Clinical and cost-effectiveness of tailored, intensive liaison between primary and secondary care to detect individuals at risk of a first psychotic illness: a theory-based, cluster-randomised controlled trial
Russo, Debra A
Croudace, Tim J
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Perez, J., Jin, H., Russo, D. A., Stochl, J., Painter, M., Shelley, G., Jackson, E., et al. (2015). Clinical and cost-effectiveness of tailored, intensive liaison between primary and secondary care to detect individuals at risk of a first psychotic illness: a theory-based, cluster-randomised controlled trial. The Lancet, 2 984-993. https://doi.org/10.1016/S2215-0366(15)00157-1
Background: General practitioners (GPs) are usually the first health professionals contacted by people with early signs of psychosis. It is unclear whether increasing the intensity of liaison between primary and secondary care improves the clinical and cost-effectiveness of detecting people with, or at high risk (HR) of developing a first psychotic illness. This is important given political commitments to facilitate early intervention and decrease waiting times in mental health. Methods: This is a cluster-randomised controlled trial (cRCT) of primary care practices (clusters) in the county of Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated into two groups: (a) Low intensity liaison between primary and secondary care, a postal campaign, comprised of biannual guidelines to help identification and referral of individuals with early signs of psychosis, and (b) high intensity intervention, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice and a theory-based educational package. Concealed randomisation involved randomly permuted sequence in blocks, with 12 strata and 96 blocks. Practices were not masked to group allocation. Practices that did not consent to be randomised comprised a practice as usual (PAU) group. The high and low intensity interventions were implemented over a period of two years for each practice during the study period April 2010 and October 2013. The primary outcome was the number of HR referrals to the early intervention service per practice site predicated on an assumption that the intensive intervention would double them. New referrals were assessed clinically and stratified into those who met criteria for HR or first-episode psychotic illness (FEP) (together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. An economic evaluation quantified the cost-effectiveness of the interventions and PAU, using decision analytic modelling. Cost-effectiveness was expressed as the incremental cost per additional true positive identified. Trial registration: ISRCTN70185866 Findings: Of the 104 eligible practices, fifty-four consented to be randomised. Twenty-eight practices were randomised to low intensity liaison and twenty-six practices were randomised to high intensity liaison. Two high intensity practices withdrew; one shut and the other was finally ineligible as it was out of area. High intensity practices referred more HR (incidence rate ratio (IRR) = 2.2, 95% CI = 0.9-5.1, p = .08), FEP (IRR = 1.9, 95% CI = 1.05-3.4, p = .04) and true positive cases (IRR = 2.0, 95% CI = 1.1-3.6, p = .02). High intensity practices also referred more false positives (IRR = 2.6, 95% CI = 1.3-5.0, p = .005). Most (68%) of these were referred-on to appropriate mental health-related services. The total costs per true positive referral in high intensity practices were lower than in low intensity or PAU practices; high intensity was the most cost-effective strategy. Interpretation: Increasing the resources aimed at managing the primary-secondary care interface provides clinical and economic value in this setting.
The authors acknowledge funding support from a National Institute for Health Research Programme Grant for Applied Research (NIHR PGfAR) programme (RP-PG-0606-1335; “Understanding Causes and Developing Effective Interventions for Schizophrenia and Other Psychoses”) awarded to PBJ. The work forms part of the NIHR Collaboration for Leadership in Applied Health Research & Care East of England (CLAHRC-EoE).
External DOI: https://doi.org/10.1016/S2215-0366(15)00157-1
This record's URL: https://www.repository.cam.ac.uk/handle/1810/249189
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