Available online at Psychiatry Research 158 (2008) 306 – 315 The functionality and economic costs of outpatients with I Hui Lee a,b, Po See Chen a,b, Yen Kuang Yang a,b,⁎, Yi Cheng Liao c, Yih Dar Lee a,d, Tzung Lieh Yeh a,b, Ling Ling Yeh e, Shu Hui Cheng b, Ching Lin Chu a a Department of Psychiatry, College of Medicine, National Cheng Kung University, 138 Sheng Li Road, Tainan 70428, Taiwan b Department of Psychiatry, National Cheng Kung University Hospital, 138 Sheng Li Road, Tainan 70428, Taiwan c Department of Psychiatry, Changhua Christian Hospital, Changhua, Taiwan d Eli Lilly and Company [Taiwan], Inc, Taipei, Taiwan e Institute of Long-Term Care, Asia University, Taichung, Taiwan Received 24 February 2006; received in revised form 12 July 2006; accepted 2 October 2006 The aims of this study were to investigate the economic costs of outpatients with schizophrenia in Taiwan, and to survey factors that influence the costs. The direct costs were defined as the costs associated with psychiatric services and other medical treatment. The indirectcosts were estimated using the Human Capital Method. Patients' characteristics, including sex, age, duration of education, duration ofillness, frequency of hospitalization, type of antipsychotic medication, severity of extrapyramidal side effects caused by antipsychoticmedication, and global functions, were used to estimate the costs. The average annual total cost was approximately US$16,576 per patient.
The direct and indirect costs were 13% and 87% of the total costs, respectively. Among the direct costs, folk therapy ranked third, just behindprescription drugs and acute ward hospitalization. The productivity loss of both the patients and their caregivers was the major component ofthe indirect costs. The patient's age and global functions had a significantly negative relationship with the direct costs. The severity ofextrapyramidal side effects, type of antipsychotic medication, and the patient's illness duration correlated positively with the indirect costs,while the patient's global function correlated negatively with the indirect costs. Overall, the indirect costs of treating schizophreniawere higher than the direct costs. Improving patients' functionality and decreasing caregivers' burden are essential to reducing costs.
2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Schizophrenia; Cost of illness; Drug side effects; Antipsychotics; Functionality Schizophrenia is a costly mental disorder ( costs of patients with schizophrenia include the direct treatment costs and indirect costs in the form of lost showed that about 2% of the total health care budget was spent on the treatment of schizophrenic patients related to schizophrenia have demonstrated a wide For the United Kingdom, reported that 3% of the total expenditure by the National Health was accounted for by schizophrenic Corresponding author. Tel.: +886 6 2766188; fax: +886 6 2759259.
0165-1781/$ - see front matter 2006 Elsevier Ireland Ltd. All rights reserved.
I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 Many of the previous studies have focused only on ). In turn, these factors might have influenced the prognosis and costs of schizophrenia treatment an obvious shortcoming, because the proportion of direct treatment pharmaco-economic costs, out of the total predictive factors of the costs may be a prerequisite for costs, is small. Besides, the costs of schizophrenia are not reducing the economic impact of schizophrenia.
simply monetary. The overall costs should also include Although the patient's functionality is one of the the social and psychological costs incurred by patients most important factors affecting the treatment outcome and their family members. Previous studies in the U.S of schizophrenia, the monetary relationship between the demonstrated that direct and indirect costs represented patient's functionality and the costs has not been well 38% (range: 33–41%) and 62% (range: 59–66%) of the elucidated. The objectives of the present study were to: (i) estimate the annual costs of outpatients with schizophrenia in Taiwan; and (ii) survey cost-related indirect costs due to lost productivity accounted for 49% factors, including global function. Given the magnitude of the National Health Service expenditure on schizo- of the cost estimates, we expect that there will be potential for improving cost-effectiveness.
reported that, in France, the average annual costfor medical care and social allowance per schizophrenic patient was estimated at F54,970 (French Francs) andF22,905, respectively. The actual ratio of indirect costs to total cost may be even higher. Indirect costs are oftenunderestimated, since schizophrenic patients are unlike- Seventy-four stable patients (42 males and 32 females) ly to become active participants in the labour force again with schizophrenia, who had remained on either haloper- idol or risperidone treatment for at least 1 year, were Modeled after the US system, the mental health care consecutively enrolled at the psychiatric outpatient clinics system in Taiwan was implemented after World War II.
