Transcript HIP Training

HIP Programme
Background: Physical health is important in serious
mental illness and nurses need to act
The problem
• People with SMI are dying too early
• Current health policy focuses on annual screening in
primary or secondary care.
• It is a population level problem that despite guidelines is not
improving fast enough for enough people
• An easy to implement solution is needed that can exploit the
contact and relationships we already have with patients
Background
• Life expectancy in SMI is declining, largely due to the
impact of cardiovascular disease 1,2
• A population level intervention is required.
• Contact with any health care professional is an
opportunity for screening and intervention
• Current health policy focuses on annual screening in
primary or secondary care 3,4
1.Brown et al, 2010 British Journal of Psychiatry, 196, 116-121
2.Chang et al, 2011 PLoS ONE, 6, e19590
3. NICE, 2006
4. NICE, 2009
Background
• Case managers and nurses in secondary care have a
positive attitude towards a physical health care role
but deficits in training and organisation of care impair
practice 1, 2,3
• Mental health nurses are the largest number of health
care professionals in secondary care in routine contact
with SMI patients
• Physical health care is an essential nursing skill 4
1.
2.
3.
4.
Howard & Gamble, 2011 Journal of Psychiatric & Mental Health Nursing 18, 105-112
Hyland et al, 2003 Australian and New Zealand Journal of Psychiatry 37: 710-714
Robson et al 2012 International Journal of Mental Health Nursing doi:10.1111/j.1447-0349.2012.00883.x
Nursing and Midwifery Council, 2010 Standards for pre-registration nursing education – Annexe 3 :Essential Skills
Clusters and guidance for their use G7.15b
Background
• No current evidence for efficacy of screening or
intervention 1,2
• Only evidence is from service evaluations of adjunct
services that were subsequently withdrawn e.g. 3
• A complex intervention is needed to target the
practitioner, the patient and the organisation 2, 4
• A pragmatic approach is needed to have the best
chance of a population effect. 5
1.
2.
3.
4.
5.
Tosh et al, 2010 Cochrane Database of Systematic Reviews:2011, Issue 11
Hardy et al, 2011 Journal of Psychiatric and Mental Health Nursing, 18: 721-727
Smith et al, 2007 European Psychiatry, 22: 413-418
Medical Research Council 2008 Developing and evaluating complex interventions: new guidance
White et al, 2010 Journal of Psychiatric and Mental Health Nursing, 16: 493-498
Life expectancy in patients with SMI
• Life expectancy in the UK at birth
– 81.5 year for girls
– 77.2 years for boys
• Cohort of 31,719 people with SMI in South
London1
– 9.8 to 17.5 years lost (women)
– 8.0 to 14.6 years lost (men)
• Systematic review of population based studies2
– Standardized Mortality Ratio, SMR of
2.50
(95% confidence interval, 2.18-2.43)
• 15-25 years of lost life
– Early 60s for women
– Late 50s for men
1Chang
2Saha
et al. PLoS ONE 6(5): e19590. doi:10.1371/journal.pone.001959
et al. Arch Gen Psychiatry. 2007;64(10):1123-1131
Mortality trends in Stockholm County Sweden
1976-79, 1990-95 cardiovascular causes of death
Osby et al, 2000 BMJ 321: 483-484
• People with schizophrenia die 20-25 years younger than the
general population1
• People with bipolar disorder die 10-15 years young than the
general population2
• Mainly due to increased risks of cardiovascular disease
(CVD) 3
• Higher than expected rates of 4
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–
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Obesity
Ischaemic heart disease
Stroke
High blood pressure
Diabetes
1.Colton & Manderscheid. Prev Chronic Dis 2006 Apr http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
2. Roshanaei-Moghaddam and Katon Psychiatr Serv.2009; 60: 147-156
3. Casey et al. J Clin Psychiatry 2004;65(suppl 7):4-18.
4. Hippisley-Cox J and Pringle M (2005) Health inequalities experienced by people with schizophrenia and manic
depression: analysis of general practice data in England and Wales. Equal treatment: closing the gap. Disability
Rights Commission.
Although the biggest killer is cardiovascular disease1,2,3
•Most of the major causes-of death categories
• are elevated and have increased during recent decades2,4
•High prevalence of comorbidities4,5,6
•Many illnesses go undiagnosed4
•Patients with SMI do not
volunteer complaints readily4
1Robson
and Gray, IJNS 2007;44:457-466 2. Müller-Oerlingshausen B et al. Lancet 2002;359:241247. 2.
