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)
Department of Psychiatry and Psychotherapy, Psychosis Centre, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Germany. The Journal of Clinical Psychiatry
(Impact Factor: 5.5).
03/2012; 73(3):e402-8. DOI: 10.4088/JCP.11m06875
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.
Available from: Niehaus DJ
- "A recent German study in Hamburg demonstrated reduced inpatient days in patients followed-up assertively for 12 months and concluded that the intervention was more cost-effective than the standard care service it was compared with. Though outpatient costs had been higher in the intervention group, the total cost was still lower due to the significantly more expensive inpatient costs . Similarly, a recent Danish study demonstrated patients receiving an assertive intervention for two years, had less substance use, better adherence to medication and were more satisfied with their treatment. "
[Show abstract] [Hide abstract]
Many countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization. Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions. We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model. We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group. The obvious question was, however, if these outcomes could be sustained for longer periods of time. This study aims to determine if modified assertive interventions in an under-resourced setting can successfully maintain reductions in hospitalizations.
Patients suffering from schizophrenia who met a modified version of Weidens’ high frequency criteria were randomized into two groups. One group received a modified assertive intervention based on the international assertive community treatment model. The other group received standard care according to the model of service delivery in this region. Data was collected after 36 months, comparing readmissions and days spent in hospital.
The results demonstrated significant differences between the groups. Patients in the intervention group had significantly less readmissions (p = 0.007) and spent less days in hospital compared to the patients in the control group (p = 0.013).
Modified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where standard care services are less comprehensive. These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-resourced setting.
[Show abstract] [Hide 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.
Material and methods:
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.
[Show abstract] [Hide abstract]
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.
Systematic literature review, additional manual search.
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).
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.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.