Integrated Care Pathways for Schizophrenia: A Scoping Review

A holistic approach to integrating patient, family, and lived experience voices in the development of the BrainHealth Databank: a digital learning health system to enable artificial intelligence in the clinic

Artificial intelligence, machine learning, and digital health innovations have tremendous potential to advance patient-centred, data-driven mental healthcare. To enable the clinical application of such innovations, the Krembil Centre for Neuroinformatics at the Centre for Addiction and Mental Health, Canada's largest mental health hospital, embarked on a journey to co-create a digital learning health system called the BrainHealth Databank (BHDB). Working with clinicians, scientists, and administrators alongside patients, families, and persons with lived experience (PFLE), this hospital-wide team has adopted a systems approach that integrates clinical and research data and practices to improve care and accelerate research. PFLE engagement was intentional and initiated at the conception stage of the BHDB to help ensure the initiative would achieve its goal of understanding the community's needs while improving patient care and experience. The BHDB team implemented an evolving, dynamic strategy to support continuous and active PFLE engagement in all aspects of the BHDB that has and will continue to impact patients and families directly. We describe PFLE consultation, co-design, and partnership in various BHDB activities and projects. In all three examples, we discuss the factors contributing to successful PFLE engagement, share lessons learned, and highlight areas for growth and improvement. By sharing how the BHDB navigated and fostered PFLE engagement, we hope to motivate and inspire the health informatics community to collectively chart their paths in PFLE engagement to support advancements in digital health and artificial intelligence.

Systematic review of structured care pathways in major depressive disorder and bipolar disorder

BACKGROUND

Structured care pathways (SCPs) consist of treatment algorithms that patients advance through with the goal of achieving remission or response. These SCPs facilitate the application of current evidence and adequate treatment, which potentially benefit patients with mood disorders. The aim of this systematic review was to provide an updated synthesis of SCPs for the treatment of depressive disorders and bipolar disorder (BD).

METHOD

PubMed, PsycINFO, and Embase were searched through June 2022 for peer-reviewed studies examining outcomes of SCPs. Eligibility criteria included being published in a peer-reviewed journal in the English language, reporting of intervention used in the SCP, and having quantitative outcomes. Studies Cochrane risk of bias tool was used to assess quality of RCTs.

RESULTS

Thirty-six studies including 15,032 patients were identified for qualitative synthesis. Six studies included patients with BD. The studies were highly heterogeneous in design, outcome measures, and algorithms. More than half of the studies reported superiority of SCPs over treatment as usual, suggesting that the standardized structure and consistent monitoring inherent in SCPs may be contributing to their effectiveness. We also found accumulating evidence supporting feasibility of SCPs in different settings, although dropout rates were generally higher in SCPs. The studies included were limited to being published in peer-reviewed journals in English language. The heterogeneity of studies did not allow quantitative evaluation.

CONCLUSIONS

The findings of our study suggest that SCPs are equally or more effective than treatment as usual in depression and BD. Further studies are required to ascertain their effectiveness, particularly for BD, and to identify factors that influence their feasibility and success.

Exploring sustainable care pathways - a scoping review

BACKGROUND

Patients with mental health problems experience numerous transitions into and out of hospital.

AIM

The review studies assessing clinical care pathways between psychiatric hospitalization and community health services.

METHODS

We used publications between 2009-2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community.

RESULTS

Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care.

RESOURCES

Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need.

ETHICAL ISSUES

Respectful communication and patient-centred, non-humiliating care.

CONCLUSIONS

System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication.

