Gray A M, Marshall M, Lockwood A, Morris J
Wolfson College, University of Oxford. alastair.gray@
Br J Psychiatry. 1997 Jan;170:47-52. doi: 10.1192/bjp.170.1.47.
Case management has become the statutory basis of community care in the UK for people with long-term mental disorders, although a randomised controlled trial found no important improvements over standard care. Here we compare the costs and cost consequences of this intervention with standard care.
Resource-use data were collected over a six-month baseline period and for 14 months after randomisation on all patients in the trial.
At 14 months the ratio of control group to treatment group weekly costs was 1.09 (95% CI 0.86-1.38) for total costs; 1.12 (0.76-1.65) for state benefits, and 1.21 (0.61-2.42) for health care costs. Costs were thus lower in the treatment group, but these differences were not significant.
Retrospective power calculations indicated that the trial could have detected differences of 30% in total cost, but would have required 700 patients per arm to detect a 20% difference in health care costs. Hence this study, which had adequate power to detect clinically meaningful differences, was found to be far too small to detect large differences in costs. Funding agencies increasingly request that clinical trials include economic alongside clinical end-points: these findings may have important lessons for that policy.
在英国，病例管理已成为为患有长期精神障碍的人群提供社区护理的法定基础，尽管一项随机对照试验发现，与标准护理相比，病例管理并无显著改善。在此，我们比较了这种干预措施与标准护理的成本及成本后果。
在为期六个月的基线期以及随机分组后的14个月内，收集了试验中所有患者的资源使用数据。
在14个月时，对照组与治疗组的每周总成本之比为1.09（95%置信区间0.86 - 1.38）；国家福利成本之比为1.12（0.76 - 1.65）；医疗保健成本之比为1.21（0.61 - 2.42）。因此，治疗组的成本较低，但这些差异并不显著。
回顾性功效计算表明，该试验本可检测出总成本30%的差异，但每组需要700名患者才能检测出医疗保健成本20%的差异。因此，这项有足够功效检测临床有意义差异的研究，被发现规模过小，无法检测出成本方面的巨大差异。资助机构越来越要求临床试验在临床终点之外纳入经济终点：这些发现可能为该政策提供重要借鉴。
