NICE UPDATE - Eating Disorders: The 2018 Quality Standard. Dr A James London 2018

Transcription

1 NICE UPDATE - Eating Disorders: The 2018 Quality Standard Dr A James London 2018

2 Background

3 Estimated number of people aged 16 years or older with eating disorders in England Description Percentage of total population aged 16 years or older Number of people Total population in England aged 16 years or older 44,381,213 Prevalence of anorexia nervosaa ,300 Prevalence of bulimia nervosaa 1 443,800 Prevalence of binge eating disordera 3.2 1,398,000 Prevalence of other specified feeding and eating disordersa 3 1,309,000 a Solmi F, Hatch S L, Hotopf M, Treasure J and Micali N (2014) Prevalence and correlates of disordered eating in a general population sample: the South East London Community Health (SELCoH) study. Social Psychiatry and Psychiatric Epidemiology 49: and Solmi F, Hatch S L, Hotopf M, Treasure J and Micali N (2016) Eating disorders in a multi-ethnic inner-city UK sample: prevalence, comorbidity and service use. Social Psychiatry and Psychiatric Epidemiology 51 (3):

4 NHS costs of specialised eating disorder services in 2015/16 Description Activity (days) Unit cost Cost (000) Adult admitted patient 87, ,653 Adult community contacts 65, ,966 Adult outpatient 51, ,646 Children admitted patient 14, ,403 Children community contact 32, ,202 Children outpatient 38, ,171 Total 290,504 83,041 NHS reference costs 2015 to 2016: mental health services

5 Mortality Following Hospital Discharge with a Diagnosis of Eating Disorder: National Record Linkage Study, England, Hoang, et al. The International journal of Eating Disorders, 2014, 47:507. The standardized mortality ratio (SMR) for adolescents and young adults with a diagnosis of ED is 7.8 (95% confidence interval: ). This compares with an SMR for people of the same age with schizophrenia of 10.2 ( ), bipolar disorder 3.6 ( ), depression 4.5 ( ).

6 Access and Waiting Time Standard for Children and Young People with an Eating Disorder Commissioning Guide Version 1.0 July 2015

7 Eating disorders are serious mental health problems. They can have severe psychological, physical and social consequences. Children and young people with eating disorders often have other mental health problems (for example, anxiety or depression), which also need to be treated in order to get the best outcomes. Children and young people with eating disorders, and their families and carers, should be involved at every stage of the commissioning process as well as service delivery and design to ensure services are developed that meet their immediate and future needs.

8 The availability of dedicated, community eating-disorder services has been shown to improve outcomes and cost effectiveness. If a child or young person starts their treatment in a general child and adolescent mental health service (CAMHS), they are more likely to be admitted to an inpatient service than those treated in community eating-disorder settings within the following year. The sooner someone with an eating disorder starts an evidence-based NICE-concordant treatment the better the outcome. The standard is for treatment to be received within a maximum of 4 weeks from first contact with a designated healthcare professional for routine cases and within 1 week for urgent cases. In cases of emergency, the eating disorder service should be contacted to provide support within 24 hours.

9 Services need to be able to respond to the broader needs of families and carers as well as the child or young person with an eating disorder. This might include supporting the family with techniques to help manage eating disorders in young people, and information about additional support services or expert advice. Providers of eating disorder services will be required to demonstrate that they deliver evidence-based, high-quality care. This can be supported through the membership of a national quality improvement and accreditation network to produce transparent and accessible data for all stakeholders, including the general public. This will enable providers to assess and continue to improve the quality of care they provide, and ultimately become accredited services.

10 Training commissioned at a national level will be offered to improve clinical and management skills specifically to meet the needs of children and young people with an eating disorder, and the needs of their family where appropriate. This is vital to providing a viable service that focuses on continuous improvement.

11 Quality Standards and their Development

12 Standards and Indicators Quality standards set out the priority areas for quality improvement in health and social care. They cover areas where there is variation in care. Each standard gives you: a set of statements to help you improve quality information on how to measure progress.

13 How are they developed? Quality standards are developed independently, in collaboration with health and social care professionals, practitioners and service users. They are based on NICE guidance and other NICE-accredited sources.

14 Who are they for? Anyone wanting to improve the quality of health and care services. For example: Commissioners Service providers Health, public health and social care practitioners. Regulators

15 Are they mandatory? No. But they can be used to plan and deliver services to provide the best possible care. They support the government's vision for a health and care system focused on delivering the best possible health outcomes.

16 Conduct an initial assessment An initial assessment of services against a quality standard will help you plan quality improvement projects. Each standard contains statements that describe priority areas for improvement. Assess each statement to understand: whether the statement is relevant to your service how current services compare with the statement the source of the evidence to support this what actions or resources would be needed in order to improve the service so that it meets the statement an initial high-level assessment of risk associated with not making these improvements. This assessment can support discussions between commissioners and providers about local quality improvement incentive schemes (including the local commissioning for quality and innovation [CQUIN] scheme in the NHS).

17 Measure the quality of care Quality standards contain associated quality measures to help you: measure levels of care develop tools and metrics measure quality improvement after implementing changes. Measurement is essential to show that changes to care or services have resulted in an improvement. It's a key part of the Plan-Do- Study-Act (PDSA) improvement cycle. If measurement shows there has been no improvement, you need to adapt the change - or try something different.

18 Mind the Gap. Identify gaps and areas for improvement Compare the care you provide or commission against quality standards to help you: understand the priority areas to focus on for quality improvement identify and prioritise improvement priorities for the coming year or business cycle identify potential areas for local audit inform local joint strategic needs assessments (JSNAs). identify decommissioning options by highlighting potential for cost saving or identifying services that are of poor quality.

