Cost-Effectiveness Evaluation of Digital Intervention for Early Psychosis Recovery HEE5042

Question 1: Present the Population, Intervention, Comparator, and Outcomes (PICO) identified in the article.

• Population: The subject of research was youth aged 1627 diagnosed with first episode psychosis (FEP) who were preparing for discharge from the Early Psychosis Prevention and Intervention Centre in the metropolitan area of EPPIC, Melbourne. They had attained a period of remission during which no active psychotic symptoms were expressed and were at a sensitive stage of leaving specialist establishments and moving back to the community (Engel et al. 2024).

• Intervention: The intervention evaluated was the Horyzons platform, a new online social therapy which consists of user-to-user social networks, remotely supervised therapist, and large amounts of qualified mental health resources. It had the objectives of assisting in facilitating social and occupational rehabilitation for their discharge to prevent relapses from occurring.

• Comparator: The participating control group had treatment as usual (TAU) in which there was follow-up care from general medical practitioners, private psychiatrist or youth/adult mental health services. As part of routine care, the TAU group of participants had e-mental health services (Engel et al. 2024).

• Results: The main outcome was the assessment of change in social functioning between the baseline level over a period of 18 months using the Personal and Social Performance (PSP) scale. The secondary outcome was the change in quality-adjusted life years, and here the AQoL-8D was used. The research provided cost-effectiveness evaluation from the healthcare perspective as well as the societal perspective, analyzing total costs and outcomes at the 18-month time point.

Question 2: Explain the motivation for performing an economic evaluation of the intervention in the Horyzons RCT.

The reason for carrying out cost-effectiveness analysis in the context of the Horyzons randomized control trial (RCT) is especially to assess if the intervention is cost-effective in the long-term recovery of young people, after receiving treatment for early psychosis. It is known that there are positive benefits of early psychosis services, however, the sustainability of such treated effects after discharge remains an issue. Thus, the research sought to determine the efficacy of a lower-intensity, scalable, and potentially lower-cost approach, such as that of Horyzons, in prolonging the advantages offered by specialized interventions. The economic impact analysis of the Horyzons RCT has been the objective of establishing if the application of a cost-effective, easily scaled up digital support to help with recovery after early psychotic treatment is sustainable. This correlates with enhanced awareness of the use of digital solutions in the management of mental disorders, better organisational resource utilisation (Kernick, 2003).
Economic evaluations are effective in ascertaining if scarce health welfare resources are optimally allocated. The consideration of both the health and the societal perspective in this research emphasizes a need to appreciate the global context of the implementation including direct medical expenses and indirect costs on society such as loss of output. What about with respect to the increasing adoption of the digital tools in mental health and the evaluation of their cost-effectiveness as argued is plausible for making many future arguments regarding their level of integration and scale (Engel et al. 2024).

Question 3: Types of Economic Evaluations Presented

The article presents two types of economic evaluations:

1.Cost-Effectiveness Analysis (CEA): This approach evaluated the incremental cost per unit change in social functioning, measured using the PSP scale.

2. Cost-Utility Analysis (CUA): This evaluated the incremental cost per QALY gained, calculated using the AQoL-8D instrument.

Preferred Approach: In terms of preference, the CEA would be the first choice because the main aim of the intervention is better social function which is a key factor in recovery of the youths suffering from psychosis. Social functioning is of pertinence to their daily life aspect and emphasizing on this measure helps in evaluating the impact of the intervention within the designed time frame from a real-world perspective or in pragmatic terms. The CUA though necessary, entails more scope in definition, and allows for wider definitions of quality of life, but may not articulate the specific recovery objectives as well as the PSP (Engel et al. 2024).

Question 4: What is the time horizon of the economic evaluation? Is the time horizon justified?

