• Abstract and Figures
• Public Full-text

Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-032179 on 24 November 2019. Downloaded from Liaison psychiatry—measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol Chris Smith,1 Jenny Hewison,1 Robert M West,1 Elspeth Guthrie ,1 Peter Trigwell,2 Mike J Crawford,3,4 Carolyn J Czoski Murray,1 Matt Fossey,5 Claire Hulme,6 Sandy Tubeuf,7 Allan House 1 To cite: Smith C, Hewison J, ABSTRACT Strengths and limitations of this study West RM, et al. Liaison Introduction We describe the protocol for a project that psychiatry—measurement will use linkage of routinely collected NHS data to answer and evaluation of service ► Study designs based on the linkage of routinely col- a question about the nature and effectiveness of liaison types, referral patterns and lected NHS data enable the generation of evidence outcomes (LP- MAESTRO): psychiatry services in acute hospitals in England. regarding the cost- effectiveness and efficiency of a protocol. BMJ Open Methods and analysis The project will use three data health services, where alternative study designs 2019;9:e032179. doi:10.1136/ sources: (1) Hospital Episode Statistics (HES), a database such as randomised controlled trails or other individ- bmjopen-2019-032179 controlled by NHS Digital that contains patient data relating ually consented study designs would be infeasible. to emergency department (ED), inpatient and outpatient ► Prepublication history for ► While our study will evaluate the impact of acute this paper is available online. episodes at hospitals in England; (2) ResearchOne, a inpatient hospital work carried out by liaison psychi- To view these files, please visit research database controlled by The Phoenix Partnership atry teams and will not cover work undertaken in the the journal online (http:// dx. doi. (TPP) that contains patient data relating to primary care emergency department, outpatient or primary care org/ 10. 1136/ bmjopen- 2019- provided by organisations using the SystmOne clinical setting, the findings will be highly relevant, as previ- 032179). information system and (3) clinical databases controlled ous claims for cost savings resulting from the imple- by mental health trusts that contain patient data relating mentation of liaison psychiatry services have been Received 06 June 2019 to care provided by liaison psychiatry services. We will Revised 09 October 2019 primarily based on their inpatient hospital work. Accepted 17 October 2019 link patient data from these sources to construct care ► Study designs based on the linkage of routinely col- pathways for patients who have been admitted to a lected NHS data present technical, ethical and legal http://bmjopen.bmj.com/ particular hospital and determine those patients who have challenges which must be considered from the start, been seen by a liaison psychiatry service during their including their implications for the validity and gen- admission. eralisability of insights and for project resources. Patient care pathways will form the basis of a matched cohort design to test the effectiveness of liaison intervention. We will combine healthcare utilisation within Results of the study will be published in academic journals care pathways using cost figures from national databases. in health services research and mental health. Details of the study methodology will also be published in an We will compare the cost of each care pathway and the on September 26, 2021 by guest. Protected copyright. impact of a broad set of health- related outcomes to obtain academic journal. Discussion papers will be authored for preliminary estimates of cost- effectiveness for liaison health service commissioners. psychiatry services. We will carry out an exploratory incremental cost- effectiveness analysis from a whole INTRODUCTION system perspective. Liaison psychiatry services provide assess- Ethics and dissemination Individual patient consent ment and treatment for people with coexis- will not be feasible for this study. Favourable ethical tent physical and mental health problems.1–4 opinion has been obtained from the NHS Research Ethics Such services are provided predominantly in Committee (North of Scotland) (REF: 16/NS/0025) for the acute hospital setting in the UK, although © Author(s) (or their Work Stream 2 (phase 1) of the Liaison psychiatry— employer(s)) 2019. Re- use measurement and evaluation of service types, referral more recently services have emerged to permitted under CC BY. patterns and outcomes study. The Confidentiality Advisory support the management of people with Published by BMJ. Group at the Health Research Authority determined that complex physical and mental health prob- 5 For numbered affiliations see Section 251 approval under Regulation 5 of the Health lems in primary as well as secondary care. end of article. Service (Control of Patient Information) Regulations 2002 Liaison psychiatry services have the poten- Correspondence to was not required for the study ‘on the basis that there is tial to improve both the quality of care and Dr Chris Smith; no disclosure of patient identifiable data without consent’ overall outcomes for people with mental C. J. Smith@ leeds. ac. uk (REF: 16/CAG/0037). and physical health problems. There is also Smith C, et al. BMJ Open 2019;9:e032179. doi:10.1136/bmjopen-2019-032179 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-032179 on 24 November 2019. Downloaded from a suggestion that liaison psychiatry services in the acute Second, there is a danger of losing sight of the other hospital setting will produce cost savings by reducing main functions of liaison psychiatry services, which do length of stay, even though it is estimated that services not exist only to reduce costs in the general hospital but see a small proportion (1%–5%) of all patients admitted which are aimed at improving the well-being of patients, to acute beds.6–12 For these reasons, NHS England has some of whom are being treated entirely or appropri- invested in expanding liaison psychiatry services to acute ately in the general hospital and happen to need mental hospitals.13 14 health service input because of the complexity of their The research evidence has not been strong for the problems. cost- effectiveness of liaison psychiatry services15 16 as Third, and related to the second point above, service opposed to evidence on the cost- effectiveness of some commissioning and provision will benefit from a more of the individual interventions used in those services.17 18 standardised approach to service descriptors. Without For that reason, more research is needed using robust more detailed knowledge about how to define the service designs derived from health services research. Claims being commissioned and how to evaluate whether it is for cost- effectiveness of liaison psychiatry go to the working to remit and to improve Health-Related Quality origins of the specialty before World War II. Individual of Life for patients, there is a risk of enthusiastic commis- components have been tested in randomised controlled sioning of services that look superficially similar to each trials (RCTs), but there have been few attempts to judge other and to a model reported as cost- effective, when in the cost- effectiveness of whole services. Although it has fact either at the time or over a period after commissioning been argued that they can pay for themselves—the cost- there are differences in staffing or referral patterns that offset debate of the 1980 and 1990s19—in truth, the cost- invalidate the original commissioning assumptions. An effectiveness evidence for any liaison psychiatry service important function is served by studies that describe what is limited. Holmes et al20 identified only two RCTs; some patient groups actually receive—what sort of service and smaller non- randomised studies include working age in what numbers. and older patients, and older and non-definitive work on This research is thus timely in exploring methods to cost- offsetting. evaluate the function and performance of liaison psychi- There are three main reasons why visiting the question atry services. now is timely. There are, however, challenges in conducting such First, cost pressures in the NHS and the emergence of research. commissioning led by Clinical Commissioning Groups First, defining exposure to liaison psychiatry is difficult will continue to lead to re- profiling of services and espe- because there is substantial heterogeneity in the compo- cially attempts to reduce unnecessary hospital costs. sition, purpose and size of liaison psychiatry services. For Work on developing and implementing risk stratifica- example, a recent survey conducted in England25 found tion models is an illustration and it is interesting that that just over half of the services provided a 24- hour 7- day http://bmjopen.bmj.com/ many of these models identify comorbid physical and service and only one- third ran specialist outpatient clinics. mental health problems as a risk, both for increased Most of the services provided cover of acute hospital wards healthcare costs and for the main driver of such costs and emergency department (ED) and nearly all services which is unscheduled hospital admission. A study were multidisciplinary, but staff mix varied such that about from Birmingham describing the evaluation of a rapid one- third employed less than one full-time equivalent of assessment, intervention and discharge service (previ- a consultant in psychiatry. Only one-third

Load more

  8

Copy Link