Shane M. Kavanagh

A comparison of the cost-effectiveness of sertraline versus tricyclic antidepressants in primary care

There has been considerable debate concerning the cost-effectiveness of selective serotonin re-uptake inhibitors (SSRIs) versus tricyclic antidepressants (TCAs) thus far using crude prescription price comparisons or reductionist decision-analytic models. This paper employs a retrospective quasi-experimental design where data on service utilisation, use of medication and informal care were collected for two groups of patients in general practice settings. The mean cost of treatment was marginally greater for those people receiving TCA medication due to greater use of psychiatric services. Factors such as age, previous depression and concomitant physical illness are all associated with greater treatment costs. Further analysis using a prospective design is recommended.

Elderly people with advanced cognitive impairment in England - resource use and costs

This paper describes where elderly people with moderate to severe (‘advanced’) cognitive impairment are living, what resources they use and the costs of these services to different funding agencies. It operationally defines dementia in terms of cognitive impairment and uses the OPCS disability surveys to estimate the prevalence of moderate to severe cognitive impairment in England. The paper goes on to describe services received by this client group on the basis of the same surveys, and costs these by supplementing the data with information from related studies by the PSSRU. Since accommodation is a major cost, the population of elderly people with cognitive impairment is classified according to their place of residence. Thus we are able to estimate the ‘baseline’ global cost of provision for this client group at current prices. We make cost projections at 1991/92 price levels to the national level, and discuss the implications in terms of burdens to different agencies.

Economic outcomes and costs in the treatment of schizophrenia

Schizophrenia is an expensive illness, with hospitalization representing a major cost of treatment. To evaluate new drugs and management strategies for schizophrenia, we must have reliable measures of outcomes and costs. Cost-outcome evaluations are particularly important because they allow comparisons of the potential costs and consequences of various strategies. The best estimates of outcome use batteries of instruments to score the well-being of patients and their caregivers. Dimensions of well-being include clinical status, functional status, access to resources and opportunities, subjective quality of life, family well-being, and patient satisfaction with services. The best overall outcome may involve trade-offs between different dimensions (eg, moving a patient from hospital-based care to community-based care may improve the patients quality of life but increase family burden). Although measuring direct costs of schizophrenia is reasonably straightforward, indirect costs are more difficult to measure. The cost of pain and suffering (intangible costs) caused by schizophrenia for an individual patient or family is seldom assessed, although quality-of-life measures may provide some information. Increased costs of treatments in one area (eg, medication) may well be offset by reduced expenditures in another (eg, hospitalization), Trade-offs between different dimensions and different schizophrenia management agencies are only possible once the boundaries between these have been made clear by proper economic evaluations.

Schizophrenia: Shifting the balance of care

Schizophrenia poses a major challenge to policy makers in health and social care in England. As deinstitutionalisation has progressed, public concern about people with the condition has increased owing to a small number of public incidents. This paper describes the overall balance of care or support for people with schizophrenia, particularly between different settings and the services received. Using these data we are able to provide a basic estimate of the current resource implications of schizophrenia care in England with respect to different public sector agencies, the voluntary sector and service users and their families. The targeting of public sector resources between different care settings is also considered. The discussion suggests that resources are still targeted at existing care facilities rather than on individuals, and examines the roles of individual care agencies and the relationships between them. Four broad resource guidelines are suggested that could improve the effective use of resources for schizophrenia care.

Purchasers, providers and managed care: Developments in the mental health market place

Deinstitutionalisation coupled with reforms to the organisation and financing of services are having a profound impact on mental healthcare. This paper outlines common difficulties facing healthcare systems and some of the evolving structures. Despite historical differences between the US and UK systems, certain common themes are emerging.

Impact of a dedicated service for male mentally disordered remand prisoners in north west London: retrospective study

Government policy has encouraged speedy transfer of mentally ill prisoners to NHS care,1 2 but arrangements have often proved slow and ineffective.3 4 The Bentham Unit was set up in February 1994 to provide rapid assessment and (where appropriate) transfer for male mentally disordered remand prisoners in the former North West Thames Regional Health Authority. The unit provides regular outreach assessment sessions at Wormwood Scrubs and other prisons and is based in a 14 bed locked ward to which patients may be admitted before court disposal and determination of final placement. We retrospectively identified all prisoners referred for NHS psychiatric assessment who had been remanded to prisons within the area covered by North West Thames Regional Health Authority (Wormwood Scrubs, Brixton, Pentonville, Wandsworth, and Feltham) between 1 April and 31 August 1994 and determined those who were assessed and admitted …