McElroy SL et al. Am J Psychiatry 2001;158:420426. 4.Saha et al. Arch Gen Psychiatry. 2007;64(10):1123-1131
5. Birkenaes AB et al. J Clin Psychiatry 2007;68:917923. 6. Kilbourne AM et al. Bipolar Disord 2004;6:368373.
3.
Cardiovascular risk factors
Non-modifiable
risk factors
Modifiable risk
factors
Gender
Obesity1
Family history
Smoking2
Personal history
Glycaemic control3
Age
Hypertension4
Ethnicity
Dyslipidaemia4
1.Allison et al. Am J Psychiatry 1999;156:1686–96.
2. Herran et al. Schizophr Res. 2000;41:373–81.
3. Goff et al. J Clin Psychiatry 2005;66:183–94.
4. Davidson et al. Aust N Z J Psychiatry. 2001;35):196–202.
Metabolic side effects of some antipsychotic medications
impose additional risk
• Although head-to-head trials have demonstrated
generally comparable overall efficacy,1,2 the long term
safety profiles of antipsychotic medications differ
considerably, in terms of likelihood of causing:
• Weight gain, which contributes to:3
– glucose intolerance
– dyslipidaemia
– hypertension
• Subsequent cardiovascular disease morbidity and
mortality
1.
Chrzanowski et al. Psychopharmacol 2006;189:259-266.;
2.
Potkin et al. Arch Gen Psychiatry 2003;60:681–690;
3.
Newcomer. CNS Drugs 2005;19(suppl 1):1-93.
But it is not that simple….
FIN11: Long term antipsychotic treatment associated
with Lower Mortality
Risk of death from any cause versus cumulative use of any antipsychotic drug*Mortality=unadjusted absolute risk
per 1000 person-years. †No antipsychotic drug=patients (18 914) who had not used any antipsychotic drugs
during follow-up.
Tiihonen et al, 2009 The Lancet 374(9690): 620-627
Key points about CVD risk and long term
conditions
Long term conditions
• Stroke
• Coronary heart disease
• Diabetes
• Chronic obstructive pulmonary disease
Stroke
• A stroke is a serious medical condition that occurs when
the blood supply to the brain is disturbed
• Can lead to brain damage and possibly death
• Afro-Caribbean origin are at increased risk
• Smoking, obesity, poor diet and excessive alcohol
consumption are risk factors for stroke
• Conditions that affect the circulation of the blood, such as
diabetes, CHD or hypertension are risk factors for stroke
• There are two main causes of strokes:
Ischaemic (accounting for 70% of all cases): the blood supply is
stopped due to a blood clot
Haemorrhagic: a weakened blood vessel supplying the brain
bursts and causes brain damage
Stroke
Ischaemic stroke caused by:
1.Atherosclerosis
2.Atrial fibrillation
– coronary artery disease
– high blood pressure
– mitral valve disease (disease of the heart valve)
– cardiomyopathy (wasting of the heart muscle)
– pericarditis (inflammation of the bag surrounding the heart)
– hyperthyroidism (overactive thyroid gland)
– excessive alcohol intake
– drinking lots of caffeine - for example tea, coffee and energy
drinks
Stroke
Haemorrhagic strokes caused by high blood pressure which
weakens the arteries in the brain. High blood pressure
caused by:
– being overweight
– drinking excessive amounts of alcohol
– certain medications e.g. venlafaxine
– smoking
– a lack of exercise
– stress, which may cause a temporary rise in blood
pressure
Coronary Heart Disease
• The heart's blood supply is blocked or interrupted by a buildup of fatty substances (atheroma) in the coronary arteries
• Coronary arteries become narrow - the blood supply to heart
will be restricted leading to chest pains (angina)
• If a coronary artery becomes completely blocked, it can
cause a myocardial infarction (MI)
Coronary Heart Disease
• Myocardial Infarction causes permanent damage to the
heart, can be fatal
• Heart palpitations. Heart beating irregularly or
harder/faster than normal
• Heart failure – heart is too weak to pump blood around the
body, causes fluid to build up in lungs, breathing difficulty.
