社区氯氮平起始的真实世界临床和成本效益：镜像队列研究。

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

机构信息

Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK and South London and Maudsley NHS Foundation Trust, UK.

Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.

出版信息

Br J Psychiatry. 2022 Dec;221(6):740-747. doi: 10.1192/bjp.2022.47.

DOI:10.1192/bjp.2022.47

PMID:35438068

Abstract

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%, χ(1,88) = 0.47, = 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), < 0.001), and 2 years (from 47.50 visits (IQR = 24.75-71.00) to 22.00 (IQR = 11.00-42.00), < 0.001), and a 74.71% decrease in psychiatric hospital bed days ( = -2.50, = 0.01). Service-use costs decreased (1 year: -£963/patient ( < 0.001); 2 years: -£1598.10/patient ( < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: -£827.40/patient ( < 0.001); 2 year: -£1668.50/patient ( < 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), < 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), = 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.

摘要

背景

氯氮平是唯一被批准用于治疗抵抗性精神分裂症（TRS）的药物，但社区起始氯氮平的实际临床和成本效益尚不清楚。

目的

旨在评估社区起始氯氮平的可行性和成本效益。

方法

这是一项对推荐使用氯氮平治疗的社区患者的自然主义研究。

结果

在 158 名推荐使用氯氮平治疗的患者中，有 88 名（56%）患者同意开始氯氮平治疗，其中 58 名（66%）成功开始氯氮平治疗。社区起始的成功率为 65.4%；与住院起始（58.82%，χ(1,88)=0.47， = 0.49）没有显著差异。在开始氯氮平治疗后，在 1 年内门诊就诊次数显著减少（从中位数 24.00（四分位距（IQR）= 14.00-41.00）减少至 13.00 次（IQR = 5.00-24.00），<0.001），2 年内（从中位数 47.50 次（IQR = 24.75-71.00）减少至 22.00 次（IQR = 11.00-42.00），<0.001），精神病院床位天数减少 74.71%（ = -2.50， = 0.01）。服务使用成本降低（1 年：-£963/患者（<0.001）；2 年：-£1598.10/患者（<0.001））。社区起始的亚分析也显示出显著的成本降低（1 年：-£827.40/患者（<0.001）；2 年：-£1668.50/患者（<0.001），与开始氯氮平前的成本相比）。与起始前相比，出院时服用氯氮平的患者症状严重程度得到改善（阳性和阴性综合征量表总分中位数：初始就诊：80（IQR = 71.00-104.00）；出院就诊：50.5（IQR = 44.75-75.00），<0.001），在 2 年随访时（国家健康结局量表总分中位数初始就诊：13.00（IQR = 9.00-15.00）；2 年随访：8.00（IQR = 3.00-13.00）， = 0.023）。