in the cities of Tainan (N = 23), Chiayi (N = 18), and Initially, mental hospitals were created for schizophrenic Changhua (N = 33) during the study period (August 1999 patients as they were often abandoned by their families.
to May 2000). During this period, the BNHI rules Psychiatric services in the general hospitals were started stipulated that only patients with the following documen- later. Following the tide of deinstitutionalization, health ted conditions could be prescribed atypical antipsychotics care providers in Taiwan also attempted to shorten (such as risperidone): (1) severe extrapyramidal side hospitalization days and reduce the number of in-patient effects (EPSEs) with conventional antipsychotics; (2) non-responsiveness to conventional antipsychotic The government covers 90% of the psychiatric care treatment; or (3) old-age psychosis. All subjects in the fees through the Bureau of National Health Insurance risperidone group were approved by the BNHI.
(BNHI) in Taiwan since 1995. According to the BNHI, These cities are located in central and southern 96% of all citizens participated in this insurance program Taiwan. The demographic and economic characteristics were not significantly different among these cities. The Due to health care resource constraints, the rising patients' mean age was 33.7 (S.D. = 8.4) years old, and costs of treating patients with schizophrenia and the the caregivers' (35 males and 38 females) mean age was emergence of the multiplicity care arrangement, strate- 54.6 (S.D. = 12.9) years old. The mean duration of gies for improving cost effectiveness have attracted research interest in recent years in Taiwan as well as The major caregiver of each patient in this study was defined according to the following criteria: (1) living with the patient; (2) entitled to decide the treatment In contrast with the West where (institutionalized care) mode and medication type; and (3) responsible for the dominates, most of the psychiatric patients in Taiwan are cared for by their families. Psychosocial factors, including Informed consent was been obtained from patients the acceptance of psychiatric services, the perception of and their caregivers. The Ethical Committee for Human illness, and the patients' or their relatives' knowledge of Research at National Cheng Kung University Medical disease, could affect the process of help-seeking in pa- Center approved the study protocols.
I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 Table 1Itemized monetary costs for each patient (Direct costs) Number of days × patient's actual payment Traditional Chinese medicine Patient's actual payment aThe unit of Costs in this column is US$ (NT$35= US$1, 1999).
those associated with psychiatric service expendituressuch as hospitalization costs, outpatient costs, day The patients were assessed using the following hospital costs, community rehabilitation costs, and instruments when they visited outpatient clinics during other medical treatment costs. The unit costs stipulated by BNHI were similar to those obtained at all threesites. The sites were defined as the psychiatric 1. Mandarin Chinese version of the Positive and departments of general hospitals. The direct costs related to psychiatric services were categorized into This scale was used to assess schizophrenic five types of unit service costs (hospitalization, OPD, symptoms. The mean score for positive and nega- emergency, home care, and day hospital). The BNHI tive symptoms was 13.77 (S.D. = 4.68) and 18.38 pays a flat fee for each day of day hospitalization, (S.D. = 6.20), respectively. EPSEs caused by antipsy- regardless of the types of care received. The costs for chotic medication were assessed using the Simpson– the remaining four types of psychiatric services were obtained by multiplying the cost per unit (or per day) mean score was 6.4 (S.D. = 3.9); the mean score in by the number of units (or days). The costs for all the haloperidol subgroup was 7.06 (S.D. = 4.33), in risper- services were obtained by adding the patient's co- idone subgroup it was 5.84 (S.D. = 3.36) (t = 1.32; payments to the BNHI's payments. All of these data P = 0.19). Global functions were assessed using the were obtained from the accounting department at the research sites. Indirect costs were defined as the costs The mean score was 48.2 (S.D. = 12.2).
associated with time, loss of productivity, transporta- tion and community resources. However, the indirect economic costs included direct costs and indirect costs costs associated with the caregivers' psychological over the previous year. The direct costs were defined as burden were omitted because the monetary estimation I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 Table 2Itemized monetary costs for each patient (Indirect costs) (for those currently employed)Time cost for patients (unit: h) Day hospitalization days × 8 h/day +One-way time + Time for treatment) ×average hourly earnings days × 8 h/day) × average hourly earnings and age in Taiwan (adjusted by unemployment rate) and age level in Taiwan(adjusted by unemployment rate) Neighbours' service time × average hourly wage aThe unit of Costs in this column is US$ (NT$35 = US$1, 1999).
of a psychological burden is difficult. The Human higher scores representing higher levels of causality.
