|
Does additional care provided by a consumer self-help group improve psychiatric outcome? A study in an Italian community-based psychiatric service |
Burti L, Amaddeo F, Ambrosi M, Bonetto C, Cristofalo D, Ruggeri M, Tansella M |
|
|
Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study aimed to compare the collaboration between a community mental health service and a consumer organisation (i.e. a consumer self-help group) versus a community mental health service alone.
Type of intervention Treatment and rehabilitation.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised patients who had at least one or more contacts with the South Verona CPS.
Setting The setting was the community and primary care. The economic analysis was carried out in Verona, Italy.
Dates to which data relate The effectiveness and resource use data appear to have been collected since autumn 1997. The baseline period of the study was considered to be the trimester November 1999 to January 2000. Follow-up data were collected 2 years after baseline. The price year was not reported.
Link between effectiveness and cost data The resource data were collected prospectively using the same sample of patients as that used in the effectiveness study.
Study sample The sample size was not determined in the planning phase of the study and power calculations were not performed retrospectively. No patients were reported to have refused to participate. The self-help group comprised patients who were members of the group and had joined in its activities for a 2-year period. In contrast, patients were included in the non self-help group only if they had never been in contact with the self-help group.
Sixty-nine patients were selected for the self-help group. Of these, only 58 were considered eligible for the study (had complete outcome evaluations). It was reported that, at follow-up, three patients had died and another two could not be interviewed. Consequently, the self-help group comprised 53 eligible patients for inclusion in the study. Three hundred and nine patients fulfilled the inclusion criteria for the non self-help group. The initial patient groups were exactly matched by gender, diagnosis, living arrangements and clinical severity, after which a sample of 88 patients (44 in each group) was included in the study.
Study design The analysis was based on a cohort study. Two researchers blinded to the objectives and methods of the study collected the data. Data were collected for a 2-year period before baseline and for a 2-year follow-up period after baseline. It was reported that the follow-up data were standardised to represent an exact 2-year period.
Analysis of effectiveness The primary health outcomes were:
global functioning, as assessed using the Global Assessment of Functioning Scale;
symptomatology, using the Brief Psychiatric Rating Scale (sub-scale for manic symptoms and negative symptoms);
disability, using the Disability Assessment Schedule; and
patients' needs, using the Camberwell Assessment of Need.
In addition, patient satisfaction with work and/or education was also evaluated using the Lancashire Quality of Life instrument. All the patients included in the study were accounted for in the analysis. However, differences at baseline (i.e. in marital status, education and occupation) were not adjusted for in the analysis. It was reported that all initially eligible patients (53 in the self-help group and 309 in the non self-help group) were also compared in terms of their baseline characteristics. However, adjustments for confounding factors were not performed.
Effectiveness results Comparisons across groups for differences between the baseline and follow-up periods demonstrated that there were no statistically significant differences in global functioning, symptomatology, disability and patient satisfaction with work and/or education.
The mean number and severity of needs increased significantly at follow-up in the non self-help group, (p<0.01). There was no statistically significant change in the self-help group.
Clinical conclusions The analysis demonstrated that there were no significant differences between the two groups in terms of their clinical and social outcomes.
Modelling The baseline characteristics of the patient groups were compared using either the chi-squared test (for categorical characteristics) or the Wilcoxon test (for continuous characteristics). Within each group, changes in outcomes between baseline and follow-up were analysed using the Wilcoxon test. All statistical analyses were performed using SPSS 11.0 software.
Measure of benefits used in the economic analysis The authors did not derive a summary measure of benefit in the economic analysis. In effect, a cost-consequences analysis was performed.
Direct costs Health service costs were included in the analysis. The categories considered were inpatient, sheltered accommodation, day-patient, outpatient and community costs. The latter (community costs) included visits made to patients' or relatives' home and to further community facilities. The resource use data were obtained from the South Verona Psychiatric Case Register, while the cost data were derived from an official source (the List of Costs per Unit). Operating costs for the self-help programme were not included in the analysis, although an estimate was quoted in the discussion. The costs were reported as the average cost per patient. The costs were not discounted; adjustments for inflation and the price year were not reported.
Statistical analysis of costs The costs and resource use data were reported using descriptive statistics, namely the mean, standard deviation (SD) and ranges. The authors used the Wilcoxon test to allow for within- and across-group comparisons between baseline and the end of the follow-up period. This was appropriate given that the data were highly skewed.
