Abstract There is a growing evidence base for the use of interpersonal approaches when working with unusual experiences and extreme states of mind (often labelled as psychosis). Psychosis experiences can be understood as meaningful communications of human distress, often in response to trauma and adversity. This chapter collaboratively considers, alongside a lived experience perspective, how the cognitive analytic therapy (CAT) model understands psychosis and how it can be applied to facilitate relational change. Specific considerations are given to how CAT tools, including the reformulation letter and map, can be used to develop a trauma-informed understanding of psychosis experiences. There is acknowledgement of the increasing evidence highlighting the impact of the therapeutic relationship on outcome when working with clients who experience psychosis and the chapter details how the therapeutic relationship can be understood and navigated using a CAT framework. A review of the current research on CAT and psychosis is given and areas for further research are highlighted.

Abstract This volume presents a comprehensive guide to the cognitive analytic therapy (CAT) model. Throughout the volume, there is a balance of established theory and practice alongside a focus on innovation in both direct work with clients and the application of CAT more broadly within teams, organizations, and training, and as a model for leadership. The handbook includes a range of innovations in ‘doing’ and ‘using’ CAT, which are directly applicable for those studying and working in health, social care, and private services, across many specialties encompassing the entire lifespan. This includes: child and adolescent services; those of working age through to older adults; individuals engaged with mental health services and within forensic and prison populations; and those experiencing physical health and neurological difficulties, both in community and inpatient settings. Given the social and dialogic origins of CAT, this volume acknowledges the importance of wider social, cultural, and political factors that can shape an individual’s understanding of self and other; there are chapters that both apply a CAT understanding to key issues, such as racism and social context, and provide a critique to the extent in which CAT engages with these issues in practice. This volume also has a focus on professional standards and governance (encompassing training, supervision, and a competency framework). Throughout the book, the editors have endeavoured to include clients’ voices in various different ways, including personal reflections, extracts from actual CATs, and co-produced chapters, to ensure the book holds true to the collaborative nature of CAT.

The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

Abstract Background Gastro-oesophageal reflux disease (GORD) is a common gastrointestinal condition characterized by heartburn, chest pain, and regurgitation. Chronic treatment with proton pump inhibitor (PPI)-based medical management is the current standard of care, with antireflux surgery considered in selected patients. RefluxStop is a novel implantable device indicated for patients eligible for laparoscopic anti-reflux surgery. The purpose of this analysis was to assess the cost-effectiveness of RefluxStop against other GORD treatment options in the UK. Methods A Markov model was developed to assess the cost-effectiveness of RefluxStop compared with PPI-based medical management, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation (MSA) for management of GORD. The UK National Health Service perspective was adopted, with clinical outcomes and costs estimated over a lifetime horizon and an annual discount rate of 3.5% applied. Clinical efficacy data for RefluxStop was obtained from its CE mark study, and comparator treatments were based on published literature. Results RefluxStop demonstrated favorable surgical outcomes compared to both laparoscopic Nissen fundoplication and MSA. The base case incremental cost-effectiveness ratios (ICERs) compared with PPIs, laparoscopic Nissen fundoplication, and MSA were £4,156, £6,517, and £249 per quality-adjusted life-year (QALY) gained, respectively. With a UK cost-effectiveness threshold of £20,000 per QALY gained, the probabilities that RefluxStop was cost-effective compared with PPIs, laparoscopic Nissen fundoplication, and MSA were 100%, 93%, and 100%, respectively. Conclusions Based on this analysis, RefluxStop was estimated to improve quality of life and extend life expectancy in GORD patients when compared to PPIs, laparoscopic Nissen fundoplication, and MSA. Furthermore, this analysis demonstrated that RefluxStop is highly likely to be a cost-effective option for treating GORD in the UK.