The period over which the economic evaluation took place is 18 months. This period is justified bearing in mind that the purpose of the intervention was to promote long-term recovery after the patient has been discharged from the psychotic services. Eighteen months is sufficient to monitor substantial improvements in social functioning and quality of life, alongside the costs of health service provision, but also ensures that the period where young people are most at risk of relapse and social alienation is covered. The rationale for selecting 18 months time horizon for the economic evaluation is that important changes in social-adjustment, quality of life, and health care services costs occur within a period of 18 months and more, which corresponds to a high risk of relapse (Tudor Edwards et al., 2019).

Question 5: What is the discount rate applied in the economic evaluation, and how is it applied?

The discount rate used in the analysis was 5%, which is the standard rate used in health economic evaluation. This was deducted from costs and QALYs associated with years following the first so as to account for time preference. Such perpendicular science informs this methodology as time has a value and economics dictate people will allow something to be done in the future rather than today (Engel et al. 2024).

Question 6: The health economic evaluation presents results for two perspectives.

The study adopts the following two perspectives:

1.Healthcare Sector Perspective: This includes out-of-pocket or direct medical costs which includes emergency department visits, in patient services, medications, and tests. Such a perspective is useful to healthcare practitioners as they can appreciate the total budgetary and resource effect.

2.Societal Perspective: This is slightly sophisticated and extends beyond simply healthcare to include economic losses due to non-attendance at work, cost of caregivers transport, time lost, and other economic detriments. It provides a clearer indication of the total cost burden to the society.

Key Differences: The societal perspective entails extra costs that are not attributable to the healthcare sector such as productivity as well as informal care costs. The health perspective is much narrower as it is only concerned with direct medical expenditures. For instance, presenting two perspectives helps in understanding the effect of the economy better and presents the various options to the different decision-makers who either favor health care savings over the rest.

Question 7a: Type of Graph Used and Explanation of Quadrants

The presented graph is a cost-effectiveness plane which shows the relationship between costs and effects on four quadrants.

• Northeast (NE) Quadrant represents interventions which are higher in cost but also higher in effect than the comparator, technique or usual control. In this quadrant, health care decision makers are forced to ask themselves whether effective treatment that comes at an elevated cost is worth the price.

• Northwest (NW) Quadrant Dominated quadrant interventions that are both elevated in cost and lesser in effect. These are unwelcome as they tend to provide the least amount of benefit for the greatest expense.

• Southeast (SE) Quadrant: This is the most favorable quadrant as it shows interventions that are easy on the pocket, whilst providing greater results. In terms of bootstrapping, 58% of the bootstrapped iterations from societal perspective ended in this quadrant in the Horyzons study, showing that a cost-effective decisive outcome is achieved by the intervention (Engel et al. 2024).

• Southwest (SW) Quadrant: This is also a dominated quadrant; it shows interventions that are less expensive but are ineffective. In terms of the CUA cost-utility analysis where 88% of the iterations ended here, this meant that costs had been saved but with an emphasis on health losses.
  Question 7b: Greatest Number of Bootstrapped Results and Difficulty of Decision

Figure 1: Cost-effectiveness plane for CEA
(Source: Engel et al. 2024)

As shown in figure 1 of the article, most bootstrapped results were also in the southeast (SE) with 58 iterations out of total 100, as summarized in table 3 97% of the intervention would be dominant (less expensive and more effective)- this result is apparent in the SE quadrant which suggests for decision making purposes, Horyzons intervention funding would be easy to convince stakeholders to take up this course of action (Engel et al. 2024).

A SE quadrant clearly represents an ideal situation where health care is able to achieve better health outcomes at lower costs which is exactly the point of cost effectiveness. With regards to Horyzons, it managed to save society overall costs of AU$5131.14 against the TAU other than enhancing the social functioning measured by the Personal and Social Performance (PSP) scale. The interventions report reinforced economic rationale for directly funding the intervention since it combines cost savings with better patient outcomes. The SE quadrant represent cost efficiency which is doing more health with less. Thus, Horyzons cost less: they received AU$5131.14 less in contrast to TAU with the enhancement of social functioning. This is in consonance with the economic approach to adopting direct funding of interventions (Drummond 2015).

