Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial

Jesus Perez, Huajie Jin, Debra A. Russo, Jan Stochl, Michelle Painter, Gill Shelley, Erica Jackson, Carolyn Crane, Jonathan P. Graffy, Tim J. Croudace, Sarah Byford, Peter B. Jones (Lead / Corresponding author)

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Abstract

Background: General practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness.

Methods: Our Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866.

Findings: Between Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05-3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9-5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1-3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3-5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26785 in high-intensity practices, £27840 in low-intensity practices, and £30007 in PAU practices.

Interpretation: This intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Funding: UK National Institute for Health Research.

Original languageEnglish
Pages (from-to)984-993
Number of pages10
JournalLancet Psychiatry
Volume2
Issue number11
Early online date19 Aug 2015
DOIs
Publication statusPublished - Nov 2015

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Secondary Care
Psychotic Disorders
Cost-Benefit Analysis
Primary Health Care
Randomized Controlled Trials
Referral and Consultation
Polytetrafluoroethylene
Costs and Cost Analysis
Decision Support Techniques
National Institutes of Health (U.S.)
General Practice
General Practitioners
Registries
Mental Health
Guidelines
Education
Incidence
Health
Research

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Perez, Jesus ; Jin, Huajie ; Russo, Debra A. ; Stochl, Jan ; Painter, Michelle ; Shelley, Gill ; Jackson, Erica ; Crane, Carolyn ; Graffy, Jonathan P. ; Croudace, Tim J. ; Byford, Sarah ; Jones, Peter B. / Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study) : a cluster-randomised controlled trial. In: Lancet Psychiatry. 2015 ; Vol. 2, No. 11. pp. 984-993.
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abstract = "Background: General practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness. Methods: Our Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866. Findings: Between Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95{\%} CI 1·05-3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9-5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1-3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3-5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26785 in high-intensity practices, £27840 in low-intensity practices, and £30007 in PAU practices. Interpretation: This intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Funding: UK National Institute for Health Research.",
author = "Jesus Perez and Huajie Jin and Russo, {Debra A.} and Jan Stochl and Michelle Painter and Gill Shelley and Erica Jackson and Carolyn Crane and Graffy, {Jonathan P.} and Croudace, {Tim J.} and Sarah Byford and Jones, {Peter B.}",
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Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study) : a cluster-randomised controlled trial. / Perez, Jesus; Jin, Huajie; Russo, Debra A.; Stochl, Jan; Painter, Michelle; Shelley, Gill; Jackson, Erica; Crane, Carolyn; Graffy, Jonathan P.; Croudace, Tim J.; Byford, Sarah; Jones, Peter B. (Lead / Corresponding author).

In: Lancet Psychiatry, Vol. 2, No. 11, 11.2015, p. 984-993.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study)

T2 - a cluster-randomised controlled trial

AU - Perez, Jesus

AU - Jin, Huajie

AU - Russo, Debra A.

AU - Stochl, Jan

AU - Painter, Michelle

AU - Shelley, Gill

AU - Jackson, Erica

AU - Crane, Carolyn

AU - Graffy, Jonathan P.

AU - Croudace, Tim J.

AU - Byford, Sarah

AU - Jones, Peter B.

PY - 2015/11

Y1 - 2015/11

N2 - Background: General practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness. Methods: Our Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866. Findings: Between Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05-3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9-5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1-3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3-5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26785 in high-intensity practices, £27840 in low-intensity practices, and £30007 in PAU practices. Interpretation: This intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Funding: UK National Institute for Health Research.

AB - Background: General practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness. Methods: Our Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866. Findings: Between Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05-3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9-5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1-3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3-5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26785 in high-intensity practices, £27840 in low-intensity practices, and £30007 in PAU practices. Interpretation: This intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Funding: UK National Institute for Health Research.

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