Healthcare utilisation is at an all time high in the UK. According to the Department of Health, last year there were over 18 million emergency department (ED) attendances, an increase of over 1 million from the previous year.
Similar figures for primary care do not exist, but a press release from the Royal College of General Practitioners gave an estimate of over 340 million visits to the GP in England last year. This is not 340 million different patients; some people are considerable higher users of care than others. Approximately half of these high-utilisers are distressed, with a substantial proportion suffering from depression, and anxiety disorder or somatisation disorder.
Mindfulness-based therapy is a popular topic in the woodland, with previous blogs discussing its use for relapse prevention in substance misuse disorders, depression and stress management in breast cancer, amongst other things. More about mindfulness practice can be found on the NHS choices website.
Qualitative research suggests that skills acquired through mindfulness training enable patients to tolerate greater degrees of uncertainty and encourage acceptance (van Ravesteijn et al., 2014). These could be useful skills for distressed high-utilisers of healthcare services. This is why a Kurdyak and colleagues (from Toronto in Canada) have conducted a population-based controlled comparison, to examine whether high-utilisers use fewer health care resources following exposure to mindfulness-based cognitive therapy (MBCT).
Data came from a national register, ED records and a health insurance plan database. Two separate cohorts were selected and age matched:
- Those who received MBCT
- Those who received a non-MBCT group therapy (all other types of group therapy were included)
The primary outcome was a measure of non-mental health service utilisation (including ED attendance, specialist visits and primary care visits).
They compared the 12-months post-therapy with the 12-months prior to therapy, looking at the difference in mean number of visits for the MBCT and non-MBCT groups. They also measured psychiatrist and mental health primary care visits over the same period.
Healthcare utilisation was stratified by high or low utilisation. High utilisation was defined as the top 40% of population-based primary care utilisers, which equalled 5 or more visits per year.
Characteristics of high-utilisers
Unsurprisingly, a greater proportion had a medical co-morbidity, especially asthma, COPD or diabetes.
Those who received MBCT (n= 10,633) had significant reductions in:
- Non-mental health primary care visits: -2.26 (95% CI -2.45 to -2.06)
- Non-psychiatrist specialist visits: -0.55 (95% CI -0.70 to -0.39)
- ED visits: -0.23 (95% CI -0.31 to -0.16)
Over a 12-month period this represents:
- 1 less non-mental health visit for every 2 high-utilisers treated, and
- 2 fewer psychiatric visits for every 3 high-utilisers treated
Those who received non-MBCT (n= 29,795) had significant reductions in:
- Non-mental health primary care visits: -2.05 (95% CI -2.19 to -1.91)
- ED visits: -0.45 (95% CI -0.51 to -0.40)
When they compared the relative change in health service utilisation between high users in the MBCT and non-MBCT groups, they found that the MBCT group had an overall reduction in:
- Non-mental health care visits: 0.55 (95% CI 0.21 to 0.89)
- Psychiatric visits: 1.53 (95% CI 1.21 to 1.85)
- Non-mental health specialist visits: 0.55 (95% CI 0.38 to 0.73)
The main limitation relates to the way data was collected. They were only able to measure MBCT provided by physicians. This means that MBCT provided by other practitioners (such as psychologists) was missed. In the NHS, this type of therapy would typically be delivered by non-medical healthcare professionals. This may not be a big issue since, low intensity psychotherapies are increasingly becoming manualised and standardised.
The study also did not mention how many sessions of therapy the patients had, or whether they completed the 8 week course. Therefore, the effect of having either MBCT or non-MBCT on healthcare utilisation could be an underestimate, and we don’t know how many sessions were effective at reducing utilisation.
The authors said that:
Receiving MBCT resulted in a significant reduction in non-mental health utilisation.
There are many great things about this study. The authors commented on the heterogeneity of study participants as a limitation. However, my experience of working with distressed high-utilisers is that they are a very heterogeneous group, and diagnosis is often unclear. The study design is probably better suited to study this population than another design with stricter inclusion criteria. I also liked that they included anyone from 15-105 years old and those with medical co-morbidity.
The RCGP chair Maureen Baker recently commented (in a press release about lipid modification) that:
At least 27 million patients will already have to wait more than a week to see a GP this year and 84% of GPs are worried their workloads are so high that they might miss something serious in a patient.
Any intervention that can re-direct patients to a more appropriate service for their needs is invaluable to the NHS. We should look forward to seeing a similar population-based study the UK, with an evaluation of the economic implications. Please drop us a line if you are working on research in this area.
Kurdyak P, et al, Impact of mindfulness-based cognitive therapy on health care utilization: A population-based controlled comparison, J Psychosom Res, 25 Jun 2014. [Abstract]
Mindfulness for mental wellbeing. NHS Choices website, last accessed 21 Jul 2014.
Ravesteijn H.J, et al, Mindfulness-based cognitive therapy (MBCT) for patients with medically unexplained symptoms: Process of change. Journal of Psychosomatic Research. Volume 77, Issue 1, July 2014, Pages 27–33. [Abstract]