Claire Planner

The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom

Background Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care. Methods and Findings Data were collected from primary care patient notes (n = 1150) by trained nurses from 64 practices in England, covering all service contacts from 1st April 2008 to 31st March 2009. The estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%). In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (20% of the total). Unemployed individuals diagnosed more recently were more likely to have contact with secondary care. Of those seen in secondary care, 61% had at most two secondary care contacts in the period. Median annual consultation rates with GPs were lower than have been reported for previous years and were only slightly above the general population. Relational continuity in primary care was poor for 21% of patients (Modified Modified Continuity Index  = <0.5), and for almost a third of new referrals to mental health services the primary care record contained no information on the referral outcome. Conclusions Primary care is centrally involved in the care of people with serious mental illness, but primary care and cross-boundary continuity is poor for a substantial proportion. Research is needed to determine the impact of poor continuity on patient outcomes, and above all, the impact of new collaborative ways of working at the primary/secondary care interface.

Bespoke smoking cessation for people with severe mental ill health (SCIMITAR): a pilot randomised controlled trial

BACKGROUND People with severe mental ill health are three times more likely to smoke but typically do not access conventional smoking cessation services, contributing to widening health inequalities and reduced life expectancy. We aimed to pilot an intervention targeted at smokers with severe mental ill health and to test methods of recruitment, randomisation, and follow up before implementing a full trial. METHODS The Smoking Cessation Intervention for Severe Mental Ill Health Trial (SCIMITAR) is a pilot randomised controlled trial of a smoking cessation strategy designed specifically for people with severe mental ill health, to be delivered by mental health nurses and consisting of behavioural support and drugs, compared with a conventional smoking cessation service (ie, usual care). Adults (aged 18 years or older) with bipolar disorder or schizophrenia, who were current smokers, were recruited from NHS primary care and mental health settings in the UK (York, Scarborough, Hull, and Manchester). Eligible participants were randomly allocated to either usual care (control group) or usual care plus the bespoke smoking cessation strategy (intervention group). Randomisation was done via a central telephone system, with computer-generated random numbers. We could not mask participants, family doctors, and researchers to the treatment allocation. Our primary outcome was smoking status at 12 months, verified by carbon monoxide measurements or self-report. Only participants who provided an exhaled CO measurement or self-reported their smoking status at 12 months were included in the primary analysis. The trial is registered at ISRCTN.com, number ISRCTN79497236. FINDINGS Of 97 people recruited to the pilot study, 51 were randomly allocated to the control group and 46 were assigned to the intervention group. Participants engaged well with the bespoke smoking cessation strategy, but no individuals assigned to usual care accessed NHS smoking cessation services. At 12 months, 35 (69%) controls and 33 (72%) people assigned to the intervention group provided a CO measurement or self-reported their smoking status. Smoking cessation was highest among individuals who received the bespoke intervention (12/33 [36%] vs 8/35 [23%]; adjusted odds ratio 2·9, 95% CI 0·8-10·5). INTERPRETATION We have shown the feasibility of recruiting and randomising people with severe mental ill health in a trial of this nature. The level of engagement with a bespoke smoking cessation strategy was higher than with a conventional approach. The effectiveness and safety of a smoking cessation programme designed particularly for people with severe mental ill health should be tested in a fully powered randomised controlled trial. FUNDING National Institute of Health Research Health Technology Assessment Programme.

Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK.

Objectives Little is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English region and deprivation quintile, antipsychotic and antidepressant medication prescription rates for people with SMI, and prevalence rates of common comorbidities in people with SMI compared with people without SMI. Design Retrospective cohort study from 2000 to 2012. Setting 627 general practices contributing to the Clinical Practice Research Datalink, a UK primary care database. Participants Each identified case (346 551) was matched for age, sex and general practice with 5 randomly selected control cases (1 732 755) with no diagnosis of SMI in each yearly time point. Outcome measures Prevalence rates were calculated for 16 conditions. Results SMI rates were highest in Scotland and in more deprived areas. Rates increased in England, Wales and Northern Ireland over time, with the largest increase in Northern Ireland (0.48% in 2000/2001 to 0.69% in 2011/2012). Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI. The discrepancy between the prevalence of those with and without SMI increased over time for most conditions. A greater increase in the mean number of additional conditions was observed in the SMI population over the study period (0.6 in 2000/2001 to 1.0 in 2011/2012) compared with those without SMI (0.5 in 2000/2001 to 0.6 in 2011/2012). For both groups, most conditions were more prevalent in more deprived areas, whereas for the SMI group conditions such as hypothyroidism, chronic kidney disease and cancer were more prevalent in more affluent areas. Conclusions Our findings highlight the health inequalities faced by people with SMI. The provision of appropriate timely health prevention, promotion and monitoring activities to reduce these health inequalities are needed, especially in deprived areas.

