Cost-effectiveness analysis of an ambulant psychiatric rehabilitation programme in Austria

Abstract

Introduction: Psychiatric rehabilitation promotes recovery, full community integration, and improved quality of life for individuals who have experienced severe psychiatric disabilities that limit their capacity to perform certain tasks and functions and their ability to perform in certain roles. The current study focuses on an ambulant psychiatric rehabilitation programme in Vienna, Austria. In Austria, psychiatric rehabilitation has been established since 2002, initially as inpatient treatment programmes, and, later on, in 2010 the “Zentrum für seelische Gesundheit BBRZ-Med, Wien-Leopoldau,” initiated ambulant psychiatric rehabilitation in Vienna. Aim: The aim of the study was to perform a cost-effectiveness study of this ambulant psychiatric rehabilitation programme. Methods: From January 2014 to December 2016, a total of 2,486 patients were admitted to the “Zentrum für seelische Gesundheit Wien-Leopoldau” and filled out questionnaire-based surveys at time of pre-contact before starting rehabilitation (screening interview), at time of admission, at time of discharge, 6 months after discharge (6-months catamnesis), and 12 months after discharge (12-months catamnesis). Clinical effectiveness was assessed using 1) the BSI-18 (Brief Symptom Inventory) to measure symptom burden, 2) the BDI (Beck Depression Inventory) to measure depressive symptoms, and 3-5) the GAF (Global Assessment of Functioning), the WHODAS 2.0 (World Health Organisation Disability Assessment Schedule 2.0) and the ICF-AT-3F (International Classification of Functioning, Disability and Health) to measure different aspects of functioning. For the cost calculation, both direct costs and indirect costs were considered. The direct costs included the treatment by specialist in psychiatry and/or general practitioner and/or psychotherapist and/or psychological treatment, as well as costs of psycho-pharmacological treatment, inpatient treatment costs, and costs of rehabilitation. Indirect costs were calculated as productivity loss measured in non-working days depending on the average income of each rehabilitand. The average income was calculated based on the Austrian classification of economic occupation groups called OENACE depending on gender, age, and scope of employment (full-time or part-time). To overcome the problem that the period of 6 weeks rehabilitation and 12 months after rehabilitation as assessed at the 12-months catamnesis (in sum 13.5 months), and the period of 12 months before admission are not directly comparable, we designed a pseudo control group to calculate the total costs of the 13.5 months period before admission. Results: Of the 2,482 patients admitted to the ambulant rehabilitation programme from 2014 to 2016, complete data on occupational information based on OENACE 2008 (including brutto income) was available for 1,781 rehabilitands after thorough data cleaning. With regard to the clinical effectiveness measures, significant improvements were found in BSI, BDI, GAF, WHODAS 2.0 and ICF-AT-3F, especially regarding rehabilitands that were employed at time of admission. Unemployed rehabilitands showed improvement to a less successful extent, and the worst outcome was found for patients receiving rehabilitation allowance. We further found a significant reduction in treatment days within the period of 12 months after rehabilitation as compared to the period of 12 months before admission, with the only exception of patients receiving rehabilitation allowance. Again, with exception of patients receiving rehabilitation allowance, treatment costs significantly decreased within the period of 12 months after end of rehabilitation when excluding the costs of 6 weeks rehabilitation in order to compare the period of 12 months before admission and the 12 months after the end of rehabilitation. However, when adding the costs of 6 weeks rehabilitation to the treatment costs, and comparing to the 13.5 months period before admission, slightly increased treatment costs were measured at 12-months catamnesis. In contrast to the treatment costs, a reduction of productivity loss was found in all subgroups. When adding up treatment costs and costs of productivity loss, we again found a significant reduction in total costs when excluding the costs of 6 weeks rehabilitation, both in the whole sample (total annual costs during the period of 12 months before admission: on average 27,325.19 EUR per rehabilitand; total annual costs during the 12 months period after rehabilitation: on average 18,588.82 EUR per rehabilitand) and in all occupational subgroups. When adding the costs of 6 weeks rehabilitation to the total costs of the period of 12 months after the end of rehabilitation, we still found a reduction of total costs within the 12 period of months after rehabilitation both in the whole sample (total annual costs during the 12 months period after rehabilitation: 22,868.74 EUR) and in all occupational subgroups, although this reduction of total costs did not remain significant in any of these groups. Subsequently, to overcome the problem that the period of 6 weeks rehabilitation and 12 months after rehabilitation as assessed at 12-months catamnesis (in sum 13.5 months), and the period of 12 months before admission are not directly comparable, we designed a pseudo control group to calculate the total costs of the 13.5 months period before admission. Using this pseudo control group, the total costs of the 13.5 months before admission were calculated to be 30,740.84 Euros, as compared to the above mentioned 22,868.74 Euros total costs within the 13.5 months after admission. This corresponds to a cost saving of 7,872.10 Euros per rehabilitand in the whole sample. Dividing the rehabilitands according to occupational status, the cost savings were 6,996.58 Euros in employed, 6,191.74 Euros in unemployed, and 12,063.62 Euros in rehabilitands receiving rehabilitation allowance. Conclusion: With regard to clinical effectiveness measures, significant improvements were found for depressive symptoms, symptom burden, and different aspects of functioning. Thus, the ambulant rehabilitation programme is without doubt highly effective in terms of clinical improvement. Nevertheless, the results of cost-effectiveness analyses were clearly promising as well, with cost savings of on average -7,872.10 Euros per rehabilitand. For the cost measures, we designed a pseudo control group to compare the period of 13.5 months before admission and the period of 13.5 months after admission, finding incremental cost savings in all occupational subgroups, whereas the incremental effectiveness was higher in employed and unemployed rehabilitands, however ambiguous in rehabilitands receiving rehabilitation allowance. Interestingly, dividing the incremental costs according to occupational subgroups, the highest cost savings were found for the patients receiving rehabilitation allowance. Investigating the latter more in detail, we found that 15.79% were employed at 12-months catamnesis. It has to be pointed out that, although only a few of those receiving rehabilitation allowance at admission were employed 12 months after rehabilitation, the latter seem to have high financial impact on the whole group of patients receiving rehabilitation allowance. In short, the results of the current study clearly show that ambulant psychiatric rehabilitation is highly effective, and it is of high importance that patients suffering from a psychiatric disease should be referred to a rehabilitation programme at an early state of disease to show the highest benefit in sense of clinical effectiveness and cost savings. Nevertheless, the rehabilitation of those chronically ill showed cost effectiveness as well, and we should put further effort in the rehabilitation of this group not only for clinical and ethic reasons but also from an economic perspective.eingereicht von Alexandra SchosserMedizinische Universität Wien, Masterarb., 2018(VLID)256885