From Loon Lake to Chuckanut Creek: The Rise and Fall of Environmental Values in Washington\u27s Water Resources Act

The year 2021 marks the 50th anniversary of the Water Resources Act of 1971, Washington’s program to protect instream flows in state rivers. Implementation has been controversial and, even a half century later, incomplete. Part 1 introduces the Act. Part 2 examines its legislative history, and administrative development by the Department of Ecology. The Act innovated water allocation, putting instream flows and public uses of rivers on par with out-of-stream water rights. But river protection labors under serious limitations, chief among them the subordination of instream flows to pre-existing water rights. And, although only half of Washington’s watersheds are protected under the Act, the program has ground to a halt. Part 3 examines twelve lawsuits that interpreted or relied on the Act, and the role of the courts in both endorsing and eroding the Act’s provisions. Part 4 concludes with recommendations for new water resources policy legislation. Absent affirmative steps by the state Legislature, Washington’s rivers are unprepared for the adverse impacts of the climate crisis

Climate Change and the Columbia River Treaty

The year 2014 is a key date for the potential re-negotiation of the Columbia River Treaty between the United States and Canada. The Treaty coordinates hydropower operations at 14 mainstem and multiple tributary dams, with the dual goals of maximizing flood control and electrical power generation. In 2024, either party may terminate, with ten years’ notice to the other. Regardless of termination, a key Treaty provision will change, requiring the United States to maximize use of its reservoirs before asking Canada to do the same, leading to deeper drawdowns in Grand Coulee’s Lake Roosevelt and other major reservoirs and potential water shortages for agriculture, hydropower generation, and instream flows for endangered salmon. Native American Tribes, First Nations, and British Columbia residents view Treaty amendment as a means to redress uncompensated historic losses associated with massive hydroelectric development of the watershed. Compounding these issues, global warming will substantially alter Columbia River hydrology, as melting glaciers and reduced snowpack exacerbate winter-spring floods and reduced instream flows and water quality degradation during summer. The United States and Canada should renegotiate a new Columbia River Treaty, recognizing the sovereign rights and interests of Tribes and First Nations. The new treaty must focus on addressing the hydrologic changes caused by global warming and achieving much needed river restoration

When Water Isn\u27t Wet: The Evolution of Water Right Mitigation in Washington State

What is water right mitigation? The allocation of surface and ground water resources for out of stream uses via the western water rights doctrine of prior appropriation comes with serious environmental consequences – depletion of streamflow and aquifers. Over-appropriation by water rights has led to deleterious impacts on natural resources, including salmon survival, water quality, and public uses of state waterways. Because of the over-appropriated condition of Washington’s rivers and aquifers, the issuance of new water rights has until recently required water-for-water or in-kind mitigation, with the goal to directly compensate for deleterious impacts. Historically, the Water Resources Program of the Department of Ecology has defined this mitigation as “replacing the amount of water being used with an equal amount of water, bucket for bucket.

Cost-effectiveness of peer-supported self-management for people discharged from a mental health crisis team: methodological challenges and recommendations

Background Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution. Methods Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively. Results Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained. Discussion There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes

Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study

Background People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. Methods We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. Findings We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47–2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10–8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5–49·9, p<0·0001), and medication reviews (2·23, 1·68–2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41–26·9, p=0·0156) and secondary care referrals (1·47, 1·05–2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09–6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03–3·65, p=0·0390), and obesity (2·49, 1·76–3·53, p<0·0001). Interpretation Targeted annual health checks for people with ID in primary care could reduce health inequities

Cost-effectiveness of peer-supported self-management for people discharged from a mental health crisis team: methodological challenges and recommendations

BackgroundMental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution.MethodsParticipants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively.ResultsFour hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained.DiscussionThere was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes

Evaluating the clinical and cost effectiveness of a behaviour change intervention for lowering cardiovascular disease risk for people with severe mental illnesses in primary care (PRIMROSE study):study protocol for a cluster randomised controlled trial

