Byford et al. (2019) «Byford S, Petkova H, Stuart R, ym. Alternative com...»1, Alternative community-based models of care for young people with anorexia nervosa: the CostED national surveillance study
P: Young people aged 8–17 years in contact with community-based secondary or tertiary child and adolescent mental health services for a first episode of anorexia nervosa in accordance with Diagnostic and Statistical Manual of Mental Disorders, between 1 February 2015 and 30 September 2015.
I: Specialist eating disorders services
C: Generic child and adolescent mental health services (generic CAMHS)
O: The primary outcome measure was the Children's Global Assessment Scale (CGAS). Secondary outcome measures included percentage of median expected body mass index (BMI) for age and sex (%mBMI) and the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Cases were also assessed for remission and relapse status.
Clinicians notifying a positive case of anorexia nervosa were sent a baseline questionnaire and, if patients were assessed as eligible for inclusion, follow-up questionnaires after 6 and 12 months. Baseline questionnaires contained sections on the following: characteristics of the notifying service to enable services to be classified as specialist eating disorders services or generic CAMHS, limited patient identifiers to provide basic sociodemographic information and check for duplicate notifications, clinical characteristics to assess case eligibility and outcome data against which to assess clinical improvements over follow-up. The 6- and 12-month follow-up questionnaires contained the same sections, but also included a section on the use of secondary and tertiary mental health services for costing purposes.
To assess which services met criteria for classification as a specialist eating disorders service, a Delphi survey was undertaken that collected opinions from a range of stakeholders interested in eating disorders. In the Delphi survey, three criteria achieved consensus for inclusion: offering specialist outpatient treatment for eating disorders, providing multidisciplinary specialist outpatient clinics dedicated to eating disorders and holding weekly multidisciplinary meetings dedicated to eating disorders.
The cost-effectiveness of specialist versus generic services was explored in a decision-making context, with a focus on the probability of specialist services being cost-effective compared with generic services given the data available, rather than a focus on statistical significance. Measures of effect analysed in the cost-effectiveness analysis were CGAS score (primary) and %mBMI (secondary). Incremental cost-effectiveness ratios were calculated as the difference in mean cost between specialist services and generic services, divided by the difference in mean effects.
A total of 305 incident cases of anorexia nervosa were eligible for inclusion in the incidence study and 298 cases were assessed as eligible for inclusion in the follow-up study of cost and cost-effectiveness. Clinicians completed and returned a 6-month follow-up questionnaire for 220 of these cases (74 %) and a 12-month follow-up questionnaire for 187 cases (63 %). The vast majority of the sample were girls (91 %), from England (70 %) and were coded as white (92 %; any white background); their mean age was 14.6 years (±1.66 years).
In terms of service use, the number of hospital admissions (mean 0.54 specialist, 0.60 generic), the length of hospital admissions (mean 32 nights specialist, 31 nights generic) and the number of outpatient contacts [including CAMHS contacts (mean 30 specialist, 27 generic)] were similar in the specialist and generic CAMHS groups.
There were no significant differences in total costs over the 12-month follow-up period between the specialist and generic groups in either the unadjusted (mean difference £1230, 95 % CI –£14,529 to £16,988; p = 0.878) or the adjusted (mean difference –£7106, 95 % CI –£23,590 to £9379; p = 0.396) analyses. However, adjustment for baseline variables resulted in observed differences favouring participants in specialist services (costs were lower, on average) because of significant baseline differences, with those initially assessed in a specialist service having poorer CGAS scores and %mBMI, both of which were prespecified covariates. This suggests that specialist services were more likely than generic services to assess more severely ill young people or those with more complex needs.
Cost-effectiveness analyses suggest that initial assessment in a specialist service has a higher probability (> 50 % irrespective of willingness to pay) of being cost-effective than initial assessment in generic CAMHS, for both the CGAS and %mBMI.
House et al. (2012) «House J, Schmidt U, Craig M, ym. Comparison of spe...»2, Comparison of Specialist and Nonspecialist Care Pathways for Adolescents with Anorexia Nervosa and Related Eating Disorders
P: 13–17 year-olds with primary diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS).
The initial number of participants was 378 from 37 (out of 44 approached) services. Males (N = 22) were excluded. Services provided specific diagnoses for 287 females, of which 200 were anorexia nervosa or EDNOS-AN, and 87 were bulimia nervosa or EDNOS-BN. For 58 females, services only provided a diagnosis of ‘‘eating disorder''.
Of the 378 adolescents approached, 127 (34.6 %) consented to the study, 15 (4.0 %) refused consent, 235 (62.2 %) did not respond, and 1 (0.3 %) had died.
I: specialist eating disorders services
C: general child and adolescent mental health services (CAMHS); specialist, nonspecialist
O: Presentation rates to services beyond primary care, admissions for inpatient treatment, continuity of care
Presentation rates to services beyond primary care. Mean observed presentation rates (per 100,000 13–17 year-olds per year) were 62.6 for the specialist eating disorders service group, 74.4 for the specialist CAMHS group, and 26.9 for the nonspecialist CAMHS group. Rates for the nonspecialist CAMHS group were significantly lower than those of the specialist eating disorders service group (observed rate: p < .01; estimated rate: p = .04). The rates of the specialist CAMHS group did not differ significantly from those of the specialist eating disorders service group (observed rate: p = 0.41; estimated rate: p = .98). The defining element of each pathway was the type of outpatient service providing treatment following referral from primary care.
