Johanna Taylor

The Effectiveness of Pharmacological and Non-Pharmacological Interventions for Improving Glycaemic Control in Adults with Severe Mental Illness: A Systematic Review and Meta-Analysis

People with severe mental illness (SMI) have reduced life expectancy compared with the general population, which can be explained partly by their increased risk of diabetes. We conducted a meta-analysis to determine the clinical effectiveness of pharmacological and non-pharmacological interventions for improving glycaemic control in people with SMI (PROSPERO registration: CRD42015015558). A systematic literature search was performed on 30/10/2015 to identify randomised controlled trials (RCTs) in adults with SMI, with or without a diagnosis of diabetes that measured fasting blood glucose or glycated haemoglobin (HbA1c). Screening and data extraction were carried out independently by two reviewers. We used random effects meta-analysis to estimate effectiveness, and subgroup analysis and univariate meta-regression to explore heterogeneity. The Cochrane Collaboration’s tool was used to assess risk of bias. We found 54 eligible RCTs in 4,392 adults (40 pharmacological, 13 behavioural, one mixed intervention). Data for meta-analysis were available from 48 RCTs (n = 4052). Both pharmacological (mean difference (MD), -0.11mmol/L; 95% confidence interval (CI), [-0.19, -0.02], p = 0.02, n = 2536) and behavioural interventions (MD, -0.28mmol//L; 95% CI, [-0.43, -0.12], p<0.001, n = 956) were effective in lowering fasting glucose, but not HbA1c (pharmacological MD, -0.03%; 95% CI, [-0.12, 0.06], p = 0.52, n = 1515; behavioural MD, 0.18%; 95% CI, [-0.07, 0.42], p = 0.16, n = 140) compared with usual care or placebo. In subgroup analysis of pharmacological interventions, metformin and antipsychotic switching strategies improved HbA1c. Behavioural interventions of longer duration and those including repeated physical activity had greater effects on fasting glucose than those without these characteristics. Baseline levels of fasting glucose explained some of the heterogeneity in behavioural interventions but not in pharmacological interventions. Although the strength of the evidence is limited by inadequate trial design and reporting and significant heterogeneity, there is some evidence that behavioural interventions, antipsychotic switching, and metformin can lead to clinically important improvements in glycaemic measurements in adults with SMI.

Implementing solutions to improve and expand telehealth adoption: participatory action research in four community healthcare settings.

BackgroundAdoption of telehealth has been slower than anticipated, and little is known about the service improvements that help to embed telehealth into routine practice or the role of frontline staff in improving adoption. This paper reports on participatory action research carried out in four community health settings using telehealth for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure.MethodsTo inform the action research, in-depth case studies of each telehealth service were conducted (May 2012–June 2013). Each service was then supported by researchers through two cycles of action research to implement changes to increase adoption of telehealth, completed over a seven month period (July 2013–April 2014). The action research was studied via observation of multi-stakeholder workshops, analysis of implementation plans, and focus groups.ResultsAction research participants included 57 staff and one patient, with between eight and 20 participants per site. The case study findings were identified as a key source of information for planning change, with sites addressing common challenges identified through this work. For example, refining referral criteria; standardizing how and when patients are monitored; improving data sharing; and establishing evaluation processes. Sites also focused on raising awareness of telehealth to increase adoption in other clinical teams and to help secure future financial investment for telehealth, which was required because of short-term funding arrangements. Specific solutions varied due to local infrastructures, resources, and opinion, as well as previous service developments. Local telehealth champions played an important role in engaging multiple stakeholders in the study.ConclusionsAction research enabled services to make planned changes to telehealth and share learning across multiple stakeholders about how and when to use telehealth. However, adoption was impeded by continual changes affecting telehealth and wider service provision, which also hindered implementation efforts and affected motivation of staff to engage with the action research, particularly where local decision-makers were not engaged in the study. Wider technological barriers also limited the potential for change, as did uncertainties about goals for telehealth investment, thereby making it difficult to identify outcomes for demonstrating the added value over existing practice.

