Setting the boundaries for economic evaluation : Investigating time horizon and family effects in the case of postnatal depression

Objectives This study investigates the impact of varying the boundaries of economic evaluation: time horizon and inclusion of family effects. The context is postnatal mental health, where although advocates for investment often include longer-term and family problems in describing the burden of postnatal depression, economic evaluations are usually limited to mothers’ effects with a relatively short time horizon. This discrepancy may lead to suboptimal allocation of healthcare resources. Methods The question of whether such boundary extensions could make a difference to decision-making is explored using decision analytic models, populated with data from the literature, to estimate the cost-effectiveness of a hypothetical preventive intervention under alternate boundary-setting approaches. Results The results suggest that broader boundaries, particularly extension of the time horizon, could make substantial differences to estimated cost-effectiveness. Inclusion of family effects without extension of the time horizon had little impact, but where a longer time horizon was used, family effects could make a significant difference to the conclusions drawn from cost-effectiveness analysis. Conclusions Considerations in applying broader boundaries include the substantial resource requirements for evaluation, potential equity implications, relevance to decision-makers, methods for inclusion, and the interpretation and use of such results in decision-making. However, this context underscores the importance of considering not only caregiving but also family health effects, and illustrates the need for consistency between the arguments presented to decision-makers and the analytical approach taken in economic evaluation

Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness

A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare

The association between primary care quality and healthcare utilisation, costs and outcomes for people with serious mental illness: retrospective observational study

Background Serious mental illness (SMI), including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with SMI are treated in primary care by general practitioners (GPs), who are financially incentivised to meet quality targets for patients with chronic conditions, including SMI, under the Quality and Outcomes Framework (QOF). The QOF, however, omits important aspects of quality. Objective(s) We examined whether better quality of primary care for people with SMI improved a range of outcomes. Design and setting We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, Accident & Emergency (A&E) attendances, Office for National Statistics mortality data, and community mental health records in the Mental Health Minimum Dataset. We used survival analysis to estimate whether selected quality indicators affect the time until patients experience an outcome. Participants Four cohorts of people with SMI depending on the outcomes examined and inclusion criteria. Interventions Quality of care was measured with: i) QOF indicators: care plans and annual physical reviews ;and ii) non-QOF indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by GPs). Main outcome measures Several outcomes were examined: emergency admissions for i) SMI and ii) ambulatory care sensitive conditions (ACSCs); iii) all unplanned admissions; iv) A&E attendances; v) mortality; vi) re-entry into specialist mental health services; vii) costs attributed to primary, secondary and community mental healthcare. Results Care plans were associated with lower risk of A&E attendance (Hazard ratio (HR) 0.74, 95%CI 0.69-0.80), SMI admission (HR 0.67, 95%CI 0.59-0.75), ACSC admission (HR 0.73, 95%CI 0.64-0.83), and lower overall healthcare (£53), primary care (£9), hospital (£26), and mental healthcare costs (£12). Annual reviews were associated with reduced risk of A&E attendance (HR 0.80, 95%CI 0.76-0.85), SMI admission (HR 0.75, 95%CI 0.67-0.84), ACSC admission (HR 0.76, 95%CI 0.67-0.87), and lower overall healthcare (£34), primary care (£9), and mental healthcare costs (£30). Higher GP continuity was associated with lower risk of A&E presentation (HR 0.89, 95%CI 0.83-0.97), ACSC admission (HR 0.77, 95%CI 0.65-0.92), but not SMI admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or A&E presentation. None of the quality measures were statistically significantly associated with risk of re-entry into specialist mental healthcare. Limitations There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences. Conclusions Better performance on QOF measures and continuity of care are associated with better outcomes and lower resource utilisation and could generate moderate cost savings. Future work Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning

Improving diabetes outcomes for people with severe mental illness : a longitudinal observational and qualitative study in England

