Real-world clinical and cost-effectiveness of community clozapine initiation: mirror cohort study

TY - JOUR

T1 - Real-world clinical and cost-effectiveness of community clozapine initiation: mirror cohort study

AU - Butler, Emma

AU - Pillinger, Toby

AU - Brown, Kirsten

AU - Borgan, Faith

AU - Bowen, Alice

AU - Beck, Katherine

AU - D'Ambrosio, Enrico

AU - Jauhar, Sameer

AU - Kaar, Stephen

AU - McCutcheon, Robert

AU - Rogdaki, Maria

AU - Gaughran, Fiona

AU - Maccabe, James

AU - Ramsay, Rosalind

AU - McCrone, Paul

AU - Egerton, Alice

AU - Howes, Oliver

N1 - Funding Information: R.A.M. has received honoraria from Otsuka pharmaceutical for educational talks. R.A.M. is funded by a clinical lectureship from the National Institute of Health Research. F.B. became an employee at COMPASS Pathways plc after the completion of this work. This work is unrelated to COMPASS Pathways plc. S.J. has received honoraria for educational talks given for Sunovion, and his employer, King's College London, has received honoraria for educational talks he has given for Lundbeck. D.T. reports grants from Janssen and Recordati, personal fees from Janssen, Mylan, Recordati and Sunovion and stock in Saladax and Psychiatric Genetic Testing. Other Authors have not declared any conflicts of interest. Funding Information: This work was supported by grants to O.D.H. from The Maudsley Charity (grant no. 666) and Medical Research Council-UK (no. MC_U120097115). Publisher Copyright: Copyright © 2022 The Author(s).

PY - 2022/12/11

Y1 - 2022/12/11

N2 - Background Clozapine is the only drug licensed for treatment-resistant schizophrenia (TRS) but the real-world clinical and cost-effectiveness of community initiation of clozapine is unclear. Aims The aim was to assess the feasibility and cost-effectiveness of community initiation of clozapine. Method This was a naturalistic study of community patients recommended for clozapine treatment. Results Of 158 patients recommended for clozapine treatment, 88 (56%) patients agreed to clozapine initiation and, of these, 58 (66%) were successfully established on clozapine. The success rate for community initiation was 65.4%; which was not significantly different from that for in-patient initiation (58.82%, χ2(1,88) = 0.47, P = 0.49). Following clozapine initiation, there was a significant reduction in median out-patient visits over 1 year (from 24.00 (interquartile range (IQR) = 14.00-41.00) to 13.00 visits (IQR = 5.00-24.00), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75-71.00) to 22.00 (IQR = 11.00-42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = -2.50, P = 0.01). Service-use costs decreased (1 year: -£963/patient (P < 0.001); 2 years: -£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: -£827.40/patient (P < 0.001); 2 year: -£1668.50/patient (P < 0.001) relative to costs prior to starting clozapine. Relative to before initiation, symptom severity was improved in patients taking clozapine at discharge (median Positive and Negative Syndrome Scale total score: initial visit: 80 (IQR = 71.00-104.00); discharge visit 50.5 (IQR = 44.75-75.00), P < 0.001) and at 2 year follow-up (Health of Nation Outcome Scales total score median initial visit: 13.00 (IQR = 9.00-15.00); 2 year follow-up: 8.00 (IQR = 3.00-13.00), P = 0.023). Conclusions These findings indicate that community initiation of clozapine is feasible and is associated with significant reductions in costs, service use and symptom severity.

AB - Background Clozapine is the only drug licensed for treatment-resistant schizophrenia (TRS) but the real-world clinical and cost-effectiveness of community initiation of clozapine is unclear. Aims The aim was to assess the feasibility and cost-effectiveness of community initiation of clozapine. Method This was a naturalistic study of community patients recommended for clozapine treatment. Results Of 158 patients recommended for clozapine treatment, 88 (56%) patients agreed to clozapine initiation and, of these, 58 (66%) were successfully established on clozapine. The success rate for community initiation was 65.4%; which was not significantly different from that for in-patient initiation (58.82%, χ2(1,88) = 0.47, P = 0.49). Following clozapine initiation, there was a significant reduction in median out-patient visits over 1 year (from 24.00 (interquartile range (IQR) = 14.00-41.00) to 13.00 visits (IQR = 5.00-24.00), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75-71.00) to 22.00 (IQR = 11.00-42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = -2.50, P = 0.01). Service-use costs decreased (1 year: -£963/patient (P < 0.001); 2 years: -£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: -£827.40/patient (P < 0.001); 2 year: -£1668.50/patient (P < 0.001) relative to costs prior to starting clozapine. Relative to before initiation, symptom severity was improved in patients taking clozapine at discharge (median Positive and Negative Syndrome Scale total score: initial visit: 80 (IQR = 71.00-104.00); discharge visit 50.5 (IQR = 44.75-75.00), P < 0.001) and at 2 year follow-up (Health of Nation Outcome Scales total score median initial visit: 13.00 (IQR = 9.00-15.00); 2 year follow-up: 8.00 (IQR = 3.00-13.00), P = 0.023). Conclusions These findings indicate that community initiation of clozapine is feasible and is associated with significant reductions in costs, service use and symptom severity.

UR - http://www.scopus.com/inward/record.url?scp=85129139351&partnerID=8YFLogxK

U2 - 10.1192/bjp.2022.47

DO - 10.1192/bjp.2022.47

M3 - Article

SN - 0007-1250

VL - 221

SP - 740

EP - 747

JO - British Journal of Psychiatry

JF - British Journal of Psychiatry

IS - 6

ER -