Abstract Background Three recent randomized controlled trials demonstrated that, in patients with symptomatic paroxysmal atrial fibrillation (PAF), first-line pulmonary vein isolation (PVI) with cryoballoon ablation reduces atrial arrhythmia recurrence when compared to initial antiarrhythmic drug (AAD) therapy. Purpose To evaluate the cost-effectiveness of initial rhythm control therapy from a German healthcare service payer perspective. Methods The cost-effectiveness model (CEM) structure consisted of a hybrid decision tree and Markov model, where the decision tree informed the initial health state allocation in the first cycle of the Markov model and had a one-year time horizon. The Markov model had a 40-year time horizon using a three-month cycle length. Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3.5% p.a. Individual patient-level data from 703 participants with untreated PAF enrolled into Cryo-FIRST (NCT01803438), STOP AF First (NCT03118518) and EARLY-AF (NCT02825979) were used to estimate efficacy, resource use and health-related quality of life parameters. Cost inputs were sourced from diagnosis-related groups and the Institute for the Hospital Remuneration System (InEK). Where parameters could not be derived, inputs were sourced from available published literature or determined through clinical expert opinion. Probabilistic sensitivity analyses were conducted to explore the impact of any assumptions on model outputs. Results In those treated with cryoablation, the three-month rate of AF recurrence was reduced by 46.7% (p<0.001) on average. Similarly, the average monthly rate of receiving an ablation following initial treatment was reduced by 72.8% (p<0.001). Cryoablation was also associated with a 4.3% (p=0.025) increase in health-related quality of life at 12 months, assessed through the standard EQ-5D-3L instrument. There was no difference in the rate of AF resolution in those who failed initial treatment. CEM results are shown in Table 1. Analysis shows that cryoablation is cost-effective, incurring a cost of ∼€1,000 per patient over a lifetime compared to AADs, while offering an increase in QALYs. Cryoablation attains an average ICER of ∼€5,500, with a 94.1% probability of being cost-effective at a willingness-to-pay threshold of €35,000 per QALY gained. Through 5,000 iterations, the probabilistic sensitivity analysis indicates that cryoablation has ∼20% probability of being cost-saving. Individuals are expected to receive a total of ∼1.2 ablations over a lifetime, regardless of initial treatment. Although, those initially treated with cryoablation as opposed to AADs experience a 45% reduction in time spent in AF health states. Conclusion Initial rhythm control with cryoballoon ablation in PAF is a cost-effective treatment option in a German healthcare setting.Table 1:Key results (per patient)

Abstract Background/Introduction Completeness of revascularisation (CR) after percutaneous coronary intervention (PCI), which is associated with improved long-term patient outcomes, is commonly quantified with the post-PCI residual SYNTAX score (rSS). In High-Risk PCI (HR-PCI), trans-axial percutaneous Left Ventricular Assist Devices (pLVADs) provide higher procedural mechanical circulatory support than intra-aortic balloon pump (IABPs). We hypothesise that pLVADs may contribute to higher CR during HR-PCI. A direct quantitative relationship between revascularisation extent, measured via rSS, and long-term clinical outcomes has not yet been established in HR-PCI. NYHA Class allocation 90-days post-PCI and Ejection Fraction (EF) have been shown strongly predictive of long-term survival, Heart Failure (HF) hospitalization risk and Quality of Life (QoL). Purpose To investigate the relationship between revascularization completeness, NYHA Class and LVEF 90-days in patients undergoing HR-PCI with either pLVAD or IABP support. Methods Individual patient data (IPD) from the PROTECT II and RESTORE-EF prospective studies of pLVADs during HR-PCI were pooled. Using patients with sufficient information, ordinal logistic regressions were performed for NYHA and EF at 90-days post-PCI. All models were refined using stepwise deletion (threshold=0.05) and included treatment group (pLVAD or IABP), baseline age, gender, race, NYHA Class at baseline, LVEF at baseline, SYNTAX Score at baseline and post-procedural rSS. Results NYHA Class utilised 641 patients (484 pLVAD;157 IABP). Baseline SYNTAX, rSS and LVEF at baseline were significant predictors of NYHA Class at 90-days post HR-PCI. Specifically, a single-unit decrease in rSS increases the odds of the patient improving NYHA at 90-days vs. baseline by 2.2%±1.0% (Mean±SE, p=0.021). Utilising solely the subjects with sufficient information enrolled in PROTECT II (178 pLVAD; 157 IABP), post-procedural rSS was the only significant predictor of NYHA Class at 90-days with every single-unit decrease in rSS increasing the odds of NYHA improvement by 3.0%±1.2% (p=0.017). EF examined 622 (405 pLVAD; 217 IABP). Baseline SYNTAX, rSS and baseline LVEF significantly predicted Ejection Fraction at 90-days. A single-unit decrease in rSS leads to an absolute higher LVEF at 90-days of 0.246%±0.05% (p<0.001). Treatment group statistically predicted LVEF at 90-days. For the same level of revascularisation, pLVAD-supported procedures result in an absolute higher LVEF of 4.13%±1.21% (p=0.001). Conclusions Completeness of revascularization, as measured by level of reduction in rSS after a HR-PCI, is significantly predictive of NYHA Class improvement and Ejection Fraction gains at 90-day follow-up. pLVADs were also shown to further increase LVEF at 90-days vs. IABP. These data further support the need for complete revascularization in this patient population and help make additional therapeutic decisions post-PCI.

