Abstract
Background
Tobacco smoking is highly prevalent among people attending treatment for a substance-use disorder (SUD). In the United Kingdom, specialist support to stop smoking is largely ...delivered by a national network of stop smoking services, and typically comprises of behavioral support delivered by trained practitioners on an individual (one-to-one) or group basis combined with a pharmacological smoking-cessation aid. We evaluate the cost-effectiveness of these interventions and compare cost-effectiveness for interventions using group- and individual-based support, in populations under treatment for SUD.
Methods
Economic modeling was used to evaluate the incremental cost-per-quality-adjusted-life-years (QALYs) gained for smoking-cessation interventions compared with alternative methods of quitting for the SUD treatment population. Allowance was made for potentially lower abstinence rates in the SUD population.
Results
The incremental cost-per-QALY gained from quit attempts supported through more frequently provided interventions in England ranged from around £4,700 to £12,200. These values are below the maximum cost-effectiveness threshold adopted by policy makers in England for judging whether health programs are a cost-effective use of resources. The estimated cost-per-QALY gained for interventions using group-based behavioral support were estimated to be at least half the magnitude of those using individual support due to lower intervention costs and higher reported quit rates. Conclusions reached regarding the cost-effectiveness of group-based interventions were also found to be more robust to changes in modeling assumptions.
Conclusions
Smoking-cessation interventions were found to be cost-effective when applied to the SUD population, particularly when group-based behavioral support is offered alongside pharmacological treatment.
Implications
This analysis has shown that smoking-cessation interventions combining pharmacological treatment with behavioral support can offer a cost-effective method for increasing rates of smoking cessation in populations being treated for a substance-use disorder. This is despite evidence of lower comparative success rates in terms of smoking abstinence in populations with SUD. Our evaluation suggests that medication combined with group-based behavioral support may offer better value for money in this population compared with interventions using individual support, though further evidence on the comparative effectiveness and cost of interventions delivered to SUD treatment populations would facilitate a more robust comparison.
Objective To identify the factors that promote and compromise the implementation of reasonably adjusted healthcare services for patients with intellectual disabilities in acute National Health ...Service (NHS) hospitals. Design A mixed-methods study involving interviews, questionnaires and participant observation (July 2011–March 2013). Setting Six acute NHS hospital trusts in England. Methods Reasonable adjustments for people with intellectual disabilities were identified through the literature. Data were collected on implementation and staff understanding of these adjustments. Results Data collected included staff questionnaires (n=990), staff interviews (n=68), interviews with adults with intellectual disabilities (n=33), questionnaires (n=88) and interviews (n=37) with carers of patients with intellectual disabilities, and expert panel discussions (n=42). Hospital strategies that supported implementation of reasonable adjustments did not reliably translate into consistent provision of such adjustments. Good practice often depended on the knowledge, understanding and flexibility of individual staff and teams, leading to the delivery of reasonable adjustments being haphazard throughout the organisation. Major barriers included: lack of effective systems for identifying and flagging patients with intellectual disabilities, lack of staff understanding of the reasonable adjustments that may be needed, lack of clear lines of responsibility and accountability for implementing reasonable adjustments, and lack of allocation of additional funding and resources. Key enablers were the Intellectual Disability Liaison Nurse and the ward manager. Conclusions The evidence suggests that ward culture, staff attitudes and staff knowledge are crucial in ensuring that hospital services are accessible to vulnerable patients. The authors suggest that flagging the need for specific reasonable adjustments, rather than the vulnerable condition itself, may address some of the barriers. Further research is recommended that describes and quantifies the most frequently needed reasonable adjustments within the hospital pathways of vulnerable patient groups, and the most effective organisational infrastructure required to guarantee their use, together with resource implications.
Background
Prior research suggests that the placement of patients on clinically inappropriate hospital wards may increase the risk of experiencing patient safety issues.
Objective
To explore ...patients' perspectives of the quality and safety of the care received during their inpatient stay on a clinically inappropriate hospital ward.
Design
Qualitative study using semi‐structured interviews.
Participants and setting
Nineteen patients who had spent time on at least one clinically inappropriate ward during their hospital stay at a large NHS teaching hospital in England.
