Translating research knowledge in dementia care organisations.

OBJECTIVE: To evaluate dementia care organisations' capacity to acquire, assess, adapt and apply dementia research. METHODS: We used the Canadian Health Services Research Foundation's survey, 'Is research working for you?' by inviting the members of the New Zealand National Dementia Cooperative to participate in the online survey. RESULTS: A total of 146 (32%) members responded and indicated that, although the workforce had the skills to engage in research and implement evidence into practice, there was limited organisational support in terms of the time, resources and access to external support. CONCLUSIONS: We propose a number of strategies to improve knowledge translation in dementia care.

Optimizing arousal to manage aggression: a pilot study of sensory modulation.

The dominant model that informs clinical training for preventing violence and managing aggression posits arousal as mediated downwards from higher cortical structures. This view results in an often-misplaced reliance on verbal and cognitive techniques for de-escalation. The emergence of sensory modulation, via the Six Core Strategies, is an alternative or complementary approach that is associated with reduced rates of seclusion and restraint. Sensory-based interventions are thought to promote adaptive regulation of arousal and emotion, but this connection has had limited theoretical and empirical development. This paper presents results of a pilot trial of sensory-based interventions in four inpatient mental health units in New Zealand. Narrative analysis of interview and focus group data suggest that modifications to the environment and the use of soothing stimuli moderate or optimize arousal and promote an ability to adaptively regulate emotion. Findings are discussed in light of recent advances in the neurophysiology of emotional regulation and the General Aggression Model that posits arousal and maladaptive emotional regulation as precursors to aggression.

One-year treatment continuation in patients prescribed risperidone long-acting injection in New Zealand: a retrospective study.

OBJECTIVE: Treatment discontinuation is a major problem in routine clinical settings and is associated with poorer outcomes for conditions like schizophrenia. Risperidone long-acting injection (RLAI) has shown low discontinuation and good tolerability in long-term clinical trials. This retrospective study investigated RLAI continuation in a naturalistic clinical setting in New Zealand. METHODS: Those starting publicly funded RLAI between October 1, 2005 and October 31, 2006 in five public mental health services were included in the study. Data were retrospectively collected for 443 patients 12 months pre- and post-RLAI initiation. Patient demographics, diagnosis, antipsychotic treatment and treatment setting were obtained from clinical files and patient information systems. RESULTS: Patients were mostly male (64%), the mean age was 35.9 years, and were predominantly European (43%) or Maori (29%). Most started RLAI due to adherence issues (77%). Adverse events due to RLAI were reported by 39%; most commonly, extrapyramidal side effects. Fifty-eight percent of patients continued treatment 12 months after starting; patient choice (either refusal or failure to turn up) was the most common reason for discontinuation (54%), followed by lack of efficacy (29%). Alternative antipsychotic treatment was prescribed for 79% of those who discontinued. Regression analysis found continuation was more common for people started in the community, on a compulsory treatment order, with a dose of >25 mg and for non-Maori. CONCLUSIONS: RLAI appears well-tolerated and over half the patients continued treatment for one year or more. Using treatment continuation as an indicator of effectiveness, RLAI appears to be an effective treatment for people with adherence problems in this real world practice setting.

Five-year follow-up of an acute psychiatric admission cohort in Auckland, New Zealand.

AIM: This paper describes a follow-up of acute psychiatric hospital contact in Auckland, New Zealand for an admission cohort in the 5-years past an index admission (published in the NZMJ in 2005). METHODS: A 5-year follow-up study of hospital psychiatric service utilisation by 924 patients admitted (index admission) in Auckland during 2000. Hospital admissions within New Zealand for this population were extracted from electronic records. Relevant demographic information (gender, age and ethnicity) and clinical data (primary diagnosis at index admission and admission history) were included for each person. Descriptive analysis of inpatient data and negative binomial regression models were conducted. RESULTS: Of 924 patients, 38.5% had no readmissions anywhere in New Zealand in the 5-years following index discharge. 41.0% were readmitted within 12 months and 61.4% were readmitted within 5 years of index discharge. Only 5.6% experienced an admission every year for the 5-years post index admission. Readmission was least likely for those with index discharge diagnosis of depression. A history of admissions prior to index admission and Maori ethnicity were characteristics associated with higher numbers of readmission. Those who were younger, or a diagnosis of schizophrenia/schizoaffective disorder or previous admissions tended to have longer total length of stay over the 5-years. CONCLUSIONS: More than a third of patients had no further hospital contact and the two factors associated with readmission were a history of previous admissions and Maori ethnicity. Reliable community-based data needs to be a priority to enable exploration of community service utilisation and impact of service alternatives to hospital for acute care.

The experience and impact of living with gout: a study of men with chronic gout using a qualitative grounded theory approach.

