Abstract
The existing economic models for schizophrenia often have 3 limitations; namely, they do not cover nonpharmacologic interventions, they report inconsistent conclusions for antipsychotics, and they have poor methodologic quality. To develop a whole-disease model for schizophrenia and use it to inform resource allocation decisions across the entire care pathway for schizophrenia in the UK. This decision analytical model used a whole-disease model to simulate the entire disease and treatment pathway among a simulated cohort of 200 000 individuals at clinical high risk of psychoses or with a diagnosis of psychosis or schizophrenia being treated in primary, secondary, and tertiary care in the UK. Data were collected March 2016 to December 2018 and analyzed December 2018 to April 2019. The whole-disease model used discrete event simulation; its structure and input data were informed by published literature and expert opinion. Analyses were conducted from the perspective of the National Health Service and Personal Social Services over a lifetime horizon. Key interventions assessed included cognitive behavioral therapy, antipsychotic medication, family intervention, inpatient care, and crisis resolution and home treatment team. Life-time costs and quality-adjusted life-years. In the simulated cohort of 200 000 individuals (mean [SD] age, 23.5 [5.1] years; 120 800 [60.4%] men), 66 400 (33.2%) were not at risk of psychosis, 69 800 (34.9%) were at clinical high risk of psychosis, and 63 800 (31.9%) had psychosis. The results of the whole-disease model suggest the following interventions are likely to be cost-effective at a willingness-to-pay threshold of £20 000 ($25 552) per quality-adjusted life-year: practice as usual plus cognitive behavioral therapy for individuals at clinical high risk of psychosis (probability vs practice as usual alone, 0.96); a mix of hospital admission and crisis resolution and home treatment team for individuals with acute psychosis (probability vs hospital admission alone, 0.99); amisulpride (probability vs all other antipsychotics, 0.39), risperidone (probability vs all other antipsychotics, 0.30), or olanzapine (probability vs all other antipsychotics, 0.17) combined with family intervention for individuals with first-episode psychosis (probability vs family intervention or medication alone, 0.58); and clozapine for individuals with treatment-resistant schizophrenia (probability vs other medications, 0.81). The results of this study suggest that the current schizophrenia service configuration is not optimal. Cost savings and/or additional quality-adjusted life-years may be gained by replacing current interventions with more cost-effective interventions.
Highlights
Economic models have increasingly been used to inform decision-making regarding health care, as they provide an explicit way of synthesizing all available data to simulate the likely costs and consequences of using alternative interventions under scenarios that cannot be directly observed in the real world.[1]
Key Points Question Which interventions are costeffective for the prevention and treatment of schizophrenia?. In this decision analytical model using a simulated cohort of 200 000 individuals, the following interventions were found to be cost-effective: practice as usual plus cognitive behavioral therapy for individuals at clinical high risk of psychosis; a mix of hospital admission and crisis resolution and home treatment team for individuals with acute psychosis; receipt of amisulpride, risperidone, or olanzapine combined with family intervention for individuals with first-episode psychosis; and receipt of clozapine for individuals with treatment-resistant schizophrenia
The cost savings of cognitive behavioral therapy (CBT) are substantial (£1243 [$1588] per person), likely because the evidence used to inform the whole-disease model (WDM) suggests that CBT can delay the transition from clinical high risk of psychosis (CHR-P) to psychosis, and the
Summary
Economic models have increasingly been used to inform decision-making regarding health care, as they provide an explicit way of synthesizing all available data to simulate the likely costs and consequences of using alternative interventions under scenarios that cannot be directly observed in the real world.[1] A 2020 systematic review found several limitations of existing economic models for schizophrenia.[2] Most existing models (83%) focused on antipsychotic medications, while there was a lack of models for nonpharmacologic interventions, such as cognitive behavioral therapy (CBT), family intervention, and crisis resolution and home treatment team (CRHT). The quality of existing models was considered low. This systematic review highlighted issues relating to inconsistent assumptions and uses of evidence, which negatively affect the quality of existing economic studies in schizophrenia. A whole-disease model (WDM) represents a type of generic model that is unique in that it can be used to inform multiple resource allocation decisions across the entire care pathway
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