Many hospitals face a daily struggle to manage capacity, especially where wards contain patients with a combination of health and social care needs. In this study, Soft Systems Methodology was used to understand the process of discharging patients from an acute hospital and to answer the question 'Why do patients with complex needs often spend longer on the wards than is necessary?'. Through a series of twenty structured interviews, several problems with the discharge planning process were identified. Problems included ineffective communication, slow processing of paperwork, limited forward planning, no clear ownership of the process and delays in finding care in the community. The persistence of these problems despite longstanding guidance on discharge planning can be understood by recognising the tension between two different philosophies in hospitals -a traditional 'Care' mindset focusing on the immediate needs of patients on the wards, and a planning-focused 'Flow' mentality, where the hospital's responsibility to the wider community dominates. Soft Systems Methodology was found to be an effective approach for discussing discharge planning and highlighting this tension. Based on the insights gained from the interviews, three practical initiatives have now been implemented to reconcile the tension and thereby reduce delays in the hospital.
Major depressive disorder (MDD) is a globally prevalent chronic psychiatric illness with a significant disease impact. As many as 30% of patients with MDD do not adequately respond to two therapies and are considered to be treatment resistant. This study aimed to quantify healthcare costs associated with treatment resistant depression (TRD) in the United Kingdom (UK). Methods A retrospective chart review of patients with TRD was conducted in primary and secondary care settings over a two-year period. Data abstracted from medical records of patients included demographics, clinical characteristics, and healthcare resource utilization (HCRU; number of consultations, use of Crisis Resolution and Home Treatment Teams (CRHTT), nondrug and drug interventions, and hospitalizations). HCRU per patient per month (28 days) was calculated for three health states: Major Depressive Episode (MDE), remission and recovery. Unit costs were from the British National Formulary (BNF) and the Personal Social Services Research Unit (PSSRU). Results A total of 295 patients with TRD were recruited between January 2016 and May 2018. The mean age of the total sample was 43.3 years; 60.3% were female. Costs per patient, per 28 days, were highest in the MDE state, with the average cost (£992) mainly driven by consultations, non-drug treatment, hospitalisations, and CRHTT, with a considerable fall in costs as patients moved into remission and subsequent recovery. A c c e p t e d M a n u s c r i p t Conclusion The results suggest that antidepressant treatments for TRD that are more effective in reducing the time spent in an MDE health state, and helping patients achieve remission and recovery, are essential for reducing the overall HCRU and costs in patients with TRD.
Improving treatment continuity and adherence to antipsychotic therapy in schizophrenia is a major challenge. The 3-monthly long-acting therapy of paliperidone palmitate (PP3M) has the longest dosing interval available compared to other antipsychotics whilst having the same active ingredient, as the existing 1-monthly long-acting therapy (PP1M). This study assessed the cost-effectiveness of PP3M versus PP1M in patients with schizophrenia in the UK. MethOds: A Markov model with monthly cycles encompassed a first treatment line (PP3M or PP1M) followed by a period off-treatment, and then a follow-up therapy (a mix of treatments reflecting UK practice). At each cycle, patients could either remain in stable disease, experience a relapse, experience temporary or permanent adverse events, or die. Relapse and adverse event rates were based on a non-inferiority head-to-head trial and were set equal in both arms; first line treatment discontinuation of PP1M was based on UK real-world evidence and assumed equivalent for PP3M. Accounting for differences in drug exposure length between PP1M and PP3M, a time-dependent relapse rate was applied during the period off-treatment. The benefits of a reduced administration frequency were reflected in the stable state utility for PP3M by applying an increment to the PP1M baseline utility. The perspective of the UK National Health Service was adopted throughout a two-year time horizon. Costs and effects were discounted at an annual rate of 3.5%. Results: PP3M is dominant compared to PP1M, showing cost savings (£ -638) and an increase in QALYs (+0.069). Cost savings were driven by reductions in relapse and administration costs for PP3M, whilst QALY gains were derived from the reduced administration frequency. Results robustness was demonstrated via sensitivity and scenario analyses. cOnclusiOns: The introduction of PP3M to the UK setting constitutes an improvement, bringing savings and QoL benefits to the current LAI-based standard of care for schizophrenia patients.
AimsTo assess the incidence and treatments currently used in clinical practice for the treatment of treatment-resistant depression (TRD) in Scotland.BackgroundPatients with major depressive disorder (MDD) who have not responded to at least two successive antidepressant (AD) treatments in a single episode are described as having Treatment-Resistant Depression (TRD). Epidemiological data on TRD in Scotland is lacking. Furthermore, there is no data to our knowledge on therapies prescribed in Scottish clinical practice to treat TRD.MethodA retrospective, longitudinal cohort study was conducted using Clinical Practice Research Datalink (CPRD) medical records. Adult patients were indexed on AD prescription, requiring MDD diagnosis within 90 days, from Jan 2011-May 2018 with 360-day baseline and 180-day minimum follow-up periods. Failure of ≥2 adequate oral AD regimens following indexing constituted TRD classification. Incidence rates of MDD and TRD (within the MDD cohort) and treatment lines following TRD classification were derived.ResultThe analysis included 20,059 patients with MDD (mean age 44 years, 63% female, median follow-up 59 months); 1,374 (6.8%) were classified as TRD. Median time-to-TRD classification was 25 months. The incidence rate of MDD was 15.9 per 1,000 patient-years and for TRD was 14.7 per 1,000 MDD-patient-years. For all first four post-TRD treatment lines, SSRI monotherapy was the most commonly prescribed therapy, followed by combination (dual/triple) therapy and augmentation therapy (at least one oral AD supplemented with lithium, an antipsychotic or an anticonvulsant therapy). At first-line of TRD treatment, 1,050 (76.4%) patients received monotherapy AD, 212 (15.4%) received combination AD therapy and 112 (8.2%) received augmentation therapy. The most common monotherapy treatments at first-line TRD were sertraline (15.6%), mirtazapine (13.8%), fluoxetine (12.2%) and venlafaxine (11.6%). Among combination therapies, mirtazapine, venlafaxine, sertraline and amitriptyline were frequently used. Among the TRD and MDD cohort, no somatic treatments were coded in CPRD, although the use of these treatments was likely underestimated.ConclusionMonotherapy AD treatment was the most common therapy type for all four post-TRD treatment lines. These data support the need for new treatments that can achieve and maintain therapeutic response, and avoid continuous cycling through similar AD therapies.This study was sponsored by Janssen Cilag Ltd.
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