BACKGROUND: Gout is commonly undertreated and can lead to significant disability. Few data are available about the lived experience of gout or the barriers to effective urate-lowering therapy in men with gout. AIMS: This study aims to understand the experience of men living with chronic gout using a qualitative grounded theory approach. METHODS: Eleven English-speaking men with chronic gout participated in an in-depth semistructured interview about their experiences of living with gout. Interviews were recorded and transcribed. Consensus groups were used to analyze and validate the themes arising from the transcripts. RESULTS: Three major themes related to the experience of gout emerged from the interviews: the impact of disease (pain, dependency on family members during flares, isolation, work disability), the progressiveness of untreated gout (increasing number of affected joints and frequency of flares, increase in food type triggers, escalating treatment required to control flares due to reducing efficacy of anti-inflammatory medication), and the lack of knowledge of gout (a community wide lack of understanding of the causes or prevention of gout, stoicism/tolerance to symptoms and disability, personal and social stigma related to gout). DISCUSSION: Chronic gout has an important impact on both the patient and his family. This work provides previously hidden perspectives of the experience of gout, which may be generalized to other men with gout, suggesting that shame, embarrassment, and stigma lead to trivialization of the impact of disease despite its severity. These experiences may lead to undertreatment of gout because of lack of disclosure of symptom severity and lack of expectation of treatment effectiveness, which in turn could contribute to the development of progressive gout.

Comparative effectiveness of long-acting risperidone in New Zealand: a report of resource utilization and costs in a 12-month mirror-image analysis.

BACKGROUND: Schizophrenia affects approximately 1% of the population and is associated with a considerable economic burden to society. The healthcare costs of the disorder are high and are compounded by substantial productivity losses. Failure to adhere to medication regimens, with subsequent relapse and hospitalization, is a key driver of these costs. A long-acting injectable formulation of the second generation antipsychotic risperidone (risperidone long-acting injection [risperidone LAI]) was licensed in New Zealand and received full government funding in October 2005. Second generation antipsychotics may have some efficacy advantages, be associated with fewer adverse effects and could improve adherence. However, the acquisition cost of risperidone LAI is higher than that of first generation antipsychotics and healthcare decision makers need information that allows them to determine whether risperidone LAI represents a cost-effective investment in terms of improved outcomes. OBJECTIVES: To explore real-world outcomes and costs of patients treated with risperidone LAI within New Zealand. METHODS: A mirror-image retrospective study was conducted comparing outcomes and costs 12 months post- versus 12 months pre-initiation of risperidone LAI in all adults receiving approval for risperidone LAI between 1 October 2005 and 31 October 2006 in five health services. Continuation rates, compulsory treatment status, psychiatric hospitalization (admission number, bed-stay and cost) and treatment data were collected from clinical files and patient information systems for the 12 months on either side of the first risperidone LAI prescription. Hospitalization costs were valued using estimates for cost per admission and cost per hospital day ($NZ, year 2009 values). RESULTS: 58.3% of patients remained on risperidone LAI 12 months after initiation. Compared with the pre-risperidone LAI treatment period the mean number of admissions for the total study population was significantly lower in the post-risperidone LAI treatment period (1.38 vs 0.61, p<0.001) but the mean length of bed-stay increased (37.2 vs 53.3 days, p<0.001), as did compulsory treatment use. Overall hospital bed-nights (hospitalization days) increased by 6877 in the post-index period, driven mostly by those who discontinued treatment. Patients who continued risperidone LAI had fewer admissions and days in hospital post-risperidone LAI than patients who discontinued risperidone LAI use in the first year. The reduction in total hospital admission rates between the two treatment periods was significantly greater in the continuation group and mean difference in bed-days between the two treatment periods was significantly less for continuers (5.4 vs 31.1 days, p<0.001). Applying a cost per admission, hospitalization costs reduced by approximately $NZ1.7 million in the post risperidone LAI-period. Applying a daily hospitalization cost resulted in an increase of approximately $NZ3.5 million in the post-risperidone LAI period. CONCLUSION: This study suggests that patients have reduced hospital admissions but longer bed-stay after starting risperidone LAI. Longer admissions were driven by those that discontinued treatment and continuation was associated with improved resource and cost outcomes compared with those who discontinued. These findings have potential implications for payers, providers and patients that require further investigation over a longer time frame.

Socioeconomic deprivation and extended hospitalization in severe mental disorder: a two-year follow-up study.

