A critical appraisal of the literature. Marita Broadstock. New Zealand Health Technology Assessment

Transcription

1 NZHTA REPORT 22 May 2002 Suicide prevention topic 12: What is the efficacy of discharge planning protocols, i.e., managing the transition from hospital to community? What should be included in the plan? A critical appraisal of the literature Marita Broadstock New Zealand Health Technology Assessment Department of Public Health and General Practice Christchurch School of Medicine Christchurch, NZ. Division of Health Sciences, University of Otago

2 NEW ZEALAND HEALTH TECHNOLOGY ASSESSMENT (NZHTA) THE CLEARING HOUSE FOR HEALTH OUTCOMES AND HEALTH TECHNOLOGY ASSESSMENT Department of Public Health and General Practice Christchurch School of Medicine and Health Sciences Christchurch, New Zealand Suicide prevention topic 12: What are the efficacy of discharge planning protocols, i.e., managing the transition from hospital to community? What should be included in the plan? A critical appraisal of the literature Marita Broadstock NZHTA REPORT 22 May 2002

3 This report should be referenced as follows: Broadstock M. Suicide prevention topic 12: What is the efficacy of discharge planning protocols, i.e., managing the transition from hospital to community? What should be included in the plan? NZHTA Report New Zealand Health Technology Assessment (NZHTA) ISBN

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5 i ACKNOWLEDGEMENTS This review was commissioned by the Suicide Working Group of the New Zealand Guidelines Group (NZGG). The staff of NZHTA developed this review. Critical appraisal and report preparation was undertaken by Ms Marita Broadstock (Researcher). The literature search strategy was developed and undertaken by Ms Margaret Paterson (Information Specialist). Ms Philippa Monkman and Miss Becky Mogridge assisted with the retrieval of articles. Mrs Ally Reid (Secretary/Word Processor) provided document formatting. Internal peer review was provided by Dr Ray Kirk. Dr Annette Beautrais (Consultant) provided invaluable input on technical and methodological issues, and peer review. Ms Emma Suttich (NZGG) facilitated liaison with the NZGG. The Canterbury Medical Library provided invaluable assistance with the retrieval of articles used in this report. NZHTA is a Research Unit of the University of Otago funded under contract to the Ministry of Health. DISCLAIMER NZHTA takes great care to ensure the information supplied within the project timeframe is accurate, but neither NZHTA nor the University of Otago can accept responsibility for any errors or omissions. The reader should always consult the original database from which each abstract is derived along with the original articles before making decisions based on a document or abstract. All responsibility for action based on any information in this report rests with the reader. NZHTA and the University of Otago accept no liability for any loss of whatever kind, or damage, arising from reliance in whole or part, by any person, corporate or natural, on the contents of this report. This document is not intended to be used as personal health advice. People seeking individual medical advice are referred to their physician. The views expressed in this report are those of NZHTA and do not necessarily represent those of the University of Otago. COPYRIGHT This work is copyright. Apart from any use as permitted under the Copyright Act 1994 no part may be reproduced by any process without written permission from New Zealand Health Technology Assessment. Requests and inquiries concerning reproduction and rights should be directed to the Director, New Zealand Health Technology Assessment, Christchurch School of Medicine and Health Sciences, P O Box 4345, Christchurch, New Zealand. CONTACT DETAILS New Zealand Health Technology Assessment The Clearing House for Health Outcomes and Health Technology Assessment Department of Public Health and General Practice Christchurch School of Medicine and Health Sciences P O Box 4345 Christchurch New Zealand Tel: Fax: nzhta@chmeds.ac.nz Web Site:

