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PURPOSE: Current RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial. METHODS: The economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs). RESULTS: Mean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups. CONCLUSION: CTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.
Subject(s)
Community Mental Health Services , Involuntary Treatment , Psychotic Disorders , Cost-Benefit Analysis , Humans , Psychotic Disorders/therapy , Quality of LifeABSTRACT
OBJECTIVE: The triple bottom line (TBL) of sustainability is an important emerging conceptual framework which considers the combined economic, environmental and social impacts of an activity. Despite its clear relevance to the healthcare context, it has not yet been applied to the evaluation of a healthcare intervention. The aim of this study was to demonstrate whether doing so is feasible and useful. DESIGN: Secondary data analysis of a 12-month randomized controlled trial. SETTING: Community based mental health care. PARTICIPANTS: Patients with chronic psychotic illnesses (n = 333). INTERVENTION(S): Community treatment orders. MAIN OUTCOME MEASURE(S): Financial and environmental (CO2 equivalent) costs of care, obtained from healthcare service use data, were calculated using publicly available standard costs; social sustainability was assessed using standardized social outcome measures included in the trial data. RESULTS: Standardized costing and CO2e emissions figures were successfully obtained from publicly available data, and social outcomes were available directly from the trial data. CONCLUSIONS: This study demonstrates that TBL assessment can be retrospectively calculated for a healthcare intervention to provide a more complete assessment of the true costs of an intervention. A basic methodology was advanced to demonstrate the feasibility of the approach, although considerable further conceptual and methodological work is needed to develop a generalizable methodology that enables prospective inclusion of a TBL assessment in healthcare evaluations. If achieved, this would represent a significant milestone in the development of more sustainable healthcare services. If increasing the sustainability of healthcare is a priority, then the TBL approach may be a promising way forward.
Subject(s)
Community Mental Health Services/methods , Psychotic Disorders/therapy , Schizophrenia/therapy , Socioeconomic Factors , Adult , Carbon Dioxide , Community Mental Health Services/economics , Feasibility Studies , Female , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Patient Acceptance of Health Care/statistics & numerical data , Psychotic Disorders/economics , Retrospective Studies , Schizophrenia/economics , United KingdomABSTRACT
Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments. Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.
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BACKGROUND: Identification of people with hypertrophic cardiomyopathy (HCM) who are at risk of sudden cardiac death (SCD) and require a prophylactic implantable cardioverter defibrillator is challenging. In 2014, the European Society of Cardiology proposed a new risk stratification method based on a risk prediction model (HCM Risk-SCD) that estimates the 5-year risk of SCD. The aim was to externally validate the 2014 European Society of Cardiology recommendations in a geographically diverse cohort of patients recruited from the United States, Europe, the Middle East, and Asia. METHODS: This was an observational, retrospective, longitudinal cohort study. RESULTS: The cohort consisted of 3703 patients. Seventy three (2%) patients reached the SCD end point within 5 years of follow-up (5-year incidence, 2.4% [95% confidence interval {CI}, 1.9-3.0]). The validation study revealed a calibration slope of 1.02 (95% CI, 0.93-1.12), C-index of 0.70 (95% CI, 0.68-0.72), and D-statistic of 1.17 (95% CI, 1.05-1.29). In a complete case analysis (n= 2147; 44 SCD end points at 5 years), patients with a predicted 5-year risk of <4% (n=1524; 71%) had an observed 5-year SCD incidence of 1.4% (95% CI, 0.8-2.2); patients with a predicted risk of ≥6% (n=297; 14%) had an observed SCD incidence of 8.9% (95% CI, 5.96-13.1) at 5 years. For every 13 (297/23) implantable cardioverter defibrillator implantations in patients with an estimated 5-year SCD risk ≥6%, 1 patient can potentially be saved from SCD. CONCLUSIONS: This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD.
