Post on 18-Dec-2015
Why we need to get to grips with alcohol in Wessex
Prescribing Observatory for Mental Health Audit:How can we manage alcohol use in Mental health Services?
Dr Shanaya Rathod/Dr Julia Sinclair
• To improve outcomes for patients with co-morbid alcohol use– Implementation of NICE guidance
• Screening• Brief interventions
• ?Consider– Develop and pilot a pathway within SHFT– Links with AHSN to evaluate and disseminate across
Wessex
Aims
Prevalence UKPsychiatric patients• CMHT (London) -44% harmful alcohol use
or recent substance use (Weaver 2003)
• Psychiatric IP - 49% harmful alcohol use (1/12)
(SW London) and 27% drug use (1/12) (Barnaby 2003)
• Psychiatric IP -50% men and 29% women
(Oxfordshire) harmful alcohol use (1/12)
(Sinclair 2008)
Barriers to effective care
• Definitions of ‘dual diagnosis’ – suggest “co-morbidity”
• Low levels of ‘Alcohol specific Health literacy’ in staff
• Culture – Details of patients addictive behaviours often poorly documented
(e.g Farrell 1988, WRISS 2001a, 2001b)
– Seen as not part of core role “refer on”
Context
NICE CG115:• “Staff working in services provided and funded by the NHS who care for people
who potentially misuse alcohol should be competent to identify harmful drinking
and alcohol dependence. They should be competent to initially assess the need
for an intervention or, if they are not competent, they should refer people who
misuse alcohol to a service that can provide an assessment of need”
NICE PH24:• “Brief interventions for adults should be delivered by Health and social care,
criminal justice and community and voluntary sector professionals in both NHS
and non-NHS settings who regularly come into contact with people who may be
at risk of harm from the amount of alcohol they drink.”
Alcohol specific health literacy
Quality improvement programme
Prescribing in substance misuse: alcohol detoxification
Baseline auditMarch 2014
Method
Participants:• 43 Mental Health Trusts participated• 174 clinical teams• 1,197 adult patients
Audit data collected:• Demographic, diagnosis, type of service• Documentation of alcohol misuse, physical and neurological assessments• Medication prescribed to treat alcohol withdrawal, dosage and details of regimen• Specialist advice sought during alcohol detoxification and for continuing management
Clinical service providing care for alcohol detoxification
Baseline N=1,197
Clinical service providing care
Sub-sample of patients whose admission for
alcohol detoxification was
planned N = 462 (39%)
Sub-sample of patients whose admission for
alcohol detoxification was
unplannedN = 735 (61%)
Total sampleAll patients who were admitted
for alcohol detoxification
N = 1,197
n (% of sub-sample) n (% of sub-sample)n (% of total
sample)
Acute adult psychiatric ward - detoxification overseen by a non-specialist adult psychiatrist
139 (30%) 694 (94%) 833 (70%)
Acute adult psychiatric ward - detoxification overseen by a specialist in alcohol/substance misuse
321 (69%) 24 (3%) 345 (29%)
Initial assessment: Documentation of past history of alcohol detoxification
Baseline N=1,197
Documentation of previous detoxifications
Sub-sample of patients whose
admission for alcohol detoxification was
planned N = 462 (39%)
Sub-sample of patients whose
admission for alcohol detoxification was
unplannedN = 735 (61%)
Total sampleAll patients who were admitted for alcohol
detoxificationN = 1,197
n (% of sub-sample) n (% of sub-sample) n (% of total sample)
1-4 previous alcohol detoxifications 224 (48%) 270 (37%) 494 (41%)
5 or more previous alcohol detoxifications
34 (7%) 40 (5%) 74 (6%)
First known alcohol detoxification
130 (28%) 175 (24%) 305 (25%)
Not documented 74 (16%) 250 (34%) 324 (27%)
Initial assessment: Standardised assessments/rating scales used
Baseline N=1,197
Standard assessments/rating scales
Total sampleAll patients who were admitted for alcohol
detoxificationN = 1,197
n (% of total sample)
CIWA-Ar (prior to starting detoxification regimen) 170 (14%)
CIWA-Ar (during detoxification regimen) 170 (14%)
SADQ 113 (9%)AUDIT 80 (7%)APQ 11 (1%)LDQ 7 (1%)None of the above 690 (58%)Other 65 (5%)
During admission: Documented brief intervention
Brief intervention
Total sampleAll patients who were admitted
for alcohol detoxificationN = 1,197
Documented 505 (42%)Not documented 692 (58%)
Discharge: Medication for relapse prevention prescribed at the point of discharge
Baseline N=1,197
Type of drug
Sub-sample of patients who were
admitted under non-specialist care N=
848 (71%)
Sub-sample of patients who were
admitted under specialist care N=349 (29%)
Total sampleAll patients who
were admitted for alcohol
detoxificationN = 1,197
n (% of type of drug)n (% of type of
drug)n (% of total
sample)
Acamprosate 115 (14%) 133 (38%) 248 (21%)Naltrexone 4 (<1%) 10 (3%) 14 (1%)Disulfiram 14 (2%) 45 (13%) 59 (5%)Nalmefene 0 0 0
Not on any of the relapse medication above
720 (85%) 178 (51%) 898 (75%)
Baclofen 2 (<1%) 0 2 (<1%)
Not applicable 17 (2%) 0 17 (1%)
Initial assessment: Documented drinking history
Proportion of patients who had a documented assessment of drinking history at admission
Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG
115, recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).