Indirect Costs Productivity losses were not included in the analysis.
Currency US dollars ($). Costs in the List of Costs per Unit were originally expressed in Italian Lire at 1996 prices. The conversion rate used and year were not reported.
Sensitivity analysis The authors did not use any methods to allow for uncertainty.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The average total costs were reported per patient and were reported for two periods.
For the self-help group, the total cost was $19,963 (SD=24,300; range: 401 to 100,702) at baseline and $17,029 (SD=20,523; range: 330 to 88,826) at the end of the 2-year follow-up period. The difference was statistically significant, (p=0.007).
For the non self-help group, the total cost was $6,666 (SD=11,188; range: 74 to 53,218) at baseline and $8,890 (SD=13,401; range: 111 to 54,181) at the end of the 2-year follow-up period. The difference was not statistically significant.
The authors reported that across groups, comparisons between baseline and follow-up total costs approximated statistical significance, (p=0.017).
Synthesis of costs and benefits The costs and benefits were not combined.
Authors' conclusions "The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome."
CRD COMMENTARY - Selection of comparators It was unclear why the authors chose the comparator used since they did not justify their choice. You should decide if this represents a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The analysis was based on a cohort study. This type of study is usually associated with some limitations arising from the lack of random allocation of patients to the study groups. Thus, some selection bias might have affected the results. Marital status, education and occupation were significantly different between the groups and this might have biased the results. Appropriate statistical analyses were not undertaken to take account of potential biases and confounding factors. No sensitivity analyses were undertaken to account for variation in patient population. Power calculations were not reported. The authors acknowledged that the study was inadequately powered to detect various statistically significant differences between the groups. The evidence came from a single centre, which might not be representative of other institutions. The potential uncertainty in the clinical results was not addressed in the sensitivity analysis. These issues represent limitations to the internal validity of the findings and suggest that the effectiveness results should be treated with some caution.
Validity of estimate of measure of benefit The authors did not derive a summary measure of benefit. In effect, a cost-consequences analysis was performed.
Validity of estimate of costs Although the perspective adopted in the economic analysis was not explicitly reported, it appears to have been that of the health care provider. The costs for a self-help programme were quoted in the discussion but were not included in the analysis; the authors stated that this omission is unlikely to have affected the results. The costs and resource use were reported separately as the average value per patient. The costs were derived from Italian sources, but no sensitivity analysis of the costs was performed. Discounting, adjustments for inflation, currency conversion and the price year were not reported. These issues may limit the interpretation of the findings.
Other issues Since the authors did not compare their findings with those from other studies, it was not possible to determine the degree of agreement with other published studies. The authors do not appear to have presented their results selectively. Although the authors acknowledged that the study sample was not representative of the study population in terms of severity, they generalised their conclusions across all levels of severity. The authors reported further limitations to their study. First, patient groups differed in previous patterns of care, which might have introduced some bias into the results. Second, the patients' baseline assessment was not undertaken concurrently with the initiation of their participation in the self-group activities.
Implications of the study Based on the results of the analysis, the authors recommend that, as patient participation in self-help activities shows no statistically significant improvement in terms of social and clinical outcomes, self-help should be considered as an activity to enhance users' own resources and motivation for recovery, rather than as a module of psychiatric treatment or rehabilitation. The authors made no recommendations for further research.
Source of funding Supported by a grant from Regione del Veneto, Giunta Regionale, Venezia, Ricerca Sanitaria Applicata.
Bibliographic details Burti L, Amaddeo F, Ambrosi M, Bonetto C, Cristofalo D, Ruggeri M, Tansella M. Does additional care provided by a consumer self-help group improve psychiatric outcome? A study in an Italian community-based psychiatric service. Community Mental Health Journal 2005; 41(6): 705-720 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Case-Control Studies; Community Mental Health Centers /economics /utilization; Female; Health Care Costs; Hospitalization /statistics & Humans; Interviews as Topic; Italy; Male; Mental Disorders /diagnosis /rehabilitation; Middle Aged; Mood Disorders /diagnosis /rehabilitation; Outcome and Process Assessment (Health Care); Registries; Schizophrenia /diagnosis /rehabilitation; Self-Help Groups /economics /utilization; Social Support; Somatoform Disorders /diagnosis /rehabilitation; numerical data AccessionNumber 22006007606 Date bibliographic record published 31/07/2007 Date abstract record published 31/07/2007 |
|
|
|