BACKGROUND: People with severe mental illnesses die up to 20 years earlier than the general population, with cardiovascular disease being the leading cause of death. National guidelines recommend that the physical care of people with severe mental illnesses should be the responsibility of primary care; however, little is known about effective interventions to lower cardiovascular disease risk in this population and setting. Following extensive peer review, funding was secured from the United Kingdom National Institute for Health Research (NIHR) to deliver the proposed study. The aim of the trial is to test the effectiveness of a behavioural intervention to lower cardiovascular disease risk in people with severe mental illnesses in United Kingdom General Practices. METHODS/DESIGN: The study is a cluster randomised controlled trial in 70 GP practices for people with severe mental illnesses, aged 30 to 75 years old, with elevated cardiovascular disease risk factors. The trial will compare the effectiveness of a behavioural intervention designed to lower cardiovascular disease risk and delivered by a practice nurse or healthcare assistant, with standard care offered in General Practice. A total of 350 people will be recruited and followed up at 6 and 12 months. The primary outcome is total cholesterol level at the 12-month follow-up and secondary outcomes include blood pressure, body mass index, waist circumference, smoking status, quality of life, adherence to treatments and services and behavioural measures for diet, physical activity and alcohol use. An economic evaluation will be carried out to determine the cost effectiveness of the intervention compared with standard care. DISCUSSION: The results of this pragmatic trial will provide evidence on the clinical and cost effectiveness of the intervention on lowering total cholesterol and addressing multiple cardiovascular disease risk factors in people with severe mental illnesses in GP Practices. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13762819 . Date of Registration: 25 February 2013. Date and Version Number: 27 August 2014 Version 5

Randomised controlled trial of the clinical and cost-effectiveness of a peer delivered self-management intervention to prevent relapse in crisis resolution team users: study protocol

Introduction: Crisis resolution teams (CRTs) provide assessment and intensive home treatment in a crisis, aiming to offer an alternative for people who would otherwise require a psychiatric inpatient admission. They are available in most areas in England. Despite some evidence for their clinical and cost-effectiveness, recurrent concerns are expressed regarding discontinuity with other services and lack of focus on preventing future relapse and readmission to acute care. Currently evidence on how to prevent readmissions to acute care is limited. Self management interventions, involving supporting service users in recognising and managing signs of their own illness and in actively planning their recovery, have some supporting evidence, but have not been tested as a means of preventing readmission to acute care in people leaving community crisis care. We thus proposed the current study to test the effectiveness of such an intervention. We selected peer support workers as the preferred staff to deliver such an intervention, as they are well-placed to model and encourage active and autonomous recovery from mental health problems. Methods and analysis: The CORE (CRT Optimisation and Relapse Prevention) self management trial compares the effectiveness of a peer provided self-management intervention for people leaving CRT care, with treatment as usual supplemented by a booklet on self-management. The planned sample is 440 participants, including 40 participants in an internal pilot. The primary outcome measure is whether participants are readmitted to acute care over 1 year of follow-up following entry to the trial. Secondary outcomes include self-rated recovery at 4 and at 18 months following trial entry, measured using the Questionnaire on the Process of Recovery. Analysis will follow an intention to treatment principle. Random effects logistic regression modelling with adjustment for clustering by peer support worker will be used to test the primary hypothesis

The CORE Service Improvement Programme for mental health Crisis Resolution Teams: results from a cluster-randomised trial

Background: Crisis Resolution Teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled up CRT care. Aims: To evaluate a one-year programme to improve CRTs’ model fidelity in a non-blind, cluster randomised trial. Methods: Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence Based Practice project, involving support from a CRT Facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was service user satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by fifteen service users per team at CRT discharge (N=375). Secondary outcomes: CRT model fidelity, continuity of care, staff wellbeing, inpatient admissions and bed use and CRT readmissions were also evaluated. Results: All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (CI -1.02, 2.97) but this was not significant (p=0.34). There were fewer inpatient admissions, lower inpatient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow up. There were no significant effects for other outcomes. Conclusions: The CRT Service Improvement Programme did not achieve its primary aim of improving service user satisfaction. It showed some promise in improving CRT model fidelity and reducing acute inpatient admissions