Results
Patients would prefer to be treated on the correct specialty ward, but it is generally accepted that this may not be possible. When patients are placed on inappropriate wards, they may lack a sense of belonging. Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care.
Conclusions
Patients generally acknowledge the need for placement on inappropriate wards due to demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.
To explore NHS staff members' perceptions and experiences of the contributory factors that may underpin patient safety issues in those who are placed on a hospital ward that would not normally treat ...their illness (such patients are often called 'outliers' 'sleep outs' or 'boarders').
Qualitative study using semi-structured interviews. Setting A single large teaching hospital in the north of England.
29 members of NHS staff (doctors, nurses and non-clinical or management staff).
Five themes describing contributory factors underlying safety issues were identified: competing demands on staff time created by having patients on inappropriate wards and patients who are on the correct specialty ward to care for; poor communication between the correct specialty ward and the clinically inappropriate ward; lack of knowledge or specialist expertise on clinically inappropriate wards; an unsuitable ward environment for patients on inappropriate wards; and the characteristics of patients who are placed on clinically inappropriate wards (specifically staff perceive patients on inappropriate wards to be medically fit and therefore of lower priority and moving patients between wards may disorientate confused or impaired patients). Examples of how these contributory factors may lead to safety issues are given.
NHS staff report that placement of patients on clinically inappropriate wards is a specific patient safety concern. The application of James Reason's Swiss cheese model of accident causation suggests that placement on an inappropriate ward constitutes a 'latent condition' which may expose patients to contributory factors that underlie adverse events.
There is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of ...untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health.
A systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised.
Few (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes.
Evidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.
Purpose
Many patients referred by their GP for an assessment by secondary mental health services are unlikely to ever meet eligibility thresholds for specialist treatment and support. A new service ...was developed to support people in primary care. “the authors evaluate” whether the phased introduction of the Lambeth Living Well Network (LWN) Hub to a population in south London led to: a reduction in the overall volume of patients referred from primary care for a secondary mental health care assessment; and an increase in the proportion of patients referred who met specialist service eligibility criteria, as indicated by the likelihood of being accepted in secondary care.
Design/methodology/approach
The evaluation applied a quasi-experimental interrupted time series design using electronic patient records data for a National Health Service (NHS) provider of secondary mental health services in south London.
Findings
Scale-up of the Hub to the whole of the population of Lambeth led to an average of 98 fewer secondary care assessments per month (95% CI −118 to −78) compared to an average of 203 assessments per month estimated in the absence of the Hub; and an absolute incremental increase in the probability of acceptance for specialist intervention of 0.20 (95% CI; 0.14 to 0.27) above an average probability of acceptance of 0.57 in the absence of the Hub.
Research limitations/implications
Mental health outcomes for people using the service and system wide-service impacts were not evaluated preventing a more holistic evaluation of the effectiveness and cost-effectiveness of the LWN Hub.
Practical implications
Providing general practitioners with access to service infrastructure designed to help people whose needs cannot be managed within specialist mental health services can prevent unnecessary referrals into secondary care assessment teams.
Social implications
Reducing unnecessary referrals through provision of a primary-care linked mental health service will reduce delay in access to professional support that can address specific mental-health related needs that could not be offered within the secondary care services and could prevent the escalation of problems.
Originality/value
The authors use NHS data to facilitate the novel application of a quasi-experimental methodology to deliver new evidence on whether an innovative primary care linked mental health service was effective in delivering on one of its key aims.
Aims
To understand issues around carer roles that affect carer involvement for people with intellectual disabilities in acute hospitals.
Background
There is evidence that a lack of effective carer ...involvement can lead to poorer health outcomes for people with intellectual disabilities, but there is a lack of insight into the reasons for poor carer involvement in acute hospitals.
Design
Mixed methods in six acute hospital trusts in England (2011–2013).
Methods
Electronic hospital staff survey (n = 990), carer questionnaires (n = 88), semi‐structured interviews with hospital staff (n = 68) and carers (n = 37). Data were triangulated and analysed using a conceptual framework.
Results
There was strong support for carer involvement among hospital staff, and most carers indicated that they felt welcomed and supported. However, an investigation of negative experiences showed that there were discrepancies in the perspectives of hospital staff and carers on the scope of ‘carer involvement’. An important contributory factor to the effectiveness of carer involvement was the degree to which staff understood the importance of carer expertise (rather than simply carer work) and welcomed it. Carers’ contributions to basic nursing care tasks could be taken for granted by hospital staff, sometimes erroneously.
