Acknowledging Patient Heterogeneity in Economic Evaluations in Schizophrenia: A Systematic Review.

OBJECTIVES: Schizophrenia is a severe mental illness with heterogeneous etiology, range of symptoms, and course of illness. Cost-effectiveness analysis often applies averages from populations, which disregards patient heterogeneity even though there are a range of methods available to acknowledge patient heterogeneity. This review evaluates existing economic evaluations of interventions in schizophrenia to understand how patient heterogeneity is currently reflected in economic evaluation. METHODS: Electronic searches of MEDLINE, Embase, and PsycINFO via Ovid and the Health Technology Assessment database were run to identify full economic evaluations of interventions aiming to reduce the symptoms associated with schizophrenia. Two levels of screening were used, and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed. RESULTS: Seventy-six relevant studies were identified. More than half (41 of 76) of the articles acknowledged patient heterogeneity in some way through discussion or methods. There was a range of patient characteristics considered, including demographics and socioeconomic factors (eg, age, educational level, ethnicity), clinical characteristics (eg, symptom severity, comorbidities), and preferences (eg, preferences related to outcomes or symptoms). Subgroup analyses were rarely reported (8 of 76). CONCLUSIONS: Patient heterogeneity was frequently mentioned in studies but was rarely thoroughly investigated in the identified economic evaluations. When investigated, included patient characteristics and methods were found to be heterogeneous. Understanding and acknowledging patient heterogeneity may alter the conclusions of cost-effectiveness evaluations; subsequently, we would encourage further research in this area.

Real-World Outcomes and Costs Following 6 Months of Treatment with the Long-Acting Injectable (LAI) Aripiprazole Lauroxil for the Treatment of Schizophrenia.

BACKGROUND: Continuous antipsychotic therapy is recommended as part of long-term maintenance treatment of schizophrenia, and gaps in antipsychotic treatment have been associated with increased risks of relapse and rehospitalization. Because the use of long-acting injectable (LAI) antipsychotics may reduce the likelihood of undetected medication gaps, initiating an LAI medication may affect resource utilization and costs. The LAI aripiprazole lauroxil (AL) was approved in the United States (US) in 2015 for the treatment of schizophrenia in adults. OBJECTIVE: The objective of this retrospective observational cohort study was to examine treatment patterns, resource utilization, and costs following initiation of AL for the treatment of schizophrenia in adults. METHODS: A retrospective analysis of Medicaid claims data identified a cohort of patients (N = 485) starting AL shortly after Food and Drug Administration approval in October 2015. Treatment patterns, resource utilization, and costs were compared 6 months before and after treatment initiation. Subgroup analyses were conducted based on the type of antipsychotic (LAI, oral, or none) received before initiation of AL. RESULTS: Over 6 months of follow-up, patients received an average of 4.6 injections out of a maximum of six (77%). After initiating AL, all-cause inpatient admissions decreased by 22.4%; other significant reductions were observed in mental health-related admissions and emergency room (ER) visits. All-cause inpatient costs decreased by an average of US$2836 per patient (p < 0.05) in the 6-month post-AL period, whereas outpatient pharmacy costs increased by US$4121 (p < 0.05), resulting in no significant difference in overall costs between the pre- and post-AL periods. The subgroup of patients who had been prescribed an oral antipsychotic before starting AL had significant reductions in proportion of patients with inpatient and ER visits and costs, but also reported a significant increase in pharmacy costs. CONCLUSIONS: AL was associated with a significant reduction in inpatient costs and an increase in outpatient pharmacy costs, resulting in no changes in total healthcare costs over 6 months. The adherence rate and reductions in inpatient use may indicate the potential for greater clinical stability among patients initiated on AL compared with their previous treatment.

Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data.

