Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness

Introduction Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients. Methods We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability. Results Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs. Conclusions The system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases

Financial incentives to improve adherence to anti-psychotic maintenance medication in non-adherent patients - a cluster randomised controlled trial (FIAT)

Background Various interventions have been tested to achieve adherence to anti-psychotic maintenance medication in non-adherent patients with psychotic disorders, and there is no consistent evidence for the effectiveness of any established intervention. The effectiveness of financial incentives in improving adherence to a range of treatments has been demonstrated; no randomised controlled trial however has tested the use of financial incentives to achieve medication adherence for patients with psychotic disorders living in the community. Methods/Design In a cluster randomised controlled trial, 34 mental health teams caring for difficult to engage patients in the community will be randomly allocated to either the intervention group, where patients will be offered a financial incentive for each anti-psychotic depot medication they receive over a 12 month period, or the control group, where all patients will receive treatment as usual. We will recruit 136 patients with psychotic disorders who use these services and who have problems adhering to antipsychotic depot medication, although all conventional methods to achieve adherence have been tried. The primary outcome will be adherence levels, and secondary outcomes are global clinical improvement, number of voluntary and involuntary hospital admissions, number of attempted and completed suicides, incidents of physical violence, number of police arrests, number of days spent in work/training/education, subjective quality of life and satisfaction with medication. We will also establish the cost effectiveness of offering financial incentives. Discussion The study aims to provide new evidence on the effectiveness and cost effectiveness of offering financial incentives to patients with psychotic disorders to adhere to antipsychotic maintenance medication. If financial incentives improve adherence and lead to better health and social outcomes, they may be recommended as one option to improve the treatment of non-adherent patients with psychotic disorders. Trial Registration Current controlled trials ISRCTN77769281

Quality improvement of physical health monitoring for people with intellectual disabilities: an integrative review

Background: Physical health needs of people with intellectual disabilities are often overlooked. Inadequate physical health skills (assessment, monitoring) of healthcare professionals working in intellectual disabilities is a barrier to equitable care. Recent reports have called for initiatives to improve training through quality improvement programmes. Aim: An integrative review was undertaken to 1) identify physical health training needs of healthcare professionals 2) identify challenges of implementing quality improvement skills training. Methods: Six electronic databases were searched (January 1990-March 2015) and included if they described the physical health assessment/monitoring skills of healthcare professionals and quality improvement programmes designed to impact the physical health of adults with intellectual disabilities. Articles were appraised using the Mixed Methods Appraisal Tool (MMAT). Results: 668 articles were identified, of which 14 were included in the review. Literature was sparse with none reporting training needs of healthcare professionals in intellectual disabilities. Identified training needs of mainstream healthcare professionals included physical assessment, communication, general and syndrome specific knowledge, and health promotion. Quality improvement studies were of limited quality, under evaluated and poorly reported. Lack of staff engagement, role confusion and sustainability were barriers to quality improvement implementation. Conclusion: Physical health skills of healthcare professionals are key to improving care for people with intellectual disabilities. However, quality improvement is poorly implemented in this area of practice. In order to better meet the needs of this group better implementation and evaluation of intellectual disabilities quality improvement programmes is required.</p

Quality improvement of physical health monitoring for people with intellectual disabilities: an integrative review

Background: Physical health needs of people with intellectual disabilities are often overlooked. Inadequate physical health skills (assessment, monitoring) of healthcare professionals working in intellectual disabilities is a barrier to equitable care. Recent reports have called for initiatives to improve training through quality improvement programmes. Aim: An integrative review was undertaken to 1) identify physical health training needs of healthcare professionals 2) identify challenges of implementing quality improvement skills training. Methods: Six electronic databases were searched (January 1990-March 2015) and included if they described the physical health assessment/monitoring skills of healthcare professionals and quality improvement programmes designed to impact the physical health of adults with intellectual disabilities. Articles were appraised using the Mixed Methods Appraisal Tool (MMAT). Results: 668 articles were identified, of which 14 were included in the review. Literature was sparse with none reporting training needs of healthcare professionals in intellectual disabilities. Identified training needs of mainstream healthcare professionals included physical assessment, communication, general and syndrome specific knowledge, and health promotion. Quality improvement studies were of limited quality, under evaluated and poorly reported. Lack of staff engagement, role confusion and sustainability were barriers to quality improvement implementation. Conclusion: Physical health skills of healthcare professionals are key to improving care for people with intellectual disabilities. However, quality improvement is poorly implemented in this area of practice. In order to better meet the needs of this group better implementation and evaluation of intellectual disabilities quality improvement programmes is required.</p

Acceptability of offering financial incentives to achieve medication adherence in patients with severe mental illness: a focus group study

BACKGROUND: Offering financial incentives to achieve medication adherence in patients with severe mental illness is controversial. AIMS: To explore the views of different stakeholders on the ethical acceptability of the practice. METHOD: Focus group study consisting of 25 groups with different stakeholders. RESULTS: Eleven themes dominated the discussions and fell into four categories: (1) ‘wider concerns’, including the value of medication, source of funding, how patients would use the money, and a presumed government agenda behind the idea; (2) ‘problems requiring clear policies’, comprising of practicalities and assurance that incentives are only one part of a tool kit; (3) ‘challenges for research and experience’, including effectiveness, the possibility of perverse incentives, and impact on the therapeutic relationship; (4) ‘inherent dilemmas’ around fairness and potential coercion. CONCLUSIONS: The use of financial incentives is likely to raise similar concerns in most stakeholders, only some of which can be addressed by empirical research and clear policies

What are the benefits of evidence-based supported employment for patients with first-episode psychosis?

AIMS AND METHOD To examine the effectiveness of integrating evidence-based supported employment into an early intervention service for young people with first-episode psychosis. Demographic, clinical and vocational data were collected over a 12-month period to evaluate the effect on vocational outcomes at 6 months and 12 months of the employment of a vocational specialist, and to assess model fidelity. RESULTS Following vocational profiling and input from the vocational specialist and the team, there were significant increases in the proportion of clients engaged in work or educational activity over the first 6 months of the intervention, and in a subsample over a second 6-month period. The evidence-based Supported Employment Fidelity Scale was used to measure the degree of implementation, which scored 71, signifying ‘good implementation’. CLINICAL IMPLICATIONS The results suggest that implementing evidence-based supported employment within an early intervention service increases employment and education opportunities for patients within the service

One-year outcome of an early intervention in psychosis service: a naturalistic evaluation

Aim: We conducted a 1-year prospective evaluation of an early intervention in psychosis service (Early Treatment and Home-based Outreach Service (ETHOS)) during its first 3 years of operation in South-west London, UK. Methods: All patients referred to ETHOS underwent structured assessments at baseline and at 1-year follow-up. In addition, hospitalization rates of ETHOS patients (intervention group) were compared with a non-randomized parallel cohort (comparison group) of first-episode patients treated by community mental health teams. Results: The Early Treatment and Home-based Outreach Service patients experienced significant improvements in symptomatic and functional outcomes, especially vocational recovery. The service received only a quarter of eligible patients from referring teams. ETHOS patients did not differ from the comparison group in number of admissions, inpatient days or detention rates. Although number of referrals increased over time, there was no evidence that patients were being referred earlier. Conclusions: There is now robust evidence for the effectiveness of specialist early intervention services. However, such services must be adequate resourced, including an early detection team and provision of their own inpatient unit