1
|
Snooks H, Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans B, Farr A, Fitzsimmons D, Harrison J, Heaven M, Howson H, Hutchings H, John G, Kingston M, Lewis L, Phillips C, Porter A, Sewell B, Warm D, Watkins A, Whitman S, Williams V, Russell IT. Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC). HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWith a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe.Study aimTo evaluate the introduction of predictive risk stratification in primary care.ObjectivesTo (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM.DesignRandomised stepped-wedge trial with economic and qualitative components.SettingAbertawe Bro Morgannwg University Health Board, south Wales.ParticipantsPatients registered with 32 participating general practices.InterventionPRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support.Main outcome measuresPrimary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs.Data sourcesRoutine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews.ResultsAcross 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets.LimitationsIn Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative.ConclusionsIntroduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients.Future research(1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners.Trial and study registrationCurrent Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874.FundingThe National Institute for Health Research Health Services Delivery and Research programme.
Collapse
Affiliation(s)
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Angela Farr
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Martin Heaven
- The FARR Institute, Swansea University Medical School, Swansea, UK
| | - Helen Howson
- Bevan Commission, School of Management, Swansea University, Swansea, UK
| | | | | | | | - Leo Lewis
- International Foundation for Integrated Care, Oxford, UK
| | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | - Bernadette Sewell
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Daniel Warm
- Hywel Dda University Health Board, Hafan Derwen, Carmarthen, UK
| | | | | | | | | |
Collapse
|
2
|
Morales-Asencio JM. [Case management and complex chronic diseases: concepts, models, evidence and uncertainties]. ENFERMERIA CLINICA 2013; 24:23-34. [PMID: 24314797 DOI: 10.1016/j.enfcli.2013.10.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/14/2013] [Accepted: 10/15/2013] [Indexed: 11/19/2022]
Abstract
Chronic diseases are the greatest challenge for Health Care, but the conventional health care models have failed noticeably. Nurses are one of the main providers of the services developed to tackle this challenge, with special emphasis on case management, as one of the most common forms. But, one of the key problems is that case management is poorly conceptualized, and with the diversity of experience available, make its development and comparative evaluation difficult. An in-depth review on case management definition and concepts is presented in this article, with a description of the models, ingredients and the effectiveness reported in various studies. The remaining uncertainties in case management, such as the heterogeneity of designs and target populations, the weak description of the components, and the scarce use of research models for complex interventions, are also discussed. Finally, some key factors for a successful implementation of case management are detailed, such as a clear definition of accountability and roles, the existence of support to guarantee the competence of case managers, the use of valid mechanisms for case finding, adjusted caseload, accessible and team-shared record systems, or the integration of health and social services.
Collapse
|
3
|
de Lusignan S, Chan T, Tejerina Arreal MC, Parry G, Dent-Brown K, Kendrick T. Referral for psychological therapy of people with long term conditions improves adherence to antidepressants and reduces emergency department attendance: controlled before and after study. Behav Res Ther 2013; 51:377-85. [PMID: 23639304 PMCID: PMC3677087 DOI: 10.1016/j.brat.2013.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 02/20/2013] [Accepted: 03/15/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Referral to psychological therapies is recommended for people with common mental health problems (CMHP) however its impact on healthcare utilisation in people with long term conditions (LTCs) is not known. METHOD Routinely collected primary care, psychological therapy clinic and hospital data were extracted for the registered population of 20 practices (N = 121,199). These data were linked using the SAPREL (Secure and Private Record Linkage) method. We linked the 1118 people referred to psychological therapies with 6711 controls, matched for age, gender and practice. We compared utilisation of healthcare resources by people with LTCs, 6 months before and after referral, and conducted a controlled before and after study to compare health utilisation with controls. We made the assumption that collection of a greater number of repeat prescriptions for antidepressants was associated with greater adherence. RESULTS Overall 21.8% of people with an LTC had CMHP vs. 18.8% without (p < 0.001). People with LTCs before referral were more likely to use health care resources (2-tailed t-test p < 0.001). Cases with LTCs showed referral to the psychological therapies clinic was associated with increased antidepressant medication prescribing (mean differences 0.62, p < 0.001) and less use of emergency department than controls (mean difference -0.21, p = 0.003). CONCLUSIONS Referral to improved access to psychological therapies (IAPT) services appears of value to people with LTC. It is associated with the issue of a greater number of prescriptions for anti-depressant medicines and less use of emergency services. Further studies are needed to explore bed occupancy and outpatient attendance.
Collapse
Affiliation(s)
- Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, Guildford GU2 7XH, UK.
| | | | | | | | | | | |
Collapse
|
4
|
Woodhams V, de Lusignan S, Mughal S, Head G, Debar S, Desombre T, Hilton S, Al Sharifi H. Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network. BMC Health Serv Res 2012; 12:153. [PMID: 22682525 PMCID: PMC3476394 DOI: 10.1186/1472-6963-12-153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 05/24/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare. METHOD We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops. RESULTS We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission. CONCLUSIONS Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change.
Collapse
Affiliation(s)
- Victoria Woodhams
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
| | - Simon de Lusignan
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
- Division of Population Health Sciences and Education, Hunter Wing, St. George’s – University of London, LONDON, SW17 0RE, UK
| | - Shakeel Mughal
- Central Wandsworth Community Ward, Southfield Group Practice, 492a Merton Road, London, SW18 5AE, UK
| | - Graham Head
- The Sollis Partnership Ltd 20 Hook Road, Epsom, Surrey, KT19 8TR, UK
| | - Safia Debar
- Portobello Clinic, 12 Raddington Road, LONDON, W10 5TG, UK
| | - Terry Desombre
- Department of Health Care Management and Policy, University of Surrey, GUILDFORD, GU2 7XH, UK
| | - Sean Hilton
- Division of Population Health Sciences and Education, Hunter Wing, St. George’s – University of London, LONDON, SW17 0RE, UK
| | - Houda Al Sharifi
- Room 147, 1st Floor, Wandsworth Town Hall, Wandsworth High Street, London, SW18 2PU, UK
| |
Collapse
|