A core outcome set for evaluating self-management interventions in people with comorbid diabetes and severe mental illness: study protocol for a modified Delphi study and systematic review

BackgroundPeople with diabetes and comorbid severe mental illness (SMI) form a growing population at risk of increased mortality and morbidity compared to those with diabetes or SMI alone. There is increasing interest in interventions that target diabetes in SMI in order to help to improve physical health and reduce the associated health inequalities. However, there is a lack of consensus about which outcomes are important for this comorbid population, with trials differing in their focus on physical and mental health. A core outcome set, which includes outcomes across both conditions that are relevant to patients and other key stakeholders, is needed.MethodsThis study protocol describes methods to develop a core outcome set for use in effectiveness trials of self-management interventions for adults with comorbid type-2 diabetes and SMI. We will use a modified Delphi method to identify, rank, and agree core outcomes. This will comprise a two-round online survey and multistakeholder workshops involving patients and carers, health and social care professionals, health care commissioners, and other experts (e.g. academic researchers and third sector organisations). We will also select appropriate measurement tools for each outcome in the proposed core set and identify gaps in measures, where these exist.DiscussionThe proposed core outcome set will provide clear guidance about what outcomes should be measured, as a minimum, in trials of interventions for people with coexisting type-2 diabetes and SMI, and improve future synthesis of trial evidence in this area. We will also explore the challenges of using online Delphi methods for this hard-to-reach population, and examine differences in opinion about which outcomes matter to diverse stakeholder groups.Trial registrationCOMET registration: http://www.comet-initiative.org/studies/details/911. Registered on 1 July 2016

Improving health outcomes for adults with severe mental illness and comorbid diabetes: is supporting diabetes self‐management the right approach?

Diabetes is a common problem in people with severe mental illness [SMI is an umbrella term used to describe disorders in which psychosis occurs, and includes schizophrenia and bipolar disorder], and is associated with poor health outcomes and reduced life expectancy (Holt & Mitchell 2015). Prevalence estimates pooled across 42 international studies suggest that around 13% of the SMI population has diabetes (Ward & Druss 2015), a figure more than twice that in the general population (Shaw et al. 2010). This inequality is likely to increase, as recent analyses of primary care data show diabetes prevalence increasing year-on-year for the whole population, with the difference between people with and without SMI widening (Reilly et al. 2015). We have established a multidisciplinary research programme called DIAMONDS (Diabetes and Mental Illness: Improving Outcomes and Services), which aims to increase understanding about the comorbid relationship between diabetes and SMI, and develop effective interventions for people living with both these conditions. In this paper, we explore whether supporting diabetes self-management, which is the cornerstone of good diabetes management, offers the right approach. We draw on evidence from the diabetes and mental health literature to outline why improving diabetes care for people with SMI is important; consider why diabetes self-management education offers the potential to improve health outcomes; discuss the risks of using this approach for people with SMI; set out the key research questions that need to be answered in order to make this approach work; and consider the implications for mental health nursing. Why is it an important area?

16 Delirium care of hospice patients: a qualitative interview study with staff and volunteers

Introduction Delirium is a distressing condition which is commonly experienced by hospice patients. Although delirium can be prevented by around one-third in hospital inpatients (Siddiqi et al. 2016) there has been little research into effective strategies to prevent and manage delirium in hospices. Greater insight into the current practice attitudes and understanding of hospice staff and volunteers would inform the development of interventions that are tailored to improve delirium care in hospices. Aim To explore the understanding attitudes and practice of hospice staff and volunteers regarding the care of patients with delirium. Methods 36 qualitative semi-structured interviews were conducted at two hospices. Participants were purposively sampled to include different disciplines (9 health care assistants, 8 nurses, 5 doctors, 4 volunteers, 3 board members, 2 allied health professionals, 2 managers, 2 domestic workers and 2 fundraisers). A topic guide and case vignettes prompted participants to describe their experiences in relation to delirium prevention recognition assessment and management. Three researchers are conducting thematic analysis to identify analyse and interpret themes from the interview data. Results Provisional results include themes of: ‘Supporting the distressing experience of delirium’; ‘Management strategies’ and ‘The burden of delirium care.’ Gaps in current practice relate to delirium prevention recognition and screening. Potential facilitators for developing interventions in hospices include education flexibility in staffing the role of volunteers and a supportive staff culture. Conclusion This study will provide important insights into staff and volunteers’ current practice which will inform the development of a targeted intervention to improve delirium care in hospices. Reference . Siddiqi N, Harrison J, Clegg A, Teale E, Young J, Taylor J, Simpkins S. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews2016;(3). Art. No.: CD005563. doi:10.1002/14651858.CD005563.pub3

