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

Abstract

Background In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown. Aims To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm. Method Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment. Results Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) −30.2% to −2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI −3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI −11.6% to 25.5%). Conclusions Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

“…Indeed, a recent evaluation found that the introduction of the clinical programme was associated with a significant increase in referral, particularly in hospitals that had limited pre-existing resources for caring for those presenting with self-harm. Consistent with this, the availability of dedicated staff has been shown to be associated with improved care for self-harm in an ED in the UK [27]. Central components of the clinical programme include the provision of a biopsychosocial assessment and appropriate follow-up and referral to secondary mental healthcare, as well aspects it was not possible to capture in this study including the provision of an emergency care plan, collaboration with next of kin, and the provision of a 24hr phone call.…”

PReCePT Devolved Nations Evaluation Report

“…The difference between the observed and counterfactually expected trends in the post-NPP period can be interpreted as the causal impact of the intervention. This method can reduce bias in natural experiment studies where there is no randomization of exposure [11][12][13] Data and assumptions used for the economic evaluation of the NPP are described in the following sections.…”

Study designs and outcomes used in evaluation studies of hospital-presenting self-harm: protocol for a methodological systematic review

“…Studies employing these designs have primarily utilised hospital records and data recorded via self-harm registries. [13][14][15][16][17][18][19] However, a systematic review that examined aspects of routine clinical care following self-harm (eg, hospital admission or specialist follow-up) found little evidence for their role in reducing repeat self-harm and suicide, 20 despite evidence from individual studies being used to inform several guidance. 21 22 The reasons for a lack of evidence from observational studies may reflect the size and representativeness of the samples used, the quality of study design, as well as the consistency, quality and range of outcomes used.…”