AIM: To identify a national population of individuals living with schizophrenia in New Zealand, and to examine health, social support, justice, economic outcomes and estimated government costs compared to a matched comparison group. METHODS: Data were sourced from the Integrated Data Infrastructure. Individuals with a schizophrenia diagnosis in public hospital discharge or specialist secondary mental health service data, aged 18 to 64 and living in New Zealand were included in the schizophrenia population. Propensity score matching was used to select a comparison group of individuals without schizophrenia from the New Zealand resident population and compare outcomes and costs. RESULTS: In 2015 there were 18,096 people living with schizophrenia in New Zealand, a prevalence of 6.7 per 1,000 people. Compared to the matched comparison population, individuals with schizophrenia had higher hospitalisation rates for mental (OR=52.80) and physical (OR=1.18) health conditions. They were more likely to receive social welfare benefits (OR=17.64), less likely to be employed (OR=0.11) and had lower income ($26,226 lower). Per-person government costs were higher for the schizophrenia group across all domains, particularly health ($14,847 higher) and social support ($11,823 higher). CONCLUSION: Schizophrenia is associated with a range of adverse health, social and economic outcomes and considerably higher government costs compared to the general population.

Economic burden in Medicaid beneficiaries with recently relapsed schizophrenia or with uncontrolled symptoms of schizophrenia not adherent to antipsychotics.

BACKGROUND: Patients with schizophrenia struggle with disease relapses and uncontrolled symptoms, which can either result in or be a result of non-adherence to antipsychotics (APs). The economic burden of such patients is hypothesized to be substantial. OBJECTIVE: To evaluate the economic burden of recently relapsed schizophrenia or of uncontrolled symptoms of schizophrenia with non-adherence to APs in Medicaid beneficiaries. METHODS: Adults with ≥ 2 schizophrenia diagnoses and controls without schizophrenia were identified in Medicaid data (1997Q1-2018Q1) from Iowa, Kansas, Mississippi, Missouri, New Jersey, and Wisconsin. The index date was the last observed schizophrenia diagnosis (cohort with schizophrenia) or the last service claim (control cohort) with ≥ 12 months of continuous Medicaid enrollment before and after it. Cohorts were matched 1:1 using propensity scores. After matching, two subgroups were identified among adults with schizophrenia: (1) patients with schizophrenia and a recent relapse (≥ 1 schizophrenia-related inpatient or emergency department claim ≤ 60 days before or on the index date) and (2) patients with uncontrolled symptoms of schizophrenia (≥ 2 schizophrenia-related hospitalizations) and non-adherence to APs (proportion of days covered < 80%) in the 12-month pre-index period. Previously matched controls were then subset to patients in each subgroup and their matched pairs without schizophrenia, thus maintaining the 1:1 matching ratio. Healthcare resource utilization (HRU) and costs ($2018 USD) in the 12-month post-index (observation) period were compared between matched pairs using adjusted regression models. RESULTS: Among 158,763 patients with schizophrenia, 18,771 (11.8%) had a recent relapse (mean age 50.5 years; 48.6% female, 51.4% male) and 13,697 (8.6%) were not adherent to APs and had uncontrolled symptoms of schizophrenia (mean age 47.1 years; 48.0% female, 52.0% male). During the observation period, patients with recently relapsed schizophrenia and those non-adherent to APs with uncontrolled symptoms of schizophrenia had significantly higher HRU relative to their controls without schizophrenia. Patients with recently relapsed schizophrenia had mean total healthcare costs $21,862 higher relative to their controls ($37,424 vs $15,563), driven by $8,486 higher mean long-term care costs (all P < 0.001). Patients non-adherent to APs with uncontrolled symptoms of schizophrenia had adjusted mean total healthcare costs $20,787 higher relative to their controls ($38,337 vs $15,241), driven by $8,019 higher adjusted mean inpatient costs (all P < 0.001). Additional total healthcare costs incurred by patients with recently relapsed schizophrenia and those of patients non-adherent to APs with uncontrolled symptoms of schizophrenia exceeded by 55.2% and 47.6%, respectively, incremental total healthcare costs incurred by all patients with schizophrenia ($14,087). CONCLUSIONS: Patients with recently relapsed schizophrenia and those non-adherent to AP therapy with uncontrolled symptoms of schizophrenia incurred higher HRU and costs relative to patients without schizophrenia. Additional healthcare costs of these subgroups of patients with schizophrenia appeared higher than in the overall population with schizophrenia. DISCLOSURES: This study was supported by Janssen Scientific Affairs, LLC. The sponsor was involved in the study design, data collection, data analysis, manuscript preparation, and publication decisions. Pilon, Lafeuille, Zhdanava, Côté-Sergent, Rossi, and Lefebvre are employees of Analysis Group, Inc., a consulting company that has provided paid consulting services to Janssen Scientific Affairs, LLC, which funded the development and conduct of this study and manuscript. Patel, Joshi, and Lin are employees of Janssen Scientific Affairs, LLC and stockholders of Johnson & Johnson. Part of the material in this manuscript has been presented at the US Psych Congress, October 3-6, 2019, San Diego, CA, and at the Virtual ISPOR Meeting, May 18-20, 2020.

