[Cost evaluation of a model for integrated care of seriously mentally ill patients]

[Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]

BACKGROUND

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.

OBJECTIVE

Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.

MATERIAL AND METHODS

A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.

RESULTS

A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.

CONCLUSION

The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.

Quality of life in patients with severe mental illness: a cross-sectional survey in an integrated outpatient health care model

PURPOSE

This study (a) assessed quality of life (QoL) in a patient sample with severe mental illness in an integrated psychiatric care (IC) programme in selected regions in Germany, (b) compared QoL among diagnostic groups and (c) identified socio-demographic, psychiatric anamnestic and clinical characteristics associated with QoL.

METHODS

This cross-sectional study included severely mentally ill outpatients with substantial impairments in social functioning. Separate dimensions of QoL were assessed with the World Health Organisation's generic 26-item quality of life (WHOQOL-BREF) instrument. Descriptive analyses and analyses of variance (ANOVAs) were conducted for the overall sample as well as for diagnostic group.

RESULTS

A total of 953 patients fully completed the WHOQOL-BREF questionnaire. QoL in this sample was lower than in the general population (mean 34.1; 95% confidence interval (CI) 32.8 to 35.5), with the lowest QoL in unipolar depression patients (mean 30.5; 95% CI 28.9 to 32.2) and the highest in dementia patients (mean 53.0; 95% CI 47.5 to 58.5). Main psychiatric diagnosis, living situation (alone, partner/relatives, assisted), number of disease episodes, source of income, age and clinical global impression (CGI) scores were identified as potential predictors of QoL, but explained only a small part of the variation.

CONCLUSION

Aspects of health care that increase QoL despite the presence of a mental disorder are essential for severely mentally ill patients, as complete freedom from the disorder cannot be expected. QoL as a patient-centred outcome should be used as only one component among the recovery measures evaluating treatment outcomes in mental health care.

Effectiveness and cost-effectiveness of a community-based mental health care programme (GBV) for people with severe mental illness in Germany: study protocol for a randomised controlled trial

BACKGROUND

The community-based mental health care programme GBV is based on the British Community Mental Health Teams and the Dutch Flexible Assertive Community Treatment model. In addition, the programme offers crisis-intervention services. A special feature of this integrated care programme is the initial standardised assessment process regarding empowerment, unmet care needs, and psychosocial functioning, used to verify the need for such a comprehensive form of care. The project evaluates the assessment process and analyses the effectiveness and cost-effectiveness of GBV compared to treatment as usual.

METHODS

This randomised, controlled study includes five assessments over 2 years. In twelve regions in Germany, 1000 patients with severely impaired psychosocial functioning and unmet care needs will be recruited. Study eligibility relies on an indication for GBV based on the results of the initial assessment. The primary outcome is improved self-reported empowerment. Further outcomes include improved treatment satisfaction and subjective quality of life, reductions in patients' unmet needs and illness-related clinical and social impairment, and an improved cost-effectiveness ratio of the resources used (from the perspectives of both statutory health insurance and the national economy). In addition, the GBV's effects on the burden and quality of life of informal caregivers of patients will be investigated.

DISCUSSION

The study's results are expected to provide information on whether the community-based mental health care programme GBV contributes to improving mental health care provision in Germany. In addition, the study will show whether the GBV successfully overcomes the weaknesses that former research has identified regarding a German integrated care programme. Such improvement is particularly expected with respect to the semi-structured assessment within GBV.

TRIAL REGISTRATION

German Clinical Trial Register, DRKS00019086 . Registered on 3 January 2020.

Complex endovascular treatment of intact aortic aneurysms: An analysis of health insurance claims data

Background

The complex endovascular repair of aortic aneurysms and dissections with fenestrated or branched stent grafts (FB-EVAR) remains challenging for interventional vascular surgery. To date, the evidence regarding treatment patterns and outcome measures consists of single center studies; however, it might be reasonable to validate results with multicenter real-world evidence.

Methods

Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, were used to determine outcomes following FB-EVAR of non-ruptured thoracic aorta (TA) or thoracoabdominal including pararenal abdominal (TAA) aorta. The study included patients operated between January 2008 and April 2017.

Results

Included were 984 patients (18.1% female) who underwent FB-EVAR. Patients with treatment of the TA were younger (71.7 vs. 73.2 years, p < 0.001) and more often female (38.5% vs. 17.0%, p < 0.001) as compared to patients with treatment of TAA. In the TA group peripheral arterial disease was less frequent compared to the TAA group (67.3% vs. 80.4%, p = 0.036). Mortality was significantly (p < 0.001) higher following repair of the TAA compared to the TA at discharge (17.3% vs. 4.6%), at 30 days (26.9% vs. 8.2%) and at 90 days (34.6% vs. 10.1%). Patients with treatment of the TAA suffered more often from stroke as compared to the TA group (7.7% vs. 1.2%, p = 0.002).

Conclusion

In this large-scale German analysis of claims data, multicenter real-world evidence was different from single center studies regarding patient risk-factors and outcome measures. Validated multicenter registry studies could help to further investigate this topic in times of increasing procedures.

