How can we best address prolonged acute hospital stays in older inpatients with medical-psychiatric multimorbidity?: A pragmatic multicentre randomised controlled trial to compare the effectiveness and cost-effectiveness of Proactive Liaison Psychiatry with usual care.
Older patients with both medical and psychiatric conditions are languishing in acute hospital beds for weeks longer than necessary, and a new trial tests whether a proactive psychiatric team can get them home faster. This matters because current practice relies on ward doctors to spot mental health problems and refer to liaison psychiatry—a reactive system that often misses patients or acts too late. The trial compares this usual care against Proactive Liaison Psychiatry (PLP), where a specialist team assesses every older patient early, creates a discharge-focused management plan, and coordinates with ward staff and community services to remove psychological barriers to leaving hospital. If PLP proves effective and cost-effective, it could transform how hospitals handle this growing patient group. Shorter stays would free up acute beds for others, reduce the risks of hospital-acquired complications in frail older people, and lower NHS costs. The economic evaluation measures quality-adjusted life-years to ensure any savings don't come at the expense of patient wellbeing. A successful model could be rolled out across the NHS, changing a quiet but costly bottleneck in hospital flow that affects thousands of older patients every year.
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DESIGN Pragmatic multicentre 2-arm parallel group individually randomised (1:1 ratio) controlled superiority trial with health economic analysis and embedded process evaluation. SETTING Acute medical wards in 3 general hospitals. INCLUSION/EXCLUSION CRITERIA Included: if aged 65 or older; non-elective admission; likely to remain an inpatient for at least two days; able to give informed consent or if unable to give consent their consultee, guardian or nearest relative advises that trial participation is appropriate. Excluded: if moribund; already enrolled in the trial. NEW INTERVENTION: PROACTIVE LIAISON PSYCHIATRY / PROACTIVE PSYCHOLOGICAL MEDICINE (PLP/PPM) PLP has 4 main components: 1. Early proactive assessment of all patients to identify psychological problems including psychiatric illness. 2. Creation of a management plan to address these and overcome barriers to prompt discharge. 3. Proactive progress reviews and communication with relevant health and social care professionals to deliver the plan. 4. Integrated working with ward teams to ensure that the management plan is communicated to other providers at discharge. COMPARATOR: USUAL CARE Usual medical care (including referral to local liaison psychiatry services if deemed necessary by the ward team). PRIMARY OUTCOME Number of days spent as an acute hospital inpatient in the month (30 days) post-randomisation, measured using routine hospital episode statistics and local hospital data. SECONDARY OUTCOMES At 1 month post-randomisation: Independent functioning, cognitive function, anxiety, depression, quality of life, experience of care, discharge destination, length of index admission. At 1 year post-randomisation: Time spent in hospital, number of readmissions, deaths. ECONOMIC EVALUATION Cost-effectiveness (over 1 year) assessed from the perspective of the NHS and personal social services. Outcomes will be expressed in terms of quality-adjusted life-years (QALYs). Full uncertainty analysis will be undertaken. Incremental cost-effectiveness ratios will be presented and compared with appropriate cost-effectiveness thresholds. PROCESS EVALUATION Process evaluation will focus on the delivery of PLP, the response to and interaction with PLP by all stakeholders and potential barriers and facilitators to its implementation. SAMPLE SIZE A total of 3,588 participants is required to detect a reduction of 1 day (from 9 to 8 days, standard deviation 9) in mean number of days in hospital with 90% power at the 5% significance level and allowing for 5% loss to follow-up. A total of 2,680 participants is required to detect the same reduction with 80% power. PROJECT TIMETABLE Recruitment has been completed (2,744 participants). Data analysis is underway and expected to be completed in 2021. EXPERTISE Design and conduct of trials in patients with multimorbidity; complex intervention development; clinical (old age and liaison psychiatry; geriatrics; primary, out of hospital and social care); service users; nursing; statistics; health economics; trials management; hospital management; process evaluation; use of routine data in clinical trials.
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