6 ii TABLE OF CONTENTS ACKNOWLEDGEMENTS... i DISCLAIMER... i COPYRIGHT... i CONTACT DETAILS... i TABLE OF CONTENTS...ii LIST OF TABLES...iii LIST OF ACRONYMS AND ABBREVIATIONS... iv METHODS 1 STUDY SELECTION... 1 Study inclusion criteria...1 Study exclusion criteria...1 SEARCH STRATEGY... 2 Principal sources of information...2 Search terms used...2 STUDY SELECTION... 3 EVIDENCE TABLES... 3 APPRAISAL METHODOLOGY... 3 STUDY LIMITATIONS 5 RESULTS 7 REFERENCES 9 APPENDIX 1: SEARCH STRATEGIES 11 MEDLINE EMBASE PSYCHINFO CINAHL CURRENT CONTENTS OTHER SOURCES APPENDIX 2: BIBLIOGRAPHY OF EXCLUDED STUDIES 15 EXCLUDED, RETRIEVED STUDIES... 15

7 iii LIST OF TABLES No evidence tables were produced for this question.

8 iv LIST OF ACRONYMS AND ABBREVIATIONS ED Emergency Department NZ New Zealand NZGG New Zealand Guidelines Group NZHTA New Zealand Health Technology Assessment RCT Randomised Controlled Trial SIGN Scottish Intercollegiate Guidelines Network

9 1 Methods STUDY SELECTION The development of this systematic review involved consultation between the NZHTA and the Suicide Working Group. Study inclusion criteria Publication type Studies published between 1990 and 17 April 2002 inclusive in the English language, including primary (original) research (published as full original reports) and secondary research (systematic reviews and meta-analyses) appearing in the published literature. Population Studies reporting on persons discharged following suicide attempt, expressing suicidal ideation, or suicide threat. Setting Studies set in emergency departments (including trauma centres in the United States) or tertiary mental health services i.e., sub-specialty mental health/psychiatric services and not general psychiatric clinics or hospitals. Intervention Studies which described, and evaluated the efficacy of, discharge planning protocols; that is, formal plans, procedures, guidelines or codes which deal with managing the transition from hospital to community of patients post-discharge. Study design Studies employing one of the following designs: systematic review or meta-analysis randomised controlled trial (RCT) controlled clinical trial (CCT) cohort study case-control study quasi experimental e.g., before and after study descriptive study. Sample size Studies with samples of at least six participants. Study exclusion criteria The following criteria was used to exclude studies from appraisal: study population concerned: - primarily (50% or more) those with deliberate self harm in the absence of suicide intent - primarily (50% or more) those involved in assisted suicide - primarily (50% or more) presentations for self-mutilation

10 2 - primarily (50% or more) children 12 years of age and under - homicidal people - criminal offenders studies concerned with: - primarily a population with underlying personality and affective disorders (and therefore, potential confounder of study results and treatments) - the treatment of people with drug/substance abuse or dependence, that is treatment directed their addiction rather than any suicide attempt - suicide prevention interventions specifically for people with HIV/AIDS - school-based suicide prevention interventions - economic analysis studies involved small numbers of case presentations (five or fewer cases) studies did not clearly describe their methods and results, or had significant discrepancies citations which were letters to the editor, comments, editorials, abstract only, conference proceedings. SEARCH STRATEGY A systematic method of literature searching and selection was employed in the preparation of this review. Searches were limited to English language material published from 1990 onwards. The searches were completed on 17 April Principal sources of information The following databases were searched using the search strategy outlined in Appendix 1: Search strategies. Bibliographic databases Medline Embase Cinahl Psychinfo Current Contents Science/Social Science Citation Index Index New Zealand Review databases Evidence-based medicine reviews Cochrane Database of Systematic Reviews DARE NHS Economic Evaluation Database Health Technology Assessment Database The search was restricted to information from 1990 in English. Hand searching of journals, or contacting of authors for unpublished research was not undertaken during the search process. Search terms used Medline subject terms (MeSH terms): suicide, suicide-attempted, patient discharge.

