Service use and costs of home-based versus hospital-based care for people with serious mental illness

The formal mental health care burden among recently deinstitutionalized patients

This article examines the extent to which the costs of formal health care are shifted from third-party payers to the patient and his or her family, especially during the transition to the community after discharge from a state hospital. Findings indicate that patients residing in the community are as likely to receive some care as their counterparts in institutions, but are at higher risk for uncovered care. Uncovered care is more likely to manifest as an unmet need for patients who have been recently discharged, especially for racial minorities, and as an out-of-pocket expense for patients who are established in the community.

Home-based versus hospital-based care for serious mental illness. Controlled cost-effectiveness study over four years

BACKGROUND

The Daily Living Programme (DLP) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital, London. The cost-effectiveness of the DLP was examined over four years.

METHOD

A randomised controlled study examined cost-effectiveness of DLP versus standard in/out-patient hospital care over 20 months, followed by a randomised controlled withdrawal of half the DLP patients into standard care. Three patient groups were compared over 45 months: DLP throughout the period, DLP for 20 months followed by standard care, and standard care throughout. Bivariate and multivariate analyses were conducted (the latter to standardise for possible inter-sample differences stemming from sample attrition and to explore sources of within-sample variation).

RESULTS

The DLP was more cost-effective than control care over months 1-20, and also over the full 45-month period, but the difference between groups may have disappeared by the end of month 45.

CONCLUSIONS

The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care, although sample attrition left some comparisons under-powered.

Measuring the economic benefit of treatment with atypical antipsychotics

Schizophrenia has a major impact on the quality of life of sufferers, and its broader impact on families and on society are well known, although less thoroughly documented. The majority of sufferers require long-term treatment and support, and there are depressingly frequent media stories about violent incidents involving people with the illness. Consequently the costs of schizophrenia, broadly defined, loom large, not just from the perspective of health care decision-makers and governments, but also from that of sufferers and their families, to many other people with only indirect experience of the disease.

Costs of schizophrenia

BACKGROUND

Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies--public and private--as well as for patients, families and the wider society.

METHOD

The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.

RESULTS

Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of 2.6 billion pounds, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.

CONCLUSIONS

Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.

Stress in community care teams: will it affect the sustainability of community care?

The study investigated whether community care is sustainable by examining the levels of stress and burnout that affect community mental health staff. Six teams from around Great Britain were chosen to take part, representing a number of different facets of care: the type of community model, whether it was in an inner city or suburban area and whether the team had been part of a scientific evaluation of care, in which case it may have contained more experienced and more highly trained staff. The results indicated that community care staff experienced high levels of burnout as a result of the work stressors. These levels were higher than those found in any published study of health professionals within hospitals, but are similar to those found in community teams recently. There was no evidence that any particular model of community care produced less burnout, but working in an inner city did seem to produce the highest levels. There did seem to be some benefit from a moderate staff turnover within teams. These results mirror those of other recent studies. Models of community care can only be sustained by reducing their toxicity on the staff who have to make them work. Therefore, levels of stress and burnout should be included in any evaluation of the cost-effectiveness of service models. The alleviation of these high levels through individual and organisational interventions should now be a high priority.

Service provision for people with schizophrenia. I. Clinical and economic perspective

BACKGROUND

The aim of this study was to provide information on patients current service use which could inform future decisions on service planning and resource allocation.

METHOD

Individuals with a diagnosis of schizophrenia, who had received in-patient care in the previous five years, were identified from the Lothian Case Register. Information was obtained from 193 subjects. Patients' service use over a six-month period was examined. The costs incurred in service provision were determined.

RESULTS

Patients differed markedly in their use of services. This was not found to be related to their mental state. Average care costs were high. In-patient care accounted for most of the overall expenditure.

CONCLUSIONS

There is considerable variation in the services used by patients with schizophrenia and in the costs incurred in service provision. When planning services it is therefore important that detailed information on the patient population is available if resources are to be allocated cost-effectively.

Importance of local differences in comparing hospital and community psychiatric services

Most of the studies that are frequently cited as examples of effective comprehensive community care, (i.e. they reduce the demand for hospital beds without any loss in treatment efficacy (Stein & Test, 1980; Hoult & Reynolds, 1984; Muijen et al., 1992) were carried out before the introduction of the Care Programme Approach (CPA) in 1991 (Department of Health, 1990) which at present only applies to England. As the CPA derives from these earlier studies the discrepancies between hospital and community based aftercare might be expected to become less, as now all services in England are expected to include a significant community element. However, there can still be important differences between those services focusing on community care as the main priority and those in which the hospital system is paramount.

The psychiatric services in the area covered by North West London Mental Health Trust (NWL Trust) represented a natural test of these two approaches as they had parallel hospital and community based teams covering the same catchment areas respectively, North Paddington, in Westminster and Brent, in outer London.

At this point it is useful to provide more detailed description of the two geographical areas at the time of the study and the community and hospital based teams that were involved.

Problems in conducting economic evaluations alongside clinical trials. Lessons from a study of case management for people with mental disorders

BACKGROUND

Case management has become the statutory basis of community care in the UK for people with long-term mental disorders, although a randomised controlled trial found no important improvements over standard care. Here we compare the costs and cost consequences of this intervention with standard care.

METHOD

Resource-use data were collected over a six-month baseline period and for 14 months after randomisation on all patients in the trial.

