Title: An investigation of the epidemiology of falls, fractures and outcomes among people with psychotic and affective disorders
Funder: Health Education England

Abstract: Aims The Lectureship will support a programme of work investigating hospitalised falls/fractures in people with psychotic/affective disorders using data from mental health, acute and primary care services, specifically seeking to: Characterise experiences of falls/fractures and rehabilitation among: 1) people with psychotic/affective disorders; 2) general hospital nursing/therapies staff. Investigate the incidence and predictors of falls/fractures. Investigate outcomes including mortality, duration of hospitalisation, readmission and service use across healthcare sectors, compared to the catchment population. Investigate quality of primary/acute care related to falls/fractures in this patient group, compared to people without mental illness. Background Falls are a leading cause of morbidity, healthcare use and mortality, but little is known about these outcomes in people with mental disorders. People with psychotic and affective disorders have a number of risk factors for osteoporosis and fractures, including diabetes, vitamin-D deficiency, sedentary lifestyle, poor nutritional intake, and hyperprolactinaemia associated with some antipsychotic agents. Recent meta-analyses have found that people with psychosis are 2.5 times more likely to have osteoporosis than controls and are at a 72% increased risk of experiencing fractures. Important gaps in the literature include a paucity of information on the experiences and predictors of falls/fractures in people with mental disorders, an absence of information on outcomes (e.g. duration of hospitalisation) and unclear evidence on targets for intervention. Methods I will conduct initial qualitative interviews with: 1) a purposive sample of people with psychotic/affective disorders who have experienced falls/fractures (supplemented by an in-depth case-note review); 2) focus groups of general hospital nursing/therapies staff. Subsequently, I will utilize a unique network of linked databases to address knowledge gaps: i) the Clinical Record Interactive Search (CRIS) resource containing de-identified mental healthcare EHR data from the South London and Maudsley Trust (SLAM) on over 350,000 patients, containing natural language processing applications enabling extraction of structured data to ascertain pharmacotherapy, physical-health and mental health symptomatology; CRIS linkages to ii) Hospital Episode Statistics (HES), providing national data on hospitalisations and associated diagnoses, iii) national mortality data from the Office of National Statistics (ONS), and iv) local primary care data from Lambeth DataNet (LDN) which currently covers all practices in one of SLaM's four catchment boroughs.Pilot data Preliminary analyses to support the application identified that between 01/2006-12/2012 among 10,988 people with psychosis, 579 and 393 were admitted to an acute hospital following a fall and fracture respectively. The median length of stay was 6.65 (+22.5, total days=6,977) and 12.1 (+32.0, total days 11,327) days for falls and fractures respectively.Project outlineSemi-structured qualitative interviews and case-note review of patients with psychotic/affective disorders who were admitted due to a fall/fracture (n=20) and focus groups with healthcare staff (n=15, Aim-1). Using CRIS, describe the incidence of falls/fractures in psychotic/affective disorders and compare patterns and rates versus standardised age-sex matched local population without mental illness and by common symptom profiles (Aim-2). Investigate predictors of falls/fractures including sociodemographic status (e.g. age, gender, ethnicity, area-level deprivation), medication, psychiatric and physical health comorbidity (Aim-2). Investigate outcomes for falls/fractures among people with psychotic/affective disorders versus catchment population (Aim-3). Investigate quality of care in primary care (LDN) and compare this to people without mental disorders (Aim-4). Outcomes/benefits to NHS Development of a risk prediction tool to identify at risk groups of people with affective/psychotic disorders of falls/fractures to inform: a)New care pathways. b)Platforms for future intervention trials to prevent falls/fractures. 2)Published and disseminated literature (for academic, clinical, service and public audiences) on risks, outcomes and points of inequality.

Lay abstract: Falls and fractures are major public health concerns, associated with increased healthcare use, hospitalization, pain and an elevated risk of earlier death. There has been considerable research to prevent hospitalized falls and fractures generally, but there are no data in the United Kingdom on this topic among people with serious mental illness. People with psychotic disorders (e.g. schizophrenia) and affective disorders (e.g. major depression, bipolar disorder) are suspected to have worse bone health, including an increased risk of osteoporosis, as well as a range of risk factors for falls and fractures such as multiple medications, low vitamin D levels, physical inactivity, poor diet and poor general physical health. As a senior Physiotherapist working in mental healthcare, I have noticed personally that this population typically do poorly in current fall/fracture models of care and that rehabilitation is often slower and more complex. This is a view shared by many physiotherapists I have spoken to who work in general hospitals. Currently, there is no evidence available in the world informing healthcare professionals how best to manage falls/fractures in people with serious mental illness, and this is a major deficiency and point of inequality.The overarching aim of this lectureship is therefore to investigate the patterns of falls and fractures requiring hospitalisation among people with psychotic and affective disorders and understand what factors may predict these outcomes. The research will involve talking to people with mental illness that have had a fall or fracture to understand their experiences, as well as talking to general hospital staff who provide their care. The research will investigate how long people with these mental disorders stay in hospital following a fall/fracture, what types of intervention they receive (e.g. surgery), and consider outcomes after a hospital admission such as death or readmission. The research will also investigate GP records to understand what type of care people with psychotic/affective disorders receive who are at risk of falls/fractures and whether this is different from people without mental illness. More specifically, to achieve the aims the following steps will be undertaken. First, I will interview around twenty people with psychotic/affective disorders who have been admitted to hospital due to a fall/fracture and (with permission) review their medical notes to understand their care and rehabilitation. I will also interview general hospital staff responsible for their care to understand their experiences of caring for these patient groups. Next, I will investigate falls/fracture rates, duration of hospital admissions, and outcomes using a large anonymous mental healthcare database called CRIS, which has been linked to national information on hospital attendances and admissions. I will also investigate what factors such as medication, physical health conditions, and mental health symptoms may influence falls/fracture risk in people with psychotic/affective disorders. In preparation for this application, I have provisionally looked at the CRIS database and found that between January 2006 and December 2012, from 10,988 people with psychosis, 579 and 369 were admitted to hospital on at least once occasion due to a fall and fracture respectively. Second, I will complete a data linkage between the CRIS and a database of records from local general practices. The general practitioner records are also anonymous and have been linked to the mental health records (CRIS) in a unique opportunity which will enable me to consider carefully in more detail information on physical health conditions, medications and the type of care that people who are at risk of falls will have received, and investigate if this is different in people with mental disorders. In the short to medium term I will use this research to develop a risk prediction tool to identify people with mental disorders at risk of falls/fractures in addition to developing models of care to better prevent and manage these outcomes. If successful, such models of care could be exported to other NHS trusts. In the longer term, the information will be used as a foundation for evaluating future interventions to prevent and manage falls/fractures in people with mental disorders. This lectureship will also provide important opportunities for me to undergo additional training in research, leadership and develop further clinical expertise, which will equip me to better design and implement research to improve the delivery of evidence based clinical care for people with mental illness. This is important, as to my knowledge; there are no other physiotherapists with an academic interest in the United Kingdom who are seeking to improve the poor evidence base and outcomes for people with mental illness.

Research activity codes: 2.4 SURVEILLANCE AND DISTRIBUTION
Health categories: INJURIES AND ACCIDENTS;MENTAL HEALTH