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COFI Report Summary

Project ID: 602645
Funded under: FP7-HEALTH
Country: United Kingdom

Periodic Report Summary 2 - COFI (Comparing policy framework, structure, effectiveness and cost-effectiveness of functional and integrated systems of mental health care)

Project Context and Objectives:
Context and objectives
Mental disorders are a leading cause of disability in Europe and determine high health-care costs and loss of productivity. Optimal service organization is required to reduce this burden and maximize the effects of mental health care. Throughout Europe, countries are seeking to improve the organization of mental health care with often radical reforms. These reforms are associated with far reaching changes for the national health care systems and consume large amounts of funding and resources. Yet, the reforms are inconsistent, and all policies are currently made in the absence of sound scientific evidence. These service reforms and the related ongoing debate focus on one central and controversial issue, i.e. whether to privilege personal continuity of care or specialization of services.

In COFI we are addressing this question and comparing these two alternative systems of mental health care. The two systems can be summarized as follows:

1) Functional systems: different primary clinicians are responsible for the treatment of a patient, depending on whether the patient is in inpatient or outpatient care. In these systems the focus is on specialization of care.

2) Integrated systems: the same primary clinician is responsible for both the inpatient and outpatient care of a patient. These systems privilege personal continuity of care.

Integrated and functional systems already co-exist in some countries. This provides the unique chance to compare the effectiveness of the two systems independently of country specific context.

COFI is a natural experiment, prospectively comparing the two systems of mental health without altering routine care provision. The comparison considers clinical and social outcomes (rates of re-hospitalizations, quality of life, living arrangements and social contact), and quality, safety and cost-effectiveness of care. Personal experiences of patients and clinicians are also being explored as well as the national legislations and policies that support delivery of care within functional and integrated systems.

The comparison of the two mental health care systems is being carried out in a wide range of settings and in countries (Belgium, Germany, Italy, Poland and the UK) with different traditions and practices of mental health care. Functional and integrated systems are supported in these countries by a variety of funding mechanisms, policies and clinical arrangements. This will allow the generalisability of our findings from the participating countries to a higher number of countries with similar characteristics across Europe and beyond.

The research questions being addressed are:
a) Primary research question
i. Do rates of re-hospitalisation differ between the specialisation and personal continuity approaches?
b) Clinical and social outcomes
i. Is there a difference in number of voluntary and compulsory rehospitalisations per patient and yearly inpatient bed days between the two approaches?
ii. Are untoward incidents (deaths, suicides, physical violence committed or experienced by patients) more frequent in either approach?
iii. What are the social outcomes, in terms of employment, accommodation, living situation, subjective quality of life and social contacts of patients treated by either approach?
c) Costs of care:
i. What are the direct costs of care (i.e. related to use of services) within each approach?
ii. Which approach is most cost-effective?
d) Quality of care
i. Does adherence to national and international treatment guidelines, and clinical decision making vary between the two systems?
e) Experience of care
i. What are treatment satisfaction and the experience of care provided by the two approaches and do they differ?
f) National policies and legislations
g) What national policies and legislations on the organization of mental health care support the implementation of functional and integrated systems?
Project Results:
Since the beginning of the COFI project (Months 1-36) we have:
1) Completed baseline data collection by Month 23. 7777 patients in mental health services in the 5 participating countries were recruited. Appropriate measures were agreed and taken to ensure the attainment of high quality data on all outcomes, i.e. clinical and social outcomes; patient reported outcomes, indicators of quality of care and cost-effectiveness. Weekly figures were used to develop the CONSORT diagram detailing the number of people admitted, eligible, providing assent, providing consent and completing the baseline assessment across the project.

2) Finalised the baseline dataset following data checking and quality assurance. The Study Manager visited each partner site during the baseline period to check the quality of data and ensure adherence to the data entry protocol. At each visit 20% of data was double entered. Concordance between the two sets of data entry was calculated and was over 95% in all cases. Data cleaning included removing participants who were not eligible due to diagnosis and removing any duplicates e.g. where participants were admitted to multiple COFI hospitals and recruited into the study more than once. 7306 participants were included in the final baseline dataset. Data analysis is currently underway with a publication submitted comparing initial length of stay and satisfaction with care between functional and integrated services within the UK.

3) Finalised the procedures for follow-up. This included a) finalising all follow-up data collection materials for the main sample (all participants) and sub-sample (random sample of 360 patients per country), b) agreeing details for determining eligibility of participants into the sub-sample, c) defining the random selection procedures for sub-sample participants, d) updating or applying for ethical permission for the follow-up study in centres where this was required (UK) e) developing and piloting a follow-up database, f) developing a plan for quality assurance procedures and data entry, g) training researchers in the follow-up procedures, h) developing guidance on using medical records to extract data for the main sample and i) developing scripts to aid the follow-up of participants over the phone and face-to-face.

4) Commenced follow-up data collection in October 2015. To monitor data collection, an included participant log was developed, which recorded whether a participant recruited at baseline is a) eligible for follow-up, b)eligible for the sub-sample, c) eligible for the adherence sample, d) whether they were randomly selected for the subsample and e) follow-up progress including the attempts to contact the person and the date of any arranged interview. The included participant log is used to populate the weekly consort. At the end of the reporting period, 5973 patients had been successfully followed up. The sub-sample questions have been completed by 2175 participants of which 134 were included in the adherence sample.

5) Conducting interviews to assess the experience of both functional and integrated systems from the perspective of the patients and clinicians (WP9). Following piloting, the final interview schedule for both patients and clinicians was developed and qualitative data collection commenced. 149 patient and 46 clinician interviews have been conducted. Procedures for transcription and anonymization of interviews were agreed, and researchers were trained in the use of the qualitative data software package. Following the initial interviews, a project meeting was held in Warsaw and attended by all researchers involved in WP9. All sites coded interviews in English to enable discussion of the emerging themes. During the meeting, the procedures for coding were outlined and the initial codebook developed. The codebook has since been applied to interviews and refined as data collection has progressed. The consistency of coding across countries was checked.

Potential Impact:
We expect that COFI will provide high quality evidence on how to best organize mental health care. This evidence will be immediately translated in mental health service development as it is obtained through assessment of routine care provision. This evidence will combine a wide range of findings including clinical outcomes, quality of life, social outcomes, patient safety, quality of care, health and social needs, patients’ and professionals’ experience and cost-effectiveness.

COFI represents a new approach of high quality research on mental health care systems. It will provide, for the first time, sound and systematic research evidence for mental health care organization that has been generated across several European countries. It will produce clear indications for policy decision-making on mental health care and guide the re-organization of services on the basis of empirical data. The findings will also generate evidence on how to maximize satisfaction of patients with the care they receive and their quality of life. Data on the cost structure and cost-effectiveness of the two systems will contribute to the development of general strategies and specific methods to reduce the huge economic burden of mental disorders due to disability and loss of productivity.

COFI has a strong focus on translating generated evidence to inform policy decision-making to achieve a wide socio-economic impact. The project will contribute to the key areas stated in the EC Green paper on Mental Health through developing a network of exchange and cooperation between different Member States, increasing the coherence of actions in their health sectors and by involving a broad range of relevant stakeholders into building solutions. These activities will substantially contribute to the European Union’s potential to inform and promote best practice in addressing common mental health challenges at a policy level. Evaluating and optimizing mental health care organization may lead to an improvement in quality of life at a population level and a reduction of direct (treatment costs) and indirect costs (loss of productivity) of mental illness.

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