RESULTS

At 14 months the ratio of control group to treatment group weekly costs was 1.09 (95% CI 0.86-1.38) for total costs; 1.12 (0.76-1.65) for state benefits, and 1.21 (0.61-2.42) for health care costs. Costs were thus lower in the treatment group, but these differences were not significant.

CONCLUSIONS

Retrospective power calculations indicated that the trial could have detected differences of 30% in total cost, but would have required 700 patients per arm to detect a 20% difference in health care costs. Hence this study, which had adequate power to detect clinically meaningful differences, was found to be far too small to detect large differences in costs. Funding agencies increasingly request that clinical trials include economic alongside clinical end-points: these findings may have important lessons for that policy.

The mental health residential care study: predicting costs from resident characteristics

BACKGROUND

Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary.

METHOD

As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs.

RESULTS

Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts.

CONCLUSIONS

The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.

Community psychiatry in Hong Kong

Community psychiatry is well developed in many western countries. However, this psychiatric subspecialty has only recently been officially recognized and established in Hong Kong. This article describes the development and current scope of services. It illustrates how local psychiatrists have met the challenge of adopting a western service model to suit the local Chinese population, with its different socio-cultural value system.

Community psychiatry in Europe: assessment and evaluation

It is tempting to suppose that changes in the mental illness service in one's own part of Europe are taking place elsewhere as well. The asylum era is drawing to a close, and politicians everywhere are closing mental illness beds in order to re-distribute health costs in order to pay for new treatments needing expensive technology, as well as to allow for the needs of a population that is now living longer.

In an attempt to become independent of official figures, key figures with a reputation for epidemiological psychiatry were approached in each European country, and asked to complete a brief questionnaire describing the mental health services in their country. Whether this method produces figures that are more or less accurate than official government figures is a question that cannot be addressed at present.

Costing day hospital and in patient care for acute psychiatric illness

This study was primarily designed as a cost effectiveness analysis, comparing the costs and outcomes of day hospital and in-patient care for acute psychiatric illness. There are a growing number of this type of study in mental health (Knappet al., 1994; McCroneet al., 1994; Wiersmaet al., 1995; Mersonet al., 1996). The costing methodology used in such studies is becoming more consistent, but economic evaluation in mental health care is still developing and there remain several unanswered questions which will be considered in this paper. The wide variation in the costs of care of people with mental health problems is a critical factor in these studies (Grayet al., 1996).

The cost effectiveness study is based on a previous randomised controlled trial conducted at Manchester Royal Infirmary which showed the feasibility and effectiveness of day patient treatment for acutely ill patients (Creedet al., 1990). In the current study 187 patients were randomly allocated, 94 to day hospital care and 93 to in-patient care. The method and results of the main cost effectiveness analysis are described in detail elsewhere (Creedet al., 1996a). This paper concentrates on reviewing the methods used to collect cost data, and further analysis of the data exploring variations in costs.

Schizophrenia: shifting the balance of care

Schizophrenia poses a major challenge to policy makers in health and social care in England. As deinstitutionalisation has progressed, public concern about people with the condition has increased owing to a small number of public incidents. This paper describes the overall balance of care or support for people with schizophrenia, particularly between different settings and the services received. Using these data we are able to provide a basic estimate of the current resource implications of schizophrenia care in England with respect to different public sector agencies, the voluntary sector and service users and their families. The targeting of public sector resources between different care settings is also considered. The discussion suggests that resources are still targeted at existing care facilities rather than on individuals, and examines the roles of individual care agencies and the relationships between them. Four broad resource guidelines are suggested that could improve the effective use of resources for schizophrenia care.

An evaluation of community-based psychiatric care for people with treated long-term mental illness

BACKGROUND

We evaluated integrated, multidisciplinary, community-based care for a cohort of people with treated long-term mental illness over two years in a field trial set in a semi-rural setting. The aim was to organise local psychiatric services on an extramural basis with general practitioner teams as the key element.

METHOD

Trained research workers used a structured interview to collect standardised base-line and three-monthly socio-demographic, clinical, social, family adjustment and burden, and treatment measures from patients, informants, and key-workers. Analysis included descriptive statistics and, for longitudinal data, analysis of best-fitted straight lines.

RESULTS

We studied 34 patients (14 with schizophrenia, 11 with major affective disorders, and 9 with minor (non-major) affective disorders and anxiety disorders) who had a mean of 12 years continuous illness. At baseline, they were mainly characterised by research workers as mildly ill with fair social adaptive functioning, and by lay informants as having moderate target symptom severity and disturbance of social performance. Over two years, there were statistically significant, slight improvements in clinical global impressions ratings by research workers, and in informants ratings of target symptoms and social performance. Most patients continued to receive prescriptions for psychotropic drugs throughout follow-up, and they had a mean of 47 therapeutic contacts, mainly from nurses. Two patients were admitted to psychiatric hospital. There were few differences between patients in different diagnostic groups.

CONCLUSIONS

Integrated, multidisciplinary, community-based psychiatric care for people with treated long-term mental illness is feasible in a semi-rural setting: patients receiving pharmacotherapy and regular psychosocial treatments remained relatively stable on clinical and social measures over two years. The unique way in which the service was monitored, by making regular, systematic assessments of patients and carers, serves as an example for other services.