Liaison Psychiatry: Measurement and Evaluation of Service Types, Referral Patterns and Outcomes (LP-MAESTRO)

Description

Aims & Objectives

Our overall aim is to evaluate the cost-effectiveness and efficiency of particular configurations of liaison psychiatry service for specified target populations.

Project website

https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/135808/#/

Our objectives are:

To characterise liaison psychiatry services in the UK, and produce a classification system that can inform our sampling for this research and also form the basis for commissioning decisions in the NHS

• To examine pathways of care for the main target populations of those services and estimate the costs associated with care
• To estimate comparative costs and cost-effectiveness in different liaison services
• To undertake qualitative studies with patients and clinicians, to aid with the interpretation of results and to suggest elements of their experience that are not captured by the routinely collected data we will use
• To prepare our results in a useful format for service planners and commissioners. More information about our aims and objectives can be found here.

Methods

We plan three inter-related programmes of work:

• Workstream 1 - service mapping and characterization.
• Workstream 2 - econometric modelling and evaluating cost-effectiveness.
• Workstream 3- developing a commissioning framework and guidelines for evaluating service performance against remit. More information about each of these workstreams can be found here.

Aims & Objectives

Our overall aim is to evaluate the cost-effectiveness and efficiency of particular configurations of liaison psychiatry service for specified target populations.  To do this we will develop and evaluate an innovative approach based upon linking routinely collected NHS data and using economic modelling with the resulting aggregated data.

A major challenge in assessing the cost-effectiveness of liaison psychiatry services resides in the variability in how they are configured and in the case-mix of referrals.  There is also considerable heterogeneity in extraneous (demographic and other service) factors that influence outcomes for liaison psychiatry. Our first objective is, therefore, to characterise liaison psychiatry services in the UK, and produce a classification system that can inform our sampling for this research and also form the basis for commissioning decisions in the NHS.

To achieve this objective we will:

1.    Undertake an observational study of liaison psychiatry services in the UK to determine the main service configurations (structures and processes) operating in hospital practice

2.    In a purposive sample of liaison services based upon their configuration, undertake interviews with key personnel to identify explicit and implicit programme theories for liaison psychiatry services

3.    Undertake a prospective audit in selected services, to confirm the main target populations and service approaches in real world practice.

Based upon this work, which maps and characterizes liaison services, we will sample services to represent the main service configurations that are candidates for commissioning.  Our second objective is to examine pathways of care for the main target populations of those services and estimate the costs associated with care:

1.    Using patient-level data from routine NHS databases we will identify patients referred to study services and matched comparison patients who were not referred, with the aim of comparing within and between hospitals the effect of referral or non-referral of patients with similar characteristics.

2.    We will estimate the cost of the pathways of care of patients referred to liaison services, and the matched comparison patient group, and the main determinants of those costs over 12 months after an index hospital episode.

Our third objective is to estimate comparative costs and cost-effectiveness in different liaison services.

1.    Using econometric techniques we will assess the comparative cost and effectiveness of alternative pathways of care (in different service configurations) using a number of individual outcomes - including length of stay, readmission, mortality, and health care use.

2.    We will also undertake exploratory cost-effectiveness analyses using decision modelling

Although our main aim is as outlined, and will allow us crucially to test claims made for costs and cost savings from liaison services, we do not want to lose sight of the fact that the important outcomes for liaison services are those experienced by patients and (secondarily) clinicians who use those services.  Our fourth objective is therefore to undertake qualitative studies with patients and clinicians, to aid with the interpretation of results and to suggest elements of their experience that are not captured by the routinely collected data we will use:

1.    We will invite clinicians working in and referring to liaison services to provide us with typical and extreme cases that illustrate the range of their experience and expectations of services, and we will ask for negative instances – cases that they regard as failures or as inappropriate for referral.

2.    Using these cases and service examples from our quantitative service studies, we will explore with patients and carers their views on the processes of liaison psychiatry services and the outcomes both aimed for and achieved, using focus group discussions and an online survey.

Our fifth objective is to prepare our results in a useful format for service planners and commissioners.

1.    We will develop a web-based tool to support commissioners with two components: a commissioning support tool based upon our cost-effectiveness data; a module based upon the results from econometric modelling to help commissioners identify local factors that will influence costs and therefore cost-effectiveness.