Cost-Sharing Increase, Medication Adherence, and Hospitalizations in Schizophrenia Patients: A Natural Experiment.

Increases in medication cost-sharing rates remain a controversial system-wide cost-containment measure for chronic mental health patients. The objective was to investigate the effects of cost-sharing increases on adherence to prescribed antipsychotic medication and psychiatric hospitalizations among patients with schizophrenia. In July 2012, a Spanish National Law raised the cost-sharing rate from 0 to 10% for pensioner outpatient medication while cost-sharing remained at 0% for other socioeconomic groups. To estimate the effects of the reform, we analyzed the prevalent adult schizophrenic population of Valencia, Spain, followed up 1 year before and after the Law took effect. We used a quasi-experimental design with a patient fixed-effects difference-in-differences regression to evaluate the reform effects on antipsychotic medication adherence, prescription, and hospitalization rates. A total of 5,672 included patients were exposed to the reform, whereas 5,545 were not. There were no differences in adherence, prescription, or hospitalization rates between exposed and nonexposed patients prior to its implementation. The odds ratio of exposed patients remaining adherent to issued prescriptions after the reform took effect were 0.70 99% confidence interval (CI 0.66-0.75), in relation to the nonexposed group. Additionally, the reform was associated with a reduction in exposure to antipsychotic medication (odds ratio (OR) 0.85, 99%CI 0.83-0.88) and an increase in hospitalization risk (OR 1.13, 99% CI 1.05-1.23) during the first year after implementation. Policies raising the cost-sharing rate of medication for patients with schizophrenia are simultaneously associated with unintended effects. We report decreases in antipsychotic exposure and increases in hospitalization rates that lasted for 1 year after follow-up.

Real-World Evidence of the Clinical and Economic Impact of Long-Acting Injectable Versus Oral Antipsychotics Among Patients with Schizophrenia in the United States: A Systematic Review and Meta-Analysis.

BACKGROUND: Long-acting injectable (LAI) antipsychotics, compared with oral antipsychotics (OA), have been found to significantly improve patient outcomes, including reduced hospitalizations and emergency room (ER) admissions and increased medication adherence among adult patients with schizophrenia. In turn, the clinical benefits achieved may translate into lower economic burden. Real-world evidence of the comparative effectiveness of LAI is needed to understand the potential benefits of LAI outside of the context of clinical trials. This study aimed to provide a comprehensive synthesis of recent published real-world studies comparing healthcare utilization, costs, and adherence between patients with schizophrenia treated with LAI versus OA in the United States. METHODS: In this systematic literature review, MEDLINE® was searched for peer-reviewed, real-world studies (i.e., retrospective or pragmatic designs) published in English between January 1, 2010 and February 10, 2020. Comparative studies reporting hospitalizations, ER admissions, healthcare costs, or medication adherence (measured by proportion of days covered [PDC]) in adults with schizophrenia treated with LAI versus OA (or pre- vs post-LAI initiation) in the United States were retained. Random effects meta-analyses were conducted among eligible studies to evaluate the association of LAI versus OA use on hospitalizations, ER admissions, healthcare costs, and treatment adherence. A sensitivity analysis among the subset of studies that compared OA with paliperidone palmitate once monthly (PP1M), specifically, was conducted. RESULTS: A total of 1083 articles were identified by the electronic literature search, and two publications were manually added subsequently. Among the 57 publications meeting the inclusion criteria, 25 provided sufficient information for inclusion in the meta-analyses. Compared with patients treated with OA, patients initiated on LAI had lower odds of hospitalization (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.54-0.71, n = 7), fewer hospitalizations (incidence rate ratio [IRR] [95% CI] 0.75 [0.65-0.88], n = 9), and fewer ER admissions (IRR [95% CI] 0.86 [0.77-0.97], n = 6). The initiation of LAI was associated with higher per-patient-per-year (PPPY) pharmacy costs (mean difference [MD] [95% CI] $5603 [3799-7407], n = 6), which was offset by lower PPPY medical costs (MD [95% CI] - $5404 [- 7745 to - 3064], n = 6), resulting in no significant net difference in PPPY total all-cause healthcare costs between patients treated with LAI and those treated with OA (MD [95% CI] $327 [- 1565 to 2219], n = 7). Patients initiated on LAI also had higher odds of being adherent to their medication (PDC ≥ 80%; OR [95% CI] 1.89 [1.52-2.35], n = 9). A sensitivity analysis on a subset of publications evaluating PP1M found results similar to those of the main analysis conducted at the LAI class level. CONCLUSIONS: Based on multiple studies with varying sub-types of patient populations with schizophrenia in the United States published in the last decade, this meta-analysis demonstrated that LAI antipsychotics were associated with improved medication adherence and significant clinical benefit such as reduced hospitalizations and ER admissions compared with OA. The lower medical costs offset the higher pharmacy costs, resulting in a non-significant difference in total healthcare costs. Taken together, these findings provide strong evidence on the clinical and economic benefits of LAI compared with OA for the treatment of schizophrenia in the real world.

