Introduction
Chronic respiratory problems such as chronic obstructive pulmonary disease (COPD), asthma and bronchiectasis are frequently complicated by the presence of psychological difficulties such as anxiety and depression; prevalence studies suggest about half of patients experience difficulties of this type (Dowson et al., Reference Dowson, Kuijer and Mulder2004; Mikkelsen et al., Reference Mikkelsen, Middelboe, Pisinger and Stage2004). Studies highlight that these difficulties are associated with problems in symptom self-management, lower quality of life, and an increased risk of respiratory exacerbations, hospital admissions and healthcare use (Atlantis et al., Reference Atlantis, Fahey, Cochrane and Smith2013; Cao et al., Reference Cao, Ong, Eng, Tan and Ng2006; Coventry et al., Reference Coventry, Gemmell and Todd2011; Felker et al., Reference Felker, Bush, Harel, Shofer, Shores and Au2010; Goodman et al., Reference Goodman, Firouzi, Banya, Lau-Walker and Cowie2013; Gudmundsson et al., Reference Gudmundsson, Gislason, Janson, Lindberg, Hallin and Ulrik2005; Hallas et al., Reference Hallas, Howard and Wray2009, Reference Hallas, Howard, Theadom and Wray2012; Kitagawa et al., Reference Kitagawa, Yasui-Furukori, Tsushima, Kaneko and Fukuda2011; Xu et al., Reference Xu, Collet, Shapiro, Lin, Yang and Platt2008).
From a service-level perspective, these difficulties thus place significant pressure on those providing respiratory services, particularly in acute settings where resources can be costly and already in high demand. Financially, the physical healthcare costs for someone with a chronic physical health problem are approximately 50% greater if they are also experiencing psychological difficulties (Hutter et al., Reference Hutter, Schnurr and Baumeister2010; Katon, Reference Katon2003; Layard and Clark, Reference Layard and Clark2014; Naylor et al., Reference Naylor, Parsonage, McDaid, Knapp, Fossey and Galea2012). It is clear that new approaches are urgently required to support patients in the ongoing management of these conditions.
The health burden and economic costs of psychological problems co-occurring with chronic health conditions have been arguments central to the upcoming long-term conditions strand of the Improving Access to Psychological Therapies (IAPT) programme, which aims to provide evidence-based psychological interventions tailored to the needs of the different chronic health conditions. Overall there is good evidence to suggest that the provision of psychological intervention serves to reduce the costs of physical healthcare (see Chiles et al., Reference Chiles, Lambert and Hatch1999; Layard and Clark, Reference Layard and Clark2014, chapter 11), and this is a key directive within the cross-government ‘No Health Without Mental Health’ policy (Department of Health, 2011).
While there are fewer studies evaluating the direct provision of psychological interventions in respiratory conditions, there is initial evidence suggesting that this can reduce psychological distress, improve patient quality of life and reduce healthcare costs such as emergency hospital attendances (Howard and Dupont, Reference Howard and Dupont2014; Howard et al., Reference Howard, Dupont, Haselden, Lynch and Wills2010; Livermore et al., Reference Livermore, Sharpe and McKenzie2010; Spurgeon et al., Reference Spurgeon, Hicks, Barwell, Walton and Spurgeon2005). However, despite these potential benefits, it remains the case that psychological intervention is rarely provided routinely in respiratory services (Kunik et al., Reference Kunik, Roundy, Veazey, Souchek, Richardson and Wray2005).
As a result, the methods and processes of delivering and evaluating psychological services in acute respiratory contexts have yet to be described in the literature. This paper aims to address this by outlining the development and implementation of a psychology service in an acute respiratory department, describing the processes and results of evaluating this work, and reflecting on what worked well along with the challenges experienced.
Service description and background
The respiratory department serves a local population of 450,000 people, of whom approximately 75,000 have respiratory conditions. Around 1300 patients are admitted to the 33-bed ward per year, with many more seen in out-patient clinics. Approximately 70 staff work in the department, across medicine, nursing, physiotherapy, occupational therapy, palliative care and social work, including liaison to colleagues in primary care, social care and community healthcare teams as appropriate.
The provision of psychology input to the department's Pulmonary Hypertension service led to an increased recognition of the need to assess and support patients’ psychological wellbeing, mood and coping ability, and the benefits this can have, including improved treatment adherence, and patients’ self-management of the condition. Consequently, the question was raised as to how psychology can be applied more widely in the respiratory department and whether this may help to reduce the burden caused by frequent and sometimes medically inappropriate hospital admissions.