11 3 Cinahl subject terms: suicide, suicide-attempted, discharge planning, patient discharge, after care. Psychinfo subject terms: suicide, suicide-attempted, suicide prevention, suicide prevention centers, hospital discharge, psychiatric hospital discharge, discharge planning, treatment termination, posttreatment followup. Embase subject terms: suicide, suicide-attempted, hospital discharge, aftercare. Additional keywords: suicidal ideation, suicidal, parasuicide, suicid* near threat*, discharge*, discharge near (plan or planning), (follow-up or aftercare) near (plan or planning or protocol), hospital near outpatient, hospital near community, inpatient near community, inpatient near outpatient, disposition planning. STUDY SELECTION Studies were selected for appraisal using a two-stage process. Initially, the titles and abstracts (where available) identified from the search strategy, were scanned for eligibility. The Researcher (MB) performed selection of articles for retrieval. Because of the lack of reviewable references from the search for studies on discharge planning or protocols, the search was extended to include articles which discussed transition from inpatient to outpatient, or from hospital to the community without actually mentioning the word discharge. A further search was made on the words "disposition planning" as this phrase was encountered in one article. These efforts were not successful in locating any studies suitable for review. EVIDENCE TABLES As no relevant literature was identified via the formal search strategies, an evidence table was not produced for this question (see above section and section Study Limitations). APPRAISAL METHODOLOGY For this question no articles were formally appraised. For this project as a whole (i.e., all other suicide prevention topics) the following process was used: Articles were formally appraised using the checklist schedules and hierarchy of evidence coding system developed by the Scottish Intercollegiate Guidelines Network (SIGN). Validated criteria were used to appraise the studies selected for review. Key facets of the selected studies (including limitations) were documented in the text. Conclusions were drawn based on the study design and the specific problems associated with individual studies. The evidence presented in the selected studies were assessed and classified according to the SIGN grades of guideline recommendation by the suicide prevention guideline group.

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13 5 Study limitations The transition from inpatient to outpatient settings can be a time of increased risk for suicidal patients (King et al. 2001). This topic concerns the efficacy of discharge planning protocols in managing the transition from the hospital (ED or tertiary mental health setting) to the community of patients presenting for suicidality. Unfortunately, there was no research identified addressing this question other than through expert opinion and the reporting of small case studies, and these only indirectly. Literature identified in the search strategy of peripheral relevance pertained to evaluating follow-up and treatment interventions (already covered in Topic 1), compliance with follow-up, liability for premature discharge, or whether health contacts predict future suicide attempts. However, there was no research identified investigating whether having a discharge plan itself affects suicidality outcomes. As efficacy was not demonstrated, it was therefore not possible to discuss what should be included in discharge plans. This review has been limited by the restriction to English language studies. Restriction by language may result in study bias, but the direction of this bias cannot be determined. In addition, the review has been limited to the published academic literature, and has not appraised unpublished work. Restriction to the published literature is likely to lead to bias since the unpublished literature tends to consist of studies not identifying a significant result. Papers published pre-1990 were not considered. The NZGG will need to assess whether the new evidence presented in this review is sufficient to alter any recommendations included in previous evidence-based guidelines. The review was limited to ED or tertiary mental health settings. Research from other settings may have investigated the impact of discharge planning protocols on suicidality beyond the scope of this topic 1. The studies were initially selected by examining the abstracts of these articles. Therefore, it is possible that some studies were inappropriately excluded prior to examination of the full text article. Studies considered did not tend to consider discharge planning protocols as their focus. Whilst it is possible that the existence of a discharge planning protocol could be investigated as a possible predictor of suicidality in a study and not reported in an abstract, the lack of reporting is likely to be biased toward an absence of any significant relationship. The lack of relevant research identified in secondary literature, including narrative reviews, on this topic increases our confidence that research eligible for review was not missed. Data extraction and report preparation was performed by a single reviewer. The review scope was developed with the assistance of Ms Emma Suttich (NZGG) and Dr Annette Beautrais. This review was conducted over a limited timeframe (April 2002 May 2002). 1 For example, a retrospective case-control study of 234 patients who died within one year of discharge from inpatient psychiatric clinics identified unplanned discharge as a risk factor for suicide (Baldwin et al. 2000; King et al. 2001). However, this study was not critically appraised as it did not meet selection criteria for this review.