Initial assessment: Documented physical examination
Proportion of patients who had a documented physical assessment at admission
Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115,
recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10).
Initial assessment: Documented assessments for the signs and symptoms of Wernicke’s encephalopathy
Proportion of patients who had documented assessments of the signs and symptoms of Wernicke’s encephalopathy
Implementation of NICE guidance• Screening• Brief interventions
How to improve outcomes for patients with co-morbid alcohol use?
Requesting help with alcohol problem New Presentation Periodic Review
Full screenAUDIT
AUDIT Score8-15
Increasing-risk
Consider joint working with
Specialist services
Full Assessment ExtendedBrief Advice
AUDIT Score16-19
Higher-risk
AUDIT Score20+
Possible Dependence
AUDIT Score 0-7
Lower-risk
Alcohol Care Pathway
No action
PositiveResult
NegativeResult
FAST AUDIT - CInitial Screening Tools
Brief Advice
Units of alcohol
2. Need to Actively Manage Alcohol Use as integral part of care
AssessmentDrinking reduction
DetoxRelapse Prevention
Ways to Optimise Treatment• Identification – CQUIN?
• Make management an integral part of the treatment plan
• Engender a culture of therapeutic optimism within the service
• Staff training in basic competencies
• Actively manage both conditions
• Drink diaries and motivational interviewing are effective tools – core part of MHS
• Don’t forget pharmacotherapy
www.warc.soton.ac.ukWessex Alcohol Research Collaborative
• To improve outcomes for patients with co-morbid alcohol use – where ever they present– Implementation of NICE guidance in MH Services
• Screening• Brief interventions• Active management of co-morbid alcohol use
Consider?– Develop and pilot a pathway for MH services– Links with AHSN to evaluate and disseminate across
Wessex
AHSN working together
Why we need to get to grips with alcohol in Wessex
Alcohol care in England’s Hospitals, an opportunity not to be wasted
Alcohol care in England’s hospitals:
An opportunity not to be wasted.
Jason MahoneyHead of Alcohol and Drugs, South East PHE Centres
Public Health England
Protecting and improving the nation’s health and wellbeing and reducing health inequalities.
www.gov.uk/phe
2525 Alcohol care in England’s hospitals
Alcohol care in England’s hospitals
• Why alcohol concerns us
• What we can do about it
• How to do that
• So, what next?
26 Alcohol care in England’s hospitals
27 Alcohol care in England’s hospitals
28 Alcohol care in England’s hospitals
29 Alcohol care in England’s hospitals
Percentage change in standardised UK mortality rates (age 0-84) normalised to 100% in 1970
Liver
CirculatoryIschaemic heartCerebrovascularNeoplasmsRespiratoryEndocrine/metabolicDiabetes
30 Alcohol care in England’s hospitals
Liver disease deaths compared with the other major killers
PHE FingertipsWessex PHE Centre Local Authorities compared to England
• Liver disease
• Alcohol specific hospital admissions
• Under 75 mortality rate – alcoholic liver disease
http://fingertips.phe.org.uk/profile/liver-disease/
31 Alcohol care in England’s hospitals
32 Alcohol care in England’s hospitals
33 Alcohol care in England’s hospitals
Reducing consumption prevents ill health Regularly consuming
25g (3 units) daily Regularly consuming 50g (6 units) daily
Regularly consuming 100g (12 units) daily
Cancers Increase over standard risk
Increase over standard risk
Increase over standard risk
Mouth and throat 96% 211% 545% Colon 5% 10% 21%Oesophagus 39% 93% 259% Rectum 9% 19% 21% Liver 19% 40% 81% Larynx 43% 102% 286% Breast 25% (f) 55% (f) 141% (f)
CardiovascularHypertension 43% 104% 315% Ischaemic stroke -10% 17% 337% Haemorrhagic stroke 19% 82% 370% Cardiac arrhythmias 51% 123% 123%
Oesophageal varices 26% 854% 854%Unspecified liver disease 26% 854% 854% Acute and chronic pancreatitis 34% 74% 219%
Evidence into action: PHE Priorities
34
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PHE_Priorities.pdf
Reducing harmful drinking
A reduction in the number of hospitaladmissions due to alcohol.