Capital Method was used to estimate the monetary There were five subscales of disease attribution: value of healthy time using market wage rates. Hence, psychodynamic, biological, environmental, moral, lost productivity was calculated using average wages and supernatural. The total score of each subscale with adjustments for age, educational level and gender, (with four questions each) was obtained by summing and for the length of time the patients had been absent up the scores on the questions. We only used the from work or how early they retired ahead of the biological attribution subscale in this study. The average age of retirement (). The monetary attribution of illness was categorized as either bio- values of these costs for each patient are summarized in logical or non-biological according to the score of biological attribution subscale with cut-off point of 5.
3. Knowledge of Schizophrenia (KOS): This 14-item The internal consistency as measured by Cronbach's questionnaire was used to assess the caregivers' α was 0.54. The mean score was 5.42 (S.D.=2.83).
knowledge regarding the four aspects of schizophre-nia: symptoms, causes, treatments, and community Trained psychologists performed personal structured interviews to collect data using an economic cost question was rated as “correct (=1)”, “wrong (= 0)”, questionnaire, the KOS, and the PCI. The PANSS, or “unknown (= 0)”. The total score (maximum of 14) SAS and GAS were rated by psychiatrists. The Chinese was derived by summing up the scores of all the versions of the KOS and the PCI had been developed and questions. The Cronbach's α in the current study was standardized, and they scored highly on both reliability .79. The mean score was 7.6 (S.D. = 3.3).
4. Perceived Causes of Illness (PCI): This self-reported questionnaire for caregivers' was compiled with reference to a study by .
The questionnaire, which comprised 20 questions, The costs were estimated by summing up all of the was used to assess the caregiver's perception of related costs. T-tests were used to analyze the differences the cause of the disease. Each question was rated on a in demographic and clinical characteristics between 4-point Likert scale (1 = not at all; 4 = totally), with two drug groups. Pearson's correlation or t-test was I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 Table 3Comparison of cost of illness in schizophrenia in different countries 2,3National study, top down approach.
1,4Non-top down approach.
3For newly diagnosed patients.
Table 4Comparison of demographic variables, clinical variables, caregivers' attitude, and costs between different drug groups Clinical variablesDuration of illness (years) PANSS: Positive and Negative Symptom Scales; GAS: Global Assessment Scale; SAS: Simpson–Angus Scale; KOS: Knowledge of Schizophrenia;PCI: Perceived Causes of Illness.
†The unit of Costs in this column is US$1000 (NT$35=US$1, 1999).
⁎: Pb.05; ⁎⁎: Pb.01; ⁎⁎⁎: Pb.001 (two-tailed).
I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 New Taiwanese dollars); (NT$35 = US$1, 1999) for each Correlations between patients' demographic variables, clinical patient, 13% (US$2115) of which was direct costs, and variables, and caregivers' attitude and costs 87% (US$14,461), indirect costs. The mean annual mental health care cost from BNHI in this study was US $1572 (S.D. = 1608). There were no significant differ- ences in any of the demographic variables (age, education years, and illness years) or the direct and r = −0.34 (0.003)⁎⁎ r = 0.15 (0.21) indirect costs among the sites. The largest component of the direct costs was medication (5.72%), followed by theexpenses for acute ward hospitalization (2.29%), and folk therapy (2.06%). As for the indirect costs, productivity loss (81.03% of the total costs, or 43.19% and 37.84% for the patient and their caregivers, respectively) accounted for the highest proportion t = −2.98 (0.004)⁎⁎ t = −2.02 (0.05)⁎ costs in our study were much lower compared to those ofthe aforementioned studies. The proportion of hospital- ization costs in the direct costs was comparable to that of the Tarricones's report while the proportion of cost of drugs in our study was the highest. Both Tarricone's and our studies support the finding that family impact costs PANSS: Positive and Negative Symptom Scales; GAS: Global account for approximately 40% of the indirect costs.
Assessment Scale; SAS: Simpson–Angus Scale; KOS: Knowledgeof Schizophrenia; PCI: Perceived Causes of Illness.