Primary care consultation rates among people with and without severe mental illness: a UK cohort study using the Clinical Practice Research Datalink

Objectives Little is known about service utilisation by patients with severe mental illness (SMI) in UK primary care. We examined their consultation rate patterns and whether they were impacted by the introduction of the Quality and Outcomes Framework (QOF), in 2004. Design Retrospective cohort study using individual patient data collected from 2000 to 2012. Setting 627 general practices contributing to the Clinical Practice Research Datalink, a large UK primary care database. Participants SMI cases (346 551) matched to 5 individuals without SMI (1 732 755) on age, gender and general practice. Outcome measures Consultation rates were calculated for both groups, across 3 types: face-to-face (primary outcome), telephone and other (not only consultations but including administrative tasks). Poisson regression analyses were used to identify predictors of consultation rates and calculate adjusted consultation rates. Interrupted time-series analysis was used to quantify the effect of the QOF. Results Over the study period, face-to-face consultations in primary care remained relatively stable in the matched control group (between 4.5 and 4.9 per annum) but increased for people with SMI (8.8–10.9). Women and older patients consulted more frequently in the SMI and the matched control groups, across all 3 consultation types. Following the introduction of the QOF, there was an increase in the annual trend of face-to-face consultation for people with SMI (average increase of 0.19 consultations per patient per year, 95% CI 0.02 to 0.36), which was not observed for the control group (estimates across groups statistically different, p=0.022). Conclusions The introduction of the QOF was associated with increases in the frequency of monitoring and in the average number of reported comorbidities for patients with SMI. This suggests that the QOF scheme successfully incentivised practices to improve their monitoring of the mental and physical health of this group of patients.

Serious Mental Illness and the Role of Primary Care

Policies and guidelines from across the international community are attempting to galvanise action to address the unacceptably high morbidity and mortality rates amongst people with a serious mental illness (SMI). Primary care has a pivotal role to play in translating policy into evidence based practice in conjunction with other providers of health care services. This paper explores the current and potential of role of primary care providers in delivering health care to people with SMI. A review of research in the following key areas of primary health care provision is provided: access, screening and preventative care, routine monitoring and follow-up, diagnosis and delivery of treatments in accordance with guidelines and delivery of interventions. There is undoubtedly a need for further research to establish the effectiveness of primary care interventions and the organisation of services. Equally, understanding how primary care services can deliver high quality care and promoting effective working at the interface with other services must be priorities.

Priorities for methodological research on patient and public involvement in clinical trials: A modified Delphi process.

Despite increasing international interest, there is a lack of evidence about the most efficient, effective and acceptable ways to implement patient and public involvement (PPI) in clinical trials.

Measuring patients’ experience of clinical trials: results of an exploratory review and stakeholder workshop

Background Measuring and responding to patient experience in clinical services is a policy priority, but this focus has not extended to the research setting. At the same time, with only 45% of trials recruiting to target, increasing recruitment and retention is a priority. It is hypothesised that using patient experience of trials data to improve the design of trials may have an impact on these outcomes. The study explored current measurement of patient experience of trials and stakeholder views around the feasibility of collecting and using this type of data.

Using electronic health records to quantify and stratify the severity of type 2 diabetes in primary care in England: rationale and cohort study design

Introduction The increasing prevalence of type 2 diabetes mellitus (T2DM) presents a significant burden on affected individuals and healthcare systems internationally. There is, however, no agreed validated measure to infer diabetes severity from electronic health records (EHRs). We aim to quantify T2DM severity and validate it using clinical adverse outcomes. Methods and analysis Primary care data from the Clinical Practice Research Datalink, linked hospitalisation and mortality records between April 2007 and March 2017 for patients with T2DM in England will be used to develop a clinical algorithm to grade T2DM severity. The EHR-based algorithm will incorporate main risk factors (severity domains) for adverse outcomes to stratify T2DM cohorts by baseline and longitudinal severity scores. Provisionally, T2DM severity domains, identified through a systematic review and expert opinion, are: diabetes duration, glycated haemoglobin, microvascular complications, comorbidities and coprescribed treatments. Severity scores will be developed by two approaches: (1) calculating a count score of severity domains; (2) through hierarchical stratification of complications. Regression models estimates will be used to calculate domains weights. Survival analyses for the association between weighted severity scores and future outcomes—cardiovascular events, hospitalisation (diabetes-related, cardiovascular) and mortality (diabetes-related, cardiovascular, all-cause mortality)—will be performed as statistical validation. The proposed EHR-based approach will quantify the T2DM severity for primary care performance management and inform the methodology for measuring severity of other primary care-managed chronic conditions. We anticipate that the developed algorithm will be a practical tool for practitioners, aid clinical management decision-making, inform stratified medicine, support future clinical trials and contribute to more effective service planning and policy-making. Ethics and dissemination The study protocol was approved by the Independent Scientific Advisory Committee. Some data were presented at the National Institute for Health Research School for Primary Care Research Showcase, September 2017, Oxford, UK and the Diabetes UK Professional Conference March 2018, London, UK. The study findings will be disseminated in relevant academic conferences and peer-reviewed journals.

1515 – Collaborative care approaches for people with severe mental illness: the results from a cochrane collaboration review

Introduction Collaborative care is a community based intervention which typically consists of a number of components. The intervention aims to improve the physical and/or mental health and health care of people with a severe mental illness (SMI). Objectives To explore how collaborative care is implemented. To assess the effectiveness of collaborative care approaches in comparison to standard care for people with SMI who are living in the community. Methods A Cochrane Review: The Cochrane Schizophrenia Group Specialised register was searched in April 2011. Fifty one experts in the field of SMI and collaborative care were also contacted. Results We included one RCT (306 participants; US veterans with bipolar disorder I or II) in this review. The trial provides data for one comparison: collaborative care versus standard care The reanalysis of data from the one included study indicated that collaborative care significantly reduced psychiatric admissions at year 2 in comparison to standard care (N= 306, 1 RCT, RR 0.75, 95% CI 0.57 to 0.99). Direct intervention (all-treatment) costs of collaborative care at the three year follow up did not differ significantly from standard care,mean difference -

1498 – Patient characteristics, service usage and continuity-of-care over one year of a representative cohort of people with a diagnosis of severe mental illness across england

2981.00 (N= 306, 1 RCT95% CI