Financial Outcome Measure

@bobbler, thank you for that information. Oh golly what a grim misuse of health data to save money. Yes this pilot study may have been picked up by the UK NHS, not sure how you would verify that but yes this mirrors the insidious creep I have observed in the health news in NZ.

Yes, it is possible frequent attendees they are describing may get referred to CL psychiatry. Whether the referral was accepted and an assessment done (it would have to be during normal working hours as CL is not an on-call acute service) is another matter. I can't speak for CL but often community psychiatrists had to give opinions on some people they described. Often there was little we could do as their symptoms were part of their medical disorder, eg anxiety with being breathless in COPD. It was actually the ambulance service wanting a management plan. CBT was not going to fix that. Often there is no psychiatric medication that could be used as it would exacerbate their medical illness. Usually we tried to get more community medical care for them and explained this to the medical team.

 

This might need to be moved as I don't know whether this later part is getting off-track from the original thread, BUT I guess it is still about resource-saving initiatives, and importantly that study with the tiny sample is the reference that puts MUS as a whole section in this next one which seems to be a national initiative.

OK this one I spotted as I saw reference to a CQUIN in the following (Exeter): Royal_Devon_and_Exeter_NHS_Foundation_Trust_Annual_Report_and_Accounts_2017-18.pdf (england.nhs.uk) it just so happened to be on p36-37 and was the section before CFS was mentioned (p37) for something else. But it caught my eye because it was about an initiative for frequent attenders.

I've looked up the CQUIN that seems to be behind this: Frequent_Attenders_in_the_ED_Aug2017.pdf (rcem.ac.uk)

this doc is from the royal college of emergency medicine.

You'll note the following on page 3:

I might be wrong and haven't read this through, or indeed the actual implementation which would be local, but could see how if eg MUS is flagged as likely cause of frequent attenders, how this could become a way in which 'MUS' (rather than the frequency banging them over the head) became something people looked up and then were on the lookout for.

Page 6 is worth scrolling to as it is all about MUS and psychological therapies:

The reference under this page is actually the west middlesex example: http://www.rcpsych.ac.uk/pdf/The West Middlesex Frequent attendersprogramme.pdf
http://www.wlmht.nhs.uk/uncategorized/ae-programme-reduces-unnecessary-attendances/

To be fair a lot of the references when clicked through on don't seem to mention MUS. However the last 2 were on CBT for hypochondriasis and MUS

Cognitive Behavior Therapy for Hypochondriasis: A Randomized Controlled Trial | Psychiatry and Behavioral Health | JAMA | JAMA Network

Cognitive-behavior therapy for medically unexplained symptoms: A critical review of the treatment literature - ScienceDirect

 

@hibiscuswahine oh OK here is another one. Better safe than sorry? Frequent attendance in a hospital emergency department: an exploratory study - PMC (nih.gov)

And I've put it here because in the middle of the paper there is actually a business case built out based on 2 frequent attenders (who both had long term conditions and were diagnosed as having anxiety 'playing a big part' and given plans involved psych therapy) suggesting a saving of £13,300 from such intervention.

The other thing to note is that the lead author Jo Daniels is quite well know in the CFS world (thread here: Jo Daniels (on CBT, ME/CFS and Long Covid) | Science for ME (s4me.info)), is based at Bath and was on the ME/CFS guideline committee. She has produced things like: Health anxiety in Chronic Fatigue Syndrome - Health Research Authority (hra.nhs.uk)

This paper has some very strange methodology. It is very much selling based on claims of a business case. Except this business case is now only based on 2 patients, who have MUS. It is in Table 1. And if look at it in the pdf version is on page 5.

But its method is firstly using business data to find the 50 most frequent attenders..... but then 'a psychologist seeking out themes across their case notes to look for homogeinities' rather than looking eg by condition or dept. then it just went into A&E one day and interviewed 25 people. Telling them it would be put verbatim in their notes. And used that survey as the basis for some of the questions. So not people who were identified as frequent attenders?

It seems to hop around and cherry-pick why certain groups were picked in such a strange fashion I can only think there was 'fishing' for things like MUS they felt 'their offering would sell for' and then searching both of these methods for a % they could cite and crowbar in.

