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The Business Case for Expanded Clozapine Utilization
Jessica L Gören1, Adam J Rose1, Eric G Smith1
1Dr. Gören is with the Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston (e-mail: jgoren@challiance.org ). She and the other authors are also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. Ney is also with the Department of Neurology, Boston University, Boston.
Objective:
In most settings, less than 25% of patients with treatment-resistant schizophrenia receive clozapine, the only medication proven effective for treatment-resistant schizophrenia. Therefore, a business case analysis was conducted to assess whether increasing clozapine utilization for treatment-resistant schizophrenia in a health care system would result in direct health care cost savings.
Methods:
Veterans with treatment-resistant schizophrenia who were treated in the Veterans Health Administration (VHA) were studied. Treatment response, suicides, adverse drug reactions (and associated mortality), and effects on inpatient hospitalization related to clozapine were derived from a systematic review of published studies. A one-factor sensitivity analysis and a probabilistic sensitivity analysis (PSA) with Monte Carlo simulation were conducted to calculate the cost-benefits of increased clozapine utilization.
Results:
Despite monitoring costs, in the base case analysis, the VHA would save $22,444 per veteran with treatment-resistant schizophrenia over the first year of clozapine therapy, primarily from 18.6 fewer inpatient days per patient. If current utilization was doubled, and 50% of those veterans continued clozapine treatment for one year, VHA would save an estimated $80 million. Cost savings were most sensitive to the proportion of treatment-resistant patients who received clozapine, decrease in inpatient days, cost of inpatient stays, clozapine response rate, and number of patients with treatment-resistant schizophrenia. In the PSA, initiation of clozapine for all VHA patients with treatment-resistant schizophrenia who were not currently treated with clozapine would save at least $290 million in 95% of simulations.
Conclusions:
Increased clozapine utilization would result in net cost savings for the VHA.