A new electronically based clinical pathway for schizophrenia inpatients: A longitudinal pilot study

Patients with schizophrenia, a severe chronic disorder, are characterized by resistance to therapy, lack of disease understanding, non-compliance and non-adherence, partly caused and maintained by an often poorly structured treatment strategy and polypharmacy. Treatment pathways in the sense of decision aids for professionals bring recommendations from guidelines into a clear and practice-oriented algorithm that can be a helpful tool for treatment. The aim of the present study was to assess the impact of a newly developed electronic clinical pathway (CPW) that integrates the standard computerized medical report system on symptomatic outcomes and process parameters in a population of inpatients with schizophrenia. In this randomized single-center study, 156 patients with schizophrenic disorder were treated in two groups: an experimental CPW group and a control "treatment as usual" (TAU) group. The treatment improvement was analyzed using various process parameters: the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression scale (CGI), the Personal and Social Performance scale (PSP) and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE). The CPW patients differentially showed greater improvement in psychopathology (PANSS) compared to TAU patients (t(154) = 2.030, p = 0.044). There also seems to be advantage for CPW concerning improvement in NOSIE. These results indicate a positive influence of CPW on the quality of treatment and support its implementation in daily clinical practice.

Digitization of Measurement-Based Care Pathways in Mental Health Through REDCap and Electronic Health Record Integration: Development and Usability Study

Background

The delivery of standardized self-report assessments is essential for measurement-based care in mental health. Paper-based methods of measurement-based care data collection may result in transcription errors, missing data, and other data quality issues when entered into patient electronic health records (EHRs).

Objective

This study aims to help address these issues by using a dedicated instance of REDCap (Research Electronic Data Capture; Vanderbilt University)—a free, widely used electronic data capture platform—that was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making.

Methods

REDCap was integrated with the primary clinical information system to facilitate the real-time transfer of discrete data and PDF reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physicians’ and clinicians’ attitudes toward the new system.

Results

The integration of REDCap with the EHR transitioned clinical workflows from paper-based methods of data collection to electronic data collection. This resulted in significant time savings, improved data quality, and valuable real-time information delivery. The digitization of self-report assessments at each appointment contributed to the clinic-wide implementation of the major depressive disorder integrated care pathway. This digital transformation facilitated a 4-fold increase in the physician adoption of this integrated care pathway workflow and a 3-fold increase in patient enrollment, resulting in an overall significant increase in major depressive disorder integrated care pathway capacity. Physicians’ and clinicians’ attitudes were overall positive, with almost all respondents agreeing that the system was useful to their work.

Conclusions

REDCap provided an intuitive patient interface for collecting self-report measures and accessing results in real time to inform clinical decisions and an extensible backend for system integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for the broad deployment of complex workflows and standardized assessments, which led to the accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate the automatic transfer of self-report data to the EHR; however, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained.

Randomized trial of a brief peer support intervention for individuals with schizophrenia transitioning from hospital to community

This phase 2 randomized trial examined the outcomes of a brief, transitional, peer support intervention designed to address the poor outcomes that are common for individuals with schizophrenia spectrum illnesses in the period immediately following hospitalization. In the context of treatment-as-usual, participants were provided with a peer support intervention, 'the Welcome Basket,' in which participants received 1-2 sessions of peer support in the two weeks before discharge and met weekly for a month post-discharge. The study also piloted a brief version of this intervention with only one community session post-discharge with the same pre-discharge process. It was hypothesized that the full intervention would improve community transition outcomes, with community functioning (Multnomah Community Ability Scale) being the primary measure and secondary measures including symptomatology, community integration, personal recovery, quality of life, and social support. The examination of the brief intervention was exploratory. Measures were completed at baseline, 1-month post-discharge, and follow-up at 6 months. A total of 110 participants were randomized to one of three interventions, with outcome data obtained from 82 and follow-up from 74. While feasible, we did not find that the Welcome Basket intervention was superior to treatment as usual for any of our primary or secondary outcome measures. Future work is needed to determine whether a more extended intervention is required and whether specific subgroups of patients may benefit (e.g. those without access to immediate psychiatric care or those better able to engage with a peer).

Using an Integrated Care Pathway for Late-Life Schizophrenia Improves Monitoring of Adverse Effects of Antipsychotics and Reduces Antipsychotic Polypharmacy

OBJECTIVE

Antipsychotic use in older patients is associated with many adverse effects, including tardive dyskinesia and extrapyramidal symptoms, which, in turn, increase the risk of falling. Antipsychotics are also associated with metabolic syndrome and cognitive impairment in older patients. Integrated care pathways (ICPs) are designed to manage specific conditions using standardized assessments and measurement-based interventions. This study aims to compare the use of recommended tools to monitor for adverse effects associated with antipsychotics in older patients managed within an ICP and those managed under usual care conditions-i.e., treatment as usual (TAU).

