Talking to parents about talking to their children about parental mental distress

Non peer reviewedFinal Accepted Versio

Models of care for the delivery of secondary fracture prevention after hip fracture:a health service cost, clinical outcomes and cost-effectiveness study within a region of England.

Background Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals. Objectives To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes. Design A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care. Setting Eleven acute hospitals in a region of England. Participants Qualitative study – 43 health professionals working in fracture prevention services in secondary care. Interventions Changes made to secondary fracture prevention services at each hospital between 2003 and 2012. Main outcome measures The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture. Data sources Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13, n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013, n = 11,243). Results Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician. Conclusion In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered. Future work Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients. Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford

An investigation of the interaction between schizotypy and cognitive monitoring processes

The concept of 'theory of mind' (or mentalising ability) refers to the capacity to attribute mental states to others in order to explain what they did, or predict what they will do. The role of theory of mind has been extensively researched in relation to autism and is thought to explain some of the social and communication abnormalities that are present in the disorder. C. Frith (1992) broadened the definition of mentalising to include the ability to represent one's own as well as others actions, and suggested that all of the commonly observed symptoms of schizophrenia could be understood as a result of a breakdown in the person's capacity to mentalise. The research presented in this thesis aimed to assess Frith's theory by comparing individuals who were found to be high and low in schizotypy. It was hypothesised that individuals who demonstrated high scores on measures of schizotypy would show poorer ability to generate willed action, and to monitor their own, and others mental states. Mentalising abilities were assessed using four tasks: in the triangles task participants watched a series of computerised animations involving two shapes which engaged in increasingly complex sequences of interaction. Participants were asked to describe what they thought was taking place and their descriptions were used to assess their ability to employ theory of mind in relation to others. Participants then completed the me-pulse; a novel task which involved a variant on the prepulse inhibition paradigm; the Hayling test, and a go/No go task. The results broadly supported Frith's theory. On the triangles task, the high schizotypes imputed 'theory of mind' significantly more than low schizotypes when the shapes were moving randomly. On the Hayling test high schizotypy participants took significantly longer to complete both parts of the test than the low schizotypes. On the go/No go task, the high schizotypy group made significantly more false alarms, indicating deficits in their ability to set shift and inhibit their responses. On the me-pulse task the low schizotypy participants showed a decrease in magnitude of response when the startling stimulus was self-initiated, in contrast the high schizotypy participants actually showed increased response amplitude in response to self-generated stimuli. Taken together, these results indicated support for the hypothesis that high schizotypes showed deficits in their ability to generate willed action, and to monitor the mental states of both others and themselves. The marked difference in the pattern of results between the two groups of participants provides further support for the concept of schizotypy. The fact that these anomalies in mentalising ability are seen in a non psychiatric population indicated some support for the idea of mentalising defects as a trait marker for psychosis, rather than simply a manifestation of the psychotic state