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Mueller-Stierlin AS, Dinc U, Herder K, Walendzik J, Schuetzwohl M, Becker T, Kilian R. The Cost-Effectiveness Analysis of an Integrated Mental Health Care Programme in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116814. [PMID: 35682397 PMCID: PMC9180080 DOI: 10.3390/ijerph19116814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
The network for mental health (NWpG = Netzwerk psychische Gesundheit) is an umbrella association for non-medical community mental health care facilities across Germany which are enabled to provide multi-professional mental health care packages including medical and psychosocial services reimbursed by German statutory health insurances since 2009. The aim of this study is to analyse the cost-effectiveness of providing NWpG mental health care packages plus treatment as usual (NWpG) to treatment as usual alone (TAU) in Germany. In a prospective, multicenter, controlled trial over 18 months, a total of 511 patients (NWpG = 251; TAU = 260) were observed in five regions, four times at six-month intervals. The EQ-5D-3L and the Client Sociodemographic and Service Receipt Inventory (CSSRI) were used to estimate quality-adjusted life-years and total costs of illness. Propensity score-adjusted cost–utility analysis was applied using the net benefit approach. No significant differences in costs and QALYs between NWpG and TAU groups were identified. The probability of NWpG being cost-effective compared to TAU was estimated below 75% for maximum willingness to pay (MWTP) values between 0 and 125,000 EUR. The additional provision of the NWpG package is not cost-effective compared to TAU alone.
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Affiliation(s)
- Annabel Sandra Mueller-Stierlin
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, 89075 Ulm, Germany
| | - Uemmueguelsuem Dinc
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | | | - Matthias Schuetzwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
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Mueller-Stierlin AS, Helmbrecht MJ, Herder K, Prinz S, Rosenfeld N, Walendzik J, Holzmann M, Dinc U, Schützwohl M, Becker T, Kilian R. Does one size really fit all? The effectiveness of a non-diagnosis-specific integrated mental health care program in Germany in a prospective, parallel-group controlled multi-centre trial. BMC Psychiatry 2017; 17:283. [PMID: 28764729 PMCID: PMC5539984 DOI: 10.1186/s12888-017-1441-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/24/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Network for Mental Health (NWpG-IC) is an integrated mental health care program implemented in 2009 by cooperation between health insurance companies and community mental health providers in Germany. Meanwhile about 10,000 patients have been enrolled. This is the first study evaluating the effectiveness of the program in comparison to standard mental health care in Germany. METHODS In a parallel-group controlled trial over 18 months conducted in five regions across Germany, a total of 260 patients enrolled in NWpG-IC and 251 patients in standard mental health care (TAU) were recruited between August 2013 and November 2014. The NWpG-IC patients had access to special services such as community-based multi-professional teams, case management, crisis intervention and family-oriented psychoeducation in addition to standard mental health care. The primary outcome empowerment (EPAS) and the secondary outcomes quality of life (WHO-QoL-BREF), satisfaction with psychiatric treatment (CSQ-8), psychosocial and clinical impairment (HoNOS) and information about mental health service needs (CAN) were measured four times at 6-month intervals. Linear mixed-effect regression models were used to estimate the main effects and interaction effects of treatment, time and primary diagnosis. Due to the non-randomised group assignment, propensity score adjustment was used to control the selection bias. RESULTS NWpG-IC and TAU groups did not differ with respect to most primary and secondary outcomes in our participating patients who showed a broad spectrum of psychiatric diagnoses and illness severities. However, a significant improvement in terms of patients' satisfaction with psychiatric care and their perception of treatment participation in favour of the NWpG-IC group was found. CONCLUSIONS Providing integrated mental health care for unspecific mentally ill target groups increases treatment participation and service satisfaction but seems not suitable to enhance the overall outcomes of mental health care in Germany. The implementation of strategies for ameliorating the needs orientation of the NWpG-IC should be considered. TRIAL REGISTRATION German Clinical Trial Register DRKS00005111 , registered 26 July 2013.
