Rosenheck R, Cramer J, Allan E, Erdos J, Frisman L K, Xu W, Thomas J, Henderson W, Charney D
Veterans Affairs Connecticut Healthcare System, West Haven 06516-2770, USA.
Arch Gen Psychiatry. 1999 Jun;56(6):565-72. doi: 10.1001/archpsyc.56.6.565.
This study examined the relationship between pretreatment hospital use and the cost-effectiveness of clozapine in the treatment of refractory schizophrenia.
Data from a 15-site randomized clinical trial were used to compare clozapine with haloperidol in hospitalized Veterans Affairs patients with refractory schizophrenia (n = 423). Outcomes were compared among those with many days in the hospital use (hereafter, high hospital users) (n = 141; mean = 215 psychiatric hospital days in the year prior to study entry) and those with few days in the hospital use (hereafter, low hospital users) (n = 282; mean = 58 hospital days). Analyses were conducted with the full intention-to-treat sample (n = 423) and with crossovers excluded (n = 291).
Clozapine treatment resulted in greater reduction in hospital use among high hospital users (35 days less than controls, P = .02) than among low users (21 days less than controls, P = .05). Patients taking clozapine also had lower health care costs; after including the costs of both medications and other health services, costs were $7134 less than for controls among high hospital users (P = .14) but only $759 less than for controls among low hospital users (P = .82). Clinical improvement in the domains of symptoms, quality of life, extrapyramidal symptoms, and a synthetic measure of multiple outcomes favored clozapine in both high and low hospital user groups.
Substantial 1-year cost savings with clozapine are observed only among patients with very high hospital use prior to initiation of treatment while clinical benefits are more similar across groups. Cost-effectiveness evaluations, and particularly studies of expensive treatments, cannot be generalized across type of use groups.
本研究探讨了治疗前住院情况与氯氮平治疗难治性精神分裂症的成本效益之间的关系。
来自一项15个地点的随机临床试验的数据，用于比较氯氮平与氟哌啶醇在住院的退伍军人事务部难治性精神分裂症患者（n = 423）中的疗效。比较了住院天数多的患者（以下简称高住院使用者）（n = 141；研究入组前一年平均精神科住院天数为215天）和住院天数少的患者（以下简称低住院使用者）（n = 282；平均住院天数为58天）的结局。分析采用全意向性治疗样本（n = 423），并排除交叉病例（n = 291）。
与低住院使用者相比，氯氮平治疗使高住院使用者的住院天数减少更多（比对照组少35天，P = 0.02）（比对照组少21天，P = 0.05）。服用氯氮平的患者医疗费用也较低；将药物和其他医疗服务的费用都计算在内后，高住院使用者的费用比对照组少7134美元（P = 0.14），而低住院使用者的费用仅比对照组少759美元（P = 0.82）。在症状、生活质量、锥体外系症状以及多个结局的综合指标方面的临床改善，在高住院使用者和低住院使用者组中均有利于氯氮平。
仅在治疗开始前住院率非常高的患者中观察到氯氮平在1年内可大幅节省成本，而临床获益在各组中更为相似。成本效益评估，尤其是对昂贵治疗的研究，不能在不同使用类型组之间进行推广。