The results of our t-tests showed that the character- aT-test; ⁎: P b0.05; ⁎⁎: Pb0.01; ⁎⁎⁎: Pb0.001 (two-tailed).
istics of the risperidone and haloperidol groups were notsignificantly different in the demographic or clinical performed to analyze the relationship between the costs variables (). The direct and indirect costs were and the explanatory variables, including (1) demograph- higher in risperidone group. However, the direct costs ic variables (patients' sex, age, duration of education); excluding the medication expenditure was not different (2) clinical variables (duration of illness, frequency of hospitalization, psychopathology (PANSS), extrapyra- The correlation matrix and t-test analyses between midal side effects (SAS), global functions (GAS), and the patients' and their caregivers' characteristics and the type of medication (risperidone or haloperidol)); and different costs are shown in . Age, duration of (3) caregivers' attitude (KOS and PCI).
Stepwise multiple linear regression models for pre- dicting the direct and indirect costs were constructed Stepwise multiple linear regression analysis of costs (N = 64) using variables that significantly correlated with the costs and independent variables. Only subjects with complete information (N = 64) were included in the models. Asdependent variables, the logarithms to the base 10 of direct costs were used, since they were symmetric and nearly normally distributed. Our analyses of the residuals showed that the logarithmic transformation was appro- priate. All of the analyses were performed using the SPSS software (SPSS Inc., Chicago, IL, U.S.A.).
a The scale of direct costs was transferred by log10. The unit of cost wasNT$1000.
The annual average total cost was approximately SAS: Simpson–Angus Scale; GAS: Global Assessment Scale.
US$16,576 (NT$580,167, S.D. = NT$344,128) (NT$ = ⁎: Pb.05; ⁎⁎: Pb.01; ⁎⁎⁎: Pb.001 (two-tailed).
I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 illness, and GAS correlated negatively with direct costs.
costs in Taiwan. Productivity loss was noted not only for Duration of illness, positive domain of the PANSS, and the patients themselves, but also for their caregivers.
SAS correlated positively, and GAS correlated nega- Low employment rates were found both in patients with tively with the indirect costs. The risperidone group low functionality and their caregivers in this study incurred higher direct and indirect costs than the (32.9% and 46.6%, respectively). The high level of haloperidol group. Caregivers' attitude (PCI and KOS) indirect costs revealed here is mostly attributable to the productivity loss. Unlike the majority of cost of illness For both direct and indirect costs, we developed regression models using the significant variables.
Stepwise multiple regression analyses of the direct assess the costs from a societal perspective and high- costs indicated statistically significant differ- lights the individual cost components including folk ences among the types of antipsychotics, the GAS therapy and loss of productivity of caregivers, but scores, and the patients' age, but not the duration of excluding the social security outlays and criminal justice illness. In the indirect cost model, all variables (the GAS system costs. The high indirect costs underscore the scores, type of antipsychotics, patients' illness duration, burden schizophrenia places on society and the and the SAS scores) were significantly different.
importance of comprehensive evaluation of cost-effectiveness.
Our previous study revealed that schizophrenia patients with more severe cognitive deficits may incur The results of this study revealed that schizophrenia is a costly disease in Taiwan as well as in the west. In model of the current study also showed that the patients' 1999, the mean of the National Health Expenditure in functionality, as measured by the GAS score, is a major Taiwan for each person was about US$734, or about predictor of not only the indirect costs but also the direct 5.46% of the Gross Domestic Product (GDP) ( costs. This finding is consistent with those of annual average of direct costs for each schizophrenic Considering the high care costs of patients with patient was US$2115, almost three times higher than the schizophrenia, the functional and occupational impair- mean of the National Health Expenditure in 1999 in ments must be rectified. To reduce the costs of Taiwan. This evidence supports our hypothesis that schizophrenia, psychiatric service policies should patients with schizophrenia in Taiwan utilized a focus on enhancing the patients' global functional disproportionately high amount of health care services, just as that reported by western countries ( days, and enabling patients to return to active employ- ). Only then can the caregivers' burden be reduced.