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Affiliation(s)
- Annabel Sandra Mueller-Stierlin
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Stefanie Prinz
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Nadine Rosenfeld
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Julia Walendzik
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Marco Holzmann
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Uemmueguelsuem Dinc
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Matthias Schützwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
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Sengul MCB, Karadag F, Sengul C, Karakulah K, Kalkanci O, Herken H. Risk of Psychotropic Drug Interactions in Real World Settings: a Pilot Study in Patients with Schizophrenia and Schizoaffective Disorder. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140311041445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Filiz Karadag
- Gazi University School of Medicine, Department of Psychiatry, Ankara - Turkey
| | - Cem Sengul
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Kamuran Karakulah
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Ozgur Kalkanci
- Servergazi State Hospital, Psychiatry Clinic, Denizli - Turkey
| | - Hasan Herken
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
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Rehospitalization risk of former voluntary and involuntary patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1719-27. [PMID: 24806950 DOI: 10.1007/s00127-014-0892-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 04/22/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. METHODS In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %) involuntarily. Follow-up assessments were conducted half-yearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a random-effect logit model and a random-effect tobit model. RESULTS After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. CONCLUSIONS Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients.
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Stierlin AS, Herder K, Helmbrecht MJ, Prinz S, Walendzik J, Holzmann M, Becker T, Schützwohl M, Kilian R. Effectiveness and efficiency of integrated mental health care programmes in Germany: study protocol of an observational controlled trial. BMC Psychiatry 2014; 14:163. [PMID: 24894310 PMCID: PMC4057655 DOI: 10.1186/1471-244x-14-163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 05/27/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since 2009 some German health insurance companies have implemented integrated mental health care services along the principles of assertive community treatment in collaboration with local mental health service providers across Germany. Focus of this study is the analysis of effectiveness and cost-effectiveness of this integrated care programme compared to care as usual in routine care surroundings in five regions in Germany. METHODS In this 18-month multi-centre observational trial 250 patients enrolled in an integrated mental health care programme and 250 patients who receive treatment as usual from five catchment areas will be included. In addition, in each group about 125 relatives of the participating patients will be included. The primary outcome criterion is the improvement of empowerment; secondary outcomes are subjective quality of life, functional impairment and costs of illness. Data will be collected at baseline and three follow-ups after 6, 12 and 18 months. Data will be analysed by means of mixed effects regression models. Propensity score methods are used for selection bias control. DISCUSSION Study results are expected to provide information about how integrated care programmes in their present form contribute to the improvement of mental health care. In addition, the study will provide hints to weaknesses of the current integrated care programme and options to overcome them. The major strengths of this study are the real-world character of the study intervention with a simultaneous high level of academic rigour. However, the fact that patients are not randomised to study groups and that there is no blinding might limit the study. TRIAL REGISTRATION German Clinical Trial Register DRKS00005111.
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Affiliation(s)
| | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | | | - Stefanie Prinz
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | - Julia Walendzik
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Marco Holzmann
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | - Matthias Schützwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
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Jäger M, Weiser P, Becker T, Frasch K, Längle G, Croissant D, Steinert T, Jaeger S, Kilian R. Identification of psychopathological course trajectories in schizophrenia. Psychiatry Res 2014; 215:274-9. [PMID: 24374114 DOI: 10.1016/j.psychres.2013.11.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 11/27/2013] [Accepted: 11/30/2013] [Indexed: 01/17/2023]
Abstract
Course trajectory analyses have been performed primarily for treatment response in acute episodes of schizophrenic disorders. As yet, corresponding data for the long-term course are lacking. Within a multicenter prospective observational study, 268 patients with schizophrenia were assessed at discharge from hospital and followed up after 6, 12, 18, and 24 months. A latent class growth analysis was performed on the scores from the Positive and Negative Syndrome Scale (PANSS). A two-class conditional latent class model showed the best data fit (Entropy: 0.924). The model divided the sample into a group with amelioration in all PANSS subscales (60%) and a group with stable positive/negative and deteriorating general psychopathology symptoms (40%). Global functioning (GAF score), gender, age, living situation and involuntary admission predicted course trajectory class membership. The model was predictive of significant differences between the two groups in health care service costs and quality of life. The results underline the heterogeneous course of the illness, which ranged from amelioration to deterioration over a 2-year period. Statistical models such as trajectory analysis could help to identify more homogenous subtypes in schizophrenia.
