1
|
Ride J, Kasteridis P, Gutacker N, Gravelle H, Rice N, Mason A, Goddard M, Doran T, Jacobs R. Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness. HEALTH ECONOMICS 2023; 32:343-355. [PMID: 36309945 PMCID: PMC10092448 DOI: 10.1002/hec.4623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.
Collapse
Affiliation(s)
- Jemimah Ride
- Health Economics UnitMelbourne School of Population and Global HealthUniversity of MelbourneParkvilleVictoriaAustralia
| | | | | | | | - Nigel Rice
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Anne Mason
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | - Tim Doran
- Health SciencesUniversity of YorkYorkUK
| | | |
Collapse
|
2
|
Multimorbidity is associated with the income, education, employment and health domains of area-level deprivation in adult residents in the UK. Sci Rep 2022; 12:7280. [PMID: 35508678 PMCID: PMC9068903 DOI: 10.1038/s41598-022-11310-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 01/12/2022] [Indexed: 11/08/2022] Open
Abstract
Evidence suggests that there are social inequalities in multimorbidity, with a recent review indicating that area levels of deprivation are consistently associated with greater levels of multimorbidity. Definitions of multimorbidity, the most common of which is the co-occurrence of more than one long term condition, can include long term physical conditions, mental health conditions or both. The most commonly used measure of deprivation in England and Wales is the Index of Multiple Deprivation (IMD), an index of seven different deprivation domains. It is unclear which features of IMD may be mediating associations with multimorbidity. Thus, there may be associations because of the individual characteristics of those living in deprived areas, characteristics of the areas themselves or overlap in definitions. Data from over 25,000 participants (aged 16+) of Understanding Society (Wave 10, 1/2018–3/2020) were used to understand the most salient features of multimorbidity associated with IMD and whether physical or mental conditions are differentially associated with the seven domains of IMD. 24% of participants report multimorbidity. There is an increased prevalence of multimorbidity composed of only long-term physical conditions in the most deprived decile of deprivation (22%, 95% CI[19,25]) compared to the least deprived decile (16%, 95% CI[14,18]). Mental health symptoms but not reporting of conditions vary by decile of IMD. Associations with multimorbidity are limited to the health, income, education and employment domains of IMD. We conclude that multimorbidity represents a substantial population burden, particularly in the most deprived areas in England and Wales.
Collapse
|
3
|
Das-Munshi J, Schofield P, Ashworth M, Gaughran F, Hull S, Ismail K, Robson J, Stewart R, Mathur R. Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years. BMJ Open Diabetes Res Care 2021; 9:e002118. [PMID: 34497046 PMCID: PMC8438718 DOI: 10.1136/bmjdrc-2021-002118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. RESEARCH DESIGN AND METHODS Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. RESULTS Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. CONCLUSIONS Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.
Collapse
Affiliation(s)
- Jayati Das-Munshi
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
- ESRC Centre for Society and Mental Health, King's College London, London, UK
| | - Peter Schofield
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Mark Ashworth
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Fiona Gaughran
- South London and Maudsley (SLaM) NHS Trust, London, UK
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
| | - Sally Hull
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - John Robson
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - Rohini Mathur
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
4
|
Osborn D, Burton A, Walters K, Atkins L, Barnes T, Blackburn R, Craig T, Gilbert H, Gray B, Hardoon S, Heinkel S, Holt R, Hunter R, Johnston C, King M, Leibowitz J, Marston L, Michie S, Morris R, Morris S, Nazareth I, Omar R, Petersen I, Peveler R, Pinfold V, Stevenson F, Zomer E. Primary care management of cardiovascular risk for people with severe mental illnesses: the Primrose research programme including cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population.
Objectives
(1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop an intervention to reduce levels of cholesterol and CVD risk in SMI and (3) test the clinical effectiveness and cost-effectiveness of this new intervention in primary care.
Design
Mixed methods with patient and public involvement throughout. The mixed methods were (1) a prospective cohort and risk score validation study and cost-effectiveness modelling, (2) development work (focus groups, updated systematic review of interventions, primary care database studies investigating statin prescribing and effectiveness) and (3) cluster randomised controlled trial (RCT) assessing the clinical effectiveness and cost-effectiveness of a new practitioner-led intervention, and fidelity assessment of audio-recorded appointments.
Setting
General practices across England.
Participants
All studies included adults with SMI (schizophrenia, bipolar disorder or other non-organic psychosis). The RCT included adults with SMI and two or more CVD risk factors.