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15 7 Results There were 135 studies identified by the search strategy. Thirteen full text articles were eligible for retrieval after excluding studies from the search titles and abstracts. Of these, all 11 retrieved full text articles did not fulfil the inclusion criteria and are presented in Appendix 2, with a brief description of their reason for exclusion. Papers were excluded for several reasons: not relevant as discharge planning was not evaluated (n=4), providing Level 4 (expert opinion, narrative review) evidence only (n=2), study not conducted in ED or tertiary mental health setting (n=3, two reporting on one study), case studies (n=2). A further two references were a book chapter and dissertation not available for retrieval in the timeframe.

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17 9 References Baldwin, D. S., Sinclair, J. M. A., & King, E. E. (2000). The Wessex recent Inpatient Suicide Study: 1. Case-control study of 234 recently discharged psychiatric inpatient suicides. European Psychiatry, 15, 407S-407S. King, E. A., Baldwin, D. S., Sinclair, J. M., Baker, N. G., Campbell, M. J., & Thompson, C. (2001). The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides. British Journal of Psychiatry, 178,

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19 11 Appendix 1: Search strategies MEDLINE 1 suicide/ or suicide attempted/ (23228) 2 suicidal ideation.mp. (994) 3 (suicidal or parasuicide or (suicid$ adj3 threat$)).mp. (6431) 4 or/1-3 (24656) 5 Patient Discharge/ (8665) 6 discharge$.mp. (66199) 7 5 or 6 (69537) 8 4 and 7 (441) 9 limit 8 to english (359) 10 limit 9 to yr= (258) 11 from 10 keep (selected references) (40) 12 ((discharge adj3 plan) or (discharge adj3 planning)).mp. (1309) 13 4 and 12 (8) 14 from 13 keep (selected references) or 14 (42) 16 (follow-up or aftercare).ti,ab. (245042) 17 (plan or planning or protocol$).mp. (191032) and 17 (14306) 19 4 and 18 (43) 20 (hospital adj5 community).mp. (8937) 21 (inpatient adj5 outpatient).mp. (2843) 22 (inpatient adj5 community).mp. (391) 23 (hospital adj5 outpatient).mp. (3524) 24 or/20-23 (14985) 25 4 and 24 (117) or 25 (158) 27 limit 26 to yr= (103) 28 limit 27 to english (93) 29 letter.pt. or case reports/ ( ) not 29 (80) not 10 (62) 32 from 31 keep (selected references) (5) 33 disposition planning.mp. (5) or 14 or 11 (47) EMBASE 1 suicide/ or suicide attempted/ (10990) 2 suicidal ideation.mp. (845) 3 (suicidal or parasuicide or (suicid$ adj3 threat$)).mp. (4343) 4 or/1-3 (12724) 5 discharge$.mp. (44481) 6 ((discharge adj3 plan) or (discharge adj3 planning)).mp. (403) 7 hospital discharge/ (5231) 8 or/5-7 (45543) 9 4 and 8 (334) 10 limit 9 to english (290) 11 limit 10 to yr= (266) 12 follow-up.mp. (202681) 13 (plan or planning or protocol$).mp. (97386)