To what extent are psychiatrists aware of the comorbid somatic illnesses of their patients with serious mental illnesses? - a cross-sectional secondary data analysis

Background

Somatic comorbidities are a serious problem in patients with severe mental illnesses. These comorbidities often remain undiagnosed for a long time. In Germany, physicians are not allowed to access patients’ health insurance data and do not have routine access to documentation from other providers of health care. Against this background, the objective of this article was to investigate psychiatrists’ knowledge of relevant somatic comorbidities in their patients with severe mental illnesses.

Methods

Cross-sectional secondary data analysis was performed using primary data from a prospective study evaluating a model of integrated care of patients with serious mental illnesses. The primary data were linked with claims data from health insurers. Patients’ diagnoses were derived on the basis of the ICD-10 and the Anatomical Therapeutic Chemical (ATC) classification system. Diabetes, hypertension, coronary artery disease (CAD), hyperlipidaemia, glaucoma, osteoporosis, polyarthritis and chronic obstructive pulmonary disease (COPD) were selected for evaluation. We compared the number of diagnoses reported in the psychiatrists’ clinical report forms with those in the health insurance data.

Results

The study evaluated records from 1,195 patients with severe mental illnesses. The frequency of documentation of hypertension ranged from 21% in claims data to 4% in psychiatrists’ documentation, for COPD from 12 to 0%, respectively, and for diabetes from 7 to 2%, respectively. The percentage of diagnoses deduced from claims data but not documented by psychiatrists ranged from 68% for diabetes and 83% for hypertension, to 90% for CAD to 98% for COPD.

Conclusions

The majority of psychiatrists participating in the integrated care programme were insufficiently aware of the somatic comorbidities of their patients. We support allowing physicians to access patients’ entire medical records to increase their knowledge of patients’ medical histories and, consequently, to increase the safety and quality of care.

Challenges and Perspectives in Bridging In- and Outpatient Sectors: The Implementation of Two Alternative Models of Care and Their Effect on the Average Length of Stay

New models of care aimed at reinforcing the outpatient sector have been introduced in Germany over the last few years. Initially, a subscription-based model ("integrated care") was introduced in 2012 in the Immanuel Klinik Rüdersdorf, wherein patients had to actively subscribe to the integrated care program. This integrated care model was replaced after 2 years by a subscription-free "model project," in which all patients insured by the contracting insurance company took part in the program. Data showed that the introduction of the integrated care program in the inpatient setting led to an increase of the average length of stay in this group. The switch to the model project corrected this unwanted effect but failed in significantly decreasing the average length of stay when compared to standard care. However, both the integrated care program and model project succeeded in reducing the length of stay in the day care setting. When adjusting for the sex and diagnosis proportions of each year, it was shown that diagnosis strongly influenced the average length of stay in both settings, whereas sex only slightly influenced the duration of stay in the inpatient setting. Thus, in spite of strong financial and clinical incentives, the introduction of the model project couldn't fulfill its primary purpose of shifting resources from the inpatient to the outpatient setting in the initial years. Possible explanations, including struggle against long-established traditions and reluctance to change, are discussed.

Frequency and clinical relevance of potential cytochrome P450 drug interactions in a psychiatric patient population - an analysis based on German insurance claims data

BACKGROUND

Numerous drugs used in the treatment of psychiatric disorders are substrates of cytochrome P450 enzymes and are potential candidates for drug-drug interactions (DDIs).

METHODS

Claims data of a German statutory health insurance company from severely mentally ill patients who registered in an integrated care contract from August 2004 to December 2009 were analysed. We measured time periods of concomitant prescription of drugs that have been reported to interact via cytochrome P450, with a focus on drugs acting as strong inhibitors. Such drug-drug exposure (DDE) is an incontrovertible precursor of DDIs. We assessed whether potential DDIs were considered clinically relevant based on the prescribing information of the respective drugs.

RESULTS

Among all 1221 patients, 186 patients (15.2 %; Clopper-Pearson 95 % confidence interval (CI): 13.3-17.4 %) had at least one DDE prescription, and 58 patients (4.8 %; 95 % CI 3.6-6.1) had at least one DDE prescription involving a strong cytochrome P450 inhibitor. In 59 patients, (4.8 %; 95 % CI: 3.7-6.2 %) five or more DDEs were identified, and five or more DDEs with a strong inhibitor were identified in 18 patients (1.5 %; 95 % CI: 0.9-2.3). The rates of DDEs were 0.27 (Garwood 95%CI: 0.25-0.28) per person-year and 0.07 (95 % CI: 0.07-0.08) for strong-inhibitor DDEs. Four of the ten most frequent DDEs were identified as clinically relevant, and seven of the eight most frequent DDEs involving a strong inhibitor were clinically relevant.

CONCLUSIONS

The number of patients with DDEs was not alarmingly high in our sample. Nevertheless, prescription information showed that some prescribed drug combinations could result in serious adverse consequences that are known to weaken or strengthen the effect of the drugs and should therefore be avoided.

Effectiveness and efficiency of integrated mental health care programmes in Germany: study protocol of an observational controlled trial

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.