CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, et al. CHOICE: Choosing Health Options In Chronic Care Emergencies. Programme Grants Appl Res 2017;5(13)

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives
The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design
A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting
Primary care. Manchester and London.

Participants
People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results
Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations
The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions
Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work
The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Investigation into NHS continuing healthcare funding

National Audit Office

National Audit Office has published findings of investigation into NHS continuing healthcare.

NHS continuing healthcare (CHC) is a package of care provided outside of hospital that is arranged and funded solely by the NHS for individuals who have significant ongoing health care needs.  Funding for ongoing health care is a complex and highly sensitive area, which can affect some of the most vulnerable people in society and those that care for them. The number of people assessed as eligible for CHC funding has been growing by an average of 6.4% a year over the last four years.  In 2015-16, almost 160,000 people received, or were assessed as eligible for, CHC funding in the year, at a cost of £3.1 billion.

NHS RightCare Pathway: Diabetes

NHS RightCare, in partnership with the Healthier You: NHS Diabetes Prevention Programme(NHS DPP) has published NHS RightCare Pathway: Diabetes.

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NHS RightCare Pathway: Diabetes is a tool that aims to support local commissioners to review local diabetes pathways in order to identify where potential improvements could be delivered. The pathway has been developed in collaboration with the National Clinical Director for Diabetes and Obesity at NHS England and Associate National Director for Diabetes, the NHS Diabetes Prevention Programme, Public Health England, Diabetes UK and patient groups.

NHS RightCare Pathway: Diabetes has two key elements:

  1. It describes the core components that should be present in an optimal diabetes service; right from detection and diagnosis through to ongoing treatment, management and care of people with diabetes
  2. It provides guidance for commissioners that will:
    1. Allow them to think through their existing diabetes service and compare it with an optimal diabetes service; and
    2. Provides guidance for commissioners about the scale of improvements that could be delivered through optimisation of local pathways.

Full resource: NHS RightCare Pathway: Diabetes

See also: Appendix 1: Examples of good practice

This resource outlines examples of models of integrated care between primary and secondary care, and contains useful links and resources.

 

Asthma self-management programmes can reduce unscheduled care

Pinnock H, Parke HL, Panagioti M, et al; PRISMS and RECURSIVE groups. Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Medicine. 2017;15(1):64. | via National Institute for Health Research

People with asthma who receive supported self-management are less likely to attend A&E or be admitted to hospital. The interventions are unlikely to increase overall costs for healthcare services. Those who self-manage are also likely to have more controlled asthma and a better quality of life.

This extensive overview of systematic reviews included evidence from 270 randomised controlled trials exploring the effects of asthma self-management on healthcare utilisation and costs. Self-management programmes were slightly more expensive, but this cost was likely to be offset by reducing unplanned medical visits and improving patient quality of life.

Trials covered different self-care education programmes delivered in a range of contexts. However, programmes which included written action plans supported by regular professional review were found to be most beneficial.

These findings are in keeping with current guideline recommendations and emphasise that supported self-management programmes for asthma should be prioritised.

Support for carers

Thomas S, Dalton J, Harden M, Eastwood A, Parker G. Updated meta-review of evidence on support for carers. Health Serv Deliv Res 2017;5(12)

The University of York Centre for Reviews and Dissemination has published Updated meta-review of evidence on support for carers.

This review updates what is known about effective activities to support carers of ill, disabled or older adults.  The report concludes that there is no ‘one size fits all’ intervention to support carers but potential exists for effective support in specific groups of carers.

 

Organisation and quality of stroke services

New review brings together recent evidence relevant to those planning and delivering stroke services, those delivering treatments to people with stroke and to those living with stroke. | National Institute for Health Research

Recent years have seen huge improvements in the clinical management of people with stroke with early assessment, use of thrombolysis and better organisation of services into acute stroke units. Over the last twenty years, stroke mortality rates have halved.

This themed review looks at the configuration of stroke services, identifying stroke and acute management, recovery and rehabilitation, and life after stroke.

It features:

  • 44 published studies
  • 29 ongoing studies
  • Questions to ask about your stroke services
  • Quotes from commissioners, clinicians and service users

Full document:
Roads to Recovery: Organisation and Quality of Stroke Services

Long term conditions and prescription charges

The Prescription Charges Coalition has launched a new survey looking at the ways in which prescription charges affect the lives of people in England with long-term conditions.

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At the moment, people with long term conditions in England who work have to pay for their medicines, because the list of illnesses that qualify for free prescriptions is limited and out of date.  The prescription charges coalition is campaigning for all people with long-term conditions to receive free prescriptions.

Find out more about the campaign, at the Prescription Charges Coalition website.