Question 7c: Advantages/Limitations of $/PSP Results

The authors decided to express their cost-effectiveness analysis as $/PSP (cost of $ for change P and S performance per unit), which has its own benefits as well as challenges.

Advantages:

• Direct relevance to the intervention: Since the Horyzons intervention uses PSP scale for its primary goal of improving social functioning, it is rather consistent with the objectives of the intervention. This gives a simple understanding how much money can be spent on factors determining improvement of one of the main mechanisms of rehabilitation of young patients with psychosis in the first place.

• Specificity: Since psychosis contains a wide range of functional outcomes and the successful management of these functional outcomes is important towards the end of treatment duration in psychosis, this becomes a very useful metric when trying to analyze cost effectiveness in this context (Engel et al. 2024).

Limitations:

• Limited scope: It has been stated of her years that while focusing on social functioning QALY would not take into account other verticals of health care like quality of life (QoL) into account. In the study, Horyzons showed a little higher number of QALYs, which suggests possible tradeoffs outside social functioning.

• Lack of comparability: One sees this in the modern world when general population in different health care or social services situations all use the same terminology but share different meanings, this is the most critical difference about normalizing Quality Adjusted Life Years with P, S Horyzons in general.

So, while the metric $/PSP can be very specific towards the social parameters, it fails to be more standard. QALYs have much wider relevance.

Question 7d: Comparison of $/PSP and $/QALY Results

Table 3: Bootstrapped incremental cost and outcomes, ICER and distribution of bootstrapped iterations on cost-effectiveness plane
(Source: Engel et al. 2024)

No, the quotations for $/QALY are not with those of $/PSP. The $/QALYs which we presented in table 3 are $. 160,366 which costs healthcare. This indicates that for one QALY more obtained, there are out of pocket costs worth AU $ 160 366 above the tested observed comparator- treatment with no intervention. The QALY results mostly fall between the south west (SW) angles of the cost-effectiveness plane, and this constitutes 88% of the bootstrap iterations (Engel et al. 2024).

The south west angle, therefore indicates that, interventions aimed at Horyzons are cheaper, but have lower QALYs effectiveness. There are therefore compromises, the intervention reduces costs but at the same time does not enhance QALYs, and may further reduce the health improvement impacts. In view of this tendency, then the selection as to invest more in the intervention seeking enhanced QALYs is of more uncertainties compared with the situation of relying on $/PSP.

Question 8: Additional Relevant Impacts or Costs Not Captured

There are four additional implications that were not considered in the analysis:

1. Caregiver burden: Family members often sustain costs of informal care for the mental illness. This could be very costly for the family of young patients suffering from psychosis.

2. Criminal justice involvement: There are chances of psychosis suffering individual coming into contact with the criminal justice system which is another area with considerable resource implications.

3. Education outcomes: Educational attainment impacts long-term productivity and societal costs (Engel et al. 2024).

4. Substance abuse: Psychotic patients exhibit substance use disorders and more prevalent and cause many healthcare costs and societal costs.

These outcomes are necessary as they tend to influence the trajectory of recovery in the long term and the effects on the costs of the society. They are important but perhaps have been overlooked due to the constraints in the collecting of data or the scope of the research.

Question 9: Consideration of Equity Issues

The equity considerations have not been dealt with or articulated in these analyses. Should the Commonwealth of Australia choose to fund the Horyzons intervention, it would create better equity by offering a low-cost and scalable support model for young people with psychosis which would reduce the need for high-cost, resource-consuming treatments in the future. Nonetheless, access to digital interventions is likely to be low for these disadvantaged populations which may affect equity (Engel et al. 2024).

Question 10: Do You Agree That Horyzons Is Cost-Effective?

Yes, I agree with the analysis that the reason to implement Horyzons is quite cost effective. The intervention achieved lower costs in both health care and societal perspectives while also improving social functioning, which is a major predictor of long-term recovery in cases of psychosis. Even though the QALY results were not as good, benefits from the PSP improvements and reduced costs justify its cost effectiveness.

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