It includes gems like:

and in the recommendations:

and

I think it is worth fishing this out given a problem with many of these questionnaires is inclusion of symptoms that would be standard in ME, like exhaustion as a symptom and not differentiating this could be due to the ME/CFS etc.

 

This might be relevant to have its own or another thread (but it relates to the articles above) and I think if I haven't posted this before, even though I drafted a post ages ago when I found it, it was because I didn't quite know what to call the thread,

but this is relevant to the initiatives/pushing of claims regarding 'MUS' and functional being some huge % causing issues. And the type of 'research' and initiative push and the source of it that perhaps is meaning there is, or has been, some active push to 'fish out functional' - to me this seems to be one of the source papers behind this 'idea' that MUS or functional people needed lots of initiative-based research doing on it.

Anyway when I was going through this paper (as it was cited in relation to the CQuin used by DEvon and Exeter): Frequent_Attenders_in_the_ED_Aug2017.pdf (rcem.ac.uk)

I found the following interesting:

I found it interesting because I think it was the only paper I found that actually made any claim that frequent attenders really included people with MUS, nevermind any such high %.

And then I looked up this reference vi and it is from the Royal College of Physicians: Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design - PMC (nih.gov)

PS the link in the reference section where it was vi never worked I just cut-pasted the full description to find it. It is from 2016. Not that 'frequent attenders in the ED 2017' as described in one of the posts above, is something heavily referenced as the reason for the introduction of 'CQUIN' intitiatives.

This is the abstract (my bolding), I think it deserves a page of its own. It 'developed personas' which is particularly disturbing (I'm familiar with them as a tool used in marketing/advertising so you know immediately 'who the type is' and it is very 'sticky' as a tool to get such people fished out), as is the methodology. It's done by Cambridge hospitals and other orgs and seems to all have been done on retrospective data from 2003, yet somehow managing to be able to decide who those people are from paperwork from 13yrs ago.

MUS weren't 'extreme frequent attenders' so the focus as seems to be common for these papers is a switch-and-bait between identifying who is the demographic underlying the problem and then talking about 'MUS' as if it is that.

 

There's a BBC story online today with the headline, "NHS billions wasted as bipolar patients left 'forgotten and failed'", but I'd agree that this seems rare. I wonder who put the press release out that led to the story. It seems to have come from "experts" who "have told the BBC" stuff.

 

But if it is anything like UK purchasers it will use something like quality adjusted life years, which, as I understand it, are a measure of benefit to the individual. Costs of carers may come in but I doubt it includes value of the person to society as a worker.

If it did you would then discriminate against not only treatments most often used on retirees and women likely to be on maternity leave but, most egregiously, all children. I guess you could try and calculate the loss to society if a child ended up disabled but I have never heard of any purchasing authority doing that.

 

Do you even have to measure the economic impact to argue for grants?

Could it be sufficient to just say that the DALY is high, so we should probably try and help these people? Maybe compare to other diseases?

If anyone cares about the numbers they would think ‘Huh, that’s a lot of people that are sick. That has to be expensive!’

After all, most political and bureaucratic decision making on spending is quite inconsistent and based on personal opinions. Only economists assume that we act perfectly rationally with perfect information.

 

I doubt it. I never came across that sort of analysis for anti-Il-6 for children with juvenile chronic arthritis. It would be far too complicated. Curing acute lymphoblastic leukaemia prolongs life but I doubt any of these calculations take into account future periods of disability. It is all much too difficult to ascertain. Apart from anything trials provide no data and it is trial data that purchasers use - I have seen them present it back to me in that form.

For women on maternity leave if the question is not whether they are in work then loss of earnings is not coming into it, as I indicated. If loss of earnings comes into it there is discrimination, surely. For retirees a consideration of whether there is impact on work would again downgrade the value, since there would be no loss of income.

I am pretty sure all these calculations are based on trial data and there simply aren't any trial data taking into account these sort of long term employment factors. I don't think they take into account 'cost to society' in employment terms at all. Those figures come from other non-interventional studies.