Workstreams

We plan three inter-related programmes of work:

In Workstream 1 (service mapping and characterization) we will undertake a focused survey of liaison psychiatry services in the UK and services for detailed case studies in which we will also undertake a prospective audit of referrals, to characterize the configurations and referral patterns of services. We will generate a taxonomy of services and we will then sample services to identify typical and critical cases e.g. Emergency Department cover only; acute ward in-reach only; mixed provision including specialist clinics; no liaison service.

In Workstream 2 (econometric modelling and evaluating cost effectiveness) we will use three resources: ResearchOne a database containing patient data from primary care settings using SystmOne; Hospital Episode Statistics (HES); a database provided by the Health and Social Care Information Centre (HSCIC) containing patient data relating to A&E, inpatient and outpatient episodes; local mental health clinical databases, such as Paris, Amigos. We will link data from these databases to construct longitudinal records that correspond to patient care pathways from a particular hospital identified by liaison service configuration (WS1).  We will combine health care utilisation within pathways of care with cost figures from national databases. We will compare the cost of each pathway of care and the impact of a broad set of health-related outcomes, for preliminary estimates of the cost-effectiveness of liaison psychiatry services.  We will carry out an exploratory incremental cost-effectiveness analysis from a whole system perspective.

In Workstream 3: (developing a commissioning framework and guidelines for evaluating service performance against remit) we will undertake a review of existing commissioning frameworks for liaison services and also examine existing and developing outcomes frameworks including that being developed by RCPsych. We will undertake a concept mapping exercise and use the findings to integrate with our findings to build a web-based resource for commissioners to design and monitor the commissioning framework for a local liaison psychiatry service.

With service users (patients and carers) and non-psychiatric clinical staff who use liaison psychiatry services, we will undertake interviews and focus group discussions and an online survey, with the aim of identifying additional outcomes and aspects of service that are not well characterised by our quantitative studies.

In addition to the Workstreams described above, an associated sub-study is being undertaken to perform an analysis of two specific hospitals in Birmingham.  This analysis will provide comparative data to the main study sites in the larger funded study.  Please see the Privacy Notice for this sub-study for further details of the data processing within this sub-study.

Privacy Notice

Who is undertaking this research project?

The research project is being undertaken by a research team based in the Leeds Institute of Health Sciences:

Leeds Institute of Health Sciences
Level 10, Worsley Building
Clarendon Way
Leeds
LS2 9NL
United Kingdom

Email: lihs@leeds.ac.uk

Leeds Institute of Health Sciences is situated within the Faculty of Medicine and Health at the University of Leeds:

Faculty of Medicine and Health
Leeds
LS2 9JT
United Kingdom

The University of Leeds is registered as a data controller with the Information Commissioner’s Office (Registration Number: Z553814X).

The Data Protection Officer for the University of Leeds is David Wardle who can be contacted by email on or by post to the University of Leeds, 11.72 EC Stoner Building, Leeds, LS2 9JT, United Kingdom.

What are the purpose(s) for which data are being processed within this research project?

The overall aim of LP-MAESTRO is to evaluate the cost-effectiveness and efficiency of particular configurations of liaison psychiatry services for specified target populations. To do this, an innovative approach based upon linking routinely collected patient-level data and using economic modelling with the resulting aggregated data will be developed and evaluated.

LP-MAESTRO is funded by the National Institute for Health Research (NIHR) - Health Services and Delivery Research (HS&DR) Programme (REF: 13/58/08).

For further information visit: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/135808

What is the legal basis under which data is processed within this research project?

Under the General Data Protection Regulation (GDPR), a legal basis is required for processing of personal data. The legal basis under which data is processed within LP-MAESTRO is:

• Article 6 (1) (e) – “processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller;”

Processing of data concerning health (and other ‘special categories’ of data) requires the fulfilment of an additional condition under GDPR.  The specific condition fulfilled by the processing of such data within LP-MAESTRO is:

• Article 9 (2) (j) – “processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.”

For further information visit: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/lawful-basis-for-processing/

Which sources of data are being used by this research project?

LP-MAESTRO will use data from a number of different sources:

• NHS Digital (NHSD)

NHSD is the national information and technology partner to the health and care system. It is responsible for collecting, analysing and presenting national health and social care data. Hospital Episode Statistics (HES) is a dataset that is held by NHSD and which includes data on all hospital episodes within all hospitals in England.

For further information visit: https://digital.nhs.uk/

• The Phoenix Partnership (TPP)

TPP is a healthcare technology company.ResearchOne is a health and care research database developed by TPP in partnership with the University of Leeds and the UK Government’s Technology Strategy Board. The database consists of clinical and administrative data that have been drawn from the electronic patient records currently held on the TPP SystmOne clinical system.