A nine-month clinical psychologist post was created with the following aims:
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• To identify levels of psychological need within the department;
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• To provide interventions to address these needs;
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• To evaluate the impact of psychology provision, particularly on hospital attendance and readmissions, demonstrating reductions where possible; and
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• To provide a psychological perspective within the multidisciplinary team.
Methods
Participants
In total, psychological intervention was provided to 79 in-patients and eight out-patients over the study period (49% female, mean age 67 years, range 19–90 years), all of whom had a chronic respiratory condition (COPD, asthma, bronchiectasis, lung cancer, interstitial lung disease, or idiopathic pulmonary fibrosis).
Design
All appropriate referrals were accepted and received at least one session with the clinical psychologist. The sample was therefore a single group of consecutive referrals. As this was an evaluation of routine service provision it was not ethically appropriate to include a control group of patients with psychological difficulties who did not receive an intervention. As the study was evaluating the service being provided, additional ethical approval was not required.
Procedure
Following consultation with staff, brief referral procedures were established for both the ward and out-patient clinics. A case-by-case discussion of potential referrals was encouraged; general criteria were: (1) psychological or emotional difficulties relating to the respiratory condition (other psychological difficulties were referred to the hospital liaison psychiatry team, or via the GP for referral to other local services), (2) the patient had consented to speak to the psychologist, and (3) the difficulties were not in relation to end of life (where a palliative care referral may be more appropriate). Following referral, individual clinical input was provided either on the ward during admission, with out-patient or telephone follow-up as appropriate, or directly as an out-patient. Interventions were predominantly cognitive behavioural and most commonly focused on breathlessness-related anxiety and panic, mood management, and adjustment to chronic conditions, all of which were negatively impacting on patient wellbeing and disease self-management. In-patient input varied based on need and length of admission, but on average consisted of two to three sessions. Out-patients received between six and ten sessions, approximately weekly.
Wider clinical input to the staff team consisted of consultation regarding the management of patients with complex needs, contribution to ward multidisciplinary team meetings, and training sessions to staff on the identification and management of common psychological difficulties in the respiratory context. Three patient information leaflets were also developed based on cognitive behavioural principles, focusing on breathlessness-related anxiety and panic, expectations following discharge, and general wellbeing in respiratory conditions. These were used to supplement the direct clinical work provided.
Data on admissions and emergency attendances were provided by the hospital business intelligence unit in order to identify patterns of frequent healthcare use and evaluate the ongoing healthcare use of patients who had received psychology input. Patients’ average monthly admission frequency was calculated using data from the 12 months prior to the admission in which they received psychology input. This was then compared with their monthly admission frequency in the period following discharge. The financial implications of any changes in admission frequency were then estimated using NHS Reference Costs 2013/14.
Lastly, brief feedback tools were developed and implemented with both patients and staff to obtain some qualitative information on their experience of psychological provision in the department.
Results
Impact on healthcare use
Of the 79 in-patients who had received 1:1 psychology input, 16% were readmitted within 30 days of discharge, lower than the ward average for all in-patients, which peaked at 25% in 2014. Of the total sample (n = 87), and after excluding patients who died in hospital (n = 8) and those with less than 1 month of post-discharge admissions data (n = 6), 75% of patients showed a decrease in their admission frequency following psychology input.
Twenty-two patients from the total sample had attended the hospital emergency department (ED) without being admitted in the 12 months prior to psychology input. Of these, 16 (73%) showed a reduction in their monthly ED attendance frequency following psychology input.
Financial evaluation
Using an average admission cost (including average excess bed days) of £2160 (based on NHS reference costs 2013/14), cost reductions were estimated to be a total of £72,360, or an average of £822 per patient. The observed reductions in ED attendances without admission following psychology input were associated with negligible cost savings at that time point.
These estimates indicate that the costs of providing psychology input for the 9-month period were likely to have been more than offset by savings made through reduced admission frequency. When combined with the income generated from out-patient activity (which represented approximately 30% of the psychologist's time, and offset 44% of the total cost of psychology input in that period), it is estimated that the net savings to the wider NHS arising from the project were £56,561 at the time of project completion. The nature of psychological intervention, in particular the focus on ongoing disease management, means it may be reasonable to anticipate longer-term benefits for some patients, and therefore the continued accrual of savings in the future linked to reduced healthcare costs.
