Transcript REDIRECT- Evaluating the Effectiveness of an Educational

REDIRECT- Evaluating the
Effectiveness of an Educational
Intervention about FEP in
Primary Care
Helen Lester
November 1st 2007
Study team
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Max Birchwood
Maria Michael
Lynda Tait
Nick Freemantle
Amrit Khera
Kate Harris
Christopher John
Primary Care Policy Context
 Primary care is viewed as increasingly important in
mental health policy terms
 Links between primary care and EI/FEP are still
tenuous
 Limited by incidence, knowledge and attitudes
Incidence of FEP
 Most GPs will see one new person with FEP each
year, and will have approximately 12 patients on their
list with a diagnosis of psychosis
 Similar incidence to meningococcal meningitis
 Negative stereotypes still exist among GPs
GP Attitudes
“When I approached my GP, he never gave me any hope
that things could change. I remember being told that I’d
never be able to work again, I’d never have an education,
never have relationships, never have anything in my life.”
P9, M, Cannock
“Write him off!” P10, F, Cannock
“That’s what they done. They never told me there are
people who do recover, so it’s not a life sentence.” P9, M,
Cannock
GP Attitudes
“Well, some people don’t come when they’re well and
some don’t come when they’re sick and to be honest it’s
a bit of a relief because I can catch up on being late.”
GP4, F, Worcester
“They are notoriously bad at keeping appointments.”
GP8, F, Birmingham
Lester HE, Tritter JQ, Sorohan H. Providing primary care for people with
serious mental illness: a focus group study. British Medical Journal
2005;330:1122-1128.
The Role of Primary Care in
FEP
 Primary care is potentially crucial in the detection and
referral pathway
(Skeate et al, 2002; Burnett et al, 1999)
 May lead to a reduction in DUP?
 Important in terms of ongoing family support
GPs and Referral Pathways
(at some point)
McGovern (1991)
Cole (1995)
Lincoln (1998)
Burnett (1999)
Skeate (2002)
62%
71%
50%
46%
79%
n=62
n=93
n=62
n=100
n=93
Birmingham
London
Melbourne
London
Birmingham
Working Practices in
Primary Care
 Random presentation of patients
 10 minute time frame for assessment
 269 million consultations each year, equivalent to
740,000 people (1.3% of the population) each day
 Multiple drivers and “must do’s’”
Methods Fit the Culture of Primary
Care
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Lack of research culture
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Competing priorities
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Question has to make sense to primary care
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Time/financial costs need to be minimal
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Minimal disruption to practice routine
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“Buy in” from PCTs
REDIRECT Methodology
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Cluster randomised controlled trial
Not previously attempted in terms of FEP…
Educational intervention of early detection training
Primary outcome is number of referrals to EIS
160 patients (80 in each arm)
Secondary outcomes of DUP, use of the MHA, time to
recovery
Recruitment from 5/4/04-7/2/07
All practices have equal access to EI teams
Sampling frame of 300,000 patients across 2 PCTs in
inner city Birmingham
Tailoring the Trial
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All data is collected in secondary care
Training (intervention) is supported by the PCT
Locum payments are made where additional training
is required
Training emphasises the key role that primary care
can play
Training imparts skills and knowledge i.e. has a CPD
value as well
Regular but unobtrusive contact
Lester HE, Birchwood M, Tait L, Wilson S, Freemantle N. Design of the
BiRmingham Early Detection In untREated psyChosis Trial:BMC Health
services research 2005;5:19.
Developing the Educational
Intervention
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Theoretical phase: literature review and exploration
of attitude and behaviour literature (e.g. contact
hypothesis)
Modelling phase: focus groups and training needs
analysis to explore what GPs wanted and needed to
know and how the education should be structured
and delivered
Content of the Educational
Intervention
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Video illustrating consultations in primary care
facilitated by a GP
Written information e.g. challenging questions
Year 2 and 3 follow up video training facilitated by
service users and carers using the contact hypothesis
Expected Changes
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Knowledge: increased awareness of symptoms
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Skills: use of specific questions to elicit symptoms
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Attitudes: more positive attitudes towards young
people with psychosis and their families
Consultation changes?
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Withdrawal from family and friends
Loss of concentration
Depression/anxiety
Loss of trust
Self neglect
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Hallucinations and delusions
Thought disorder
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+Family history
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Drug misuse
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Practice Recruitment and
Training
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148 practices approached in two waves of
recruitment and 110 recruited (74.3%)
100% of practices had year 1 training, 69% year 2
and 50% year 3
65% of practices have had at least 2 training
sessions
Training well received
Lester HE, Tait L, Khera A, Birchwood M. The development and
evaluation of an educational intervention on first episode psychosis for
primary care. Medical Education 2005;39:1006-14.
Results: Attendance and
Feedback
GP Feedback (n = 53, 85%)
100%
80%
60%
40%
20%
0%
Key
Information
Useful
Questions
Improved
Confidence
Patient Recruitment
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Primary outcome (referred for possible psychosis,
diagnosed as psychotic and then referred to EIS):
125
Those referred for possible psychosis, diagnosed as
psychotic but NOT referred to EIS = 57
Total primary outcome of 182
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Secondary outcomes: 83 with 6m follow up of 68
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Results
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Neutral trial
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9% increase in referrals from Intervention practices
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No change in any secondary outcomes except for
delay in reaching EIS (p 0.002)
Comparison
Difference
Lower
CI
Upper
CI
P value
Delay_in_help_seeking
-105.97
-267.49
55.5584
0.1949
Delay_in_help_seeking_pathway
4.0713
-51.5086
59.6513
0.8842
Delay_in_reaching_EIS*
222.03
83.5375
360.52
0.0021
Delay_within_MH_services
87.3422
-22.4520
197.14
0.1170
Duration_of_prodromal_period
59.3417
-290.21
408.89
0.7358
Duration_of_untreated_illness
187.23
-106.26
480.73
0.2072
Duration_of_untreated_psychosis
-13.7760
-199.12
171.57
0.8825
* time from first decision to seek care to referral to EIS
"Declare the past, diagnose the present, foretell the
future; practice these acts. As to diseases, make a habit
of two things — to help, or at least to do no harm."
Hippocrates: Epidemics, Bk. I, Sect. XI.
Did we do harm?
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False positive rate across the other mental health
services in the 6m pre trial was 9/67 = 13.4%
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False positive rate in the subsequent 18 months was
stable at 20/157= 12.7%
Who got stuck in services?
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57 people in each of the 14 local MHTs
Demographics were no different to the other EI
group
52/57 included a clear reference to psychosis in the
referral letter
All were later confirmed as having a psychosis
May have been a consequence of the waiting list in
the EIS in 2004
Implications
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GP education does no harm
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GP education alone is not sufficient to increase
referrals to EIS and decrease DUP
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GP education may simply do exactly what it says on
the tin - enable GPs to diagnose young
people more quickly and refer them to EIS
 Primary care is just part of the jigsaw and
interventions will need to be multifaceted
Thanks for listening