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Clozapine is the only drug licensed for treatment-resistant schizophrenia (TRS) but the real-world clinical and cost-effectiveness of community initiation of clozapine is unclear.
The aim was to assess the feasibility and cost-effectiveness of community initiation of clozapine.
This was a naturalistic study of community patients recommended for clozapine treatment.
Of 158 patients recommended for clozapine treatment, 88 (56%) patients agreed to clozapine initiation and, of these, 58 (66%) were successfully established on clozapine. The success rate for community initiation was 65.4%; which was not significantly different from that for in-patient initiation (58.82%, χ2(1,88) = 0.47, P = 0.49). Following clozapine initiation, there was a significant reduction in median out-patient visits over 1 year (from 24.00 (interquartile range (IQR) = 14.00–41.00) to 13.00 visits (IQR = 5.00–24.00), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75–71.00) to 22.00 (IQR = 11.00–42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = −2.50, P = 0.01). Service-use costs decreased (1 year: –£963/patient (P < 0.001); 2 years: –£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: –£827.40/patient (P < 0.001); 2 year: –£1668.50/patient (P < 0.001) relative to costs prior to starting clozapine. Relative to before initiation, symptom severity was improved in patients taking clozapine at discharge (median Positive and Negative Syndrome Scale total score: initial visit: 80 (IQR = 71.00–104.00); discharge visit 50.5 (IQR = 44.75–75.00), P < 0.001) and at 2 year follow-up (Health of Nation Outcome Scales total score median initial visit: 13.00 (IQR = 9.00–15.00); 2 year follow-up: 8.00 (IQR = 3.00–13.00), P = 0.023).
These findings indicate that community initiation of clozapine is feasible and is associated with significant reductions in costs, service use and symptom severity.
Utilization of ambulatory and outpatient services for primary, specialty, and surgical care has risen in the United States over the last decade, in parallel with the evolution of health care emergency management. Regulatory and accreditation authorities; legislature and policies; and real-life events such as hurricanes, tornadoes, and wildfires throughout the country have caused health care systems to take a more all-hazards approach for emergency management. While health care emergency management has grown tremendously in significance, outpatient settings have yet to see the same growth. However, concepts of comprehensive emergency management and the incident command system are important and valuable across all health care system settings, including outpatient facilities. The purpose of this article is to summarize regulatory requirements for outpatient health care emergency management, describe nuances of outpatient settings, and provide recommendations for how to successfully incorporate outpatient and ambulatory locations into the “Enterprise” model for comprehensive health care emergency management.
In September 2015, Pope Francis visited Philadelphia, Pennsylvania, and led outdoor events over the course of 2 days. As a result, The Children’s Hospital of Philadelphia (CHOP) was faced with the challenge of planning for and responding to a mass gathering that was anticipated to be one of the largest in US history. As a result of unprecedented traffic restrictions, it was anticipated that patients, staff, and vendors would have severe challenges accessing the hospital, along with impaired communications from widespread cell phone service disruption. Previous mass gatherings have proven a need for early, detailed planning with multidisciplinary stakeholders, but little has been published on the impact of mass gatherings on area hospitals. This lack of data makes it difficult to predict the extent to which demand for hospital services would be increased and which services would be most affected. Early, coordinated planning allowed CHOP leaders to delegate responsibilities to those with specific expertise, prioritize needs, prevent duplication of efforts, and ensure engagement and accountability from key stakeholders. Emergency preparedness-led efforts including housing almost 1000 employees for 3 consecutive nights and assisting families with access allowed our hospital to maintain operations. The planning strategies shared here will provide emergency preparedness planners with a blueprint for future mass gathering preparedness. (Disaster Med Public Health Preparedness. 2017;11:267–276)
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