OBJECTIVE: This study examined the association between socioeconomic deprivation and extended hospitalization in severe mental disorder, after taking account of confounding variables. METHODS: A representative sample of 660 inpatients from South Auckland, New Zealand, was followed for two years from their index admission. Additional data were collected during the index admission for a subsample of 291 patients. RESULTS: Greater levels of socioeconomic deprivation in the inpatient's neighborhood of residence was associated with extended hospitalization after adjustment for demographic factors and primary diagnosis but not after adjustment for comorbid diagnosis, chronicity, function, and severity. Most extended hospitalizations were related to poor illness recovery. CONCLUSIONS: People from more deprived areas are likely to need longer psychiatric admissions, mostly because of the association between deprivation and having more disabling symptoms and a comorbid psychiatric diagnosis. Interventions to prevent psychiatric hospitalization, reduce duration of stay, and enhance recovery must be tested among those with greater levels of socioeconomic deprivation.

Unmet needs and treatment seeking in high users of mental health services: role of illness perceptions.

OBJECTIVE: A small number of patients tend to use a disproportionately high amount of mental health services. Understanding the needs and behaviours of this group is important in order to improve patient management. Few studies have investigated the role that patients' perceptions about their mental illness play in guiding coping responses and treatment seeking. The aim of the present study was to investigate how illness perceptions in high users of mental health services were related to unmet needs and treatment-seeking behaviours. METHOD: A total of 203 high users of mental health services were interviewed using the Brief Illness Perception Questionnaire, the Camberwell Assessment of Need and the Drug Attitude Inventory, and were also asked to report the number of visits they had made to the general practitioner in the past year. District Health Board clinical staff completed the Camberwell Assessment of Need and the Global Assessment of Functioning for each user. RESULTS: More negative perceptions about mental illness were associated with higher ratings of unmet needs by both patients and staff. Negative perceptions were also related to poorer attitudes towards medication, and lower functioning. Perceptions about the personal ability to control the illness were consistently associated with better outcomes. Patients' causal attributions could be categorized as social, psychological, biological and behavioural. More frequent visits to the general practitioner were associated with perceptions of more severe symptoms, greater concern and higher emotional responses to the illness, and psychosocial causal attributions. CONCLUSION: Illness perceptions provide a framework to assess patients' ideas about severe mental illness and a means by which to identify maladaptive beliefs. Interventions targeted at changing these beliefs may encourage better self-management.

Socio-economic deprivation and duration of hospital stay in severe mental disorder.

Adults from South Auckland, New Zealand who required acute admission to hospital were followed from admission to discharge. After adjusting for demographic factors, diagnosis, chronicity, severity, consultant psychiatrist and involuntary admission, the length of stay for those from more deprived areas was significantly longer by 7 days than for those from less deprived areas. Information on socio-economic deprivation should be used in discharge planning and in optimising access to community care. Research is needed on group-level factors that may affect recovery from mental disorders.

Psychiatric hospitalization: reasons for admission and alternatives to admission in South Auckland, New Zealand.

OBJECTIVE: To describe reasons for admission and alternatives to admission in a government funded acute inpatient unit. METHOD: Reasons for admission and alternatives to admission were rated for a consecutive sample of 255 admissions to an acute psychiatric unit in Auckland, using interviews with staff and case note review. RESULT: Most patients had a functional psychosis and were admitted involuntarily. Forty percent came from areas of marked social deprivation. The major reasons for admission were for reinstatement of medication (mainly linked to non-concordance with prescribed medication), intensive observation, risk to self and risk to others. Only 12% of admissions could have been diverted, of whom most would have required daily home treatment. For those still admitted at 5 weeks, 26% could have been discharged, mainly to 24 h nurse-staffed accommodation. If the alternatives had all been available, simulated bed-day savings were 11 bed years per year. Simulated bed day savings were greater through implementing early discharge than by diverting new admissions. CONCLUSION: Greater availability of assertive community treatment and of interventions to improve medication concordance may have prevented a small number of admissions. For patients admitted longer than 5 weeks, it appeared that greater availability of 24 h nurse-staffed accommodation would have allowed considerable bed-day savings.

More deprived areas need greater resources for mental health.

OBJECTIVE: This study set out to investigate the relationship in New Zealand between the newly developed small area index of socio-economic deprivation, NZDep96, and measures of psychiatric bed utilisation. It aims to contribute to the debate on resource allocation and to estimate the distribution of beds required in relation to levels of deprivation. METHOD: A cohort study of 872 persons admitted to the psychiatric in-patient unit within Counties Manukau, involving 1299 episodes of in-patient care between 1998 and 2000. The annual period prevalence of admission and the rate of total occupied bed days were calculated for the different deciles of deprivation, standardized for age and gender. RESULTS: There was a three-fold gradient in admission prevalence and in total occupied bed days between persons living in the most and least deprived areas. CONCLUSIONS: Mental health services need to be organized and funded in ways that take account of the high use of in-patient care among those living in deprived areas. Further research is required to explore the relationship between socio-economic deprivation and use of community mental health services.