Clinical outcomes
The high uptake of psychological input when it was offered suggests a strong level of acceptability to patients, although systematic monitoring of this is recommended for future studies. As this work involved the development of appropriate treatment pathways across the study period, the evaluation of clinical outcomes could not be fully standardized in the time available. We therefore present two illustrative case examples below, noting that across the participants seen, the range of improvements reported included quality of life, mood, coping ability, and functional capacity. Additionally, many highlighted the value of having time and space allocated to discuss and address issues around these topics as part of their care.
Case example one
Mrs B had a history of frequent respiratory admissions for her asthma and bronchiectasis, including four in the past year. The most recent of these required an 8-day admission and treatment for an infection. A psychology referral was made for Mrs B while an in-patient due to low mood. Psychology input both on the ward and following discharge identified that Mrs B's most recent infection was likely to have come about due to a lapse in her medication regime. She reported struggling to cope with the chronic and restrictive nature of her conditions and the related programmes of exercise and medication.
Psychology sessions, totalling 12 over a 4- to 5-month period, focused on addressing low mood, concordance with treatment programmes, and Mrs B's beliefs and behaviours around illness. Through implementing changes to her routine and strategies to address patterns of negative thinking, Mrs B reported feeling better able to manage the demands of her conditions, along with improvements in mood and quality of life. The duration of episodes between admissions increased as a result, leading to an overall drop in admission frequency during and following the intervention.
Case example two
Mr R had attended the ED seven times in the past year with shortness of breath, two of which resulted in admission. During the most recent admission Mr R experienced significant anxiety and frequent panic attacks linked to breathlessness. This led to increased use of medical oxygen and high levels of distress such that he was refusing nursing care for fear that any movement could bring on an attack of breathlessness.
Following liaison with physiotherapy and Mr R's consultant physician, psychology input focused on addressing the anxious beliefs underpinning his anxiety, and associated unhelpful behaviours. This helped Mr R to manage his anxieties around moving, and build his confidence to the point he felt ready for discharge, which occurred 2 days earlier than anticipated. Seven out-patient follow-up sessions over the subsequent 3 months consolidated this change and further helped Mr R to understand and manage his COPD, including more frequent exercise. He had no further panic attacks, emergency attendances or hospital admissions in the 7-month remainder of the study period.
Patient and clinician feedback
Patient feedback was extremely positive, with comments suggesting that this meets an important need in their holistic care and their experience of healthcare. Twelve patients completed a survey about their experiences of psychology post-intervention. All patients described psychology sessions as helpful, with 83% reporting that they had helped a great deal in better understanding their concerns, worries or emotions regarding their respiratory condition. All patients reported that sessions had helped them manage these issues better, either ‘a little’ (33%) or ‘a great deal’ (67%). All patients would recommend psychological support to a friend in a similar position, and 92% felt it is ‘extremely important’ that psychological provision is continued in the department. Example comments are below:
‘Helpful – brought things to your attention that you may not have thought about. Looked at the whole person.’
‘It is so nice to have someone to talk to who can help you coping with your health problem. I look forward to talking and it has helped me deal with my health issues.’
‘The support and understanding has been invaluable. I sincerely hope the service can be offered to those in need.’
Nine members of respiratory staff also completed a feedback survey. All respondents rated that having psychology input available in the department had benefited both patients and the multidisciplinary team ‘a great deal’, and all rated it ‘extremely important’ that psychological provision is continued in the department. Example comments are below:
‘Many patients with long term respiratory conditions suffer with health related anxiety, and being able to refer to an appropriately trained professional to help manage and follow them up post-discharge has been very useful.’
‘Supportive role with anxious patients particularly helpful. Enables more holistic approach to patient care. Really beneficial with complex patients at risk of reattending. ’
Discussion
The approach described here represents one method for initiating, implementing and evaluating psychological provision in an acute medical setting. Results indicated that this model of service delivery was associated with a number of benefits for patients and the service, including improved psychological functioning, reduced hospital admissions and cost savings. Staff feedback highlighted ways in which psychology had a valued impact in the department, suggesting it was and can be readily integrated into the acute multidisciplinary context. In particular, the feedback suggested that psychology provision has enabled an enhanced focus on the holistic care of patients, assessing and supporting emotional and psychological needs as appropriate. This is consistent with best practice recommendations in a number of national guidelines (Bolton et al., Reference Bolton, Bevan-Smith, Blakey, Crowe, Elkin and Garrod2013; NICE, 2009, 2010, 2011, 2013; Pasteur et al., Reference Pasteur, Bilton and Hill2010).