Economic Impact of Schizophrenia from a Hospital and Social Security System Perspective in Italy.

BACKGROUND: Schizophrenia is one of the mental disorders with the highest economic and social costs, with an important burden on patients, caregivers, and society. OBJECTIVE: The objective of this study was to estimate the direct and social security costs of schizophrenia in Italy. As far as direct costs are concerned, those related to hospitalizations and pharmaceutical expenditure have been analyzed, while disability benefits (DBs) and incapacity pensions (IPs) have been considered for the social security costs. METHODS: In order to provide annual economic burden of schizophrenia using the real-world data, we analyzed the main regional and national databases related to hospitalizations and pharmaceuticals. Hospitalizations have been analyzed considering the Hospital Information System, which collects all the information regarding hospital discharges from all public and private hospitals (psychiatric wards or residential facilities have not been considered). Hospitalizations with a discharge date between 2009 and 2016, and with a primary or secondary diagnosis of schizophrenia (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 295.xx) were selected. Hospital costs have been estimated considering the national tariffs associated with each selected hospitalization. In addition, using the same inclusion criteria, the average DBs (for workers with reduced working capacity) and IPs (for workers without working capacity) provided each year have been analyzed from the social security benefit applications database. The estimate of pharmaceutical expenditure was prepared based on the OsMed 2018 Report (Italian Medicines Agency, latest issue 18 July 2019). A one-way deterministic sensitivity analysis was conducted to examine the robustness of the results. RESULTS: In Italy from 2009 to 2016, schizophrenia had an important economic impact from a social perspective. On average, 13,800 patients were hospitalized, with an average of 2.98 hospitalizations per patient. From a National Health Service (NHS) perspective and with specific reference to hospitalizations, the annual economic burden was €101.4 million, with an average cost per patient of €7338. On the other hand, pharmaceutical expenditure amounts to over €147 million each year, while residential, semi-residential, and specialist facilities amount to approximately €1 billion. Again, schizophrenia led to approximately 15,000 recipients of social security benefits (DBs and IPs) yearly from 2009 to 2015, with an average annual expenditure of €160.1 million (average cost per patient = €10,675). CONCLUSIONS: Our study estimates an economic burden of schizophrenia of €1250 million per year in direct costs, of which 20% is related to hospitalizations and pharmaceutical expenditure. With regard to social security benefits, an average annual expenditure of €160.1 million was calculated (average cost per patient = €10,675).

Cost of the Illness of Treatment-Resistant Schizophrenia: A Mirror Image Study Comparing Clozapine With Other Antipsychotics.

