The Children and Young People’s Health Partnership (CYPHP) Evelina London Model of Care: an opportunistic cluster randomised trial to assess child health outcomes, healthcare quality, and health service use

摘要

Background: Chronic, non-communicable disease, accounts for the vast majority of all disability adjusted life years lost (DALYS), among children and young people in high income countries. Our current model of hospital‐centred paediatric care was developed to deliver acute inpatient and high intensity specialist services rather than high quality care for children and young people (CYP) with long-term conditions. The CYPHP Evelina London model was developed with key stakeholders including CYP, carers, front line practitioners and health service commissioners in response to these evolving health care needs.  The CYPHP Evelina London model is an innovative approach to reshaping everyday healthcare services, expanding on the principles of integrated care. CYPHP brings together physical and mental healthcare, addresses the social context of families, integrates primary and secondary healthcare, and links healthcare with local government efforts to improve the wider determinants of health. A major focus of the CYPHP Evelina London model is improving front line care for all CYP. Methods: The CYPHP model will be rolled out in phases, allowing an opportunistic evaluation using a cluster Randomised Controlled Trial (cRCT) design involving 90,000 children and young people in 23 clusters. The evaluation has four component parts: 1- Pseudonymised population-based evaluation for all children and young people in participating GP practices to assess health service use; 2- An evaluation of consented children with asthma, eczema, and constipation to assess impact on health-related quality of life, parental-reported disease severity, prevalence and severity of mental health difficulties, and mental wellbeing among parents, using validated questionnaires. 3- A mixed-methods process evaluation to understand the barriers and facilitators to implementing the model of care; 4- Economic evaluation. Results: Initial baseline results from the first 219 Health Checks showed poorly controlled symptoms for asthma, eczema and constipation in between 60 and 76% of young people. In total, 28% of CYP  scored ‘High’/’Very High’ on Strengths & Difficulties Questionnaire for mental health difficulties. Over a quarter of families reported problems paying bills and 12% of parents expressed concerns regarding their own mental health.   Discussion: The ongoing CYPHP evaluation is the largest population based evaluation of a pediatrics integrated care model to date in the UK. We will discuss the need for robust evaluation in the space of health transformation using CYPHP as an exemplar. Conclusions: Initial results show high levels of unmet physical, psychological and social needs in children and young people with common and chronic illness.  Clinical academic partnerships are key to robust evaluation of health service models at scale. Lessons learned: The difficulties, of carrying out a large randomised controlled trial of a health systems transformation programme across two London Boroughs including partnership working, funding models, ethics approval and recruitment will be discussed. Limitations: Though final results are not available, initial results show high levels of unmet need in our population which the CYPHP model of care is meeting.   Suggestions for future research: Robust evaluation using experimental designs is possible and needed in the health systems space. These evaluations at scale will inform new health system design.