Interventions
The intervention consisted of 8–12 appointments with a practice nurse/health-care assistant over 6 months, involving collaborative behavioural approaches to CVD risk factors. The intervention was compared with routine practice with a general practitioner (GP).
Main outcome measures
The primary outcome for the risk score work was CVD events, in the cost-effectiveness modelling it was quality-adjusted life-years (QALYs) and in the RCT it was level of total cholesterol.
Data sources
Databases studies used The Health Improvement Network (THIN). Intervention development work included focus groups and systematic reviews. The RCT collected patient self-reported and routine NHS GP data. Intervention appointments were audio-recorded.
Results
Two CVD risk score models were developed and validated in 38,824 people with SMI in THIN: the Primrose lipid model requiring cholesterol levels, and the Primrose body mass index (BMI) model with no blood test. These models performed better than published Cox Framingham models. In health economic modelling, the Primrose BMI model was most cost-effective when used as an algorithm to drive statin prescriptions. Focus groups identified barriers to, and facilitators of, reducing CVD risk in SMI including patient engagement and motivation, staff confidence, involving supportive others, goal-setting and continuity of care. Findings were synthesised with evidence from updated systematic reviews to create the Primrose intervention and training programme. THIN cohort studies in 16,854 people with SMI demonstrated that statins effectively reduced levels of cholesterol, with similar effect sizes to those in general population studies over 12–24 months (mean decrease 1.2 mmol/l). Cluster RCT: 76 GP practices were randomised to the Primrose intervention (n = 38) or treatment as usual (TAU) (n = 38). The primary outcome (level of cholesterol) was analysed for 137 out of 155 participants in Primrose and 152 out of 172 in TAU. There was no difference in levels of cholesterol at 12 months [5.4 mmol/l Primrose vs. 5.5 mmol/l TAU; coefficient 0.03; 95% confidence interval (CI) –0.22 to 0.29], nor in secondary outcomes related to cardiometabolic parameters, well-being or medication adherence. Mean cholesterol levels decreased over 12 months in both arms (–0.22 mmol/l Primrose vs. –0.39 mmol/l TAU). There was a significant reduction in the cost of inpatient mental health attendances (–£799, 95% CI –£1480 to –£117) and total health-care costs (–£895, 95% CI –£1631 to –£160; p = 0.012) in the intervention group, but no significant difference in QALYs (–0.011, 95% CI –0.034 to 0.011). A total of 69% of patients attended two or more Primrose appointments. Audiotapes revealed moderate fidelity to intervention delivery (67.7%). Statin prescribing and adherence was rarely addressed.
Limitations
RCT participants and practices may not represent all UK practices. CVD care in the TAU arm may have been enhanced by trial procedures involving CVD risk screening and feedback.
Conclusions
SMI-specific CVD risk scores better predict new CVD if used to guide statin prescribing in SMI. Statins are effective in reducing levels of cholesterol in people with SMI in UK clinical practice. This primary care RCT evaluated an evidence-based practitioner-led intervention that was well attended by patients and intervention components were delivered. No superiority was shown for the new intervention over TAU for level of cholesterol, but cholesterol levels decreased over 12 months in both arms and the intervention showed fewer inpatient admissions. There was no difference in cholesterol levels between the intervention and TAU arms, which might reflect better than standard general practice care in TAU, heterogeneity in intervention delivery or suboptimal emphasis on statins.
Future work
The new risk score should be updated, deployed and tested in different settings and compared with the latest versions of CVD risk scores in different countries. Future research on CVD risk interventions should emphasise statin prescriptions more. The mechanism behind lower costs with the Primrose intervention needs exploring, including SMI-related training and offering frequent support to people with SMI in primary care.
Trial registration
Current Controlled Trials ISRCTN13762819.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 2. See the NIHR Journals Library website for further project information. Professor David Osborn is supported by the University College London Hospital NIHR Biomedical Research Centre and he was also in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust.
Collapse
Affiliation(s)
- David Osborn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Alexandra Burton
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Lou Atkins
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
| | - Thomas Barnes
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Ruth Blackburn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Thomas Craig
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Hazel Gilbert
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ben Gray
- The McPin Foundation, London, UK
| | - Sarah Hardoon
- Department of Primary Care and Population Health, University College London, London, UK
| | - Samira Heinkel
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Richard Holt
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rachael Hunter
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Johnston
- School of Health and Education, Faculty of Professional and Social Sciences, Middlesex University, London, UK
| | - Michael King
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Judy Leibowitz
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - Susan Michie
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
| | - Richard Morris
- Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Morris
- Department of Allied Health Research, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Robert Peveler
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Fiona Stevenson
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ella Zomer
- Department of Primary Care and Population Health, University College London, London, UK
| |
Collapse
|
5
|
Dawson J, Rigby-Brown A, Adams L, Baker R, Fernando J, Forrest A, Kirkwood A, Murray R, West M, Wike P, Wilde M. Developing and evaluating a tool to measure general practice productivity: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Systems for measuring the performance of general practices are extremely limited.
