Biomedical subjects
Chris Flood
Publications and source records attributed to Chris Flood.
Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial.
OBJECTIVE: To investigate the cost effectiveness of joint crisis plans, a form of advance agreement for people with severe mental illness. DESIGN: Single blind randomised controlled trial. SETTING: Eight community mental health teams in southern England. PARTICIPANTS: 160 people with a diagnosis of psychotic illness or non-psychotic bipolar disorder who had been admitted to hospital at least once within the previous two years. INTERVENTION: Joint crisis plan formulated by the patient, care coordinator, psychiatrist, and project worker containing contact information, details of illnesses, treatments, relapse indicators, and advance statements of preferences for care for future relapses. Control group was standardised service information. MAIN OUTCOME MEASURES: Admission to hospital; service use over 15 months. RESULTS: Use of a joint crisis plan was associated with less service use and lower costs on average than in the standardised service information group, but differences were not significant. Total costs during follow-up were 7264 pounds sterling (10,616 euros, 13,560 dollars) for each participant with a joint crisis plan and 8359 pounds sterling (12,217 euros, 15,609 dollars) for each participant with standardised service information (mean difference 1095 pounds sterling; 95% confidence interval -2814 to 5004). Cost effectiveness acceptability curves, used to explore uncertainty in estimates of costs and effects, suggest there is a greater than 78% probability that joint crisis plans are more cost effective than standardised service information in reducing the proportion of patients admitted to hospital. CONCLUSION: Joint crisis plans produced a non-significant decrease in admissions and total costs. Though the cost estimates had wide confidence intervals, the associated uncertainty suggests there is a relatively high probability of the plans being more cost effective than standardised service information for people with psychotic disorders.
Occupational therapy compared with social work assessment for older people. An economic evaluation alongside the CAMELOT randomised controlled trial.
OBJECTIVES: To compare costs and outcome of occupational therapy-led assessment with social worker-led assessment of older people, in terms of their independence and quality of life. DESIGN: Cost-effectiveness analysis alongside a randomised controlled trial. The analysis took viewpoints of health services and patients. The primary outcome measure for cost-effectiveness was dependency using the Community Dependency Index (CDI). Secondary outcomes included utility scores based on the EuroQoL (EQ-5D). Resource use was measured for each patient, from clinical records and from patient carer interviews at 8 months. Unit costs of health and social care resources were derived from local sources and national datasets. Cost-effectiveness was analysed using cost-effectiveness acceptability curves. RESULTS: There were no differences between the two arms of the trial in terms of cost-effectiveness. There is an apparent increase in mean cost per case for the occupational therapy arm but this is not statistically significant (mean difference in cost per case 542 pounds, 95% CI 434-1,519 pounds). Mean total costs of care per participant were 4,379 pounds and 3,837 pounds for the occupational therapy and social work arms, respectively. At best the intervention would improve outcomes at a cost of 14,000 pounds per quality-adjusted life year (QALY). The probability of such an outcome was <50%. CONCLUSIONS: From a policy perspective, the lack of difference in clinical and cost-effectiveness means that either a social work or an occupational therapy service is successful in making care assessments that enable an older person to remain in their own home.
Are occupational therapists more effective than social workers when assessing frail older people? Results of CAMELOT, a randomised controlled trial.
OBJECTIVES: To compare the effectiveness of occupational therapist-led assessments of older people on dependency and service costs with that of social worker-led assessments. DESIGN: Pragmatic community-based randomised controlled trial over 2 years 4 months. SETTING: Cambridgeshire, UK. PARTICIPANTS: 321 older people aged 65 and over living in their own homes and 113 carers. INTERVENTION: participants were randomised to two groups, to receive either occupational therapist-led or social worker-led assessment. OUTCOME MEASURES: Primary outcome was dependency (Community Dependency Index). Secondary outcomes included quality of life scores (EQ-5D) and psychological outlook (Perceived Stress Scale (PSS)). Outcome measures for carers included Carer Assessment of Difficulty Index (CADI), PSS and EQ-5D, collected at baseline, 4 and 8 months. Resource use data were collected from professional practice records, participants and carers at final follow-up. RESULTS: 264 (82%) of the randomised participants completed the study. No between-group statistically significant differences were found, except that carers in the occupational therapist arm had significantly better EQ-5D scores at the 8 month follow-up (thermometer P = 0.03) and in the social worker arm better CADI scores on stress (P = 0.047) and amount of caring (P = 0.049). CONCLUSIONS: There was no clear difference in patient-centred effectiveness measures between occupational therapists and social workers in assessing frail older people and their carers in the community. More extensive use of primary care health services by occupational therapists may have contributed to the differences in EQ-5D scores for carers. Delays in making occupational therapy assessments and in completing recommended housing adaptations may have contributed to these negative findings.
Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial.
OBJECTIVE: To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment. DESIGN: Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation. SETTING: Eight community mental health teams in southern England. PARTICIPANTS: 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years. INTERVENTION: The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse. MAIN OUTCOME MEASURES: Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up. RESULTS: Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, -61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, -18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference -24, -72 to 24, P = 0.39 for those admitted). CONCLUSIONS: Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services.