Can be acute or chronic
Coronary Heart Disease
Atherosclerosis is significantly increased if a person smokes,
has high blood pressure, has a high blood cholesterol level,
does not take regular exercise, has a thrombosis, has
diabetes.
Other risk factors for developing atherosclerosis include
being obese or overweight, and having a family history of
heart attack or angina.
Diabetes
Two types – type 1 and 2
Type 2
Caused by too much glucose (sugar) in the blood
due to insulin resistance and lack of insulin
Causes: obesity, genetic factors, ethnicity and age
Diabetes
The main symptoms of diabetes (when blood sugars very raised) are:
• feeling very thirsty
• producing excessive amounts of urine (going to the toilet a lot)
• extreme tiredness (fatigue)
• weight loss and muscle wasting (loss of muscle bulk)
Other symptoms of diabetes can include:
• itchiness around the vagina or penis
• recurring thrush as a result of the excess glucose in your urine
• blurred vision caused by the lenses of your eyes becoming very dry
Often patients have no symptoms
COPD
• An inability to breathe in and out properly. This is also
referred to as airflow obstruction.
• Caused by long-term damage to the lungs, usually as a
result of smoking
• Builds up over a number of years
• Airways of lungs (bronchioles) narrow
• Permanently damages air sacs (alveoli)
• Breathing in and out becomes increasingly difficult
• Not enough oxygen gets through the narrowed airways to
the heart increasing risk of heart failure
COPD
Symptoms:
• early morning ‘smoker’s cough’
• persistent coughing
• mucus and phlegm
• wheezing
• tight chest
• difficulty breathing
• shortness of breath
• repeated lung and chest infections
COPD
• Oxygen reduced to heart and muscles causing tiredness
• Difficulty in breathing uses up energy causing tiredness
• Breathlessness makes it hard to eat, leading to weight loss
and muscle wasting
• Severe weight loss can result in serious complications, such
as heart failure
• Obesity can make COPD worse
Other physical problems
Include:
• Cancers
• Dental problems
• Visual problems
• Neglect causing fungal infections
• Hyperprolactinaemia – leading to menstrual
disturbance, sexual problems, osteoporosis
• Numerous undisclosed conditions
So now for some good news
Reductions in independent risk factors can lead to reduction in
Cardiovascular Disease [CVD] Risk
Risk factor
Reduction
Outcome
Blood Cholesterol1
10% 
30%  in risk of CVD
High blood pressure
(> 140 mm Hg SBP or
90 mm Hg DBP)1
6mm Hg  in DBP
16%  in risk of CVD; 42% 
in risk of stroke
Cigarette smoking1
Cessation
50%  in risk of CVD
Obesity2
4-10 kg 
27%  in risk of CVD
1 BMI unit 
8%  in risk of CVD
CVD – cardiovascular disease, DBP – dystolic blood pressure
1. Hennekens CH. Circulation. 1998;97:1095-1102.
2. Li et al. Circulation 2006;113:499-506.
Primary health care workers or secondary
health care workers should be monitoring the
physical health of all people with bipolar
disorder and schizophrenia once a year1,2
1. National Institute of Clinical Health and Excellence (2006) CG38 The management of bipolar disorder in adults,
children and adolescents, in primary and secondary care NICE
2. National Institute of Clinical Health and Excellence (2009) CG82 Core interventions in the treatment and
management of schizophrenia in primary and secondary care (update) NICE
BUT….
• Although 82% Mental Health Nurses [MHNs] agree this
should be their role1
– 50-75% report no training2,3
– 78% feel that their current workload is a barrier to
promoting physical health2
– Majority not familiar with guidelines or policies3
• GPs and practice nurses believe care of SMI too complex4
– 98% practice nurses have no formal training in mental
health.
1
Nash (2005) Mental Health Practice 9(4) 20-23
2
Robson et al 2012 International Journal of Mental Health Nursing doi:10.1111/j.1447-0349.2012.00883.x
3
Howard & Gamble (2011) JPMHN 18, 105-112
4. DH (2003) Fast forwarding Primary Care Mental Health: Graduate Primary Care Mental Health Workers – Best Practice Guidance
Changes to the Mental Health Quality and
Outcomes Framework (QOF) 2011/12
Indicators that were removed
Had a review in the last 15 months including health promotion advice
If did not attend review, are contacted within 14 days
Indicators that were added
• Recorded in the last 15 months:
• Alcohol consumption
• Body mass index
• Blood pressure
• Cholesterol level (if over 40 years)
• Glucose level (if over 40 years)
• A smear within last 5 years (if within national screening age)
Indicators that were changed
For those on lithium:
• Record of creatinine and TSH in last 9 months (was 12)
• Lithium level in therapeutic range in last 4 months (was 6)
Unchanged
• Have a documented care plan
Hardy S (2011) British Journal of Wellbeing. 2 (5) 18-21.
