Title: How can we best address prolonged acute hospital stays in older inpatients with medical-psychiatric multimorbidity?: A pragmatic multicentre randomised controlled trial to compare the effectiveness and cost-effectiveness of Proactive Liaison Psychiatry with usual care.
Funder: Department of Health and Social Care

Abstract: DESIGN Pragmatic multicentre 2-arm parallel group individually randomised (1:1 ratio) controlled superiority trial with health economic analysis and embedded process evaluation. SETTING Acute medical wards in district general and teaching hospitals (4 centres). INCLUSION/EXCLUSION CRITERIA Included: if aged 65 or older; non-elective admission; likely to remain an inpatient for at least two days; able to give informed consent or if unable to give consent their consultee, guardian or nearest relative advises that trial participation is appropriate. Excluded: if moribund; already enrolled in the trial. NEW INTERVENTION: PROACTIVE LIAISON PSYCHIATRY (PLP) PLP has 4 main components: 1. Early proactive assessment of all patients to identify psychosocial problems including psychiatric illness 2. Creation of a management plan to address these and overcome barriers to prompt discharge 3. Proactive progress reviews and communication with care partners to deliver the plan 4. Proactive follow-through post-discharge COMPARATOR: USUAL CARE Usual medical care (including referral to local liaison psychiatry services if deemed necessary by the ward team). PRIMARY OUTCOME Number of days spent as an acute hospital inpatient in the month (30 days) post-randomisation, measured using routine hospital episode statistics and local hospital data. SECONDARY OUTCOMES At 1 month post-randomisation: Independent functioning, cognitive function, anxiety, depression, quality of life, experience of care, discharge destination, length of index admission. At 1 year post-randomisation: Time spent in hospital, number of readmissions, deaths. ECONOMIC EVALUATION Cost-effectiveness (over 1 year) assessed from the perspective of the NHS and personal social services. Outcomes will be expressed in terms of quality-adjusted life-years (QALYs). Full uncertainty analysis will be undertaken. Incremental cost-effectiveness ratios will be presented and compared with appropriate cost-effectiveness thresholds. PROCESS EVALUATION Process evaluation will focus on the delivery of PLP, the response to and interaction with PLP by all stakeholders and potential barriers and facilitators to its implementation. SAMPLE SIZE A total of 3,244 participants is required to detect a reduction of 1 day (from 9 to 8 days, standard deviation 7) in mean number of days in hospital with 90% power at the 5% significance level adjusting for potential clustering by PLP team (ICC 0.01, cluster size 100, assuming 16 PLP teams) and allowing for 5% loss to follow-up. PROJECT TIMETABLE Duration: 36 months (6m set up, 12m recruitment including a 6 month internal pilot, 12m follow up, 6m analysis and reporting). EXPERTISE Design and conduct of trials in patients with multimorbidity; complex intervention development; clinical (old age and liaison psychiatry; geriatrics; primary, out of hospital and social care); service users; nursing; statistics; health economics; trials management; hospital management; process evaluation; use of routine data in clinical trials.

Lay abstract: THE PROBLEM Most people admitted to acute hospitals are aged over 65. Many stay in hospital a long time. This is bad for them because they can develop new illnesses and lose their independence. It is also bad for the NHS because it increases costs and reduces the number of beds available for others. Many older inpatients have a psychiatric illness (one that may benefit from psychiatric expertise) such as dementia, confusion, depression or anxiety, as well as the medical illness that led to their admission. This combination leads to longer hospital stays. Acute hospital doctors and nurses look after patients’ psychiatric illnesses but they often lack the expertise to identify and treat these effectively. They can refer patients to a liaison psychiatry service (a psychiatric service to the acute hospital provided by a mental health trust). However few patients are referred and there is no clear evidence that this reduces the time patients spend in hospital. The problem is therefore how we reduce the time that older people spend in hospital by better detection and treatment of psychiatric illness. A POTENTIAL SOLUTION A new way of providing liaison psychiatry, called Proactive Liaison Psychiatry (PLP) may solve this problem. PLP teams actively assess all new patients for problems like confusion or anxiety. They then work with the patient, their caregiver, the medical team and out of hospital care providers to address these problems, with the aim of helping patients to leave hospital earlier. PLP has been found to reduce length of stay in two hospitals in the USA but has not been tested in the UK. We have found PLP to be deliverable in the UK NHS and now want to test its effectiveness. WHAT IS THE AIM OF THE RESEARCH? The research aims to find out if adding PLP to usual care is better than usual care alone in reducing the time that older inpatients spend in hospital, improving their quality of life and enhancing their ability to do the things they want to. We will also study how PLP is delivered and its effect on patients’ experience of care and on other staff. WHO WILL TAKE PART? We will recruit 3,244 older adults admitted to acute hospitals. We will only exclude patients who: (a) are about to leave hospital, (b) are too ill to take part (c) decline to participate. WHAT ARE THE TREATMENTS? Participants will be randomly allocated in equal numbers to receive either: (a) usual medical care plus PLP or (b) usual medical care (with access to the hospital’s usual liaison psychiatry service). WHAT ARE THE OUTCOMES? The main outcome is the amount of time that patients spend in hospital in the month after randomisation, measured using routine hospital data. Other outcomes include the patient’s independent functioning, cognitive function, quality of life, experience of care, and where they are discharged to. We will also measure deaths and readmissions to hospital and will measure whether PLP is cost-effective. PATIENT AND PUBLIC INVOLVEMENT Involvement of patients and other stakeholders has shaped the research plan. We will create a PPI panel to provide advice on all aspects of its conduct. DISSEMINATION If PLP is cost-effective we will share our findings widely in order to inform the currently planned NHS nationwide investment in liaison psychiatry services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH;NEUROLOGICAL