Abstract
BACKGROUND: The absence of economic evidence hinders current reforms of hospital-based mental health systems in central and eastern Europe. We aimed to assess the cost-effectiveness of discharge to community care for people with chronic psychoses compared with care in psychiatric hospitals in the Czech Republic.
METHODS: We did a prospective study of people aged 18-64 years with chronic psychotic disorders in the Czech Republic who had been discharged into community services or were receiving inpatient psychiatric care for at least 3 months at baseline. We measured health-related quality of life with the EuroQol five-dimension five-level questionnaire. Adjusting for baseline differences between the two groups, we assessed differences in societal costs in 2016 and quality-adjusted life-years (QALYs) during a 12-month follow-up, which we then used to estimate the incremental cost-effectiveness ratio (ICER). We did multiple sensitivity analyses to assess the robustness of our results.
FINDINGS: In our baseline case scenario, we included 115 patients who were either community service users (n=35) or inpatients (n=80) at baseline. The two groups were similar in terms of baseline characteristics. The annual QALY was 0·77 in patients receiving community care at baseline compared with 0·80 in patients in hospital at baseline (difference 0·03, 95% CI -0·04 to 0·10), but the costs of discharge to the community were €8503 compared with €16 425 for no discharge (difference €7922, 95% CI 4497-11 346), such that the ICER reached more than €250 000 per QALY. This ICER is substantially higher than levels that are conventionally considered to be cost-effective and the estimated probability that discharge to the community was cost-effective was very high (≥97%). None of the sensitivity analyses changed these results qualitatively.
INTERPRETATION: This study provides economic evidence for deinstitutionalisation by showing that discharge to community care is cost-effective compared with care in psychiatric hospitals in the Czech Republic. These findings add to the human rights and clinical-based arguments for mental health-care reforms in central and eastern Europe.
FUNDING: Ministry of Education, Youth and Sports of the Czech Republic; EEA and Norway Grants.
| Original language | English |
|---|---|
| Pages (from-to) | 1023-1031 |
| Number of pages | 9 |
| Journal | The Lancet. Psychiatry |
| Volume | 5 |
| Issue number | 12 |
| DOIs | |
| Publication status | Published - Dec 2018 |
| Externally published | Yes |
Bibliographical note
Copyright © 2018 Elsevier Ltd. All rights reserved.Funding
The study was supported by the project MERRPS , CZ.03.3.X/0.0/0.0/15_124/0006067 , Ministry of Labour and Social Affairs of the Czech Republic. The study was further supported by the project Sustainability for the National Institute of Mental Health, LO1611, Ministry of Education, Youth and Sports of the Czech Republic under the NPU I programme. The study was also supported by the project SUPR financed by the EEA and Norway Grants (project number NF-CZ11-PDP-1-002-2014; The Creation of the Comprehensive Rehabilitation System for the Mentally Ill and its Implementation in the Inpatient Facilities). We would like to thank Anna Kagstrom for proofreading the report. We are grateful to all respondents as well as to all individuals who collected the data.
| Funders | Funder number |
|---|---|
| Comprehensive Rehabilitation System | |
| National Institute of Mental Health | LO1611 |
| European Environment Agency | |
| Ministerstvo Školství, Mládeže a Tělovýchovy | |
| Norway Grants | NF-CZ11-PDP-1-002-2014 |
Keywords
- Adult
- Community Mental Health Services/economics
- Cost-Benefit Analysis
- Czech Republic
- Female
- Hospitals, Psychiatric/economics
- Humans
- Male
- Middle Aged
- Prospective Studies
- Psychotic Disorders/therapy
- Quality-Adjusted Life Years
- Young Adult