20 and 13 (8440) 15 3 and 14 (19) 16 AFTERCARE/ (471) 17 4 and 16 (18) or 17 (37) 19 limit 18 to english (36) 20 limit 19 to yr= (31) or 20 (287) 22 from 21 keep (selected references) 23 from 22 keep (selected references)(37) 24 ((hospital adj5 community) or (hospital adj5 outpatient)).ti,ab. (6827) 25 ((inpatient adj5 community) or (inpatient adj5 outpatient)).ti,ab. (2267) or 25 (8734) 27 4 and 26 (87) 28 limit 27 to english (80) 29 limit 28 to yr= (76) not 21 (59) 31 from 30 keep (selected references) PSYCHINFO 1 suicide/ (8799) 2 suicide, attempted/ (3935) 3 suicidal ideation/ (1500) 4 suicide prevention/ or suicide prevention centers/ (1409) 5 ((suicid$ adj3 threat$) or suicidality).mp. (1376) 6 parasuicid$.mp. (500) 7 or/1-6 (13515) 8 hospital discharge/ or psychiatric hospital discharge/ or discharge planning/ or treatment termination/ (2380) 9 aftercare/ or posttreatment followup/ (1444) 10 8 or 9 (3684) 11 7 and 10 (84) 12 limit 11 to yr= (51) 13 limit 12 to english (50) 14 from 13 keep 10,25,28-30,35,39-40 (8) 15 discharg$.mp. (11252) 16 (plan or plans or planning or protocol$).mp. (39639) and 16 (765) 18 7 and 17 (33) not 11 (26) 20 limit 19 to yr= (17) 21 limit 20 to english (16) 22 from 21 keep (selected references) or 22 (13) 24 (hospital adj5 community).ti,ab. (1830) 25 (hospital adj5 outpatient).ti,ab. (705) 26 (inpatient adj5 community).ti,ab. (372) 27 (inpatient adj5 outpatient).ti,ab. (1530) 28 or/24-27 (4141) 29 7 and 28 and 15 (6) 30 from 29 keep (selected references)

21 13 CINAHL 1 suicide/ or suicide, attempted/ (1867) 2 suicidal ideation.mp. (280) 3 (suicidal or parasuicid$ or (suicid$ adj3 threat$)).mp. (513) 4 or/1-3 (2110) 5 Discharge Planning/ or Patient Discharge/ (3229) 6 4 and 5 (17) 7 discharg$.mp. (6879) 8 After Care/ (1086) 9 (plan or plans or protocol$ or planning).mp. (21924) 10 7 or 8 (7647) 11 9 and 10 (1329) 12 4 and 11 (3) 13 ((hospital adj5 outpatient) or (hospital adj5 community)).mp. (2134) 14 ((inpatient adj5 outpatient) or (inpatient adj5 community)).mp. (496) or 14 (2565) 16 4 and 15 (9) 17 6 or 12 or 16 (28) 18 limit 17 to yr= (28) 19 from 18 keep (selected references)(6) 20 suicid$.mp. (3143) 21 7 and 20 (43) 22 limit 21 to yr= (43) not 18 (28) 24 from 23 keep (selected references) or 24 (9) CURRENT CONTENTS 1 suicid$.mp. (13636) 2 discharg$.mp. (66409) 3 1 and 2 (250) 4 aftercare.mp. (552) 5 1 and 4 (35) 6 ((inpatient adj5 community) or (inpatient adj5 outpatient)).ti,ab. (1655) 7 ((hospital adj5 community) or (hospital adj5 outpatient)).ti,ab. (4828) 8 6 or 7 (6216) 9 1 and 8 (80) 10 3 or 5 or 9 (342) 11 limit 10 to english (317) 12 letter.pt. (373136) not 12 (315) 14 (schizophren$ or personality disorder$ or depression).ti. (26887) not 14 (263) 16 from 15 keep (selected references) (7) 17 from 15 keep (163) 18 from 17 keep (selected references)(13) or 18 (20) 20 parasuicid$.mp. (358) 21 2 or 4 (66862) and 21 (29) 23 8 and 20 (5) or 23 (31) not 10 (3) 26 from 25 keep (selected references) or 26 (21)

22 14 OTHER SOURCES Other databases and sources for which index terms were not available were searched free text combinations of vocabulary drawn from the index terms and additional keywords contained in the strategies above.

