Improving the quality of mental health services using patient outcome data: Making the most of HoNOS

Efforts to assess and improve the quality of mental health services are often hampered by a lack of information on patient outcomes. Most mental health services in England have been routinely collecting Health of the Nation Outcome Scales (HoNOS) data for some time. In this article we illustrate how clinical teams have used HoNOS data to identify areas where performance could be improved. HoNOS data have the potential to give clinical teams the information they need to assess the quality of care they deliver, as well as develop and test initiatives aimed at improving the services they provide

Understanding jumping to conclusions in patients with persecutory delusions: working memory and intolerance of uncertainty

Background. Persecutory delusions are a key psychotic experience. A reasoning style known as ‘jumping to conclusions’ (JTC) – limited information gathering before reaching certainty in decision making – has been identified as a contributory factor in the occurrence of delusions. The cognitive processes that underpin JTC need to be determined in order to develop effective interventions for delusions. In the current study two alternative perspectives were tested: that JTC partially results from impairment in information-processing capabilities and that JTC is a motivated strategy to avoid uncertainty.Method. A group of 123 patients with persistent persecutory delusions completed assessments of JTC (the 60:40 beads task), IQ, working memory, intolerance of uncertainty, and psychiatric symptoms. Patients showing JTC were compared with patients not showing JTC.Results. A total of 30 (24%) patients with delusions showed JTC. There were no differences between patients who did and did not jump to conclusions in overall psychopathology. Patients who jumped to conclusions had poorer working memory performance, lower IQ, lower intolerance of uncertainty and lower levels of worry.Working memory and worry independently predicted the presence of JTC.Conclusions. Hasty decision making in patients with delusions may partly arise from difficulties in keeping information in mind. Interventions for JTC are likely to benefit from addressing working memory performance, while in vivo techniques for patients with delusions will benefit from limiting the demands on working memory. The study provides little evidence for a contribution to JTC from top down motivational beliefs about uncertainty

Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design

BACKGROUND:At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK. RESEARCH QUESTIONS:(1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention? METHODS:We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial. RESULTS:Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’s d = 0.34), after 6 months (Cohen’s d = 0.29) and after 12 months (Cohen’s d = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs. LIMITATIONS:The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings. CONCLUSIONS:(1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life. FUTURE RESEARCH:Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression. TRIAL REGISTRATION:Current Controlled Trials ISRCTN34757603. FUNDING:The National Institute for Health Research Programme Grants for Applied Research programme

Parametrisation of the orographic enhancement of precipitation and deposition in a long-term, long-range transport model

International audienceOrographic enhancement of wet deposition arising from the 'seeder-feeder' effect is, by necessity, highly parametrised in long-range transport models of acid deposition that are long-term (i.e. annual average) and spatially resolved at tens of kilometres. Here, we describe a mechanistic approach to the incorporation of these mechanisms into such a model. The model formulation required the following: precipitation rate by direction and quantification of the fractions that are orographic and non-orographic; treatment of the fast oxidation of sulfur dioxide in clouds; the directionality of the seeder-feeder process; and a quantitative basis for increasing wet deposition factors to account for the seeder-feeder process. The directionality of non-orographic precipitation was determined from meteorological data at 47 sites across the UK. Orographic precipitation varies on a much finer scale than can be interpolated from measurements, and thus a modelling approach was adopted. The directionality of the seeder-feeder effect was taken from measurements. The enhancement factor of the orographic component of precipitation, assumed to represent feeder-rain, was determined from a review of measurements. Fast oxidation of sulfur dioxide is an observed phenomenon in cap-cloud, but limited in duration. An adjustment was made to the sulfur dioxide oxidation rate in the model in locations where cap-cloud was assumed to be present. The results from the model were compared with UK deposition budgets and enhanced wet deposition maps. The revised parametrisation underestimated the UK wet deposition budgets of oxidised N and S, but spatial patterns of deposition were improved for much of the UK. It was concluded that this was a satisfactory outcome given the constraints of the statistical approach of weighting of deposition at receptors utilising straight line trajectories. The sensitivity of the model to directional constraints of seeder-feeder enhancement was tested and it was concluded that a fairly narrow constraint resulted in similar estimations to a broader one, and the broader constraint was thus adopted as frontal conditions which result in the process arrive from a fairly broad band of directions. When enhancement was allowed to occur from all directions, UK wet deposition of oxidised N and S was increased by 10%. The sensitivity to the enhancement factor on wet deposition was tested and found to be relatively robust. An increase in the enhancement factor from 2 to 6 resulted in increases in UK wet deposition of oxidised N and S of 9 and 6%, respectively.Key words: Atmospheric composition and structure (pollution ? urban and regional) ? Meteorology and atmospheric dynamics (precipitation

Emission-line Helium Abundances in Highly Obscured Nebulae

This paper outlines a way to determine the ICF using only infrared data. We identify four line pairs, [NeIII] 36\micron/[NeII] 12.8\micron, [NeIII]~15.6\micron /[NeII] 12.8\micron, [ArIII] 9\micron/[ArII] 6.9\micron, and [ArIII] 21\micron/[ArII] 6.9\micron, that are sensitive to the He ICF. This happens because the ions cover a wide range of ionization, the line pairs are not sensitive to electron temperature, they have similar critical densities, and are formed within the He$^+$/H$^+$ region of the nebula. We compute a very wide range of photoionization models appropriate for galactic HII regions. The models cover a wide range of densities, ionization parameters, stellar temperatures, and use continua from four very different stellar atmospheres. The results show that each line pair has a critical intensity ratio above which the He ICF is always small. Below these values the ICF depends very strongly on details of the models for three of the ratios, and so other information would be needed to determine the helium abundance. The [Ar III] 9\micron/[ArII] 6.9\micron ratio can indicate the ICF directly due to the near exact match in the critical densities of the two lines. Finally, continua predicted by the latest generation of stellar atmospheres are sufficiently hard that they routinely produce significantly negative ICFs.Comment: Accepted by PASP. Scheduled for the October 1999 issue. 11 pages, 5 figure

The role of healthcare professionals in encouraging parents to see and hold their stillborn baby: a meta-synthesis of qualitative studies.