The low utilization of community care services may cantly higher than the direct costs, which is consistent be one of the important reasons for the high productivity loss in caregivers. This study showed that the costs of community care in this study were only about 0.06% of indirect costs in this study (87%) was even higher than the provision of active community services for patients with schizophrenia may lead to overall savings in care costs. However, if community care programs are not service utilization patterns and costs exist among well organized and developed following a reduction in various studies, the methodological inconsistencies in-patient beds, efforts to reduce direct costs may just should be taken into consideration when comparing shift the burden back to the patients, their families and communities, and hence increase the indirect costs.
One of the reasons for the higher proportion of indi- Because the illness attribution (to supernatural causes) rect costs for treating schizophrenia in Taiwan may be and the stigmatization of schizophrenia in countries with the lower insurance payment for medical services (the less developed mental health care system differ from those usual physician's fee for each visit is only about US$10 of the west, delay in help-seeking is prevalent ( in Taiwan). In addition, our results showed that the loss of productivity was the major component of indirect I.H. Lee et al. / Psychiatry Research 158 (2008) 306–315 families more frequently rely on sources of support The third-party payment agent in Taiwan, the BNHI, outside the mental health care sector such as priests, implemented strict rules for prescribing atypical anti- confidants or traditional “alternative” treatments, such as psychotics in order to contain the increasing psychiatric care expenditures during the period of study. The Although the PCI and KOS scores did not correlate BNHI's strict rules for prescribing risperidone have with the costs, the actual outlays for psychiatric acute resulted in a selection bias in the risperidone group. The ward treatment were comparable to those for folk higher costs for the risperidone group patients may also therapy in the current study. 31.5% (23/73) of be attributable to their more serious conditions com- schizophrenic families in our study either donated money to the temples or paid the healers for rituals to These results should be interpreted with caution for several reasons. First of all, only stable outpatients were To our knowledge, this is the first head-to-head enrolled in this study. Those subjects who were selection- comparison study about the costs of mental health care biased may not be representative of all patients with and alternative treatments. One previous study reported schizophrenia from general hospitals in Taiwan. The that, in Taiwan, over 30% of patients and their relatives composition of costs for patients in different stages may believe that the cause of schizophrenia is supernatural Both community-based patients and chronic inpatients should be enrolled in the future. Secondly, the Needless to say, the delay in help-seeking increases to validity of the data related to the patients' conditions, such the financial burden of the families in the form of the as psychotic symptoms and EPSE, may be short-lived, higher productivity loss of the caregivers. Andrews since the patients' conditions may have fluctuated estimates that, even with optimal treatment, only 22% throughout the year in which the costs were calculated.
the burden of schizophrenia could be averted Thus, results regarding the relationships between the patients' conditions and the annual costs must be inter- inevitable. The high expenditure in folk therapy reflects preted with discretion. Thirdly, the productivity loss figu- an underlying dissatisfaction about current treatment res used in this study are only subjective estimates, at best, modalities and the unmet needs of the schizophrenic due to the lack of an objective method of measurement.
patients and families even in the stable stage.
Our results also demonstrated that the undesirable extrapyramidal effects of antipsychotics in terms of SASscores have a positive correlation with the indirect costs Janssen-Cilag Company Taiwan, Inc. funded this and total costs. Similar findings have been reported by research. The authors wish to thank Mr. Mitchell Chen, Miss Shu Chuan Lin, Miss Linda J. Chang, and Dr.
imply both disability and loss of productivity. For that Chwen Cheng Chen, for their statistical, administrative, reason, one may expect the use of atypical antipsycho- and editorial assistance in the preparation of this tics, such as risperidone, which have fewer propensities for EPSE than haloperidol, to be associated with lowercosts Unfortunately, atypical anti- psychotics are much more expensive than conventionalantipsychotics.
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Microsoft word - 2010 health form

2010 Health Form Page 1 of 4 Camper Name Please complete and RETURN TO CAMP BY MAY 1st for all sessions. PLEASE PRINT. If enrolling after May 1st, please return ASAP. Camper Name : ___________________________________________ Session: ________________ :_____________________________ (For Camp Use) Age : _____________________ Birthday : __________________________ Gender

RECURSO DE MULTAS Se puede interponer recurso contra algunos actos (actas de contravención, providencia de apremio y requerimiento de pago*) ante el Juzgado del lugar donde se ha cometido la infracción y entre el plazo indicado en el acto impugnado–o sea a partir de la notificación. Se puede interponer recurso también contra las penas accesorias (ej. Comiso). COMPETENCIAJUZGADO DE P

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