Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
Lancet Psychiatry. 2024 Sep;11(9):684-695. doi: 10.1016/S2215-0366(24)00188-3. Epub 2024 Aug 10.
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.
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).
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.
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.
UK National Institute for Health and Care Research.
急诊入院的老年人通常住院时间延长，这会导致他们的预后恶化，增加医疗保健成本，并减少床位供应。越来越多的证据表明，他们的问题具有生物心理社会的复杂性，包括认知障碍、抑郁、焦虑、多种医学疾病以及功能依赖导致的护理需求，这会降低医疗效率，并使出院后护理计划更加困难，从而延长住院时间。我们旨在评估在 The HOME 研究中，通过积极主动的综合联络精神病学咨询（PICLP）来增强老年住院患者护理的效果。我们之前已经描述了 PICLP 对患者和临床医生报告的益处。在本文中，我们报告了与单独常规护理相比，PICLP 增强护理在减少住院时间方面的有效性和成本效益，这是通过比较住院后 30 天内的住院时间来评估的。
我们在三家英国急性综合医院的 24 个内科病房进行了一项平行组、多中心、随机对照试验。如果患者符合以下条件，则有资格参加试验：年龄在 65 岁或以上，因急诊入院，并且预计从入组之日起至少需要住院 2 天。参与者按照医院、性别和年龄进行分层，随机选择块大小以确保分配隐藏，按照 1:1 的比例随机分配到 PICLP 或常规护理组。PICLP 临床医生（由协助临床医生支持的联络精神病医生）对患者问题进行积极主动的生物心理社会评估，然后作为病房团队的成员提供以出院为重点的护理。主要结局是随机分组后 30 天内的住院时间（包括索引入院和任何急诊再入院）。次要结局是索引入院的总住院时间的出院率；出院地点；随机分组后截断至 30 天的索引入院长度；急诊再入院次数；急性综合医院住院天数；随机分组后 1 年内的死亡率；患者的住院体验；他们对住院时间的看法；焦虑（广泛性焦虑障碍-2）；抑郁（患者健康问卷-2）；认知功能（蒙特利尔认知评估电话版）；独立功能（日常生活活动的巴氏量表）；健康相关生活质量（五维五度问卷）；整体生活质量。统计人员和数据收集人员对治疗分配进行了盲法；参与者和病房工作人员无法进行盲法。分析采用意向治疗。该试验有一个患者和公众参与小组，并在 ISRTCN （ISRTCN86120296）上注册。
2018 年 5 月 2 日至 2020 年 3 月 5 日期间，共纳入 2744 名参与者（1399 名[51.0%]男性和 1345 名[49.0%]女性）；1373 名被分配到 PICLP，1371 名被分配到常规护理。参与者的平均年龄为 82.3 岁（标准差 8.2），2565 名（93.5%）参与者为白人。随机分组后 30 天内的平均住院时间（分析了 2710 名[98.8%]参与者）为 11.37 天（标准差 8.74），PICLP 为 11.85 天（标准差 9.00）；调整后的平均差异为-0.45（95%CI-1.11 至 0.21；p=0.18）。次要结局中唯一具有统计学和临床意义的差异是出院率，PICLP 组高出 8.5%（比值比 1.09 [95%CI 1.00 至 1.17]；p=0.042），这一差异在住院超过 2 周的患者中最为明显。与常规护理相比，PICLP 在 1 个月和 3 个月时估计略有成本节约和成本效益，但在 12 个月时没有。没有与干预相关的严重不良事件发生。
这是首次对 PICLP 的随机对照试验。老年内科住院患者和病房工作人员体验到 PICLP 增强了医疗护理。它在短期内也可能节省成本。尽管该试验没有提供 PICLP 降低住院时间的有力证据，但它确实支持并为其未来的发展和评估提供了信息。
英国国家卫生与保健研究所。