Objectives
The aim was to develop, pilot test and evaluate a measure of productivity that can be applied across all typical general practices in England, and that may result in improvements in practice, thereby leading to better patient outcomes.
Methods
Stage 1 – the approach used was based on the Productivity Measurement and Enhancement System (ProMES). Through 16 workshops with 80 general practice staff and 72 patient representatives, the objectives of general practices were identified, as were indicators that could measure these objectives and systems to convert the indicators into an effectiveness score and a productivity index. This was followed by a consensus exercise involving a face-to-face meeting with 16 stakeholders and an online survey with 27 respondents. An online version of the tool [termed the General Practice Effectiveness Tool (GPET)] and detailed guidance were created. Stage 2 – 51 practices were trained to use the GPET for up to 6 months, entering data on each indicator monthly and getting automated feedback on changes in effectiveness over time. The feasibility and acceptability of the GPET were examined via 38 telephone interviews with practice representatives, an online survey of practice managers and two focus groups with patient representatives.
Results
The workshops resulted in 11 objectives across four performance areas: (1) clinical care, (2) practice management, (3) patient focus and (4) external focus. These were measured by 52 indicators, gathered from clinical information systems, practice records, checklists, a short patient questionnaire and a short staff questionnaire. The consensus exercise suggested that this model was appropriate, but that the tool would be of more benefit in tracking productivity within practices than in performance management. Thirty-eight out of 51 practices provided monthly data, but only 28 practices did so for the full period. Limited time and personnel changes made participation difficult for some. Over the pilot period, practice effectiveness increased significantly. Perceptions of the GPET were varied. Usefulness was given an average rating of 4.5 out of 10.0. Ease of use was more positive, scoring 5.6 out of 10.0. Five indicators were highlighted as problematic to gather, and 27% of practices had difficulties entering data. Feedback from interviews suggested difficulties using the online system and finding time to make use of feedback. Most practices could not provide sufficient monthly financial data to calculate a conventional productivity index.
Limitations
It was not possible to create a measure that provides comparability between all practices, and most practices could not provide sufficient financial data to create a productivity index, leaving an effectiveness measure instead. Having a relatively small number of practices, with no control group, limited this study, and there was a limited timescale for the testing and evaluation.
Implications
The GPET has demonstrated some viability as a tool to aid practice improvement. The model devised could serve as a basis for measuring effectiveness in general practice more widely.
Future work
Some additional research is needed to refine the GPET. Enhanced testing with a control sample would evaluate whether or not it is the use of the GPET that leads to improved performance.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Jeremy Dawson
- Sheffield University Management School, The University of Sheffield, Sheffield, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Anna Rigby-Brown
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Lee Adams
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Amanda Forrest
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Anna Kirkwood
- The Medical School, The University of Sheffield, Sheffield, UK
| | | | | | | | | |
Collapse
|
6
|
da Rocha HA, dos Santos ADF, Reis IA, Santos MADC, Cherchiglia ML. Mental health in primary care: an evaluation using the Item Response Theory. Rev Saude Publica 2018; 52:17. [PMID: 29489992 PMCID: PMC5825122 DOI: 10.11606/s1518-8787.2018052000051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/22/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the items of the Brazilian National Program for Improving Access and Quality of Primary Care that better evaluate the capacity to provide mental health care. METHODS This is a cross-sectional study carried out using the Graded Response Model of the Item Response Theory using secondary data from the second cycle of the National Program for Improving Access and Quality of Primary Care, which evaluates 30,523 primary care teams in the period from 2013 to 2014 in Brazil. The internal consistency, correlation between items, and correlation between items and the total score were tested using the Cronbach's alpha, Spearman's correlation, and point biserial coefficients, respectively. The assumptions of unidimensionality and local independence of the items were tested. Word clouds were used as one way to present the results. RESULTS The items with the greatest ability to discriminate were scheduling of the agenda according to risk stratification, keeping of records of the most serious cases of users in psychological distress, and provision of group care. The items that required a higher level of mental health care in the parameter of location were the provision of any type of group care and the provision of educational and mental health promotion activities. Total Cronbach's alpha coefficient was 0.87. The items that obtained the highest correlation with total score were the recording of the most serious cases of users in psychological distress and scheduling of the agenda according to risk stratification. The final scores obtained oscillated between -2.07 (minimum) and 1.95 (maximum). CONCLUSIONS There are important aspects in the discrimination of the capacity to provide mental health care by primary health care teams: risk stratification for care management, follow-up of the most serious cases, group care, and preventive and health promotion actions.
