REDIRECT- Evaluating the Effectiveness of an Educational Intervention about FEP in Primary Care
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Transcript of REDIRECT- Evaluating the Effectiveness of an Educational Intervention about FEP in Primary Care
REDIRECT- Evaluating the Effectiveness of an
Educational Intervention about FEP in Primary Care
Helen LesterNovember 1st 2007
Study team 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) 62% n=62
BirminghamCole (1995) 71% n=93 LondonLincoln (1998) 50% n=62 MelbourneBurnett (1999) 46% n=100 LondonSkeate (2002) 79% n=93 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
Lack of research culture Competing priorities Question has to make sense to primary care Time/financial costs need to be minimal Minimal disruption to practice routine “Buy in” from PCTs
REDIRECT Methodology 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 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
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
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 Knowledge: increased awareness of symptoms
Skills: use of specific questions to elicit symptoms
Attitudes: more positive attitudes towards young people with psychosis and their families
Consultation changes? Withdrawal from family and friends Loss of concentration Depression/anxiety Loss of trust Self neglect
Hallucinations and delusions Thought disorder
+Family history
Drug misuse
Practice Recruitment and Training
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
0%
20%
40%
60%
80%
100%
KeyInformation
UsefulQuestions
ImprovedConfidence
GP Feedback (n = 53, 85%)
Patient Recruitment 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
Secondary outcomes: 83 with 6m follow up of 68
Results Neutral trial
9% increase in referrals from Intervention practices
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? False positive rate across the other mental
health services in the 6m pre trial was 9/67 = 13.4%
False positive rate in the subsequent 18 months was stable at 20/157= 12.7%
Who got stuck in services? 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 GP education does no harm
GP education may simply do exactly what it says on the tin - enable GPs to diagnose youngpeople more quickly and refer them to EIS
GP education alone is not sufficient to increase referrals to EIS and decrease DUP
Primary care is just part of the jigsaw and interventions will need to be multifaceted
Thanks for listening