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Affiliation(s)
- Markus Jäger
- Ulm University, Department of Psychiatry and Psychotherapy II, BKH Günzburg, Ludwig-Heilmeyer-Str. 2, 89312 Günzburg, Germany.
| | - Prisca Weiser
- Ulm University, Department of Psychiatry and Psychotherapy II, BKH Günzburg, Ludwig-Heilmeyer-Str. 2, 89312 Günzburg, Germany
| | - Thomas Becker
- Ulm University, Department of Psychiatry and Psychotherapy II, BKH Günzburg, Ludwig-Heilmeyer-Str. 2, 89312 Günzburg, Germany
| | - Karel Frasch
- Ulm University, Department of Psychiatry and Psychotherapy II, BKH Günzburg, Ludwig-Heilmeyer-Str. 2, 89312 Günzburg, Germany
| | - Gerhard Längle
- Zentrum für Psychiatrie Südwürttemberg, Bad Schussenried, Germany; Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Daniela Croissant
- PP.rt Hospital for Psychiatry, Psychotherapy and Psychosomatics, Reutlingen, Germany
| | - Tilman Steinert
- (e)Ulm University, Department of Psychiatry and Psychotherapy I, Ravensburg, Germany; (f)Zentrum für Psychiatrie Südwürttemberg, Weissenau, Ravensburg, Germany
| | - Susanne Jaeger
- (e)Ulm University, Department of Psychiatry and Psychotherapy I, Ravensburg, Germany; (f)Zentrum für Psychiatrie Südwürttemberg, Weissenau, Ravensburg, Germany
| | - Reinhold Kilian
- Ulm University, Department of Psychiatry and Psychotherapy II, BKH Günzburg, Ludwig-Heilmeyer-Str. 2, 89312 Günzburg, Germany
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Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion. Soc Psychiatry Psychiatr Epidemiol 2013; 48:1787-96. [PMID: 23604621 DOI: 10.1007/s00127-013-0687-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 04/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of the study was to examine the long-term influence of involuntary hospitalization on medication adherence, engagement in out-patient treatment and perceived coercion to treatment participation. METHODS In a naturalistic observational multi-centre study, 290 voluntarily and 84 involuntarily hospitalized patients with schizophrenia or schizoaffective disorder had been followed up over a period of 2 years with half-yearly assessments. Assessments included self-rated medication adherence, externally judged medication adherence by blood levels, engagement in treatment and perceived coercion. The statistical analyses were based on multilevel hierarchical modelling of longitudinal data. Level and development of the outcome was controlled for involuntariness, for sociodemographic characteristics and clinical history. RESULTS Involuntariness of the index-hospitalization did not have an effect on the development of treatment engagement or medication adherence judged by blood levels in the course of the follow-up period when the models were controlled for sociodemographic variables and clinical history. It was associated, though, with a continuously lower self-rated medication adherence. Moreover, former involuntarily hospitalized patients more often felt coerced in several treatment aspects at the follow-up assessments. Yet, there was no difference between the voluntary and involuntary group with regard to the development of the levels of adherence or coercion experiences over time. CONCLUSIONS Involuntary hospitalization does not seem to impair future treatment engagement in patients with schizophrenia, but formerly involuntarily hospitalized patients continue to be more sensitive to subjective or real coercion in their treatment and more vulnerable to medication non-adherence. Hereby, their risk of future involuntary hospitalization might be increased.
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