Subject(s)
Cardiology , Cardiomyopathy, Hypertrophic/epidemiology , Death, Sudden, Cardiac/prevention & control , Cardiomyopathy, Hypertrophic/complications , Cardiomyopathy, Hypertrophic/diagnosis , Cohort Studies , Death, Sudden, Cardiac/etiology , Defibrillators, Implantable/statistics & numerical data , Europe/epidemiology , Follow-Up Studies , Humans , Incidence , Practice Guidelines as Topic , Prognosis , Research Design , Retrospective Studies , Risk , Societies, MedicalABSTRACT
BACKGROUND: Patient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen's capability approach intended for use as an outcome measure in mental health research. METHODS: The Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) is a 16-item self-complete capability measure that covers multiple domains of functioning and welfare. Data for validation of the instrument were collected through a national randomised controlled trial of community treatment orders for patients with psychosis. Complete OxCAP-MH data were available for 172 participants. Internal consistency was established with Cronbach's alpha; an interclass correlation coefficient was used to assess test-retest reliability in a sub-sample (N = 50) tested one week apart. Construct validity was established by comparing OxCAP-MH total scores with established instruments of illness severity and functioning: EuroQol (EQ-5D), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) and Objective Social Outcomes Index (SIX). Sensitivity was established by calculating standard error of measurement using distributional methods. RESULTS: The OxCAP-MH showed good internal consistency (Cronbach's alpha 0.79) and test-retest reliability (ICC = 0.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, p < .001) (Utility 0.45, p < .001), and divergent validity through more modest associations with the BPRS (-0.41, p < .001), GAF (0.24, p < .001) and SIX (0.12, p = ns). A change of 9.2 points on a 0-100 scale was found to be meaningful on statistical grounds. CONCLUSIONS: The OxCAP-MH has demonstrable reliability and construct validity and represents a promising multi-dimensional alternative to existing patient-reported outcome measures for quality of life used in mental health research.
Subject(s)
Health Services Research , Mental Health Services/standards , Outcome Assessment, Health Care/methods , Quality of Life/psychology , Adult , Female , Humans , Male , Mental Disorders/psychology , Mental Disorders/therapy , Middle Aged , Patient Reported Outcome Measures , Psychiatric Status Rating Scales , Psychometrics , Reproducibility of ResultsSubject(s)
Community Mental Health Services , Mental Disorders , Commitment of Mentally Ill , HumansABSTRACT
PURPOSE: Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes. METHODS: A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. RESULTS: No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. CONCLUSIONS: CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.
Subject(s)
Community Mental Health Services/statistics & numerical data , Psychotic Disorders/therapy , Social Support , Adolescent , Adult , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Quality of Life , Surveys and Questionnaires , Time Factors , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: In 2008, the Mental Health Act (MHA) 2007 amendments to the MHA 1983 were implemented in England and Wales. The amendments were intended to remove perceived obstacles to the detention of high risk patients with personality disorders (PDs), sexual deviance and learning disabilities (LDs). The AMEND study aimed to test the hypothesis that the implementation of these changes would lead to an increase in numbers or proportions of patients with these conditions who would be assessed and detained under the MHA 2007. METHOD: A prospective, quantitative study of MHA assessments undertaken between July-October 2008-11 at three English sites. Data were collected from local forms used for MHA assessment documentation and patient electronic databases. RESULTS: The total number of assessments in each four month period of data collection varied: 1034 in 2008, 1042 in 2009, 1242 in 2010 and 1010 in 2011 (n = 4415). Of the assessments 65.6% resulted in detention in 2008, 71.3% in 2009, 64.7% in 2010 and 63.5% in 2011. There was no significant change in the odds ratio of detention when comparing the 2008 assessments against the combined 2009, 2010 and 2011 data (OR = 1.025, Fisher's exact Χ 2 p = 0.735). Only patients with LD and 'any other disorder or disability of the mind' were significantly more likely to be assessed under the MHA post implementation (Χ2 = 5.485, P = 0.018; Χ2 = 24.962, P > 0.001 respectively). There was no significant change post implementation in terms of the diagnostic category of detained patients. CONCLUSIONS: In the first three years post implementation, the 2007 Act did not facilitate the compulsory care of patients with PDs, sexual deviance and LDs.