The quality of health checks in primary care?*
Hardy S. et al. (2013) Journal of Mental Health 2013; 22(1): 42–50
State of the evidence : systematic Reviews
1. Physical health care monitoring for people with
serious mental illness 1 .
2. Educating healthcare professionals to act on the
physical health needs of people with serious
mental illness: A systematic search for evidence 2.
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No RCT papers identified
Intervention studies do not report knowledge
gain or change in attitude outcomes.
Recent EPOC* Cochrane review of screening in
SMI suggested an RCT of the HIP 2
1 Tosh et al, The Cochrane Library 2010 ,Issue 3
2 Hardy et al, Journal of Psychiatric and Mental Health Nursing. 2011 18(8) 721-727
EPOC = Effective Practice and Organisation of Care Group
New standards for Trusts from the annual
National Audit of Schizophrenia
Physical Health: Monitoring Standards
The following have been monitored in the past 12 months:
I.
II.
III.
IV.
V.
VI.
Body mass index, waist-hip ratio or waist circumference
Blood pressure
Use of tobacco
Excessive use of alcohol
Substance misuse
Blood levels of glucose, lipids (total cholesterol and HDL) and
prolactin (if indicated)
VII. Family history of CVD, diabetes, hypertension or hyperlipidemia
HQIP & Royal College of Psychiatrists (2012) Report of the (NAS) National Audit of Schizophrenia
Royal College of Psychiatrist's Centre for Quality Improvement (CCQI)
Physical Health: Intervention Standards
Where monitoring has indicated a need for intervention within
the last 12 months, the following has been offered or a
referral has been made for:
I.
Advice about diet and exercise, aimed at helping the person to
maintain a healthy weight
II. Treatment for hypertension
III. Treatment for diabetes
IV. Treatment for hyperlipidaemia
V. An intervention to reduce levels of prolactin
VI. Help with smoking cessation
VII. Help with reducing alcohol consumption
VIII.Help with reducing substance use
HQIP & Royal College of Psychiatrists (2012)
Physical Health Recommendations
All health professionals should be trained in:
– Common physical health problems experienced by people
with schizophrenia
– Assessment and monitoring
– Available interventions and treatments
• Mental health services and primary care services need to
work together to agree who will monitor and treat physical
health problems
• Mental health service staff must
– have access to the correct monitoring equipment
– help access treatment if required
HQIP & Royal College of Psychiatrists (2012)
Introducing the HIP : a pragmatic solution
The Health Improvement Profile (HIP)
• A pragmatic RISK ASSESSMENT tool for physical health
• Nurses can be trained to be competent in using the HIP in
one workshop
• The physical health of all patients can be profiled
• A HIP for every patient once a year
• Enables [nudges] nurses to plan care/make appropriate
referrals
• Guides nurses to evidence based interventions
• Bridges communication between primary and secondary
care
• Is free to access and adapt
White J. et al (2009) Journal of Psychiatric and Mental Health Nursing 16, 493-498
Items on the HIP
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BMI
Waist circumference
Pulse
Blood pressure
Temperature
Liver function tests
Lipid levels
Glucose
Cervical smear
Prostate and testicles check
Sleep
Teeth
Eyes
Feet
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Breast check (female & male)
Menstrual cycle
Smoking status
Exercise
Alcohol intake
Diet: 5-a-day
Diet: fat intake
Fluid intake
Caffeine intake
Cannabis use
Safe sex
Urine
Bowels
Sex satisfaction
Methods
• Literature reviews to establish parameters at risk and
recommended actions1
• Pilot and development of training package1
• Service evaluation following cascade of HIP training2
– Cross sectional observation of consecutive ‘first contact’
HIPs
– Governance approval
– Database Excel – SPSS
– Descriptive statistics
– Qualitative feedback from patients, nurses, psychiatrists
and GPs
1 White J. et al (2009) Journal of Psychiatric and Mental Health Nursing 16, 493-498
2 Shuel et al. Int J Nursing Studies 2010; 47: 136-145
White J. et al (2009) Journal of Psychiatric and Mental Health Nursing 16, 493-498
HIP 31 and HIP 100 : Methodology
• Service evaluation following cascade of HIP training
• Pragmatic case series
• Cross sectional observation of consecutive ‘first contact’
HIPs
• Governance and ethical approval
• Database (Excel to SPSS)
• Descriptive statistics
• Feedback from patients, nurses, psychiatrists and GPs
Shuel et al. Int J Nursing Studies 2010; 47: 136-145
HIP
311
HIP 1002
• 31 community SMI patients
• 108 acute SMI inpatients
• Nurse led clinic
• All nurses trained
189 physical health issues
– 6.1 per patient
1.