PURPOSE/BACKGROUND: This study aimed to evaluate and compare the cost of illness in patients with treatment-resistant schizophrenia (TRS) during 3 months before starting clozapine and for the initial 3 months of treatment with clozapine. METHODS/PROCEDURES: Fifty-two patients with TRS were evaluated for the cost of illness (direct, indirect, and provider cost) by using a structured questionnaire for the period of 3 months before starting clozapine and then at the end of the 3 months of clozapine therapy. FINDINGS/RESULTS: Total treatment cost for the period of 3 months before starting clozapine was Indian rupees (INR) 40,372 (560.72 US dollars), and the total treatment cost for the first 3 months of clozapine therapy was INR 40,553 (563.23 US dollars). At both the assessments, indirect cost formed the main bulk of the total cost, with no significant difference in the indirect cost. The total direct treatment cost reduced from INR 13,931.6 (193.49 US dollars) to INR 8756 (121.61 US dollars), and the difference between the 2 assessments was statistically significant, with an advantage for clozapine. Overall, after starting clozapine, the total direct cost reduced from 34.5% to 21.6%, and the total indirect cost reduced from 54.3% to 40.2%. After starting clozapine, total provider cost increased from 11.2% to 38.2% of the totalcost. IMPLICATIONS/CONCLUSIONS: Treatment with clozapine is not associated with a significant increase in the overall treatment cost, in the short term. However, there is a significant reduction in direct treatment costs.

Using the NIH Research, Condition and Disease Categorization Database for research advocacy: Schizophrenia research at NIMH as an example.

In 2008 the National Institutes of Health established the Research, Condition and Disease Categorization Database (RCDC) that reports the amount spent by NIH institutes for each disease. Its goal is to allow the public "to know how the NIH spends their tax dollars," but it has been little used. The RCDC for 2018 was used to assess 428 schizophrenia-related research projects funded by the National Institute of Mental Health. Three senior psychiatrists independently rated each on its likelihood ("likely", "possible", "very unlikely") of improving the symptoms and/or quality of life for individuals with schizophrenia within 20 years. At least one reviewer rated 386 (90%), and all three reviewers rated 302 (71%), of the research projects as very unlikely to provide clinical improvement within 20 years. Reviewer agreement for the "very unlikely" category was good; for the "possible" category was intermediate; and for the "likely" category was poor. At least one reviewer rated 30 (7%) of the research projects as likely to provide clinical improvement within 20 years. The cost of the 30 projects was 5.5% of the total NIMH schizophrenia-related portfolio or 0.6% of the total NIMH budget. Study results confirm previous 2016 criticisms that the NIMH schizophrenia-related research portfolio disproportionately underfunds clinical research that might help people currently affected. Although the results are preliminary, since the RCDC database has not previously been used in this manner and because of the subjective nature of the assessment, the database would appear to be a useful tool for disease advocates who wish to ascertain how NIH spends its public funds.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees.

Importance: Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. Objective: To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. Design, Setting, and Participants: This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Exposures: Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Main Outcomes and Measures: Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. Results: The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). Conclusions and Relevance: This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.

Productivity Loss in Patients With Chronic Diseases: A Pooled Economic Analysis of Hungarian Cost-of-Illness Studies.

OBJECTIVES: To assess productivity loss (PL) variations across a set of chronic diseases and analyze significant PL drivers (demographics, health status, healthcare resource use) in Hungary. METHODS: Data from 11 cost-of-illness studies (psoriasis, dementia, systemic sclerosis, multiple sclerosis, benign prostatic hyperplasia, Parkinson's disease, psoriatic arthritis, rheumatoid arthritis, schizophrenia, epilepsy, and diabetes) were pooled, and patient-level data were analyzed. A weighted multiple linear regression analysis was run to identify significant PL indicators. All costs were adjusted to 2018 euro rates and PL was further presented as a proportion of gross domestic product/capita, facilitating results comparability and transferability. RESULTS: The dataset comprised 1888 patients from 11 chronic diseases. The average indirect cost/(gross domestic product/capita) ratio was highest in schizophrenia (72.4%) and rheumatoid arthritis (71.3%) and lowest in benign prostatic hyperplasia (1.6%). Correlation results infer that a higher EuroQol 5-dimension 3-level index score was significantly associated with lower PL. The number of hospital admissions was the main contributor toward increasing PL among resource use indicators. Age and sex showed inconsistent and insignificant correlations with PL. In regression analysis, a better EuroQol 5-dimension 3-level index score and higher education were consistently associated with decreasing PL in all models. CONCLUSIONS: This article will enable health decision makers to understand the importance of adopting a societal perspective for chronic disease reimbursement decisions. The correlation between PL and health status supports that timely started effective treatments may prevent patients from losing their workability.

