Evaluating the impact of the London Pathway Project

Background: The London Pathway Project (LPP) is an innovative whole-systems approach to addressing the needs of offenders who have severe personality disorder, with the goal of reducing their risk of harm. Previous research has evaluated the initial implementation of the LPP. Aims: This paper focused on evaluating the impact of the LPP on a number of criminogenic needs over time and its impact on the risk of reoffending and harm compared with a similar group who did not experience the pathway. Method Data for men who had been identified for the LPP were used to explore changes in key criminogenic needs an average of 11 months after commencing on the pathway. In addition, Offender Assessment System data was used to match men who had experienced the LPP for at least 12 months to a comparison group on key demographic and criminal history variables. Changes in validated risk assessment devices and changes in practitioners’ perception of risk were examined. Results: The LPP was associated with desirable within-individual change for most of the criminogenic needs explored. However, strong non-desirable changes in lifestyle and associates were also identified, but this was particularly the case for those sentenced to prison. When compared with a matched group, those identified for the pathway showed a significant reduction on an objective measure of risk of reoffending but were rated as having significantly increased risk of harm on the basis of practitioner’s perceptions. There was no evidence that greater progression along the pathway was associated with greater benefits. Conclusions: This is the first impact evaluation of the LPP, and the results were generally positive in terms of its relation to criminogenic needs and risks. Much more research that clearly links project inputs to actual behavioural outcomes, such as later reoffending, is needed

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey.

BackgroundThe COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers.ObjectiveThis study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care.MethodsA 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel.ResultsTwenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence.ConclusionsTo our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices

315 Searching for a prodrome for rheumatoid arthritis in the primary care record: a clinical practice research datalink study

Background: Outcomes in rheumatoid arthritis (RA) are improved by early treatment with disease modifying anti-rheumatic drugs (DMARD). This requires prompt recognition of symptoms when patients present to their general practitioner (GP) in order to institute a referral. However, presentation is not always classical and patients may be difficult to identify. We have investigated whether it is possible to increase the index of suspicion for early RA by defining a prodromal syndrome for RA in the electronic primary care records.Methods: We conducted a case-control study in the Clinical Practice Research Datalink (CPRD). Cases were those with definite RA diagnosed between 2007 and 2012, according to a previously published definition. Controls were matched to cases on age, gender and general practice, and did not have any record of inflammatory arthritis. For each case, an index date was created - date of the first indication that RA was suspected (read code for RA or other inflammatory arthritis, DMARD prescription, referral to rheumatology). This was used as the start of the look-back period. We compared rates of consultation in cases and controls in the six months prior to the index date and looked for a difference in the rate of two types of exposure between cases and controls: empirical exposures (3-character read codes seen in ≥ 5% of cases or controls); pre-defined exposures (compiled from literature and expert opinion and defined by a list of read codes).Results: We identified 3577 definite RA cases, matched to 14287 controls. We found a 79% (95% CI 76%, 81%) increased rate of consulting in cases (mean 19.0 consultations per year) compared to controls (10.7). As expected, in the pre-defined analyses, those with RA were more likely to have codes for joint specific symptoms (e.g. hand problems, odds ratio (OR): 44.14; 95% CI 31.80, 61.25), systemic problems (e.g. fatigue: 1.59; 1.24, 2.03) and other musculoskeletal syndromes (carpal tunnel: 8.50; 5.72, 12.62). When considering empirical exposures, those with RA were more likely to have received Read codes for joint and soft tissue disorders, but most exposures associated with RA were general codes relating to the patient having been reviewed (e.g. complaining of a general symptom: 2.53; 2.03, 3.16).Conclusion: In the six months prior to a diagnosis of RA, patients consulted their GP at a much higher rate than those without inflammatory arthritis. Symptoms previously described as being associated with the onset of RA were more common in those who went on to receive an RA diagnosis. We did not find any new presentations associated with RA from our empirical analyses. Dissemination of these results to the general practice community could help to expedite referrals to specialist services by facilitating early recognition of RA symptoms, potentially improving patient outcomes