Collapse
Affiliation(s)
- Hugo André da Rocha
- Universidade Federal de Minas Gerais. Faculdade de Medicina. Programa de Pós-Graduação em Saúde Pública. Belo Horizonte, MG, Brasil
| | - Alaneir de Fátima dos Santos
- Universidade Federal de Minas Gerais. Faculdade de Medicina. Departamento de Medicina Preventiva e Social. Belo Horizonte, MG, Brasil
| | - Ilka Afonso Reis
- Universidade Federal de Minas Gerais. Instituto de Ciências Exatas. Departamento de Estatística. Belo Horizonte, MG, Brasil
| | - Marcos Antônio da Cunha Santos
- Universidade Federal de Minas Gerais. Instituto de Ciências Exatas. Departamento de Estatística. Belo Horizonte, MG, Brasil
| | - Mariângela Leal Cherchiglia
- Universidade Federal de Minas Gerais. Faculdade de Medicina. Departamento de Medicina Preventiva e Social. Programa de Pós-Graduação em Saúde Pública. Belo Horizonte, MG, Brasil
| |
Collapse
|
7
|
Quality indicators in the treatment of patients with depression, bipolar disorder or schizophrenia. Consensus study. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2018; 11:66-75. [PMID: 29317210 DOI: 10.1016/j.rpsm.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/18/2017] [Accepted: 09/18/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To define a set of indicators for mental health care, monitoring quality assurance in schizophrenia, depression and bipolar disorders in Spain. MATERIAL AND METHOD Qualitative research. Consensus-based study involving 6 psychiatrists on the steering committee and a panel of 43 psychiatrists working in several health services in Spain. An initial proposal of 44 indicators for depression, 42 for schizophrenia and 58 for bipolar disorder was elaborated after reviewing the literature. This proposal was analysed by experts using the Delphi technique. The valuation of these indicators in successive rounds allowed those with less degree of consensus to be discarded. Feasibility, sensitivity and clinical relevance were considered. The study was carried out between July 2015 and March 2016. RESULTS Seventy indicators were defined by consensus: 17 for major depression, 16 for schizophrenia, 17 for bipolar disorder and 20 common to all three pathologies. These indicators included measures related to adequacy, patient safety, exacerbation, mechanical restraint, suicidal behaviour, psychoeducation, adherence, mortality and physical health. CONCLUSIONS This set of indicators allows quality monitoring in the treatment of patients with schizophrenia, depression or bipolar disorder. Mental health care authorities and professionals can use this proposal for developing a balanced scorecard adjusted to their priorities and welfare objectives.
Collapse
|
8
|
The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review. Br J Gen Pract 2017; 67:e775-e784. [PMID: 28947621 PMCID: PMC5647921 DOI: 10.3399/bjgp17x693077] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/12/2017] [Indexed: 11/24/2022] Open
Abstract
Background Improving care for people with long-term conditions is central to NHS policy. It has been suggested that the Quality and Outcomes Framework (QOF), a primary care pay-for-performance scheme that rewards practices for delivering effective interventions in long-term conditions, does not encourage high-quality care for this group of patients. Aim To examine the evidence that the QOF has improved quality of care for patients with long-term conditions. Design and setting This was a systematic review of research on the effectiveness of the QOF in the UK. Method The authors searched electronic databases for peer-reviewed empirical quantitative research studying the effect of the QOF on a broad range of processes and outcomes of care, including coordination and integration of care, holistic and personalised care, self-care, patient experience, physiological and biochemical outcomes, health service utilisation, and mortality. Because the studies were heterogeneous, a narrative synthesis was carried out. Results The authors identified three systematic reviews and five primary research studies that met the inclusion criteria. The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations is causal. No clear effect on mortality was found. The authors found no evidence that the QOF influences integration or coordination of care, holistic care, self-care, or patient experience. Conclusion The NHS should consider more broadly what constitutes high-quality primary care for people with long-term conditions, and consider other ways of motivating primary care to deliver it.
