Using HoNOS to assess outcomes in perinatal services
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1 Using HoNOS to assess outcomes in perinatal services Comparison of a perinatal inpatient service and a community team with other services Alastair Macdonald South London & Maudsley NHS Foundation Trust
2 Rationale for this analysis Clinical Example of issues in comparing outcomes across teams Systematic Development of routine analysis of routine outcomes data Product of semi-automatic programs: step-wise development Provision of better datasets to sit underneath dashboards like PowerBI or Tableau Free added extra Show change in Crittenden CARE-Index: mother infant interactions
3 ... Bonus: a new non-crom non-prom outcome measure Crittenden CARE-Index Videos taken at start and end of episode of care Interactions rated 2 Raters for each video High levels of inter-rater reliability (80% min agreement) but differences then resolved by consensus Domains Maternal sensitivity Maternal unresponsiveness Maternal controlling behaviour Infant co-operativeness Infant passivity Infant difficultness
4 The 3 dimensions of RCOM Condition / Context / Case-mix (Diagnosis, Ethnicity, Gender etc) Outcome Comparison of health status at the start and completion of episode Interventions
5 HoNOS change reported today Episodes of care- not patients One inpatient mother and baby unit Admissions from 22-Oct closed episodes; currently 14 active One community perinatal mental health team Referrals from 19-May discharged episodes; currently 147 active Closed episodes only for outcomes analysis
6 Compared with: Inpatient unit All women in same age range at admission admitted over the same period to acute inpatient units excluding PICUs and Triage wards 9145 discharged episodes Community team All women in the same age range referred over the same period to assessment or home treatment teams closed episodes
7 Context- age EMBARGOED
8 Context- ethnicity...
9 Context- ethnicity... Other other!
10 Context- diagnosis
11 Context- other diagnosis
12 Context- severity at onset
13 Context- length of episode...
14 The 3 dimensions of RCOM Condition / Context / Case-mix (Diagnosis, Ethnicity, Gender etc) Outcome Comparison of health status at the start and completion of episode Interventions
15 The 3 dimensions of RCOM Condition / Context / Case-mix (Diagnosis, Ethnicity, Gender etc) Outcome Comparison of health status at the start and completion of episode Interventions
16 Outcomes=change; from start to end of episode- min 2 ratings needed
17
18 Are episodes with outcomes data representative of all episodes? Or is there... BIAS?
19 Age
20 Ethnic Group
21 Diagnosis
22 Initial HoNOS score The most powerful determinant of change
23 So the following may have led to bias In perinatal teams more pairs in depression and affective psychosis than other diagnoses, whereas in other teams more in non-affective psychosis In all teams except perinatal inpatient, more pairs of ratings in older women than younger In perinatal teams more pairs of ratings in nonblack than in black ethnic groups In all teams more pairs of ratings with higher initial HoNOS scores (community and inpatient)
24 Comparison of outcomes
25 Outcomes a) Change in mean total HoNOS score
26 Outcomes b) HoNOS profile change
27 Comparison of inpatient units
28 Comparison of community services
29 Comparison of HoNOS profile change by diagnosis
30 Non-affective psychosis: inpatient teams
31 Depression: community teams
32 Outcomes profiles by ethnic group
33 Ethnic group: community teams
34 Ethnic group: community teams
35 Outcomes c) Categorical change
36
37 Stays below cut
38 Stays below cut Moves to below cut
39 Stays below cut Moves to below cut Stays above cut
40 Stays below cut Moves above cut Moves to below cut Stays above cut
41 Comparison of inpatient units
42 Comparison of community teams
43 Comparison of HoNOS categorical change by diagnosis
44 Non-affective psychosis: inpatient teams
45 Depression: community teams
46 Summary of HoNOS changes A simple reading of mean HoNOS change suggest that perinatal inpatient and community services have significantly better outcomes than generic teams dealing with women of the same age But there is possible bias in all teams And the more you look into context differences, the more difficult it is to sustain any global message about outcomes
47 So.. Comparison of teams is very difficult indeed, and thus presumably comparison of services or providers The central point of outcomes measurement is to encourage reflective practice within teams Comparisons are only useful either in the spirit of gentle rivalry, or to stimulate deeper enquiry within teams
48 Non-CROM-non-PROM outcomes ncnprom?
49 ... Bonus: a new non-crom non-prom outcome measure Crittenden CARE-Index Videos taken at start and end of episode of care Interactions rated 2 Raters for each video High levels of inter-rater reliability (80% min agreement) but differences then resolved by consensus Domains Maternal sensitivity Maternal unresponsiveness Maternal controlling behaviour Infant co-operativeness Infant passivity Infant difficultness
50 Depression: N=40
51 fin
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