Conclusion
The roles and contributions of carers should be clarified on an individual basis by hospital staff. The authors propose a new model to support this clarification. Further research is needed to assess the suitability of the model for patients with intellectual disabilities and other vulnerable patient groups.
There has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement ...the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors.
This was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities.
Staff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders.
The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents, and may be difficult to attribute as causal to the harm suffered. Acts of omission (failure to give care) are more difficult to recognise, capture and monitor than acts of commission (giving the wrong care). In order to improve patient safety for this group, the reasonable adjustments needed by individual patients should be identified, documented and monitored.
Background: Almost all NHS hospitals regularly place patients on wards that are not clinically appropriate if there are no beds available on the correct specialty ward. Such patients are commonly ...called outliers. Approximately one in ten NHS inpatients experience an adverse event that causes them harm as a direct result of the care they receive while in hospital. It was hypothesised that placement on a ward that is not clinically appropriate for patients’ needs could act as an underlying (latent) condition which may increase patients’ susceptibility to adverse events. Methods: A descriptive quantitative study of the outliers and other inpatients in a single large NHS Foundation Trust was conducted using routinely available data. The aims were to investigate: the trend of outliers over the course of one year, age, gender, specialty, internal transfers between wards, length of stay in hospital and mortality. Two separate qualitative interview studies were conducted at the Trust to ascertain NHS staff members’ and patients’ perceptions and experiences of the quality and safety of care received by outlying patients. Results: Medical and elderly outliers increased over the winter months. Outliers were transferred between wards a significantly greater number of times than other inpatients. Multivariate analyses demonstrated no differences in age, gender, or mortality; however, outliers stayed in hospital significantly longer than other inpatients and outliers were significantly more likely to come from medicine than from any other specialty. Both staff and patients identified a number of factors which may contribute to healthcare errors experienced by outlying patients. Placement of patients on clinically inappropriate wards creates competing demands on staff members’ time and consequently results in delays, poses a number of communication barriers, compromises input from knowledgeable staff, may provide an unsuitable ward environment, and can be inappropriate for individual patients’ needs. Conclusions: The placement of patients on clinically inappropriate wards is a specific patient safety concern and constitutes a latent condition which may expose patients to a number of contributory factors that underlie adverse events. The quality of care may be compromised as outliers are often prioritised beneath other inpatients.
Background: Almost all NHS hospitals regularly place patients on wards that are not clinically appropriate if there are no beds available on the correct specialty ward. Such patients are commonly ...called outliers. Approximately one in ten NHS inpatients experience an adverse event that causes them harm as a direct result of the care they receive while in hospital. It was hypothesised that placement on a ward that is not clinically appropriate for patients’ needs could act as an underlying (latent) condition which may increase patients’ susceptibility to adverse events. Methods: A descriptive quantitative study of the outliers and other inpatients in a single large NHS Foundation Trust was conducted using routinely available data. The aims were to investigate: the trend of outliers over the course of one year, age, gender, specialty, internal transfers between wards, length of stay in hospital and mortality. Two separate qualitative interview studies were conducted at the Trust to ascertain NHS staff members’ and patients’ perceptions and experiences of the quality and safety of care received by outlying patients. Results: Medical and elderly outliers increased over the winter months. Outliers were transferred between wards a significantly greater number of times than other inpatients. Multivariate analyses demonstrated no differences in age, gender, or mortality; however, outliers stayed in hospital significantly longer than other inpatients and outliers were significantly more likely to come from medicine than from any other specialty. Both staff and patients identified a number of factors which may contribute to healthcare errors experienced by outlying patients. Placement of patients on clinically inappropriate wards creates competing demands on staff members’ time and consequently results in delays, poses a number of communication barriers, compromises input from knowledgeable staff, may provide an unsuitable ward environment, and can be inappropriate for individual patients’ needs. Conclusions: The placement of patients on clinically inappropriate wards is a specific patient safety concern and constitutes a latent condition which may expose patients to a number of contributory factors that underlie adverse events. The quality of care may be compromised as outliers are often prioritised beneath other inpatients.
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