Cost-effectiveness of aripiprazole orally disintegrating tablets in the treatment of schizophrenia in China.

BACKGROUND: Orally disintegrating tablet (ODT) formulation of antipsychotics is one of the innovative drug delivery systems developed to improve medication adherence. We aimed to evaluate the cost-effectiveness of aripiprazole ODT vs. aripiprazole standard oral tablet (SOT), as well as olanzapine SOT in China. METHODS: We developed a discrete event simulation model from government payers' perspective. On the entry, 100,000 patients in each group were simulated for relapse, adverse events, changing adherence level, medication discontinuation, switching or quitting in response to three different medication adherence levels. The model projected quality adjusted life years (QALYs) and treatment costs over a 1-year time horizon. Parameter uncertainties were assessed through sensitivity analyses. RESULTS: The QALYs per patient over 1-year treatment with aripiprazole ODT, aripiprazole SOT, or olanzapine SOT, were 0.7282, 0.7112, and 0.7218, respectively. The corresponding costs were $1,423, $2,215, and $1,493. In both comparisons, aripiprazole ODT was dominant. Compared with aripiprazole SOT and olanzapine SOT, the likelihood of aripiprazole ODT being cost-effective was 99.2% and 69.2%, respectively, using 3 times per capita GDP per QALY as willingness-to-pay threshold. CONCLUSIONS: The aripiprazole ODT is associated with more QALYs at lower costs compared with both aripiprazole SOT and olanzapine SOT in treating schizophrenia in China.

The cost-of-illness trend of schizophrenia in South Korea from 2006 to 2016.

Globally, about one in four people develop a psychiatric disorder during their lifetime. Specifically, the lifetime prevalence of schizophrenia is about 0.48%, and schizophrenia can have detrimental effects on a patient's life. Therefore, estimating the economic burden of schizophrenia is important. We investigated the cost-of-illness trend of schizophrenia in South Korea from 2006 to 2016. The cost-of-illness trend was estimated from a societal perspective using a prevalence-based approach for direct costs and a human capital approach for indirect costs. We utilized information from the following sources: 1) National Health Insurance Service, 2) Korean Statistical Information Service, Statistics Korea, 3) the National Survey of Persons with Disabilities, 4) Budget and Fund Operation Plan, Ministry of Justice, 5) Budget and Fund Operation Plan, Ministry of Health and Welfare, and 6) annual reports from the National Mental Health Welfare Commission. Direct healthcare costs, direct non-healthcare costs, and indirect costs by sex and age group were calculated along with sensitivity analyses of the estimates. The cost-of-illness of schizophrenia in Korea steadily increased from 2006 to 2016, with most costs being indirect costs. Individuals in their 40s and 50s accounted for most of the direct and indirect costs. Among indirect costs, the costs due to unemployment were most prevalent. Our estimation implies that schizophrenia is associated with a vast cost-of-illness in Korea. Policymakers, researchers, and physicians need to put effort into shortening the duration of untreated psychosis, guide patients to receive community-care-based services rather than hospital-based services and empower lay people to learn about schizophrenia.

Factors associated with 30-day readmissions following medical hospitalizations among Medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder.