BackgroundInpatient falls are the most common safety incident reported by hospitals worldwide. Traditionally, responses have been guided by categorising patients’ levels of fall risk, but multifactorial approaches are now recommended. These target individual, modifiable fall risk factors, requiring clear communication between multidisciplinary team members. Spoken communication is an important channel, but little is known about its form in this context. We aim to address this by exploring spoken communication between hospital staff about fall prevention and how this supports multifactorial fall prevention practice.MethodsData were collected through semistructured qualitative interviews with 50 staff and ethnographic observations of fall prevention practices (251.25 hours) on orthopaedic and older person wards in four English hospitals. Findings were analysed using a framework approach.FindingsWe observed staff engaging in ‘multifactorial talk’ to address patients’ modifiable risk factors, especially during multidisciplinary meetings which were patient focused rather than risk type focused. Such communication coexisted with ‘categorisation talk’, which focused on patients’ levels of fall risk and allocating nursing supervision to ‘high risk’ patients. Staff negotiated tensions between these different approaches through frequent ‘hybrid talk’, where, as well as categorising risks, they also discussed how to modify them.ConclusionTo support hospitals in implementing multifactorial, multidisciplinary fall prevention, we recommend: (1) focusing on patients’ individual risk factors and actions to address them (a ‘why?’ rather than a ‘who’ approach); (2) where not possible to avoid ‘high risk’ categorisations, employing ‘hybrid’ communication which emphasises actions to modify individual risk factors, as well as risk level; (3) challenging assumptions about generic interventions to identify what individual patients need; and (4) timing meetings to enable staff from different disciplines to participate.

Background Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging. Objective To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity. Design A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only. Setting Mainstream schools in the north of England. Participants Children and young people (aged 7–15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only). Intervention Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation. Main outcome measure The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people’s unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events. Results A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval –0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported. Conclusions The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered. Limitations The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator). Future work The study team recommends future research into LEGO® based therapy, particularly in school environments. Trial registration This trial is registered as ISRCTN64852382. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

BackgroundThe EARLY-AF (NCT02825979), STOP AF First (NCT03118518), and Cryo-FIRST (NCT01803438) randomised controlled trials (RCTs) demonstrated that cryoballoon pulmonary vein isolation reduces atrial fibrillation (AF) recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). The present study developed a cost-effectiveness model (CEM) of first-line cryoablation compared with first-line AADs for PAF, from the Canadian health care payer’s perspective. MethodsData from the 3 RCTs were analysed to estimate key CEM parameters. The model structure used a decision tree for the first 12 months and a Markov model with a 3-month cycle length for the remaining lifetime time horizon. Costs were set at 2023 Canadian dollars, health benefits were expressed as quality-adjusted life years (QALYs), and both were discounted 3% annually. Probabilistic sensitivity analysis (PSA) considered parameter uncertainty. ResultsThe statistical analysis estimated that first-line cryoablation generates a 47% reduction (P < 0.001) in the rate of AF recurrence, a 73% reduction in the rate of subsequent ablation (P < 0.001), and a 4.3% (P = 0.025) increase in health-related quality of life, compared with first-line AADs. The PSA indicates that an individual treated with first-line cryoablation accrues less costs (−$3,862) and more QALYs (0.19) compared with first-line AADs. Cryoablation is cost-saving in 98.4% of PSA iterations and has a 99.9% probability of being cost-effective at a cost-effectiveness threshold of $50,000 per QALY gained. Cost-effectiveness results were robust to changes in key model parameters. ConclusionsFirst-line cryoballoon ablation is cost-effective when compared with AADs for patients with symptomatic PAF.

BackgroundEstablishing and maintaining relationships and ways of connecting and being with others is an important component of health and wellbeing. Harnessing the relational within caring, supportive, educational, or carceral settings as a systems response has been referred to as relational practice. Practitioners, people with lived experience, academics and policy makers, do not yet share a well-defined common understanding of relational practice. Consequently, there is potential for interdisciplinary and interagency miscommunication, as well as the risk of policy and practice being increasingly disconnected. Comprehensive reviews are needed to support the development of a coherent shared understanding of relational practice.MethodThis study uses a scoping review design providing a scope and synthesis of extant literature relating to relational practice focussing on organisational and systemic practice. The review aimed to map how relational practice is used, defined and understood across health, criminal justice, education and social work, noting any impacts and benefits reported. Searches were conducted on 8 bibliographic databases on 27 October 2021. English language articles were included that involve/discuss practice and/or intervention/s that prioritise interpersonal relationships in service provision, in both external (organisational contexts) and internal (how this is received by workers and service users) aspects.ResultsA total of 8010 relevant articles were identified, of which 158 met the eligibility criteria and were included in the synthesis. Most were opinion-based or theoretical argument papers (n = 61, 38.60%), with 6 (3.80%) critical or narrative reviews. A further 27 (17.09%) were categorised as case studies, focussing on explaining relational practice being used in an organisation or a specific intervention and its components, rather than conducting an evaluation or examination of the effectiveness of the service, with only 11 including any empirical data. Of the included empirical studies, 45 were qualitative, 6 were quantitative, and 9 mixed methods studies. There were differences in the use of terminology and definitions of relational practice within and across sectors.ConclusionAlthough there may be implicit knowledge of what relational practice is the research field lacks coherent and comprehensive models. Despite definitional ambiguities, a number of benefits are attributed to relational practices.Systematic review registrationPROSPERO CRD42021295958