Background: Globally, during 2013 there were three million recorded stillbirths. Where clinical guidelines exist some recommend that professionals do not encourage parental contact. The guidance is based on quantitative evidence that seeing and holding the baby is not beneficial for everyone, but has been challenged by bereaved parents' organisations. We aim to inform future guideline development through a synthesis of qualitative studies reporting data relevant to the research question; how does the approach of healthcare professionals to seeing and holding the baby following stillbirth impact parents views and experiences? Methods/Findings: Using a predetermined search strategy of PubMed and PsychINFO we identified robust qualitative studies reporting bereaved parental views and/or experiences relating to seeing and holding their stillborn baby (final search 24 February, 2014). Eligible studies were English language, reporting parental views, with gestational loss >20weeks. Quality was independently assessed by three authors using a validated tool. We used meta-ethnographic techniques to identify key themes and a line of argument synthesis. We included 12 papers, representing the views of 333 parents (156 mothers, 150 fathers, and 27 couples) from six countries. The final themes were: "[Still]birth: Nature of care is paramount", "Real babies: Perfect beauties, monsters and spectres", and "Opportunity of a lifetime lost." Our line-of-argument synthesis highlights the contrast between all parents need to know their baby, with the time around birth being the only time memories can be made, and the variable ability that parents have to articulate their preferences at that time. Thus, we hypothesised that how health professionals approach contact between parents and their stillborn baby demands a degree of active management. An important limitation of this paper is all included studies originated from high income, westernised countries raising questions about the findings transferability to other cultural contexts. We do not offer new evidence to answer the question "Should parents see and hold their stillborn baby?", instead our findings advance understanding of how professionals can support parents to make appropriate decisions in a novel, highly charged and dynamic situation. Conclusions: Guidelines could be more specific in their recommendations regarding parental contact. The role of healthcare professionals in encouraging parents to see and hold their stillborn baby is paramount. Parental choice not to see their baby, apprehension, or uncertainty should be continuously revisited in the hours after birth as the opportunity for contact is fleeting and final

Chemical evolution of the Small Magellanic Cloud based on planetary nebulae

We investigate the chemical evolution of the Small Magellanic Cloud (SMC) based on abundance data of planetary nebulae (PNe). The main goal is to investigate the time evolution of the oxygen abundance in this galaxy by deriving an age-metallicity relation. Such a relation is of fundamental importance as an observational constraint of chemical evolution models of the SMC. We have used high quality PNe data in order to derive the properties of the progenitor stars, so that the stellar ages could be estimated. We collected a large number of measured spectral fluxes for each nebula, and derived accurate physical parameters and nebular abundances. New spectral data for a sample of SMC PNe obtained between 1999 and 2002 are also presented. These data are used together with data available in the literature to improve the accuracy of the fluxes for each spectral line. We obtained accurate chemical abundances for PNe in the Small Magellanic Cloud, which can be useful as tools in the study of the chemical evolution of this galaxy and of Local Group galaxies. We present the resulting oxygen versus age diagram and a similar relation involving the [Fe/H] metallicity based on a correlation with stellar data. We discuss the implications of the derived age-metallicity relation for the SMC formation, in particular by suggesting a star formation burst in the last 2-3 Gyr.Comment: 11 pages, 6 figures, accepted for publication in Astronomy and Astrophysic

Preferences and skills of Indian public sector teachers

With a sample of 700 future public sector primary teachers in India, a Discrete Choice Experiment is used to measure job preferences, particularly regarding location. General skills are also tested. Urban origin teachers and women are more averse to remote locations than rural origin teachers and men respectively. Women would require a 26-73 percent increase in salary for moving to a remote location. The results suggest that existing caste and gender quotas can be detrimental for hiring skilled teachers willing to work in remote locations. The most preferred location is home, which supports decentralised hiring, although this could compromise skills

Delivering reform in English healthcare: an ideational perspective

A variety of perspectives has been put forward to understand reform across healthcare systems. Recently, some have called for these perspectives to give greater recognition to the role of ideational processes. The purpose of this article is to present an ideational approach to understanding the delivery of healthcare reform. It draws on a case of English healthcare reform – the Next Stage Review led by Lord Darzi – to show how the delivery of its reform proposals was associated with four ideational frames. These frames built on the idea of “progress” in responding to existing problems; the idea of “prevailing policy” in forming part of a bricolage of ideas within institutional contexts; the idea of “prescription” as top-down structural change at odds with local contexts; and the idea of “professional disputes” in challenging the notion of clinical engagement across professional groups. The article discusses the implications of these ideas in furthering our understanding of policy change, conflict and continuity across healthcare settings