Cost-effectiveness of 12-month therapeutic assertive community treatment as part of integrated care versus standard care in patients with schizophrenia treated with quetiapine immediate release (ACCESS trial).
ABSTRACT To compare the 1-year cost-effectiveness of therapeutic assertive community treatment (ACT) with standard care in schizophrenia. ACT was specifically developed for patients with schizophrenia, delivered by psychosis experts highly trained in respective psychotherapies, and embedded into an integrated care system.
Two catchment areas in Hamburg, Germany, with similar population size and health care structures were assigned to offer 12-month ACT (n = 64) or standard care (n = 56) to 120 first- and multiple-episode patients with schizophrenia spectrum disorders (DSM-IV), the latter with a history of relapse due to medication nonadherence. Primary outcome was the incremental cost-effectiveness ratio (ICER) based on mental health care costs from a payer perspective and quality-adjusted life-years (QALYs) as a measure of health effects during the 12-month follow-up period (2006-2007).
ACT was associated with significantly lower inpatient but higher outpatient costs than standard care, resulting in nonsignificantly lower total costs (P = .27). Incremental QALYs in the ACT group were 0.1 (P < .001). Thus, the point estimate for the ICER showed dominance of ACT. The probability of an ICER below 50,000 per QALY gained was 99.5%.
The implementation of a psychotherapeutically oriented schizophrenia-specific and -experienced ACT team led to an improved patient outcome with reduced need of inpatient care. Despite the introduction of such a rather "costly" ACT team, treatment in ACT was cost-effective with regard to improved quality of life at comparable yearly costs.
ClinicalTrials.gov identifier: NCT01081418.
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ABSTRACT: The study explores the necessity to develop and to implement a sufficient referral system of patients for hospital care in rural China. Current rules of utilising hospital care result in a lack of effectiveness and quality due to fragmentation and insufficient exchange of patients' data, but particularly when the providing hospital has to be changed during one diagnosis-related care cycle. The study aims to describe patterns and diseases of particular concern regarding the lacking exchange of data between different providers leading to the disintegration and fragmentation of services.For the purpose of this study data from the Cooperative Medical System for Urban and Rural Residents were collected in 2010. From a total of 443 355 enrollees a total of 29 062 was admitted to hospital at least once. That is an admission rate of 6.6%. Among these patients, those were counted who had changed the hospital within the same treatment cycle.1 199 inpatients from the total of 29 062 changed the provider during the same disease cycle (4.12%), and they caused a total of 35 866 visits. 2 547 visits were due to patients who changed hospital during the disease-related treatment cycle. About 75% of these inpatients were aged from 30 to 75 years. Distinguishing providing hospitals into higher and lower level ones, those inpatients moving "upwards" are mainly vulnerable to respiratory diseases while the inpatients moving "downwards" are mainly suffering from injury and poisoning. The simple linear correlation result shows that the capacity of providing hospitalisation service of low-level medical institutions might have an impact on the standardised number of the "upward" referred inpatients.A health service system with different levels of provision is badly in need of a sufficient referral mechanism, if it is intended to integrate competence and to save recourses. This raises fundamentally the problem of the providers' interests in cooperation, if the frames that are guiding them are influenced by economic incentives and market mechanisms.Das Gesundheitswesen 03/2013; 75(3):160-5. DOI:10.1055/s-0033-1334931 · 0.62 Impact Factor
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ABSTRACT: Objective: Cross-sectoral integrated health-care and the regional psychiatry budget are two models of cross-sectoral health care (comprising in-patient and out-patient care) in Germany. Both models of financing were created in order to overcome the so-called fragmentation in German health care. The regional psychiatry budget is a specific solution for psychiatric services whereas integrated health care models can be developed for all areas of health care. The purpose of this overview is to elucidate both the current state of implementation of these models and the results of evaluation research.Methods: Systematic literature review, additional manual search.Results: 28 journal articles and 38 websites referring to 21 projects were identified. The projects are highly heterogenuous in terms of size, included populations and services, aims, and steering-function (concerning the different pathways of care).Conclusions: The projects yield innovative models of mental health care capable of competing with the co-existing traditional financing systems of in-patient and out-patient services. The future of mental health care organisation in Germany is currently open and under political discussion.Psychiatrische Praxis 05/2013; 40(8). DOI:10.1055/s-0033-1343192 · 1.64 Impact Factor
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ABSTRACT: The model for integrated care (IC) of those seriously mentally ill patients insured with the DAK-Gesundheit health insurance and various Betriebskrankenkassen (members of the VAG Mitte) from the regions Berlin, Brandenburg, Lower Saxony and Bremen allows a complex treatment in the outpatient setting which consists of psychiatrists, general practitioners and clinicians, psychiatric nursing, sociotherapy (only in Berlin), internal medicine quality circles, orientation on treatment guidelines and conceptual consensus with the relevant care clinics. The aim of the evaluation is to illustrate the health economic effects of IC.In the period from 2006 to 2010 insured members of the DAK-Gesundheit and other involved health insurance companies with a serious mental illness, a significant impairment of social functioning and the need to be treated to avoid or substitute an in-hospital stay were included in the integrated care. The cost perspective was that of the statutory health insurance companies. For the health economic evaluation, the utilisation of continuous IC over 18 months was compared to the last 18 months prior to the inclusion in IC. The clinical findings were gathered quarterly during the IC using CGI (Clinical Global Impressions) and GAF (Global Assessment of Functioning Scale).A total of 1 364 patients receiving IC in 66 doctor's practices were documented (of those, 286 had diagnoses of ICD-10 F2, 724 ICD-10 F32-F39). The median age was 48.8 years, 69% were female. 24% had their own source of income, 40% were on the pension, and the rest of the patients were receiving transfer benefits in some form. In 54% of the cases IC was used to avoid an in-hospital stay, in 46% of the cases to substitute an in-hospital stay. The degree of the CGI was 5.5 on average at the time of inclusion and the GAF score was 36.5 on average. The 226 patients with continuous documentation over 18 months were included in the health economic analysis. The number of days spent in hospital was lower during the IC period as compared to the 18 months prior to IV (11.8 vs. 28.6 days, p<0.001), the inpatient costs were lower (5 929±13 837 Euro vs. 2 458±6 940 Euro, p<0.001), the total was not significantly changed (7 777±14 263 Euro vs. 7 321±7 910 Euro, p=0.65). The substantial reduction of inpatient costs was compensated by the additional costs for medication and the costs of the complex outpatient care. Results were comparable for the 2 subgroups of schizophrenic/schizoaffective (n=66, 40.9 vs. 17.9 days, p=0.03; inpatient cost 9 009±15 677 Euro vs. 3 650±8 486 Euro, p=0.02; total expenditures 11 789±15 975 Euro vs. 9 623±9 262 Euro, p=0.33) and unipolar depressive patients (n=90, 29.8 vs. 9.8 days, p=0.006; inpatient cost 5 664±14 921 Euro vs. 1 967±5 276 Euro, p=0.02; total expenditures 7 146±15 164 Euro vs. 6 234±6 292 Euro, p=0.57).The IC was able to considerably reduce the utilisation of inpatient treatment through offering a complex range of services in the outpatient setting and allowed for a weight-shift in a low-threshold comprehensive care structure without an increase in costs from the statutory health insurance companies' perspective. For a detailed description of clinical effects further studies are required.Das Gesundheitswesen 06/2013; 76(2). DOI:10.1055/s-0033-1343438 · 0.62 Impact Factor