Shuel et al. Int J Nursing Studies 2010; 47: 136-145
2.
White J et al In prep
• 1007 physical health issues
– 9.3 (4.03) 95% CI ±0.76
per patient
Results (N = 108)
Red flagged items
** All patients had liver function tests
CVD risk
n = 58 (54%) were smokers
Substance use
54% (58) reported smoking cigarettes
98% (57) reported ≥20/day
29% (31) reported ≥40/day
45% (49) reported drinking above recommended units*,
significantly more in males (p=0.002)
Women 21.14 (40.05) mean units per day
Men 43.55 (59.58) mean units per day
25% (27) reported smoking cannabis
*Recommended alcohol units 2-3/day women, 3-4/day men
Next steps
• Individualised (evidence based) care and treatment was
planned based on individual profiles
• 28 separate interventions were used
e.g. Exchanging information, promoting health
behaviour change, performing an ECG, referral to
weight management groups, smoking cessation services
etc
 Referrals were made for potentially serious conditions
e.g. to cardiology
• If health improvement was not observed as a result of
planned care continued monitoring of ‘red’ flagged
items was planned
Examples of next steps taken
• Of 41 patients with an abnormal pulse, 29% (12) had an
abnormal ECG requiring a change in medication.
• Of 21 patients reporting sexual dissatisfaction 71% (15) had
raised prolactin and 6 went on to try a change of antipsychotic.
• Of patients who were asked 20% (17) reported NOT practicing
safe sex so the opportunity to have a conversation about this
and exchange information was exploited.
Cluster RCT of the serious mental illness Health
Improvement Profile [HIP] reports in 2014
• NIHR Research for Patient Benefit East of England
– April 2011 - April 2014
• Sponsor – Norfolk and Suffolk Foundation NHS Trust
• Universities of East Anglia, Hull and the West of England
• NHS Sites
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NSFT Norfolk
NSFT Suffolk
LPFT Lincolnshire
SEPT South Essex + Luton and Bedford
Former PCTs
http://www.controlled-trials.com/ISRCTN41137900
The Northampton Physical Health and Wellbeing
(PhyHWell) project
• GP’s Practice - bespoke training ,SMI register validation ,
invitation system
• Practice nurse(s) and link community mental health nurse
trained to use the HIP-PC1 and the website
http://physicalsmi.webeden.co.uk
Objectives (outcome measures) at 2 years
– Patient outcomes: BMI, blood pressure, blood glucose
and cholesterol, CVD risk
– Do patients receive diet, exercise or smoking advice?
– Practice nurse attitude and knowledge
– Primary:Secondary care interface communication
– Patients’ opinion of the health check.
Winner of Nursing in Practice award 2010
1. Hardy, S. and Gray, R. (2009) Primary Care Physical Health checks for people with Severe Mental
Illness (SMI) - Best Practice Guide. The Health Improvement Profile for Primary Care (HIP-PC).
Northampton: NTPCT.
Key points
• Physical comorbidity in SMI is a serious public health challenge
• The is a lack of evidence of interventions (including education)
to inform how best to help patients.
• Nurses are well placed to intervene.
• The HIP is a pragmatic RISK ASSESSMENT tool for physical
health
• Utility and acceptability has been demonstrated in 139 patients
• A cluster RCT of the HIP Programme is testing efficacy and
effectiveness in the NHS.
• The HIP-PC Programme is being used in primary care
Q&A