While evidence suggests that adults with serious mental illness have an elevated rate of 30-day readmissions after medical hospitalizations, most studies are of patients who are privately insured or Medicare beneficiaries, and little is known about the differential experiences of people with schizophrenia, bipolar disorder, and major depression. We used the Truven Health Analytics MarketScan® Medicaid Multi-State Database to study 43,817 Medicaid enrollees from 11 states, age 18-64, who were discharged from medical hospitalizations in 2011. Our outcome was unplanned all-cause readmissions within 30 days of discharge. In a multivariable analysis, compared to those with no SMI, people with schizophrenia had the highest odds of 30-day readmission (aOR: 1.46, 95% CI: 1.33-1.59), followed by those with bipolar disorder (aOR: 1.25, 95% CI: 1.14-1.38), and those with major depressive disorder (aOR: 1.18, 95% CI: 1.06-1.30). Readmissions also were more likely among those with substance use disorders, males, those with Medicaid eligibility due to disability, patients with longer index hospitalizations, and those with 2 or more medical co-morbidities. This is the first large-scale study to demonstrate the elevated risk of hospital readmission among low-income, working-age adults with schizophrenia. Given their greater psychological, social, and economic vulnerability, our findings can be used to design transition interventions and service delivery systems that address their complex needs.

Evaluation of the Cost-effectiveness of Services for Schizophrenia in the UK Across the Entire Care Pathway in a Single Whole-Disease Model.

Importance: 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. Objectives: 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. Design, Setting, and Participants: 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. Exposures: 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. Main Outcomes and Measures: Life-time costs and quality-adjusted life-years. Results: 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). Conclusions and Relevance: 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.

Disease burden of schizophrenia patients visiting a Chinese regional mental health centre.

Aim & methods: A decision-analytic model was constructed to simulate a real-world cohort of Chinese patients visiting a Chinese regional mental health center for long-term health outcomes and direct medical costs. Results: When compared with age and gender-matched general population, the Chinese patients with schizophrenia were associated with reduced overall survival by 20.6 years (27.6 vs 48.2 years) and reduced quality-adjusted life years (QALY) by 18.4 QALY (18.4 vs 36.8 QALY), respectively, and increased lifetime direct medical costs by about three-times (US$84,324 vs 33,387 as of 31 December 2017) on average. Conclusion: The burden of schizophrenia was mainly driven by the mortality associated with relapsed schizophrenia and direct medical costs for schizophrenia in local mental health rehabilitation institutes.

Comparative cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China.

BACKGROUND: Both amisulpride and olanzapine are leading treatments for schizophrenia in China. This study aimed to investigate the long-term cost-effectiveness of amisulpride and olanzapine in the treatment of schizophrenia in China. METHODS: A decision-analytic Markov model was developed to simulate the lifetime clinical and economic outcomes of schizophrenia treatment from the healthcare payer perspective. The long-term costs and QALYs were estimated. Sensitivity analyses were performed to explore the impact of variance of parameters on the results. RESULTS: Treatment with amisulpride provided an effectiveness gain of 16.59 QALYs at an average cost of USD 25,884 whereas olanzapine resulted in 16.38 QALYs at a cost of USD 34,839 over a lifetime horizon. One-way sensitivity analysis suggested that the most sensitive variable was the unit cost of olanzapine. In a probabilistic sensitivity analysis based on a Monte Carlo simulation with a lifetime horizon, the probability of amisulpride being cost-effective was 99.8% at a willingness-to-pay threshold of USD 9,322, the GDP per capita in China 2018. A scenario analysis with updated olanzapine unit cost suggested an ICER of 7,857 USD/QALY. CONCLUSIONS: Amisulpride is likely to be a cost-effective option with increased effectiveness compared with olanzapine in the treatment of schizophrenia patients in China.

Schizophrenia: opportunities to improve outcomes and reduce economic burden through managed care.

Schizophrenia is a complicated chronic disease affecting approximately 3.5 million people in the United States, and its annual healthcare costs exceed $155 billion. People living with schizophrenia often experience a reduced quality of life (QOL) and are more likely to be homeless, unemployed, or living in poverty compared with the general population. Life expectancy for patients with schizophrenia is 15 to 20 years below the average and is complicated by numerous comorbidities, such as weight gain, increased cardiovascular risk, and changes in mood and cognition. Treatment nonadherence can increase the risk of relapse, rehospitalization, and self-harm, leading to a reduced QOL and increased economic burden. Managed care professionals are positioned to improve adherence and outcomes through various drug utilization strategies. Clinicians may also empower patients with schizophrenia through shared decision making and the creation of a therapeutic alliance. Careful monitoring of medication-related adverse effects and offering potential medication alternatives and routes of administration when indicated may also improve adherence to treatment regimens, resulting in improved outcomes and reduced healthcare costs.