Alcohol care in England’s hospitals
Alcohol as a public health priority
• Reducing harmful drinking: What works?- Social Marketing
- Licensing
- Identification and Brief Advice
- Alcohol care teams / hospital settings
- Specialist alcohol treatment
35 Alcohol care in England’s hospitals
36 Alcohol care in England’s hospitals
RCP 2001Dh 2009BSG, Alcohol Health Alliance UK 2010HM Govt 2012NHS evidence 2012 University of Stirling 2013
10+ years of recommendations
Alcohol care in England’s hospitals
2001 “a dedicated alcohol health worker or an alcohol liaison nurse in each major acute hospital”
2009 “High impact change 5: Appoint an alcohol health worker”
2010 “a multidisciplinary Alcohol Care Team in each district hospital”
2012 “We encourage all hospitals to employ Alcohol Liaison Nurses“
2012 “Multidisciplinary alcohol care teams should organise systematic interventions”
2013 “Every acute hospital should have a specialist, multi-disciplinary alcohol care team tasked with meeting the alcohol-related needs of those attending the hospital and preventing readmissions.”
37 Alcohol care in England’s hospitals
NICE quality and productivity proven case study:
38 Alcohol care in England’s hospitals
39 Alcohol care in England’s hospitals
Commissioning of services
Broad service types
40 Alcohol care in England’s hospitals
Services are diverse, but fall into three broad categories:
• multi-disciplinary alcohol care teams – Supporting patient care from within the hospital and liaising with community services
• in-reach alcohol care teams – based in the community to support the care of hospital patients
• high impact user (HIU) services - identify and assertively engage with a relatively small number of those patients who attend A&E or are admitted most frequently
What’s recommendedHospital alcohol services, led by a senior clinician with dedicated time for the team and providing evidence-based interventions. Teams will facilitate identification of alcohol misusers in hospitals and appropriate packages of care provided by multi-disciplinary teams. Whether teams are large or small, set within the hospital or in-reach, they should be able to provide:
• case identification/Identification and Brief Advice (IBA)
• comprehensive alcohol use Assessment
• contribution to nursing and medical care planning
• psychotherapeutic interventions
• medically assisted alcohol withdrawal management
• discharge planning including referral to community services
41 Alcohol care in England’s hospitals
42
Report recommendations• Every district general hospital should consider having effective specialist
alcohol provision
• Existing services should be maintained and developed
• Alcohol Care Teams to support training for colleagues in all clinical areas
• Ensure that existing services are adequately integrated across primary and secondary care and that new services are implemented where there are none
• Local partners should consider employing assertive out-reach or in-reach services for high impact service users in all major hospitals and existing services should be evaluated to assess their impact on hospital and community services
• System planning should ensure that community services are accessible and available to ensure continuation of detoxification with psychosocial interventions outside of the hospital
Alcohol care in England’s hospitals
43
What PHE will do next• We will develop pro-forma service specifications
for each of the broad service types
• We will develop a core minimum dataset for alcohol care teams
• We will develop a pro-forma evaluation template to help ensure that service evaluations are comparable.
• We will re-run the survey of hospital services
Alcohol care in England’s hospitals
So, what could you do?• Is there an alcohol care team at the local
hospital?
• How is it funded?
• Has it been evaluated?
• Does it reflect the recommendations?
44 Alcohol care in England’s hospitals
Thank you
Jason Mahoney
Head of Alcohol and Drugs, South East PHE Centres
Jason.Mahoney@phe.gov.uk
07787 005 689
45 Alcohol care in England’s hospitals
Why we need to get to grips with alcohol in Wessex
James Linde Alliance Alcohol Related Liver Disease Priority Setting PartnershipBeccy Maeso, Senior Programme Manager, NIHR Evaluation, Trials and Studies Coordinating Centre
James Lind Alliance (JLA)
Alcohol Related Liver Disease Priority Setting Partnership
Beccy Maeso
The James Lind Alliance (JLA)
• Involving patients and clinicians in setting priorities for research
• Finding out what research is important to:• Patients / service users• Carers / relatives• Clinicians / healthcare professionals
What is the JLA?
•Established in 2004•Royal Society of Medicine – Dr John Scadding•James Lind Library - Sir Iain Chalmers•INVOLVE – Sir Nick Partridge
•Since April 2013: part of NETSCC•JLA Advisers•The Guidebook
Who was James Lind?