Alongside the clinical benefits for patients, the observed reductions in healthcare use and associated cost savings also appear to support the value of the psychological provision implemented, and strengthen the case for this to be considered a routine part of acute respiratory care. The findings here were broadly consistent with existing literature, in that the costs of psychology provision were offset by subsequent savings arising from reduced admissions. Unlike other studies, cost savings linked to reduced emergency attendances were negligible among our sample. It is hypothesized that similar findings around the clinical and economic benefits of psychology provision may occur for other chronic health conditions, and research across a wider range of diagnoses is warranted.
As a small-scale study of the early stages of implementing psychology provision, there are a number of limitations. Firstly, while the results demonstrated an association between psychology provision and reduced admissions, the absence of a waitlist control group of patients makes it difficult to state confidently that one leads to the other. Temporal factors within this study, i.e. that no psychology input was provided prior to the study, and that admission frequency was measured after psychology input, suggest that this is likely to be the case, but other designs, such as extended pre-therapy baselines, or randomized controlled trials would be particularly important to examine this more closely. Secondly, the nature of the service provided meant that patients received different types and amounts of intervention according to clinical need, meaning only broader conclusions can be drawn rather than those specific to the effects of a standardized intervention. Thirdly, the study time frame meant that opportunities for obtaining longer term follow-up data were limited; this would be recommended for future studies to explore the ongoing psychological and financial effects. Lastly, feedback was only obtained from a small number of patients, which may have increased the risk of bias.
The process of implementing and evaluating this work has generated a number of reflections and recommendations, which are included here should they assist those developing or delivering services in similar settings. One element that seemed key to the effectiveness of the study was the integration of psychology within the team, which occurred through attendance at team meetings and case discussions, consultation with staff of all disciplines, and being present and accessible within the ward environment. Keeping referral processes as straightforward as possible worked well (e.g. through discussions on the ward or in team meetings), as did updating the team on the progress of the post. Working across the in-patient/out-patient boundary meant psychology was able to provide a continuity of care that patients found helpful when admitted or discharged. Practically, it was helpful to protect time for the evaluation elements of the post, and we benefited from excellent support and data from the hospital business intelligence unit.
The principal challenge in undertaking this work has been time; over the 9-month period it was possible to implement many procedures and provide a range of clinical interventions, but the ability to allow these to establish and to collect follow-up data has been limited. Additionally there were other possible interventions that could not be implemented within the time frame that may further develop the role and benefits of psychology in the department, for example staff training and consultation, group interventions, guided self-help approaches, further liaison with community services, and staff support and supervision.
Other challenges include the need for flexibility in how and when interventions are delivered; in-patient work means referral rates can be inconsistent, input may be requested within a short time frame, and work must accommodate factors such as medical status, visiting hours, and input from other professionals. The large catchment area for the hospital creates potential challenges in ensuring that psychological provision is equitable for patients regardless of their distance from hospital. We found that providing support and intervention via telephone was a reasonable solution, although this can carry difficulties such as maintaining a therapeutic focus in the absence of face-to-face contact.
This project has outlined a set of procedures for delivering a psychology service within an acute respiratory context. It has demonstrated the need for psychological provision within this client group, and described a framework for implementing and evaluating interventions in this setting. We suggest it is important for those commissioning and managing services to consider the potential benefits that psychological provision can offer to patients, staff, and services as a whole.
Summary
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• Psychological difficulties are a common co-morbidity among people with chronic respiratory conditions.
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• Provision of psychological intervention in respiratory settings is not routine, despite recommendations from national guidelines.
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• This 9-month pilot project developed, implemented and evaluated psychology input to a hospital respiratory department.
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• Results indicated that providing psychological support for patients was cost effective, and was associated with reductions in emotional distress, positive patient experience of healthcare and staff feedback, increased staff awareness and willingness for addressing patients’ psychological needs, and reduced hospital admissions.
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• For further reading, see Layard and Clark (Reference Layard and Clark2014), Kunik et al. (Reference Kunik, Roundy, Veazey, Souchek, Richardson and Wray2005), Coventry et al. (Reference Coventry, Gemmell and Todd2011), and Howard and Dupont (Reference Howard and Dupont2014).
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Acknowledgements
The authors wish to thank the patients and staff of the respiratory department.
Financial support
Financial support for this study was provided by the Innovation Panel of the Royal United Hospital, Bath, UK.
Conflicts of interest
None.
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• To understand the frequency and impact of psychological difficulties in the context of chronic respiratory disease.
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• To consider the procedures and interventions used to develop, implement and evaluate psychological input in the acute respiratory setting.
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• To develop knowledge around the benefits and challenges of delivering a psychology service in this context.
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