Clinical and health economic outcomes of an outcomes-based agreement to prevent relapse in schizophrenia

Background

Relapse is common in schizophrenia and is associated with poor outcomes and the development of treatment resistance. The use of long-acting injectable antipsychotics has been shown to reduce relapse rates. This report summarises the results of an outcomes-based agreement between Leicestershire Partnership NHS Trust and Lundbeck Ltd. that linked the acquisition cost of treatment to the achievement of a specific health outcome – relapse prevention.

Methods

Outcomes were evaluated in schizophrenia patients admitted to hospital with a psychotic episode (index admission) who were subsequently discharged on aripiprazole once-monthly long-acting injectable (AOM). Patients were allocated to three-monthly cohorts. The agreement specified that, for each cohort, the number of admissions in the 6 months post-discharge should be at least 30% lower than in the preceding 6 months, including the index admission. If the threshold was exceeded, the cost of treatment for the entire cohort for the subsequent 6 months would be reimbursed. Using a mirror-image design, the primary outcome was the number of admissions in the 6 months post-discharge compared with the number of admissions in the preceding 6 months. Secondary outcomes included bed occupancy and a range of economic measures with costs estimated for: i. bed occupancy; ii. the cost of AOM; iii. the cost of community visits for administration of AOM.

Outcomes

Over two years, in eight cohorts of varying size, a total of 95 patients entered the scheme. The total number of admissions including the index admission in the 6 months prior to discharge on AOM was 121. In the 6 months post-discharge, the total number of admissions was 19, a reduction of 84.2%. The threshold for breaching the agreement was not met for any cohort.

The total number of bed days occupied before discharge on AOM was 10,694, with a mean length of hospital stay in the index admission of 99.7 days. In the 6 months post-discharge, the total number of bed days occupied was 2,137, with a mean length of stay of 112.5 days. The difference was 8,557 bed-days, equivalent to an increase in bed availability of 47 beds.

Post-discharge, 76 patients were not re-admitted and each received 6 doses of AOM with a total estimated cost of GBP 228,187 including community visits; 19 patients who were re-admitted received between them a total of 22 AOM doses at a total estimated cost of GBP 11,009 including community visits.

The total cost difference, pre- and post-discharge, including bed occupancy and the cost of AOM plus community visits was GBP 4.68 million, equivalent to a saving of GBP 49,275 per patient.

Conclusions

The outcomes-based agreement aligned with usual clinical practice and no outcomes data were required beyond those that were routinely collected. Relapse rates were reduced by nearly 85% with an estimated cost saving of GBP 4.68 million.

References

No references