23 15 Appendix 2: Bibliography of excluded studies EXCLUDED, RETRIEVED STUDIES The following papers were reviewed but rejected for inclusion in the analysis (reasons for exclusion follow): Antonowicz, J. L., Taylor, L. H., Showalter, P. E., Farrell, K. J., & Berg, S. (1997). Profiles and treatment of attempted suicide by self-immolation. General Hospital Psychiatry, 19, Not relevant to topic as discharge planning not discussed or evaluated. Instead the study briefly describes the cases of seven patients who had attempted suicide by self-immolation, their treatment, after-care and whether they were perceived as being improved, as well as, or worse than before the suicide attempt (based on brief interview with patient or family member). Baldwin, D. S., Sinclair, J. M. A., & King, E. E. (2000). The Wessex recent Inpatient Suicide Study: 1. Case-control study of 234 recently discharged psychiatric inpatient suicides. European Psychiatry, 15, 407S-407S. A one page summary of King (2001), not ED or tertiary mental health setting (psychiatric inpatients retrospectively traced back from mortality data). Berman, A. L., Kleespies, P. M., Marshall, S. C., Pokrajac, T., Amodio, R., & Goldblatt, M. J. (1994). The transition from inpatient to outpatient care. Suicide & Life-Threatening Behavior, 24, Case study (n=1). Brent, D. A., & Shaffer, D. (2001). Assessment and treatment of the youthful suicidal patient. Annals of the New York Academy of Sciences, 932, Expert opinion, narrative review. Dennehy, J. A., Appleby, L., Thomas, C. S., & Faragher, E. B. (1996). Case-control study of suicide by discharged psychiatric patients. BMJ, 312, Not relevant to topic as discharge planning not evaluated. This case control study investigates risk factors for suicide. Hulten, A., Wasserman, D., Hawton, K., Jiang, G. X., Salander-Renberg, E., Schmidtke, A., Bille- Brahe, U., et al. (2000). Recommended care for young people (15-19 years) after suicide attempts in certain European countries. European Child & Adolescent Psychiatry, 9,

24 16 Not relevant to topic. The study found that suicide attempters were more likely to receive aftercare than non-suicide attempters. However, outcomes post aftercare were not measured and discharge planning protocols were not discussed. King, E. A., Baldwin, D. S., Sinclair, J. M., Baker, N. G., Campbell, M. J., & Thompson, C. (2001). The Wessex Recent In-Patient Suicide Study, 1. Case-control study of 234 recently discharged psychiatric patient suicides. British Journal of Psychiatry, 178, Not ED or tertiary mental health setting (psychiatric inpatients retrospectively traced back from mortality data). Lewin, R., & Sharfstein, S. S. (1990). Managed care and the discharge dilemma. Psychiatry, 53, ; discussion Case study (n=1). Moeller, H. J. (1992). Attempted suicide: Efficacy of different aftercare strategies. International Clinical Psychopharmacology, 6 Suppl 6, Narrative review. Sherman, M. E., Burns, K., Ignelzi, J., Raia, J., Lofton, V., Toland, D., Stinson, B., et al. (2001). Firearms risk management in psychiatric care. Psychiatric Services, 52, Not ED or tertiary mental health setting (committed psychiatric inpatients). Suominen, K. H., Isometsa, E. T., Ostamo, A. I., & Lonnqvist, J. K. (2002). Health care contacts before and after attempted suicide. Social Psychiatry & Psychiatric Epidemiology, 37, Not relevant to topic as discharge planning not evaluated. This study looked at health contacts before and after suicide attempts for patients treated in Helsinki ED s over 12 months. Peripherally relevant to this study was the finding that suicide attempters who were not referred to aftercare were less likely to be receiving treatment after their suicide attempt, although outcomes of suicidality were not measured. Not able to be retrieved in time for inclusion in review Moonshine, C. (1999). Outcome of partial hospitalisation treatment for suicidal older adults. Dissertation Abstracts International: Section B: the Sciences and engineering, 60, Silverman, M. M., Berman, A. L., Bongar, B., Litman, R. E., & Maris, R. W. (1998). Inpatient standards of care and the suicidal patient. Part II. An integration with clinical risk management. In B. Bongar & A. L. Berman (Eds.), Risk management with suicidal patients (pp ). New York: The Guildford Press.