Admissions for inpatient treatment. Admissions for inpatient treatment did not differ significantly by group. However, a different picture emerged when actual care pathways were examined. A total of 8/53 (15.1 %) of the specialist assessment to specialist treatment group were admitted for inpatient treatment, compared with 3/16 (18.8 %) of the nonspecialist assessment to specialist treatment group and 6/15 (40.0 %) of the nonspecialist assessment to nonspecialist treatment group. Compared with the specialist assessment to specialist treatment group, the chance of inpatient admission in the nonspecialist assessment to specialist treatment group was statistically non-significant (32 % higher, adjusted OR = 1.32; 95 % CI 0.30–5.81, p = 0.71); in the nonspecialist assessment to nonspecialist treatment group, it was significantly 261 % higher (adjusted OR = 3.61; 95 % CI 1.00– 13.02, p < .05).
Continuity of care. Mapping of actual care pathways highlighted a difference in continuity of care, depending on where outpatient treatment started. In the specialist assessment to specialist treatment group, 83.0 % of participants stayed in their original treating service for the subsequent 12 months, compared with 75.0 % in the nonspecialist assessment to specialist treatment group, and 41.7 % in the nonspecialist assessment to nonspecialist treatment group. The proportion of those who remained in their original treating service was significantly higher in the specialist assessment to specialist treatment group than in the nonspecialist assessment to nonspecialist treatment group (p < 0.01).
To conclude, in areas where specialist outpatient services were available, 2–3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care.
Gowers et al. (2010) «Gowers SG, Clark AF, Roberts C, ym. A randomised c...»3, A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial
P: young people age 12 to 18 presenting to community Child and Adolescent Mental Health Services (CAMHS) with anorexia nervosa.
Two hundred and fifteen young people (199 female) were identified, of whom 167 (mean age 14 years 11 months) were randomised and 48 were followed up as a preference group.
I & C: Randomised patients were allocated to either inpatient treatment in one of four units with considerable experience in the treatment of anorexia nervosa, a specialist outpatient program delivered in one of two centres, or treatment as usual in general community CAMHS.
O: Follow-up assessments were carried out at 1, 2 and 5 years. The primary outcome measure was the Morgan-Russell Average Outcome Scale (MRAOS) and associated categorical outcomes. Secondary outcome measures included physical measures of weight, height, body mass index (BMI) and % weight for height. Research ratings included the Health of the National Outcome Scale for Children and Adolescents (HoNOSCA). Self report measures comprised the user version of HoNOSCA (HoNOSCA-SR), the Eating Disorder Inventory 2 (EDI-2), the Family Assessment Device (FAD) and the recent Mood and Feelings Questionnaire (MFQ). Information on resource use was collected in interview at 1, 2 and 5 years using the Child and Adolescent Service Use Schedule (CA-SUS). Satisfaction was measured quantitatively using a questionnaire designed for the study and qualitative (free) responses on it. The questionnaire data were supplemented by qualitative analysis of user and carer focus groups.
Of the 167 patients randomised, 65 % adhered to the allocated treatment. Adherence was lower for inpatient treatment (49 %) than for general CAMHS (71 %) or specialist outpatient treatment (77 %) (p = 0.013). Every subject was traced at both 1 and 2 years, with the main outcome measure completed (through contact with the subject, family members or clinicians), by 94 % at 1 year, 93 % at 2 years, but only 47 % at 5 years. A validated outcome category was assigned for 98 % at 1 year, 96 % at 2 years and 60 % at 5 years.
There was significant improvement in all groups at each time point, with the number achieving a good outcome being 19 % at 1 year, 33 % at 2 years and 64 % (of those followed up) at 5 years. Analysis demonstrated no difference in treatment effectiveness of randomisation to inpatient compared with outpatient treatment, or, specialist over generalist treatment at any time point, when baseline characteristics were taken into account.
Generalist CAMHS treatment was slightly more expensive over the first 2 years of the study, largely because greater numbers were subsequently admitted to hospital after the initial treatment phase.
The specialist outpatient program was the dominant treatment in terms of incremental cost-effectiveness. Specialist treatments had a higher probability of being more cost-effective than generalist treatments and outpatient treatment had a higher probability of being more cost-effective than inpatient care. Parental satisfaction with treatment was generally good, though better with specialist than generalist treatment. Young people's satisfaction was much more mixed, but again better with specialist treatment, including inpatient care.
The authors suggest that outpatient care, supported by brief (medical) inpatient management for correction of acute complications may be a preferable approach. The health economic analysis and user views both support NICE guidelines, which suggest that anorexia nervosa should be managed in specialist services that have experience and expertise in its management. Comprehensive general CAMHS might, however, be well placed to manage milder cases.
General Comment:
Based on these studies, the cost-effectiveness and continuity of care (treatment retention) in units specialized in the treatment of eating disorders are superior, and the likelihood of later admission to inpatient care is lower compared to units offering general psychiatric care. However, there are challenges with research associated to this topic. These challenges may distort the results and weaken the generalizability of the findings. In observational studies, the severity of the eating disorder and the overall psychiatric comorbidity inevitably influence the choice of treatment setting, making them confounding factors. Even in mathematical adjustments, these factors can only be partially accounted for. In randomized trials, the most severely ill patients may not be permanently allocatable to a treatment group. On the other hand, commitment to inpatient care is weaker than commitment to outpatient care.