Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial.

BACKGROUND: Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression. DESIGN: Cluster randomised controlled trial. SETTING: UK primary care practices (n = 51) in three UK primary care districts. PARTICIPANTS: A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. INTERVENTIONS: Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice. MAIN OUTCOME MEASURES: Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. RESULTS: In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. CONCLUSIONS: Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se. TRIAL REGISTRATION: Current Controlled Trials ISRCTN32829227. FUNDING: This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership

Understanding the workforce needs of health and social care services for people living with frailty: a scoping review protocol

Why is this review needed?Older people with complex health problems are increasingly characterised as “living with frailty” within health and social care settings. Frailty is more common in older people, affecting 44% of adults aged 65 and older in England. Better care for people living with frailty is essential to improve health and quality of life and help the NHS and Social Care to be more efficient. The NHS needs to ensure that they have the right number of staff, with the right skills working in the right place. To do this, organisations delivering health and social care need to know more about what services are required by people living with frailty, and the numbers and type of health and social care staff needed to run those services. This review is part of a larger study which aims to develop a tool (a computer model) to predict the staff numbers with the skills the that are needed to provide the best care for adults living with frailty. This review will help to gather background information on what is currently happening and available, so that this information can be considered by the research team and their NHS and Social care partners, as they develop the tool. How will this review be done?This review aims to gather data from sources around the world which provide information about specific services which deliver health and social care for adults living with frailty. To do this, the study team will use online databases and the internet to search for the relevant information, using keywords which are relevant for the topic area. We will search academic journals, as well as information from people who provide the services such as NHS Trusts and Local Authorities, and other organisations whose remit includes informing, designing, delivering or evaluating services for older people living with frailty. Working with our stakeholder consultation group, including NHS and Social care partners, patients, carers and members of the public, we will decide which information is important to extract to be able to meet our aim, and how to present it. How will the results from the review be used?The results from this review should include a description of different health and social care services that are used by people living with frailty, and the type and numbers of staff providing care. This information, together with other information collected during the study, will be applied to an existing tool which predicts the numbers of people living with frailty in the future and their needs for health and social care. The research team and the stakeholders will look at different scenarios for service delivery, with its associated workforce, and estimate what the future workforce to provide care for this patient and service user group might be. This will help people who plan services to plan the workforce required in their local areas. <br/

Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006–2017

Background: frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population-level use of health services and associated costs is needed to plan for ageing populations.Aim: t describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category.Design and setting: retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017.Methods: primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced.Results: individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12 years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for socio-demographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe.Conclusions: increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level