METHODS

We reviewed and compared the health records of 100 older patients enrolled in an ICP for late-life schizophrenia with those of 100 older patients treated with antipsychotics under TAU conditions.

RESULTS

Monitoring rates were significantly higher in the ICP group than in the TAU group for all assessments: extrapyramidal symptoms (94% versus 5%), metabolic disturbances (91% versus 25%), fall risk (82% versus 35%), and cognitive impairment (72% versus 28%). Rates of antipsychotic polypharmacy were also six times higher in the TAU group.

CONCLUSION

Older patients with schizophrenia treated with antipsychotics within an ICP experience higher rates of monitoring and less psychotropic polypharmacy than older patients treated with antipsychotics under TAU conditions. These findings suggest that an ICP can improve the quality of antipsychotic pharmacotherapy in older patients and thus possibly its effectiveness. This needs to be confirmed by a randomized controlled trial.

Patient Characteristics, Length of Stay, and Functional Improvement for Schizophrenia Spectrum Disorders: A Population Study of Inpatient Care in Ontario 2005 to 2015

OBJECTIVES

Schizophrenia and associated illnesses account for a large proportion of mental illness burden and health care expenditures, with the majority of expense involving inpatient care. To date, the literature exploring factors associated with length of stay (LOS) and functional improvement during inpatient care is underdeveloped. In response, this study examined the association between patient characteristics, LOS, and functional improvement using Ontario Mental Health Reporting System (OMHRS) data from 2005 to 2015.

METHODS

The associations of patient characteristics (including key demographics, psychosocial variables, reasons for admission, and service use history) and 2 outcome measures (LOS and Global Assessment of Functioning [GAF]) were analysed with generalised linear mixed modelling (GLMM). From 2005 to 2015, a total of 48,498 episodes for distinct patients from 18 psychiatric hospitals and 57 general hospitals in Ontario were included.

RESULTS

For psychiatric and general hospitals, mean LOS was 96.6 and 20.5 days, and mean GAF improvement was 14.8 and 16.1, respectively. The majority of associations probed demonstrated a high degree of significance with similar patterns across general and tertiary facility contexts. Older age and more recent readmission following a psychiatric discharge were associated with longer LOS and less GAF improvement. Recent experience of adverse life events and substance misuse were associated with shorter LOS.

CONCLUSIONS

While the findings of this exploratory cross-sectional analysis will require further inquiry with respect to validity and reliability, they suggest that a different service pathway is likely required for individuals with greater psychosocial challenge and extensive service use histories.

Essential components of integrated care for youth with mental health and addiction needs: protocol for a scoping review

INTRODUCTION

Efforts to move towards integrated care have been met with increased interest and enthusiasm in recent years given the potential to improve care and population health while containing costs. However, there is a need to better understand community-based integrated care approaches for youth with mental health and/or addiction concerns to guide future implementation efforts and develop a set of standards for key components. The objectives of this scoping review are to: (1) identify the populations, settings, service providers, interventions, infrastructure and care coordination methods that have been included in integrated care for youth with mental health and/or addiction needs and (2) identify constructs that have been measured and evaluated (eg, outcomes, engagement) in the context of youth integrated care.

METHODS AND ANALYSIS

Seven electronic databases and several grey literature sources will be searched for material from 2001 to 2016. Inclusion criteria will be broad with respect to type of work, as we will include all types of research studies as well as non-research studies that provide information relevant to characteristics and constructs measured in the context of integrated care for youth mental health. Titles and abstracts will be independently screened for eligibility by two raters using inclusion criteria. Full-text articles will then be accessed and independently screened for inclusion. A formal data extraction method will be employed, enabling synthesis of results in quantitative and qualitative formats.

ETHICS AND DISSEMINATION

Results will be widely disseminated to various stakeholders to inform implementation and research efforts. Findings will also launch a Delphi method study leading to the development of an assessment tool for youth mental health services integration. This review does not require ethics approval.