Background: people with severe mental illness experience poorer health outcomes than the general population. Diabetes contributes significantly to this health gap.Objectives: the objectives were to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with severe mental illness.Design: under a social inequalities framework, a concurrent mixed-methods design combined analysis of linked primary care records with qualitative interviews.Setting: the quantitative study was carried out in general practices in England (2000–16). The qualitative study was a community study (undertaken in the North West and in Yorkshire and the Humber).Participants: the quantitative study used the longitudinal health records of 32,781 people with severe mental illness (a subset of 3448 people had diabetes) and 9551 ‘controls’ (with diabetes but no severe mental illness), matched on age, sex and practice, from the Clinical Practice Research Datalink (GOLD version). The qualitative study participants comprised 39 adults with diabetes and severe mental illness, nine family members and 30 health-care staff.Data sources: the Clinical Practice Research Datalink (GOLD) individual patient data were linked to Hospital Episode Statistics, Office for National Statistics mortality data and the Index of Multiple Deprivation.Results: people with severe mental illness were more likely to have diabetes if they were taking atypical antipsychotics, were living in areas of social deprivation, or were of Asian or black ethnicity. A substantial minority developed diabetes prior to severe mental illness. Compared with people with diabetes alone, people with both severe mental illness and diabetes received more frequent physical checks, maintained tighter glycaemic and blood pressure control, and had fewer recorded physical comorbidities and elective admissions, on average. However, they had more emergency admissions (incidence rate ratio 1.14, 95% confidence interval 0.96 to 1.36) and a significantly higher risk of all-cause mortality than people with diabetes but no severe mental illness (hazard ratio 1.89, 95% confidence interval 1.59 to 2.26). These paradoxical results may be explained by other findings. For example, people with severe mental illness and diabetes were more likely to live in socially deprived areas, which is associated with reduced frequency of health checks, poorer health outcomes and higher mortality risk. In interviews, participants frequently described prioritising their mental illness over their diabetes (e.g. tolerating antipsychotic side effects, despite awareness of harmful impacts on diabetes control) and feeling overwhelmed by competing treatment demands from multiple morbidities. Both service users and practitioners acknowledged misattributing physical symptoms to poor mental health (‘diagnostic overshadowing’).Limitations: data may not be nationally representative for all relevant covariates, and the completeness of recording varied across practices.Conclusions: people with severe mental illness and diabetes experience poorer health outcomes than, and deficiencies in some aspects of health care compared with, people with diabetes alone.Future work: these findings can inform the development of targeted interventions aimed at addressing inequalities in this population.Study registration: National Institute for Health Research (NIHR) Central Portfolio Management System (37024); and ClinicalTrials.gov NCT03534921.Funding: this project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.<br/

Efficiency and equity in perinatal mental health

This research investigates different ways to improve the care provided to pregnant women and new mothers with mental health problems. First, it suggests how to help more women to choose treatment that works. Second, it tests whether a particular programme for new parents would be value for money. Third, it proposes that important costs and outcomes are usually missing from this type of research, and that including them could change funding decisions. Lastly, it highlights the bigger mental health burden faced by poorer mothers, and how this might contribute to a lifetime of disadvantage for their children

Improving primary to secondary school transitions: A systematic review of school-based interventions to prepare and support student social-emotional and educational outcomes

The transition from primary to secondary school is characterised by multiple substantial changes in children's physical, organisational, social, and pedagogical environments. Adjusting to these changes can be difficult, and problems doing so can have serious and wide-ranging long-term consequences. Currently it is not clear for educators, policy makers and researchers which programs and practices to prepare and support students are most efficacious, feasible to deliver, and suitable for different student populations. This review systematically identified and evaluated published experimental and quasi-experimental studies of school-based interventions to improve student social-emotional (i.e., peer-relationships, self-concept, mental health) and educational (i.e., school engagement, academic achievement) outcomes following primary-secondary transition. Searches were conducted across five bibliographic databases (ERIC, ERC, PsycINFO, CINAHL and Web of Science Core Collections), several program databases and research registers, in February 2022. A total of 26 studies met inclusion criteria. Overall, the review found most interventions had positive effects on at least one relevant transition adjustment outcome. However, there is a need for replication across different educational contexts, consistent measurement of outcomes, and use of more rigorous evaluation methods. The evidence presented in this review will inform decisions about the design or selection, implementation and further evaluation of primary-secondary transition interventions. In turn, this should lead to better social-emotional and educational outcomes for students, and may reduce some of the inequities exacerbated by a difficult transition to secondary school