Collapse
|
9
|
The Primary Mental Health Care Project: an example of triple integration. BJGP Open 2017; 1:bjgpopen17X100797. [PMID: 30564659 PMCID: PMC6169962 DOI: 10.3399/bjgpopen17x100797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
10
|
Heald A, Pendlebury J, Anderson S, Narayan V, Guy M, Gibson M, Haddad P, Livingston M. Lifestyle factors and the metabolic syndrome in Schizophrenia: a cross-sectional study. Ann Gen Psychiatry 2017; 16:12. [PMID: 28289436 PMCID: PMC5310063 DOI: 10.1186/s12991-017-0134-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/01/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiometabolic disease is more common in patients with schizophrenia than the general population. AIM The purpose of the study was to assess lifestyle factors, including diet and exercise, in patients with schizophrenia and estimate the prevalence of metabolic syndrome. METHODS This is a cross-sectional study of a representative group of outpatients with schizophrenia in Salford, UK. An interview supplemented by questionnaires was used to assess diet, physical activity, and cigarette and alcohol use. Likert scales assessed subjects' views of diet and activity. A physical examination and relevant blood tests were conducted. RESULTS Thirty-seven people were included in the study. 92% of men had central adiposity, as did 91.7% of women (International Diabetes Federation Definition). The mean age was 46.2 years and mean illness duration was 11.6 years. 67.6% fulfilled criteria for the metabolic syndrome. The mean number of fruit and vegetable portions per day was 2.8 ± 1.8. Over a third did not eat any fruit in a typical week. 42% reported doing no vigorous activity in a typical week. 64.9% smoked and in many cigarette use was heavy. The Likert scale showed that a high proportion of patients had insight into their unhealthy lifestyles. CONCLUSIONS Within this sample, there was a high prevalence of poor diet, smoking and inadequate exercise. Many did not follow national recommendations for dietary intake of fruit and vegetables and daily exercise. These factors probably contribute to the high prevalence of metabolic syndrome. Many had insight into their unhealthy lifestyles. Thus, there is potential for interventions to improve lifestyle factors and reduce the risk of cardiometabolic disease.
Collapse
Affiliation(s)
- Adrian Heald
- Department of Medicine, Leighton Hospital, Crewe, CW1 4QJ Cheshire UK.,The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M13 9PT UK
| | - John Pendlebury
- Greater Manchester West Mental Health NHS Foundation Trust, Greater Manchester, UK
| | - Simon Anderson
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Vinesh Narayan
- Greater Manchester West Mental Health NHS Foundation Trust, Greater Manchester, UK
| | - Mark Guy
- Department of Clinical Biochemistry, Salford Royal Hospital, Salford, M6 8HD UK
| | - Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M13 9PT UK
| | - Peter Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Greater Manchester, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, WS2 9PS UK
| |
Collapse
|
11
|
Anderson SG, Narayanan RP, Radford D, Hodgson R, De Hert M, Heald AH. BMI independently relates to glycaemia in patients with severe enduring mental illness (SMI). J Ment Health 2016; 26:232-236. [PMID: 27687613 DOI: 10.1080/09638237.2016.1207233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND People with severe mental illness (SMI) have higher rates of diabetes than the general population. AIMS To assess the type-2 diabetes screening rates in primary care and the relation between body mass index (BMI) and dysglycaemia for patients on the SMI register in the Cheshire region of the United Kingdom. METHODS The setting was 24 general practices in Central and Eastern Cheshire, United Kingdom. Subjects were identified through a semianonymized search of GP registers. RESULTS About 451 of the 787 SMI patients were screened for dysglycaemia and dyslipidaemia. Fasting glucose was in the impaired fasting glycaemia range (6.1-6.9 mmol/l) in 6.5%, and indicative of type-2 diabetes (≥7.0 mmol/l) in 17.3%. There was a positive univariate relation between BMI and fasting glucose (normalized β = 0.26, p < 0.001). In multivariate models, adjusting for age, gender, smoking and blood pressure, each unit increase in BMI [OR = 1.07 (1.01, 1.13); p = 0.031] and triglycerides [OR = 1.28 (1.06, 1.55); p = 0.009] were independently associated with an increased risk of having type-2 diabetes. CONCLUSION Increasing BMI relates to dysglycaemia in patients with severe enduring mental illness (SMI). All patients with SMI whether or not receiving neuroleptic treatment should undergo routine monitoring of weight and metabolic parameters.