•James Lind (1716-1794)•A pioneer of clinical trials
Alcohol Related Liver Disease Priority Setting Partnership
• Bring patients and clinicians together to Identify uncertainties about the effects of treatments
• Agree by consensus a prioritised “top 10” list of uncertainties for research
• Publicise the methods and results of the PSP• Draw the results to the attention of research funders
independently of the JLA• More info jla.southampton.ac.uk
How do we do it?
The priority setting process:• Set up steering group • Invite partners• Gather uncertainties• Prioritise uncertainties • Promote priorities to researchers and
funders
Set up steering group• Patient, carer and clinician representatives • Resources and expertise
• Regular meetings• Publicising the project• Overseeing the process • Responsible for dissemination of results
• JLA chair – a neutral facilitator • Protocol
Gather uncertainties •What are treatment uncertainties?
•no up-to-date, reliable systematic reviews of research evidence addressing the uncertainty about the effects of treatment exists•up-to-date systematic reviews of research evidence show that uncertainty exists
ARLD steering groupPatient representative/s:
Diane Goslar, patient representative Andrew Langford, British Liver Trust Nick Rosland, patient representative Lynda Waters, carer representative
Clinical representative/s:
Dr Michael Allison, Consultant Hepatologist – Addenbrooke’s Hosptal Dr Jane Collier, Consultant Hepatologist – Oxford Aisling Considine, Acting Liver Pharmacy Team Leader – Kings College Ranjita Dhital, Community Pharmacist Dr Carsten Grimm, GP, Clinical Lead RCGP Alcohol Certificate Board Member,
Bradford Districts CCG Dr Zul Mirza, Consultant in Emergency Medicine Lynn Owens, Nurse Consultant- Alcohol Services Dr Steve Ryder, Consultant Hepatologist BSG representative Dr Nick Sheron, Consultant Hepatologist – British Association for the Study of Liver
Disease Dr Julia Sinclair, Associate Professor in Psychiatry
Gather uncertainties • Survey
• Patients and carers • Clinicians
• Research recommendations• UK Database of Uncertainties about the
Effects of Treatments (UK DUETs)• www.library.nhs.uk/duets
Check the uncertainties
• Prepare the dataset• Remove out of scope submissions• Categorise eligible submissions• Format the submissions
• PICO questions: Patient/Population, Intervention, Comparator, Outcome
• “Lumping and splitting” • Verify the uncertainties• Identify research recommendations• Prepare the long list
Prioritise uncertainties – step 1 (interim stage)
• From a long list to a short list • Top 10 uncertainties chosen by partners
• As individuals• On behalf of members• On behalf of colleagues• Representing an organisation
Prioritise uncertainties – step 2 (final)
•Priority setting workshop •Patients, carers and clinicians •A day of democratic discussion and ranking
•Nominal Group Technique•Prioritise the remaining uncertainties•Agree the top 10
Final priority setting
JLA Priority Setting Principles
• The principle of patients, carers and clinicians working together
• Methodological transparency• Declaration of interests• Working with UK Database of Uncertainties
about the Effects of Treatments www.library.nhs.uk/duets
Next steps
Promote priorities to researchers and funders• NIHR Evaluation, Trials and Studies
Coordinating Centre (NETSCC)• Dissemination of findings
• Publications• Conferences
Current Partnerships
•Anaesthesia •Depression•Hip and knee replacement for osteoarthritis•Inflammatory bowel disease•Intensive care•Late stillbirth•Mesothelioma•Neuro-oncology•Palliative and end of life care•Parkinson’s disease•Spinal cord injury•Common Shoulder problems
•Alopecia•Renal Transplantation• Surgical Treatment for Early Hip and Knee Osteoarthritis•Endometrial Cancer•Teenage and Young Adult cancer•Mild to moderate hearing loss•Alcohol related liver disease•Non alcohol related liver and gall bladder diseases•Cavernoma
Completed Partnerships•Asthma•Urinary incontinence•Vitiligo•Prostate cancer•Schizophrenia•Type 1 diabetes•ENT aspects of balance•Life after stroke•Eczema•Tinnitus•Cleft lip and palate
•Lyme disease•Pressure ulcers•Sight loss and vision •Dementia•Dialysis•Multiple sclerosis •Hidradenitis suppurativa•Acne•Pre-term birth•Childhood disability
What difference does it make?Asthma
• Funding has been awarded by NIHR HTA programme to fund research to provide better evidence on the effects of breathing exercises for asthma
Prioritised areas from PSP uncertainties
• Non-pharmacological interventions to reduce weight gain in people with schizophrenia prescribed antipsychotic medication
• Management of sexual dysfunction due to antipsychotic drug therapy
• Training to recognise the early signs of recurrence in schizophrenia (joint research call between NIHR and Australian National Health and Medical Research Council)
For more information…
• email jla@soton.ac.uk • More info www.jla.nihr.ac.uk• @lindalliance
@LindAlliance
Questions ?