Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study) 2024 Sharpe+

Summary

Background
Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult.

We aimed to assess the effects of enhancing older inpatients’ care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital.

Methods
We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment.

PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients’ problems, then delivered discharge-focused care as integrated members of ward teams.

The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient's experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life.

Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296).

Findings
2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants’ mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White.

The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference –0·45 (95% CI –1·11 to 0·21; p=0·18).

The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP—a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred.

Interpretation
This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation.

Open access, https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00188-3/fulltext

 

Posting mostly because the corresponding author is our 'mate' Michael Sharpe.

 

Home study thread here
The HOME study - Michael Sharpe s CBT for the elderly | Science for ME (s4me.info)

 

No control group other than "usual care"
Given loneliness is a huge issue for the elderly, a befriending project as a comparison with hospital and home visits may have been interesting.

 

Ah, a very biopsychosocial study indeed: it's useless, but it feels like it should be useful to the health care system, so let's do it anyway, to reduce costs, which it doesn't, in fact adds costs since you're adding an additional layer to it. So, in a nutshell: useless, more expensive, let's do it! It's really fortunate for them that they work in a system that is too big to fail and doesn't seem to mind wasting billions, because if they ever had to show results for their work, well, they'd have stopped working a long time ago.

Evidence actually does not suggest that. Ideologues like Sharpe do suggest that. Even when their own studies show otherwise. This is all speculative and based on aspirational goals of making this liaison crap seem valuable even though it's clearly not.

I don't know why this is called a controlled study. It doesn't meet the standard for it at all, it's just a randomized study. But whatever.

What a bizarre sentence. I wonder what it's doing there. What is "enhancing" here, and who even cares about that?

Ah. Yes. The very famous process of sticking a label onto something, then claiming it means the same thing as what the label implies. You stick a "Quality" label onto a product, and you know it's a quality product. I don't make the rules, this is just how life, well, doesn't work. What asinine nonsense. This would get you slapped with fines from regulators if you tried that with a commercial product. In medical research? Yeah, sure, whatever.

Also, when the abstract just lies a bit:

So, reading the abstract, it sounds like a recommendation to implement. Since they claim it's cost-effective, even though their own data don't support it. But the text of the paper says, actually, no. They have the usual "we want to do it again, bigger, more expensive", but this study was already plenty big and is a bust.

I actually wonder if Sharpe has actually produced a single useful thing in his entire career. It sure doesn't look like it.

 

Also, unrelated, but trying to find how much this dud of a study cost by going on their website, it looks like they've been hacked, it redirects to an online gaming scam:

Ah, well.

Can't find how much it cost. But this was a big study. And their conclusion is: more bigger studies. The grift cycle has no end.