Collapse
Affiliation(s)
- Simon G Anderson
- a Cardiovascular Sciences Research Group and Manchester Academic Health Science Centre, The University of Manchester , Manchester , United Kingdom
| | - Ram P Narayanan
- b Department of Obesity and Endocrinology , University of Liverpool , Liverpool , United Kingdom
| | - Daniela Radford
- c Department of Medicine , Leighton Hospital , Crewe , United Kingdom
| | - Richard Hodgson
- d Bradwell Hospital Site, Staffordshire and Stoke-on-Trent Partnership NHS Trust , Newcastle-under-Lyme , United Kingdom
| | - Marc De Hert
- e University Psychiatric Center, Katholieke Universiteit Leuven , Campus Kortenberg, Leuvensesteenweg, Kortenberg , Belgium
| | - Adrian H Heald
- f Institute of Population Health, University of Manchester , Manchester , United Kingdom
| |
Collapse
|
12
|
McAvoy S, Cordiner M, Kelly J, Chiwanda L, Jefferies C, Miller K, Shajahan P. Body mass index and blood glucose in psychiatric and general practice populations. BJPsych Bull 2016; 40:127-31. [PMID: 27280032 PMCID: PMC4887729 DOI: 10.1192/pb.bp.115.051219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/19/2015] [Accepted: 06/30/2015] [Indexed: 11/23/2022] Open
Abstract
Aims and method Using a retrospective observational approach, we aimed to discern whether there was a difference in metabolic parameters between psychiatric and general practice populations in the same locality. Second, we aimed to establish differences in metabolic parameters of patients taking olanzapine, clozapine or aripiprazole. Results Patients with psychiatric illness had a body mass index (BMI) comparable to that of the general practice population (28.7 v. 29.7 kg/m(2)), but blood glucose was significantly lower in the general practice population (4.8 v. 6.1 mmol/L). Olanzapine was associated with the lowest BMI (26.1 kg/m(2)) and aripiprazole the highest (32.2 kg/m(2)), with no difference in blood glucose between antipsychotics. Clinical implications Awareness of environmental factors and how they affect individuals is important and medications are not the only cause of metabolic effects. There may be a channelling bias present, meaning practitioners are cognisant of potential metabolic effects prior to prescribing. Overall monitoring of physical health is important regardless of potential cause.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Polash Shajahan
- NHS Lanarkshire, Scotland, UK
- University of Glasgow, Scotland, UK
| |
Collapse
|
13
|
Woodhead C, Ashworth M, Broadbent M, Callard F, Hotopf M, Schofield P, Soncul M, Stewart RJ, Henderson MJ. Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care. Br J Gen Pract 2016; 66:e374-81. [PMID: 27114210 PMCID: PMC4871302 DOI: 10.3399/bjgp16x685189] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/28/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Suboptimal treatment of cardiovascular diseases (CVD) among patients with severe mental illness (SMI) may contribute to physical health disparities. AIM To identify SMI characteristics associated with meeting CVD treatment and prevention guidelines. DESIGN AND SETTING Population-based electronic health record database linkage between primary care and the sole provider of secondary mental health care services in south east London, UK. METHOD Cardiovascular disease prevalence, risk factor recording, and Quality and Outcomes Framework (QOF) clinical target achievement were compared among 4056 primary care patients with SMI whose records were linked to secondary healthcare records and 270 669 patients without SMI who were not known to secondary care psychiatric services, using multivariate logistic regression modelling. Data available from secondary care records were then used to identify SMI characteristics associated with QOF clinical target achievement. RESULTS Patients with SMI and with coronary heart disease and heart failure experienced reduced prescribing of beta blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB). A diagnosis of schizophrenia, being identified with any indicator of risk or illness severity, and being prescribed with depot injectable antipsychotic medication was associated with the lowest likelihood of prescribing. CONCLUSION Linking primary and secondary care data allows the identification of patients with SMI most at risk of undertreatment for physical health problems.
Collapse
Affiliation(s)
- Charlotte Woodhead
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| | - Mark Ashworth
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| | - Matthew Broadbent
- Head of information governance, South London and Maudsley NHS Foundation Trust, London
| | - Felicity Callard
- Reader in social science for medical humanities, Durham University, Centre for Medical Humanities, Durham
| | - Matthew Hotopf
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| | - Peter Schofield
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| | - Murat Soncul
- Head of information governance, South London and Maudsley NHS Foundation Trust, London
| | - Robert J Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| | - Max J Henderson
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London
| |
Collapse
|