Extending the liaison psychiatry service in a large hospital in the UK: a before and after evaluation of the economic impact and patient care following ED attendances for self-harm

Abstract

ObjectivesTo evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm.DesignRetrospective before and after cohort study using routinely collected Self-Harm Surveillance Register data.SettingA large hospital in South West England.SubjectsPatients attending the ED for self-harm.InterventionsExtension of the LPS’ working hours from 9:00 to 17:00, Monday to Friday to 8:00 to 22:00, 7 days a week, following a £250 000 annual investmentMain outcome measuresNumber and characteristics of ED attendances for self-harm. The before and after cohorts were compared in terms of key process measures, including proportion of patients receiving a psychosocial assessment, average length of hospital stay, waiting times for assessment, proportion of patients who self-discharged without an assessment, levels of repeat self-harm attendances and mean cost per patient attendance.Results298 patients attended ED for self-harm on 373 occasions between January and March 2014, and 318 patients attended on 381 occasions between January and March 2015. The proportion of ED attendances where patients received a psychosocial assessment increased from 57% to 68% (p=0.003), median waiting time decreased by 3 hours and 14 min (p=0.017), and the proportion of episodes where patients self-discharged without a psychosocial assessment decreased from 20% to 13% (p=0.022). The mean cost per patient attendance was marginally lower after the intervention (−£84; 95% CI −£254 to £77).ConclusionsThe extended LPS seems to have had a favourable effect on the management and outcomes of self-harm patients. The cost of extending the LPS’ working hours might be partially offset by more efficient assessment and discharge. The impact of the extended LPS on the care of hospitalised patients with mental health problems other than self-harm requires further evaluation.

Long-term impact of the expansion of a hospital liaison psychiatry service on patient care and costs following emergency department attendances for self-harm

“…Comparison with other studies UK clinical guidelines recommend psychosocial assessment for all patients presenting with self-harm. 13 The findings of this evaluation suggest that the short-term decrease in median waiting time from arrival in emergency department to psychosocial assessment identified by Opmeer et al 18 has persisted longer term, with a median 2 h reduction in waiting times. Short-term increases in referrals to the crisis or other community teams also appear to have continued, with an overall increase in referrals made to other agencies identified long term.…”

“…In contrast, evidence for a reduction in the number of episodes self-discharging without an assessment was less clear than in the initial evaluation. 18 There was an indication of an increase in the number of episodes that received a psychosocial assessment, however, this finding was also less clear than in the initial evaluation. Neither evaluation identified an effect on the number of patients with repeat self-harm attendances or median time to first repeat following the investment.…”

“…The methods used in the current study not only enabled the evaluation of the effects of the intervention over a longer, 3-year period of time than the previous evaluation by Opmeer et al, 18 but was also able to account for secular and seasonal trends. In addition, in the absence of randomised controls, the Bayesian structural time series method enabled the construction of a synthetic control to act as a comparison with the observed data.…”

The effect of a hospital liaison psychiatry service on inpatient lengths of stay: interrupted time series analysis using routinely collected NHS hospital episode statistics

“…There were however important weaknesses in the original evaluation, which was based upon a before-andafter design using short evaluation epochs; case-by-case matching led to small numbers in the comparison groups; confounding by indication remained a possibility, and there was little contextual information to aid interpretation of the findings. Further evaluations of liaison services in Sheffield [10] Bristol [11], Newcastle [12] and London Hospitals [13] have also suggested savings, and although the methods of evaluation have varied they have all involved comparisons of retrospective data in the year before and after service introduction.…”

Liaison psychiatry—measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol

“…There were however substantial problems with that evaluation: it reported only on the first 9 months of delivery of a new service; it used a simple before and after design; it compared outcomes between referred and a matched group of non-referred patients in only 79 cases with minimal matching that cannot have dealt with indication bias and much of the benefit was attributed to the so-called indirect liaison cases who were in fact not seen by the service but assumed to benefit by its existence in the hospital. Other ‘RAID’-like services have also reported large savings in cost or reductions in hospital use following implementation 23 24. So a key answer to the question of why this research is needed now is the pressing need to confirm or refute the very striking claims made for similar services, but using larger numbers and more robust research methods.…”