Gloucestershire Evidence & Research Repository

Aims and method: This study explored the association among dissociative experiences, recovery from psychosis and a range of factors relevant to psychosis and analysed whether dissociative experiences (compartmentalisation, detachment and absorption) could be used to predict specific stages of recovery. A cross-sectional design was used, and 75 individuals with psychosis were recruited from the recovery services of the Gloucestershire Health and Care NHS Foundation Trust. Five questionnaires were used - the Dissociative Experiences Scale - II (DES), Detachment and Compartmentalisation Inventory (DCI), Questionnaire about the Process of Recovery, Stages of Recovery Instrument (STORI), and Positive and Negative Syndrome Scale - and a proforma was used to collect demographic data. Results: Our findings indicated that compartmentalisation, detachment and absorption, as measured by DES and DCI, do not predict stages of recovery as measured by the STORI. Clinical implications: The results of this study suggest that there is no simple relationship between dissociative and psychotic symptoms. They also suggest a need to assess these symptoms separately in practice and indicate that special approaches to treatment of psychosis may be needed in cases where such symptoms have a significant role.

In Gloucestershire we are rightly proud of our strong track record in collaborative working across organisations in the wider health, care and wellbeing system. We are committed to the delivery of Integrated Neighbourhood Teams building on integrated care. Across our partnerships we strive to continuously improve the care and outcomes for our people. However we are not without our challenges. While life expectancy continues to improve for the most affluent 10%, it has either stalled or fallen for the most deprived 10%. An ageing population means there’s a growing demand and pressure on the system to remain sustainable. The Working as One transformation Programme endeavours “to deliver quality, integrated care for the people of Gloucestershire to support the best possible physical and mental health outcomes, enabling them to lead the most happy and healthy lifestyles”. One improvement cycle of the Prevention workstream of Working as One is the development of Integrated Proactive Neighbourhoods; Integrated Neighbourhood Teams focussed on proactive frailty. We know there are over 73,000 people in Gloucestershire over the age of 65 coded as frail within our GP clinical systems. If and when people in this age group attend our acute hospital emergency department, they are more likely to spend longer there than those aged under 65, and more likely than the younger age group for that attendance to lead to an admission. We are keen to prevent attendances where reasonably avoidable and where people can be proactively supported to remain in their own homes and communities. We know a patchwork of interventions has developed for different cohorts of people living with frailty. This programme enables us; a system comprising teams of teams around specific populations; to collectively work better together to improve the health and care outcomes for our populations. It is an opportunity to systematise adoption of the most impactful evidence based interventions for people across our county by cohort and individual need and positively impact the wider system. We acknowledge that, whilst transformative in many respects, this is also an evolutionary change that builds on examples of already successful integrated working practices. We’re phasing our approach across fifteen neighbourhoods in Gloucestershire to collectively run improvement and change cycles. Importantly whilst system and senior strategic colleagues can provide the structure, conditions for change and permissions for this new way of working, it is the local health and care professionals, our vibrant voluntary and community sector and people in communities who hold the key to delivering locally appropriate adaptations of the model to meet local people’s needs in a meaningful and sustainable way. Our work links most to pillars 1,2,3 and 6 of integrated care. Our key next step is convening a series of workshops to enable local teams the time and space to co-develop the integrated working in their neighbourhoods. With the support of our systemwide Improvement Community and strategic leaders, local teams will be enabled and empowered to work with people to continuously develop and iterate integrated care for, and with the people we serve.

Background & aims: The Barrett's Oesophagus Surveillance Study (BOSS) was the first randomized study of surveillance. This study reports the costs and quality of life outcomes from the BOSS trial and models the outcomes and cost-effectiveness of surveillance beyond the follow-up period of the BOSS study. This trial showed similar stages and rates of esophageal cancer in both arms, but the regular surveillance arm did identify more high-grade dysplasia after a median of 12.8 years follow-up. Methods: We used a decision tree model based on results from BOSS to conduct a cost-effectiveness analysis of costs and quality-adjusted life years (QALYs). A Markov model was used to extrapolate costs and outcomes over a further 10 years after the trial had ended, representing a 22.8-year time horizon. The proportion with high-grade dysplasia and QALYs was derived from the randomized trial. Results: The total costs associated with 2-yearly surveillance was $5309 vs $3182 in the at-need arm. Total QALYs in the 2-yearly endoscopy arm were 8.647 compared with 8.629 in the at-need arm. Compared with at-need endoscopy, 2-yearly surveillance costs $115,563/QALY gained. In the sensitivity analyses around assumptions on the proportion of high-grade dysplasia that is undetected in the at-need endoscopy arm, surveillance had an incremental cost effectiveness ratio of $94,513/QALY for the best-case and $146,272/QALY for the worst-case scenario. Conclusion: Barrett's esophagus surveillance every 2 to 3 years is unlikely to be a cost-effective strategy. Guidelines should take this into account when deciding surveillance intervals.

Background IV-to-oral-switch (IVOS) is a multidisciplinary approach in which patients who are treated with IV antibiotics are stepped down to oral antibiotics, providing they are afebrile, clinically improving, eating and drinking and not suffering with a deep-seated infection (ACED). The IVOS of antibiotics for inpatients is a fundamental decision in both upholding antimicrobial stewardship and expediting discharge; the switch also reduces operational and financial pressures on the trust. The latest NHS planning guidance brings an intensified financial demand on the NHS and for this reason, more than ever, the cost-saving opportunities within effective IVOS should not be overlooked. Objectives To analyse the IV antibiotic prescribing against drug cost and highlight the cost saving opportunities if IVOS took place; and to identify the barriers preventing this in practice and make recommendations for improvement. Methods The patient list on IV antibiotics over 24 h was extracted from Business Intelligence (BI) and data was analysed against the electronic patient record (EPR) using the modified version of the UKHSA Antimicrobial IV-to-oral (IVOS) decision aid tools1 as a snapshot study across the whole hospitals. Patients on IV antibiotics for prophylaxis, antifungal and antiviral treatment and patients in intensive or high-dependency units are excluded in the study. Results Thirty-six out of 110 patients (33%) met the criteria1 for IVOS and the average length of IV antibiotic course was 5.7 days in total (range 2-21 days). Twenty-five patients (23%) were found to be able to switch to oral antibiotic(s) sooner than the audit day which meant that a total of 39 hospital-bed days could be saved if they were medically fit for discharge. Surgery in digestive tract used the highest volume of IV antibiotics which contributed to 14.5% of all IV antibiotic prescriptions (n=159), 53% of these patients were suitable for IVOS. The highest rate of IVOS was seen in acute medicine with 3 out of 5 patients have changed to oral antibiotics on the audit day. The most common reason for being unsuitable for IVOS was ‘one or more infection marker criteria not met’. The total expenditure of IV antibiotics was £5348.83 in which £1124.55 (21%) was spent on piperacillin-tazobactam; the most commonly used antibiotic in the study. Conclusions The results highlight key opportunities to maximize IVOS efficiency, by directing resources toward high IV antibiotic prescribing specialities such as GI Surgery and regular review of broad-spectrum antibiotics such as piperacillin-tazobactam. IVOS should be advocated through educational and training to the doctors and nurses, regular antimicrobial stewardship ward round and advocacy of IVOS through hospital staff communications. The use of artificial Intelligence should be maximized to help ‘detect’ the patients on IVOS whom met the criteria for oral switch and alert the clinical team for prompt review which could help reducing the unnecessary use of IV antibiotic and promote hospital discharge