For further information visit: http://www.researchone.org/

• NHS Mental Health Trusts

Mental health trusts provide health and social care services for people with mental health problems. Clinical databases are maintained by these trusts to record details of contacts with mental health services.

For further information visit: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/authoritiesandtrusts.aspx

How is the data being collected within this research project?

LP-MAESTRO will use NHS data that is collected routinely by clinicians and healthcare professional as part of direct care.  Such data is typically collected within the Electronic Health Records maintained by NHS organizations. 

No additional or amended data is being collected for the purpose of LP-MAESTRO.

Data required for the project will be provided from the data sources detailed above.

What categories of data will be obtained from these sources?

LP-MAESTRO will obtain different data from each of the data sources.  The data that will be obtained has been identified by the research team as necessary and sufficient to robustly answer the research question.

The following data will be obtained:

• NHS Digital (NHSD)

Data relating to Accident and Emergency, Inpatient and Outpatient episodes from Hospital Episode Statistics will be obtained for specific hospitals in England that have been chosen for the study. This data will include diagnoses, procedures, patient demographics, mental health status and provider organizations.

For further information visit: https://digital.nhs.uk/ 

• The Phoenix Partnership (TPP)

Data relating to primary care will be obtained from ResearchOne for patients with a hospital episode included in the data obtained from NHSD. This data will include diagnoses, prescriptions, referrals, diagnostic tests, and patient demographics.

For further information visit: http://www.researchone.org/research-faqs/

NHS Mental Health Trusts

Data relating to referrals for Liaison Psychiatry services will be obtained for patients with a hospital episode included in the data obtained from NHSD. This data will include referral dates, hospital details and service provider details.

Will my data be used by the research project?

Data relating to hospital admissions will be included in the data obtained for use in LP-MAESTRO if:

1. You have been previously admitted to one of the hospitals in England chosen for the study

AND

2. Your admission to this hospital was within the specific one year index period chosen for the study (1st April 2013 – 31st March 2014)

AND

3. You have not registered an opt-out through the national opt-out programme

Additionally, data relating to primary care will be included if:

4. Your hospital admissions data are included (see 1-3)

AND

5. Your General Practice has opted-in to ResearchOne, and you have not opted out of ResearchOne.

Finally, data relating to liaison psychiatry referrals will be included if

1. Your hospital admissions data are included (see 1-3)
2. You were referred to a Liaison Psychiatry service as part of a hospital admission within the specific one year index period chosen for the study.

Can I opt-out of the use of my data by the research project?

Your data will not be included in the study if you have registered an opt-out through the national opt-out programme prior to the point at which the study populations at each hospital are determined by NHS Digital.

For further information visit: https://digital.nhs.uk/services/national-data-opt-out-programme

How will my privacy be protected?

LP-MAESTRO will use anonymised data for analysis purposes.  This means that no patient identifiable data, such as name and address, will be included in the data obtained by the research team at the University of Leeds.  Instead, patients will be uniquely referenced using non-personal identifiers that can’t be decoded by the researchers to re-identify individuals.  Additionally, LP-MAESTRO will use only that data which is necessary and sufficient to robustly answer the research question.

The data sources (NHSD, TPP, NHS Mental Health Trusts) will remove all patient identifiable data and use unique (non-personal) identifiers to reference patients in the data supplied to the University of Leeds.  Additionally, pseudonyms will be generated for patient by these sources in such a manner that it enables patients to be consistently identified across different sources of data, without enabling the specific individual to whom the data relates to be determined.  NHSD will use these pseudonyms to generate mapping files that enable the research team to match unique (non-personal) identifiers generated by NHSD to unique (non-personal) identifiers generated by TPP and NHS Mental Health Trusts.  NHSD will provide these files to the research team to the University of Leeds to enable data relating to each patient from the data sources to be linked for analysis.

All data received at the University of Leeds will be securely stored within a secure computer environment known as an IG-Toolkit approved facility (see https://www.igt.hscic.gov.uk, Reference: ECC0010), and will be managed in accordance with the Data Sharing Agreements that govern the use of the data obtained from the different sources.  Access to the data will be restricted to a small number of named and approved members of the research team.

What are my rights in relation to the data?

The General Data Protection Regulation provides the following rights for individuals in relation to their personal data:

• The right to be informed
• The right of access
• The right of rectification
• The right to erasure
• The right to restrict processing
• The right to data portability
• The right to object
• Rights in relation to automated decision making and profiling

For further information, see: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/.