Exploring the rewards and challenges of paediatric palliative care work – a qualitative study of a multi-disciplinary children’s hospice care team

BackgroundChildren’s hospices are a key provider of palliative care for children and young people with life-limiting and life-threatening conditions. However, despite recent policy attention to the provision of paediatric palliative care, little is known about the role of children’s hospice staff and the factors that may impact on their wellbeing at work. This study explored the rewards and challenges of working in a children’s hospice with an aim to identify staff support and development needs.MethodsWe conducted an exploratory, qualitative study involving thematic analysis of semi-structured interviews with 34 staff and three focus groups with 17 staff working in a multi-disciplinary care team in a UK children’s hospice.ResultsParticipants identified rewards and challenges related to the direct work of caring for children and their families; team dynamics and organisational structures; and individual resilience and job motivation. Participants described the work as emotionally intensive and multi-faceted; ‘getting it right’ for children was identified as a strong motivator and reward, but also a potential stressor as staff strived to maintain high standards of personalised and emotional care. Other factors were identified as both a reward and stressor, including team functioning, the allocation of work, meeting parent expectations, and the hospice environment. Many participants identified training needs for different aspects of the role to help them feel more confident and competent. Participants also expressed concerns about work-related stress, both for themselves and for colleagues, but felt unable to discuss this at work. Informal support from colleagues and group clinical reflection were identified as primary resources to reflect on and learn from work and for emotional support. However, opportunities for this were limited.ConclusionsProviding regular, structured, and dedicated clinical reflection provides a mechanism through which children’s hospice staff can come together for support and learning, and demonstrates an organisational commitment to staff wellbeing and development. Being aware of children’s hospice specific rewards and challenges can help to ensure that staff feel supported and competent in their role. Breaking down barriers to discussing work-related stress and enhancing awareness about early signs of burnout is also important.

P15 Improving diabetes outcomes in severe mental illness: A systematic review and meta-analysis of pharmacological and non-pharmacological interventions

Background People diagnosed with schizophrenia and other severe mental illness (SMI) have a reduced life expectancy compared to the general population, which can partly be explained by their increased risk of diabetes and associated poor diabetes management. A growing number of interventions are targeting this patient group to reduce physical health inequalities and improve life expectancy, which is around 20 years shorter compared to the general population. Several systematic reviews have investigated the effectiveness of interventions for managing body weight and other anthropometric markers. Less is known about their effectiveness for improving diabetes outcomes, or the quality of evidence focusing on this co-morbidity. This systematic review aimed to evaluate the clinical effectiveness of pharmacological and non-pharmacological interventions for improving diabetes outcomes in adults with SMI. Methods We searched key databases from inception to October 2015 to identify randomised controlled trials measuring the effects of interventions for improving diabetes outcomes. The primary outcome was blood glucose control measured using HbA1c or fasting blood glucose. Trials which measured one of these outcomes and included adults with SMI, with or without diabetes, were included. Screening and data extraction were carried out independently by two researchers. A meta-analysis and narrative synthesis were performed to investigate the effects and components of different interventions. Risk of bias was assessed using the Cochrane Collaboration’s tool for critical appraisal. For non-pharmacological interventions, which targeted behaviour change, we also coded the behaviour change techniques (e.g. goal setting, rewards) employed. Results We included 53 studies, comprising 39 pharmacological (intervention n = 1497, control n = 1346), 13 non-pharmacological (intervention n = 661, control n = 641), and one mixed intervention (intervention n = 96, control n = 32). Studies included lifestyle and other behavioural interventions, metformin, anti-psychotic switching, and a range of adjunctive pharmacological therapies to existing anti-psychotic medications. Many studies included small sample sizes and targeted different sub-groups of the population; for example inclusion criteria commonly set limits regarding body weight, medications, and presence of diabetes and other co-morbidities. Compared to usual care, both pharmacological and non-pharmacological interventions showed a small clinical improvement in both HbA1c and fasting glucose levels in people with SMI; however, there was considerably heterogeneity between studies, and few conclusions can be drawn about the effectiveness of interventions to improve diabetes outcomes for people with co-existing SMI and diabetes, due to poor reporting of sample characteristics and study findings.