halling Hastrup, Region Zealand, Psychiatric Research Unit, Toftebakken 9, DK-4000 Roskilde, Denmark. Email: lhhs@regionsjaelland.dk

Footnotes

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Declaration of interest

None.

Footnotes

References

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Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study)

  • Lene Halling Hastrup (a1), Christian Kronborg (a2), Mette Bertelsen (a3), Pia Jeppesen (a4), Per Jorgensen (a3), Lone Petersen (a1), Anne Thorup (a5), Erik Simonsen (a5) and Merete Nordentoft (a5)...
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eLetters

Early intervention in psychosis is not cost-effective

Andrew J. Amos, Psychiatric Registrar
19 February 2013

Recent attempts to demonstrate the cost-effectiveness of early intervention in psychosis have been severely limited by the absence of adequately powered randomised controlled designs and unrealistic cost assessment(1). Hastrup and colleagues provide an economic evaluation of the OPUS early intervention in psychosis (EI) program which randomised patients with first episode psychosis (FEP) either to assertive community treatment (ACT) or TAU(2), addressing concerns regarding the demonstrationof treatment effectiveness, though at five years clinical differences wereminimal(3). Hastrup et al. also acknowledge that outpatient costs are dominated by case-load, not by instances of care, though they do not identify that this was first pointed out by Amos(1) in a review of the extant literature. Neither do they provide an alternative authority for this innovation. They include measures of QALY, previously identified as asignificant failing of economic evalutions of EI(4).

These significant improvements in methodology notwithstanding, Hastrup et al. inappropriately include hospitalisation costs in their analysis, despite no change having occurred in the resources devoted to hospital treatment(2). As they describe in an earlier article(5), when patients in the EI group were hospitalised, their care was transferred to the hospital, receiving TAU. Thus, before the OPUS intervention support for FEP patients included hospital care of a certain capacity plus TAU outpatient care. After the OPUS intervention, there was identical hospitalcapacity, plus TAU outpatient care, plus EI care. Hastrup et al.(2) do notreport any attempt to reduce hospital capacity or TAU outpatient care to compensate for any presumed reduction in service demand due to the EI service.

The essential flaw in the analysis is to analyse EI as if it is an alternative treatment to TAU as haloperidol is an alternative treatment for risperidone. As described, EI is an addition to an existing service which utilises the pre-existing system for inpatient care, and in which there was no effort to adjust the pre-existing outpatient service to compensate for lower demand as a result of the EI service. In order to include hospitalisation in their cost-effectiveness analysis Hastrup et al. would need to demonstrate how their intervention affected hospitalisation, and specifically how it affected hospitalisation costs, not on the basis of individual rates of hospitalisation, but on bed capacity, occupancy, and staff numbers. If there was no effort to implement or measure such changes it must be assumed that there were no changes in hospital costs or in TAU outpatient costs, in which case the economic evaluation of the EI program would suggest that the entire cost of the OPUS program was in addition to pre-existing costs. If they are unable to demonstrate that hospitalisation costs have been modified as part of their intervention, it is inappropriate to include them in a cost-effectiveness analysis.

References

1. Amos A. Assessing the cost of early intervention in psychosis: A systematic review. Aust N Z J Psychiatry. 2012;46(8):719-34.

2. Hastrup LH, Kronborg C, Bertelsen M, Jeppesen P, Jorgensen P, Petersen L, et al. Cost-effectiveness of early intervention in first- episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study). Br J Psychiatry. 2013;202(1):35-41.

3. Bertelsen M, Jeppesen P, Petersen L, Thorup A, ?hlenschlaeger J, Le Quach P, et al. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry. 2008;65(7):762-71.

4. McCrone P, Craig TKJ, Power P, Garety PA. Cost-effectiveness of anearly intervention service for people with psychosis. Br J Psychiatry. 2010;196(5):377-82.

5. Petersen L, Jeppesen P, Thorup A, Abel M-B, ?hlenschlaeger J, Christensen T?, et al. A randomised multicentre trial of integrated versusstandard treatment for patients with a first episode of psychotic illness.BMJ. 2005;331(7517):602-608.

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Conflict of interest: None declared

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