A summary of these rights and their applicability in respect of the LP-MAESTRO project is provided in the table below.

Right	Applies to LP-MAESTRO	Rationale
The right to be informed	Yes	Details regarding the project and its use of data is provided within this privacy notice.  Additional information regarding the project can be found on the website of the research funder.
The right of access	No	The research team at the University of Leeds are not able to identify specific data subjects in the data provided by NHS Digital, ResearchOne and NHS Mental Health Trusts. The right of access does not apply to LP-MAESTRO as the research team are unable to determine the data that relates to a specific data subject.
The right to rectification	No	The research team at the University of Leeds are not able to identify specific data subjects in the data provided by NHS Digital, ResearchOne and NHS Mental Health Trusts. The right to rectification does not apply to LP-MAESTRO as the research team are unable to determine the data that relates to a specific data subject.
The right to erasure	No	The research team at the University of Leeds are not able to identify specific data subjects in the data provided by NHS Digital, ResearchOne and NHS Mental Health Trusts. The right to erasure does not apply to LP-MAESTRO as the research team are unable to determine the data that relates to a specific data subject.
The right to restrict processing	No	The research team at the University of Leeds are not able to identify specific data subjects in the data provided by NHS Digital, ResearchOne and NHS Mental Health Trusts. The right to data portability does not apply to LP-MAESTRO as the research team are unable to determine the data that relates to a specific data subject.
The right to object	No	Your data will not be included in the study if you have registered an opt-out through the national opt-out programme prior to the point at which the study population is determined by NHS Digital. For further information, see: https://digital.nhs.uk/services/national-data-opt-out-programme If you have not registered an opt-out through the national opt-out programme and you fulfil the criteria of the study population (see “Will my data be used by the research project?”) then your data relating to hospital admissions will be included in the study. If your data relating to hospital admissions is included in the study, your data relating to liaison psychiatry referrals will not be included in the study if you have registered an opt-out of the usage of your data for research purposes through any mechanisms that are in place locally at NHS Mental Health Trusts. For further information, see the information published by NHS Mental Health Trusts. If your data relating to hospital admissions is included in the study, your primary care data will not be included in the study if you have registered an opt-out from the ResearchOne database with your General Practice prior to the data being extracted from the ResearchOne database for the study. For further information, see: http://www.researchone.org/documentation/ The research team at the University of Leeds are not able to identify specific data subjects in the data provided by NHS Digital, ResearchOne and NHS Mental Health Trusts. Once the data has been received by the research team from NHS Digital, ResearchOne and NHS Mental Health Trusts, the right to object does not apply to LP-MAESTRO as the research team are unable to determine the data that relates to a specific data subject.
Rights in relation to automated decision making and profiling	No	The analysis performed by the research will evaluate the cost-effectiveness and efficiency of particular configurations of liaison psychiatry services for specified target populations.  Patients referenced in the data will be analysed in respect of their health by automated means to understand referral patterns and outcomes.   The analysis performed by the research team will not produce automated decisions about specific patients who are referenced in the data.  Analysis will be used to determine the cost-effectiveness and efficiency of different liaison psychiatry configurations and will inform decisions about the commissioning of such services by health service commissioners.

Will my data be transferred to any organisations outside of the University of Leeds?

Data will only be trasnferred outside of the University of Leeds for the purposes of off-site backup. Off-site backup locations are designated by the University of Leeds and located within the United Kingdom.

How long will my data be retained by the research project?

Data will be retained by the research project for two years after the end of the project to facilitate the publication of reports.

What approvals have been obtained by the research project?

For the analysis of data from patients attending hospitals without a LP service (Workstream 2 – Phase 1), LP-MAESTRO has successfully obtained:

• Favourable opinion from the North of Scotland NHS Research Ethics Committee (REF: 16/NS/0025).
• Decision from Confidentiality Advisory Group at the Health Research Authority that Section 251 support is not required (REF: 16/CAG/0037).
• Approval from the Independent Group Advising on the Release of Data (IGARD) (REF: DARS-NIC-77953-C4M3T).

For the analysis of data from patients attending hospitals with specific LP service configurations (Workstream 2 – Phase 2), such approvals will be obtained prior to receipt of the associated data from the data sources.

What if I have further questions?

Any questions regarding LP-MAESTRO can be directed to the research team at the Leeds Institute of Health Sciences, who can be contacted using the details provided above.

Additionally, any queries or concerns regarding the processing of personal data can be made to the Information Commissioner’s Office.