Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult. We aimed to assess the effects of enhancing older inpatients’ care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital. We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment. PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients’ problems, then delivered discharge-focused care as integrated members of ward teams. The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient's experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life. Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296). 2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants’ mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White. The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference –0·45 (95% CI –1·11 to 0·21; p=0·18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP—a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred. This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation. UK National Institute for Health and Care Research.

中文翻译：

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英格兰老年内科住院患者的主动综合咨询联络精神病学和住院时间（HOME 研究）：一项多中心、平行组、随机对照试验


在紧急情况下入院的老年人通常住院时间延长，这会使他们的预后恶化，增加医疗保健成本，并减少床位可用性。越来越多的证据表明，他们问题的生物心理社会复杂性，包括认知障碍、抑郁、焦虑、多种医学疾病以及功能依赖导致的护理需求，通过降低医疗效率和制定出院后护理的计划来延长住院时间。我们旨在评估 HOME 研究中通过主动综合咨询联络精神病学 （PICLP） 加强老年住院患者护理的效果。我们之前已经描述了患者和临床医生报告的 PICLP 的好处。在本文中，我们报告了与单独的常规护理相比，PICLP 增强护理在减少住院时间方面的有效性和成本效益。我们在 3 家英国急症综合医院的 24 个内科病房进行了一项平行组、多中心、随机对照试验。如果患者年满 65 岁，在紧急情况下入院，并且预计从入组时起至少住院 2 天，则他们有资格参加。参与者通过数据库软件算法以 1：1 的比例随机分配到 PICLP 或常规护理组，该算法按医院、性别和年龄分层，并随机选择块大小以确保分配隐藏。PICLP 临床医生（由协助临床医生支持的咨询联络精神科医生）对患者的问题进行积极的生物心理社会评估，然后作为病房团队的综合成员提供以出院为中心的护理。 主要结局是随机分组后 30 天内住院时间（指数入院和任何紧急再入院期间）。次要结局是指数入院总长度的出院率;出货目的地;随机分配后指数录取的时长截断为 30 天;紧急再入院的人数、在急性综合医院住院的天数以及随机分配后一年的死亡率;患者住院的经历;他们对住院时间长短的看法;焦虑 （Generalized Anxiety Disorder-2）;抑郁 （患者健康问卷 2）;认知功能（蒙特利尔认知评估 - 电话版）;独立功能（Barthel 日常生活活动指数）;与健康相关的生活质量（五级 EuroQol 五维问卷）;以及整体生活质量。统计学家和数据收集者对治疗分配不知情;参与者和病房工作人员不能。分析是意向性治疗。该试验有一个患者和公众参与小组，并在 ISRTCN （ISRCTN86120296） 注册。2018 年 5 月 2 日至 2020 年 3 月 5 日期间招募了 2744 名参与者（1399 名 [51·0%] 男性和 1345 名 [49·0%] 女性）;1373 例被分配到 PICLP，1371 例被分配到常规护理。参与者的平均年龄为 82·3 岁 （SD 8·2），2565 名 （93·5%） 参与者为白人。随机分组后 30 天内的平均住院时间（对 2710 名 [98·8%] 参与者进行分析）为 PICLP 组 11·37 天 （SD 8·74） 和常规护理组 11·85 天 （SD 9·00）;校正均数差 -0·45（95% CI -1·11 至 0·21;p=0·18）。 次要结局的唯一统计学和临床显著差异是出院率，PICLP 组出院率高出 8.5% （比率 1·09 [95% CI 1·00 至 1·17];p=0·042），这一差异在住院超过 2 周的患者中最为明显。与常规护理相比，PICLP 估计在 1 个月和 3 个月内适度节省成本和成本效益，但不是 12 个月。未发生与干预相关的严重不良事件。这是 PICLP 的首个随机对照试验。老年内科住院患者和病房工作人员体验 PICLP 可以增强医疗保健。它也可能在短期内节省成本。尽管该试验没有提供强有力的证据证明 PICLP 减少了住院时间，但它确实支持并告知其未来的开发和评估。英国国家健康与护理研究所。