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Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study): a multicentre, parallel-group, randomised controlled trial

Sharpe, Michael; Walker, Jane; van Niekerk, Maike; Toynbee, Mark; Magill, Nicholas; Frost, Chris; White, Ian R.; Walker, Simon; Duarte, Ana; Owens, Colm; Dickens, Chris; Price, Annabel; Sharpe, Michael; Walker, Jane; van Niekerk, Maike; Toynbee, Mark; Magill, Nicholas; Frost, Chris; White, Ian R; Walker, Simon; Duarte, Ana; Owens, Colm; Dickens, Chris; Price, Annabel; Aitken, Peter; Bajorek, Tomasz; Berk, Gunes; Bold, Rhian; Burke, Katy; Burns, Jonathan; Campbell, Shelley; Chaitow, Hannah; Clay, Felix; Daly, Michael; Emmens, Tobit; Hampsey, Elliot; Hannaway, Naomi; Harris, Jessica; Harwood, Rowan; Hill, Laura; Hobbs, Harriet; Hollands, Laura; Howitt, Sophie; Kant, Rhian; Lamb, Sarah E; Lasserson, Daniel; Lee, Hochang Benjamin; Macey, Eleanor; Palmer, Aelfrida; Philps, Julie; Pollard, Louise; Rocroi, Isabelle; Scholz, Anna; Shepperd, Sasha; Sirois-Giguere, Gabrielle; Solomons, Luke; Steward, Ben; Turner, Will; Yousif, Michael

Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study): a multicentre, parallel-group, randomised controlled trial Thumbnail


Authors

Michael Sharpe

Jane Walker

Maike van Niekerk

Mark Toynbee

Nicholas Magill

Chris Frost

Ian R. White

Simon Walker

Ana Duarte

Colm Owens

Chris Dickens

Annabel Price

Michael Sharpe

Jane Walker

Maike van Niekerk

Mark Toynbee

Nicholas Magill

Chris Frost

Ian R White

Simon Walker

Ana Duarte

Colm Owens

Chris Dickens

Annabel Price

Peter Aitken

Tomasz Bajorek

Gunes Berk

Rhian Bold

Katy Burke

Jonathan Burns

Shelley Campbell

Hannah Chaitow

Felix Clay

Michael Daly

Tobit Emmens

Elliot Hampsey

Naomi Hannaway

Jessica Harris

Laura Hill

Harriet Hobbs

Laura Hollands

Sophie Howitt

Rhian Kant

Sarah E Lamb

Daniel Lasserson

Hochang Benjamin Lee

Eleanor Macey

Aelfrida Palmer

Julie Philps

Louise Pollard

Isabelle Rocroi

Anna Scholz

Sasha Shepperd

Gabrielle Sirois-Giguere

Luke Solomons

Ben Steward

Will Turner

Michael Yousif



Abstract

Background: Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult. We aimed to assess the effects of enhancing older inpatients’ care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital. Methods: We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment. PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients’ problems, then delivered discharge-focused care as integrated members of ward teams. The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient's experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life. Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296). Findings: 2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants’ mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White. The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference –0·45 (95% CI –1·11 to 0·21; p=0·18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP—a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred. Interpretation: This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation. Funding: UK National Institute for Health and Care Research.

Citation

Sharpe, M., Walker, J., van Niekerk, M., Toynbee, M., Magill, N., Frost, C., White, I. R., Walker, S., Duarte, A., Owens, C., Dickens, C., Price, A., Sharpe, M., Walker, J., van Niekerk, M., Toynbee, M., Magill, N., Frost, C., White, I. R., Walker, S., …Yousif, M. (2024). Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study): a multicentre, parallel-group, randomised controlled trial. Lancet Psychiatry, 11(9), 684-695. https://doi.org/10.1016/s2215-0366%2824%2900188-3

Journal Article Type Article
Acceptance Date Jul 11, 2024
Online Publication Date Aug 10, 2024
Publication Date Sep 1, 2024
Deposit Date Aug 12, 2024
Publicly Available Date Aug 13, 2024
Journal Lancet Psychiatry
Print ISSN 2215-0366
Electronic ISSN 2215-0374
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 11
Issue 9
Pages 684-695
DOI https://doi.org/10.1016/s2215-0366%2824%2900188-3
Public URL https://nottingham-repository.worktribe.com/output/38370889
Publisher URL https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00188-3/fulltext

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