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

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

Emma Butler  1 , Toby Pillinger  1 , Kirsten Brown  2 , Faith Borgan  2 , Alice Bowen  2 , Katherine Beck  2 , Enrico D'Ambrosio  3 , Lisa Donaldson  4 , Sameer Jauhar  1 , Stephen Kaar  1 , Tiago Reis Marques  5 , Robert A McCutcheon  1 , Maria Rogdaki  1 , Fiona Gaughran  2 , James MacCabe  1 , Rosalind Ramsay  1 , David Taylor  1 , Paul McCrone  2 , Alice Egerton  2 , Oliver D Howes  6
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Real-world clinical and cost-effectiveness of community clozapine initiation: mirror cohort study

Emma Butler et al. Br J Psychiatry. 2022 Dec.

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%, χ2(1,88) = 0.47, P = 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), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75-71.00) to 22.00 (IQR = 11.00-42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = -2.50, P = 0.01). Service-use costs decreased (1 year: -£963/patient (P < 0.001); 2 years: -£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: -£827.40/patient (P < 0.001); 2 year: -£1668.50/patient (P < 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), P < 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), P = 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.

Keywords: Psychotic disorders; mirror study; out-patient treatment; real word service use; schizophrenia.

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