19 Quality statements Statement 1 People with anorexia nervosa have a discussion about their options for first-line psychological treatment. Statement 2 People with binge eating disorder participate in guided self-help programmes as first-line psychological treatment. Statement 3 Children and young people with bulimia nervosa participate in bulimia- nervosa-focused family therapy. Statement 4 People with eating disorders and comorbidities have the impact of all their treatments monitored using outcome measures.

20 Questions about the quality standard: Question 1 Does this draft quality standard accurately reflect the key areas for quality improvement? Question 2 Are local systems and structures in place to collect data for the proposed quality measures? If not, how feasible would it be for these to be put in place? Question 3 Do you think each of the statements in this draft quality standard would be achievable by local services given the net resources needed to deliver them? Please describe any resource requirements that you think would be necessary for any statement. Please describe any potential cost savings or opportunities for disinvestment. Questions about the individual quality statements Question 4 There is no specific statement on access to services. Do you think this should be a key area for quality improvement? If so, how could quality of access to services be measured? Question 5 Statement 1 focuses on people with anorexia nervosa having a discussion about their options for first-line psychological treatment to reflect the options within NICE guideline NG69. Will this discussion on treatment options drive up quality improvement for people with anorexia nervosa? Please give reasons for your answer.

21 Statement 1 People with anorexia nervosa have a discussion about their options for first-line psychological treatment.

22 Schmidt U et al, J Consult Clin Psychol 2015 Aug;83(4): The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: A randomized controlled trial.

23 Schmidt U et al, J Consult Clin Psychol 2015 Aug;83(4): OBJECTIVE: This study evaluated the efficacy and acceptability of Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA compared with Specialist Supportive Clinical Management (SSCM). METHOD: 142 outpatients with broadly defined AN (body mass index [BMI] 18.5 kg/m²) were randomly allocated to receive 20 to 30 weekly sessions plus add-ons (4 follow-up sessions, optional sessions with dietician and with carers) of MANTRA (n = 72) or SSCM (n = 70). Assessments were administered blind at baseline, 6 months, and 12 months

24 Schmidt U et al, J Consult Clin Psychol 2015 Aug;83(4): RESULTS: Both treatments resulted in significant improvements in BMI and reductions in eating disorders symptomatology, distress levels, and clinical impairment over time, with no statistically significant difference between groups at either 6 or 12 months. One SSCM patient died. Compared with SSCM, MANTRA patients rated their treatment as significantly more acceptable and credible at 12 months. There was no significant difference between groups in additional service consumption. CONCLUSIONS: Both treatments appear to have value as first-line outpatient interventions.

25 Cognitive Behavioural Therapy Extended (CBT-E) CBT-E has been shown to be suitable for all forms of eating disorder encountered in adults (Fairburn et al, 2009; Fairburn et al, 2013). CBT-E has also been shown to be effective in the treatment of younger patients (Dalle Grave et al, 2013). It is therefore a potential alternative to the leading evidence-based treatment for this age group, family-based therapy. CBT-E may be used in inpatient and day-patient settings. BUT.therapists need to receive training in CBT-E in order to obtain optimal effects.

26 Statement 2 People with binge eating disorder participate in guided self-help programmes as first-line psychological treatment.

27 Statement 3 Children and young people with bulimia nervosa participate in bulimia- nervosa-focused family therapy.

28 Bulimia nervosa in adolescents: prevalence and treatment challenges Despite the increasing research devoted to the treatment of youth with anorexia nervosa (AN) and adults with BN, there remains a dearth of evidence for treating younger individuals with BN. To date, there have been four published randomized controlled trials comparing psychosocial treatments, leaving significant room to improve treatment outcomes. Family-based treatment is the leading treatment for youth with AN, while cognitive-behavioral therapy is the leading intervention for adults with BN. Involving caregivers in treatment shows promising results, however, additional research is needed to investigate ways in which this treatment can be adapted further to achieve higher rates of recovery Hail and Le Grange. Adolesc Health Med Ther, 2018, 9:11.

29 Randomized Clinical Trial of Family-Based Treatment and Cognitive- Behavioral Therapy for Adolescent Bulimia Nervosa Le Grange, et al. J Am Acad Child Adolesc Psychiatry, 2015, 54:886.

30 Statement 4 People with eating disorders and comorbidities have the impact of all their treatments monitored using outcome measures.

31 Other quality standards that should be considered when commissioning or providing eating disorder services include: Transition from children s to adults services (2016) NICE quality standard 140. Diabetes in adults (update, 2016) NICE quality standard 6. Diabetes in children and young people (2016) NICE quality standard 125. Anxiety disorders (2014) NICE quality standard 53. Depression in children and young people (2013) NICE quality standard 48. Self-harm (2013) NICE quality standard 34. Depression in adults (2011) NICE quality standard 8.

32 Two priorities in providing treatment consist of addressing: 1) research-practice gap; 2) treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing.

33 Kazdin, et al. The International Journal of Eating Disorders, 2017, 50:170 Increase the number receiving Evidence Based Treatments : Train the trainer Web based training Electronic support Higher level Support and Policy 20% of those with AN receiving treatment

34 Models used for addressing the research-practice and treatment gaps. Kazdin, et al. The International Journal of Eating Disorders, 2017, 50:170. Train-the-Trainer Zandberg and Wilson (2013) Web-Centred Training In the field of eating disorders, online training programs in cognitive behavioural therapy enhanced (CBT-E) Fairburn and Patel (2014) and interpersonal psychotherapy (IPT) Wilfley et al. (2016).

35 Thank you for listening.