Subject(s)
Commitment of Mentally Ill/legislation & jurisprudence , Mental Disorders/diagnostic imaging , Mental Health/legislation & jurisprudence , Adult , England , Female , Humans , Male , Personality Disorders/diagnosis , Prospective Studies , Qualitative Research , WalesABSTRACT
BACKGROUND: Most studies investigating the effectiveness of Community Treatment Orders (CTOs) use readmission to hospital as the primary outcome. Another aim of introducing CTOs was to improve continuity of care. Our study was a 3-year prospective follow-up which tested for associations between CTOs and continuity of care. METHODS: Our study sample included 333 patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data on continuity of care using eight previously operationalized measures. We analysed the association between CTOs and continuity of care in two ways. First, we tested the association between continuity of care and OCTET randomisation arm (CTO versus voluntary care via Section 17 leave). Second, we analysed continuity of care and CTO exposure independent of randomisation; using any exposure to CTO, number of days on CTO, and proportion of outpatient days on CTO as outcomes. RESULTS: 197 (61%) patients were made subject to CTO during the 36-month follow-up. Randomisation to CTO arm was significantly associated with having a higher proportion of clinical documents copied to the user but no other measures of continuity. Having a higher proportion of outpatient days on CTO (irrespective of randomisation) was associated with fewer 60 day breaks without community contact. A sensitivity analysis found that any exposure to CTO and a higher proportion of outpatient days on CTO were associated with fewer days between community mental health team contacts and 60 day breaks without contact. CONCLUSION: We found some evidence of an association between CTO use and better engagement with the community team in terms of increased contact and fewer breaks in care. Those with CTO experience had a higher number of inpatient admissions which may have acted as a mediator of this association. We found limited evidence for an association between CTO use and other measures of continuity of care.
Subject(s)
Community Mental Health Services/statistics & numerical data , Continuity of Patient Care/statistics & numerical data , Mandatory Programs/statistics & numerical data , Adolescent , Adult , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Prospective Studies , Young AdultABSTRACT
BACKGROUND: The appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available. AIMS: As part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals' understanding of the ATT, and its impact on clinical practice. METHOD: Forty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process. RESULTS: We found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient's age rather than diagnosis. The ATT has had little impact on clinical practice. CONCLUSIONS: Our findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Over the past 15 years there has been a move away from consultants having responsibility for the care of patients both in the community and when in hospital towards a functional split in responsibility. In this article Tom Burns and Martin Baggaley debate the merits or otherwise of the split, identifying leadership, expertise and continuity of care as key issues; both recognise that this move is not evidence based.
Subject(s)
Inpatients , Mental Disorders/therapy , Mental Health Services/organization & administration , Outpatients , Patient Care/standards , Continuity of Patient Care/standards , Humans , Mental Health Services/standards , United KingdomABSTRACT
The autonomy preference index scale (API) has been designed to measure patient preference for 2 dimensions of autonomy: Their desire to take part in making medical decisions (decision making, [DM]) and their desire to be informed about their illness and the treatment (information seeking; [IS]). The DM dimension is measured by 6 general items together with 9 items related to 3 clinical vignettes (3 × 3 items). The IS dimension is measured by 8 items. While the API is widely used, a review of literature has identified several inconsistencies in the way it is scored. The first aim of this study was to determine the best scoring structure of the API on the basis of validity and reliability evidence. The second aim was to investigate the long-term stability of API scores. Two-hundred and 85 patients with a diagnosis of psychosis were assessed as they were about to be discharged from involuntary psychiatric hospitalization and they were reassessed after 6 and 12 months. Confirmatory factor analysis (CFA) revealed that a 3-factor solution was most adequate and that 2 distinct DM subscales should be preferred to 1 total DM score. While internal consistency estimates of the 3 subscales were good, the long-term stability of API scores was only modest. Multigroup-CFA revealed scalar invariance indicating API scores kept the same meaning longitudinally. In conclusion, a 3-factor structure seemed to be most adequate for the API scale. Long-term stability estimates suggested that clinicians should regularly assess patients' preferences for autonomy because API scores fluctuate over time. (PsycINFO Database Record
Subject(s)
Decision Making , Information Seeking Behavior , Patient Participation/psychology , Patient Preference/psychology , Personal Autonomy , Psychotic Disorders/psychology , Schizophrenic Psychology , Adult , Factor Analysis, Statistical , Female , Humans , Male , Middle Aged , Psychotic Disorders/therapy , Reproducibility of Results , Schizophrenia/therapy , Surveys and QuestionnairesABSTRACT
PURPOSE: Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. AIMS: To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. METHOD: 36-month observational prospective study of patients on CTO in the OCTET follow-up study. RESULTS: The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CONCLUSIONS: CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.