Title: Location of care for people with serious mental illness: implications for service use and costs
Funder: Department of Health (England)

Abstract: The proposed study consists of 1) a quantitative component based on routinely collected health records 2) a qualitative component investigating users’ views and experiences and 3) an economic modelling component.COMPONENT 1. People living in Lambeth who have severe mental illness (SMI) will be identified from SMI registers in primary care. We will produce a dataset containing information on demographic clinical details physical health conditions and use of primary and secondary care services. Data on secondary mental health care use and clinical ratings will be obtained from the Clinical Record Interactive Search (CRIS) system. Primary care data will be obtained from Lambeth DataNet supplemented with specifically requested GP consultation data. The PCT is also able to link primary and acute hospital services data for the purposes of data validation and risk stratification and these can be additionally linked to CRIS. These data are encrypted but proceadures are in place to combine them by third party de-encryption/re-encryption. Data will be obtained on service contacts and clinical characteristics for the 12 months prior to the SMI register index date (January 2010). These data will be used to categorise patients as being under secondary care management or primary care management. Comparisons in terms of clinical and demographic characteristics will be made between the two groups using appropriate statistical tests. Service use data will be combined with unit cost information to generate service costs. Service use will be compared between the two groups. The proportion using specific services will be compared using logistic regression models controlling for background differences. Costs will be modelled using linear regression models in order to identify cost predictors. Separate models will be generated for each group and these will be used to ‘cross-predict’ what the costs would have been for patients with similar characteristics managed in the alternative setting. We will conduct survival analyses (using Cox’s regression) to identify demographic clinical and service use variables in the year prior to the index date that are associated with a move from secondary care to primary care or primary care to secondary care. Two separate models will be produced (one for each form of management) plus a combined model where the original form of care will be entered as a potential predictor variable. COMPONENT 2.This will explore the experiences/views of service users subject to the transition from secondary to primary care and receiving at least one of the health and social care interventions aimed at supporting people with severe mental illness in a primary care setting. Given the complex nature of the interventions and the fact that these are new and potentially developing services an exploratory qualitative approach is proposed comprising of semi-structured interviews conducted longitudinally in order to fully explore the transition process. Interviews will begin at the point of discharge from secondary care as service users take up the new services. The same respondent will then be interviewed again at a point up to one year after the transition from secondary care where they can reflect on their experience of primary care. Interviews will follow a standard topic guide modified according to the type of service received and the interview stage. An important part of this component will be to achieve triangulation by collecting data from a range of sources including: health records the accounts of service users and also the accounts of primary mental health and social care professionals involved in their care. While the emphasis in this part of the study would be on the accounts of the service users themselves these would be complemented by interviews with workers involved in their care.A purposive sample of 30 service users with a SMI recently discharged from secondary care and in receipt of at least one of the three specified primary care interventions will be recruited. Patients will be recruited via their GP or one of the services being evaluated. The study will include a further sample of workers associated with the respondents’ care – comprising approximately 3 participants per intervention. A semi-structured interview will take place at a time point where participants have recently been discharged from secondary care. Participants will be interviewed again up to one year later. The emphasis in the topic guide will be on their overall views and experience of the primary care services and their reflections on the transition from secondary care. Interviews will be transcribed and analysed following a structured thematic analysis approach. Analysis will follow the constant comparison method [2930]. That is transcripts will be initially coded by the researcher using categories derived from the topic guide as a starting point with new codes subsequently added when necessary. Each category will then be compared with the rest using an iterative process to look for patterns differences and similarities to further refine existing categories and create new ones.COMPONENT 3. We will produce decision models to assess the cost-effectiveness of the three interventions. Data generated in Component 1 will serve as a baseline against which the impact on costs of these will be assessed. The first stage in this will be to structure the models followed by ‘populating’ the models with local data. Finally the models will be tested using sensitivity analyses. The structuring will involve service users clinical staff commissioners and research staff in focus groups to ensure that the models are acceptable. The structure will map out the pathways through the care system following engagement with the intervention. It will need to include the most likely types of service use such as admission readmission psychiatrist contact etc. Data on the probabilities of different services being used will be largely derived from the databases described above. Changes in these probabilities will be estimated from data collected as part of the record keeping for the interventions themselves. Costs of different events occurring will be calculated again using data already described. The models once ‘populated’ will be ‘rolled back’ to reveal the expected costs of the different interventions. One-way and probabilistic sensitivity analyses will be conducted. During the focus groups we will ask participants to complete two measures to rate their expected satisfaction (Client Satisfaction Questionnaire) and health-related quality of life (EQ-5D) following use of the interventions.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: MENTAL HEALTH