Cost effectiveness of a structured treatment for people with long-term severe non-psychotic disorders

OBJECTIVE

This study aims for health gain and cost reduction in the care for people with long-term psychiatric disorders. The research
questions is what the (cost)effectiveness is of Interpersonal Community Psychiatric Treatment (ICPT), compared to care as
usual (CAU).



HYPOTHESIS

ICPT is more effective in (1) improving patients’ quality of life and social networks, (2) preventing or decreasing professionals’
perception of patients as ‘difficult’, (3) discharging patients to a lower level of care, (4) being less costly in reaching these
clinical goals than CAU



STUDY DESIGN

Multi-center cluster-randomized clinical trial: participating professionals will be randomly allocated to either ICPT or CAU for an
intervention period of 12 months, and a follow-up of 6 months.

STUDY POPULATION

Patients between 18-65 with non-psychotic disorders who are long-term and/or intensive users of specialty mental health care.



INTERVENTION

ICPT is a structured treatment for people with long-term, often difficult to treat non-psychotic disorders, developed with patients,
professionals, and experts. ICPT uses a number of evidence-based techniques and was positively evaluated in a controlled
pilot study.

OUTCOME MEASURES

Primary: quality of life (MANSA)
Secundary: quality of life (EQ-5D), costs (TiC-P), therapeutic alliance (STAR), professional-perceived difficulty of patient
(DDPRQ), care needs (CANSAS), social contacts (SNM)



SAMPLE SIZE/DATA ANALYSIS

Based on the primary outcome variable, quality of life (MANSA), and assuming 20-25% attrition we need to include 40 clusters
of 6 patients each. Outcomes will be analysed using linear mixed models. All analyses will be performed on the
intention-to-treat set.



CEA/BIA

The economic evaluation will be based on the general principles of a cost-effectiveness analysis. Both the cost-utility and
cost-effectiveness analysis will be performed from the societal perspective. The BIA will be conducted from 3 perspectives: (1)
societal perspective, i.e. including productivity losses, (2) the perspective of the public purse (VWS) (base case), and (3) the
perspective of the third party payers.

ICPT is more effective in (1) improving patients’ quality of life and social networks, (2) preventing or decreasing professionals’
perception of patients as ‘difficult’, (3) discharging patients to a lower level of care, (4) being less costly in reaching these
clinical goals than Care as usual

Total treatment period for clients is 18 months; the RCT is 4 years. There is a measurement at baseline, an intermediate measurement (6 months after for baseline-measurement), after intervention period (after an intervention period of 12 months), and a follow-up measurement (6 months after end of intervention). Information will be obtained from different sources (client, professional) using multiple methods (interviews, questionnaires). The same questionnaires will be used in both groups, on all four measuring moments.

ICPT was developed from an empirical study of so-called ‘difficult’ patients, in which it became evident that both patient and
professional play an important role in the occurrence of ‘ineffective chronic illness behaviour’. A five-stage heuristic model
shows that the 'difficult'-patient label is given by professionals when certain patient characteristics are present and a specific
causal attribution about the patient's behaviours is made [18]. The status of 'difficult' patient is easily reinforced by subsequent patient and/or professional behaviour, turning initial unusual elp-seeking behaviour into 'difficult' or ineffective chronic illness behaviour. Furthermore, a lack of resources in the psychiatric service and the patient's social system negatively influence the
patient-professional interaction [18]. From this theoretical model we conceptualized a number of stages in the intervention
program, each fitting an important step in the theoretical model, resulting in a stage model which fits the patient's level of acceptance of help and cooperation.