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Cicek M, Greenfield G, Nicholls D, Majeed A, Hayhoe B. Predictors of unplanned emergency hospital admissions among patients aged 65+ with multimorbidity and depression in Northwest London during and after the Covid-19 lockdown in England. PLoS One 2024; 19:e0294639. [PMID: 38394234 PMCID: PMC10890757 DOI: 10.1371/journal.pone.0294639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 11/07/2023] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Individuals with multimorbidity have an increased likelihood of using unplanned secondary care including emergency department visits and emergency hospitalisations. Those with mental health comorbidities are affected to a greater extent. The Covid-19 pandemic has negatively impacted on psychosocial wellbeing and multimorbidity care, especially among vulnerable older individuals. AIM To examine the risk of unplanned hospital admissions among patients aged 65+ with multimorbidity and depression in Northwest London, England, during- and post-Covid-19 lockdown. METHODS Retrospective cross-sectional data analysis with the Discover-NOW database for Northwest London was conducted. The overall sample consisted of 20,165 registered patients aged 65+ with depression. Two time periods were compared to observe the impact of the Covid-19 lockdown on emergency hospital admissions between 23rd March 2020 to 21st June 2021 (period 1) and equivalent-length post-lockdown period from 22nd June 2021 to 19th September 2022 (period 2). Multivariate logistic regression was conducted on having at least one emergency hospital admission in each period against sociodemographic and multimorbidity-related characteristics. RESULTS The odds of having an emergency hospitalisation were greater in men than women (OR = 1.19 (lockdown); OR = 1.29 (post-lockdown)), and significantly increased with age, higher deprivation, and greater number of comorbidities in both periods across the majority of categories. There was an inconclusive pattern with ethnicity; with a statistically significant protective effect among Asian (OR = 0.66) and Black ethnicities (OR = 0.67) compared to White patients during post-lockdown period only. CONCLUSION The likelihood of unplanned hospitalisation was higher in men than women, and significantly increased with age, higher deprivation, and comorbidities. Despite modest increases in magnitude of risk between lockdown and post-lockdown periods, there is evidence to support proactive case-review by multi-disciplinary teams to avoid unplanned admissions, particularly men with multimorbidity and comorbid depression, patients with higher number of comorbidities and greater deprivation. Further work is needed to determine admission reasons, multimorbidity patterns, and other clinical and lifestyle predictors.
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Affiliation(s)
- Meryem Cicek
- Applied Research Collaboration Northwest London (ARC NWL), Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Geva Greenfield
- Applied Research Collaboration Northwest London (ARC NWL), Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dasha Nicholls
- Applied Research Collaboration Northwest London (ARC NWL), Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
- Division of Psychiatry, Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Azeem Majeed
- Applied Research Collaboration Northwest London (ARC NWL), Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Benedict Hayhoe
- Applied Research Collaboration Northwest London (ARC NWL), Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
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Lee CT, Harty S, Adegoke A, Palacios J, Gillan CM, Richards D. The Effectiveness of Low-Intensity Psychological Interventions for Comorbid Depression and Anxiety in Patients with Long-Term Conditions: A Real-World Naturalistic Observational Study in IAPT Integrated Care. Int J Behav Med 2023:10.1007/s12529-023-10215-9. [PMID: 37697142 DOI: 10.1007/s12529-023-10215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Low-intensity psychological interventions may be a cost-effective, accessible solution for treating depression and anxiety in patients with long-term conditions, but evidence from real-world service settings is lacking. This study examined the effectiveness of low-intensity psychological interventions provided in the Improving Access to Psychological Therapies programme in England for patients with and without long-term conditions. METHODS A retrospective analysis was conducted on patients (total N = 21,051, long-term conditions n = 4024) enrolled in three low-intensity psychological interventions, i.e. Internet-delivered cognitive behavioural therapy (iCBT), guided self-help (GSH), and psychoeducational group therapy (PGT) within a Talking Therapies service from 2016 to 2020. Primary outcomes included pre-post-treatment changes in depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7). RESULTS Overall, both cohorts significantly improved on all outcomes post-treatment, with large effect sizes. Patients with long-term conditions experienced a greater reduction in depression while those without experienced a greater reduction in anxiety, but these differences were marginal (< 1 score difference on both measures). No difference between the cohorts was shown when comparing the differential effectiveness across interventions, but those engaging in iCBT showed greater reduction in depression and anxiety than those in GSH and PGT, while those in GSH improved more than PGT. CONCLUSIONS Low-intensity psychological interventions, particularly iCBT, were effective in treating depression and anxiety in patients with long-term conditions in a real-world service setting. Our large-scale study supports the continued and increased implementation of low-intensity psychological interventions for this subpopulation via integrated care.
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Affiliation(s)
- Chi Tak Lee
- School of Psychology, Trinity College Dublin, Dublin, Ireland.
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland.
| | - Siobhan Harty
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Adedeji Adegoke
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Jorge Palacios
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
| | - Claire M Gillan
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Derek Richards
- School of Psychology, Trinity College Dublin, Dublin, Ireland
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
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Menear M, Duhoux A, Bédard M, Paquette JS, Baron M, Breton M, Courtemanche S, Dubé S, Dufour S, Fortin M, Girard A, Larouche-Côté É, L'Espérance A, LeBlanc A, Poitras ME, Rivet S, Sasseville M, Achim A, Archambault P, Bajurny V, Brown JB, Carrier JD, Côté N, Couturier Y, Dogba MJ, Gagnon MP, Ghio SC, Marshall EG, Kothari A, Lussier MT, Mair FS, Smith S, Vachon B, Wong S. Understanding the impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity: protocol for a mixed methods study. BMC PRIMARY CARE 2023; 24:154. [PMID: 37488515 PMCID: PMC10364355 DOI: 10.1186/s12875-023-02106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients' care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences. METHODS We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases. DISCUSSION Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.
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Affiliation(s)
- Matthew Menear
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada.
- VITAM Centre de recherche en santé durable, Quebec City, Canada.
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montreal, Canada
- Centre de Recherche Charles-Le Moyne, Montreal, Canada
| | - Myreille Bédard
- Person With Lived Experience (Patient Partner), Montreal, Canada
| | - Jean-Sébastien Paquette
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Marie Baron
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Mylaine Breton
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | | | - Savannah Dubé
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Stefany Dufour
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Martin Fortin
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Ariane Girard
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | | | | | - Annie LeBlanc
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Marie-Eve Poitras
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Sophie Rivet
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Maxime Sasseville
- VITAM Centre de recherche en santé durable, Quebec City, Canada
- Faculty of Nursing, Université Laval, Quebec, Canada
| | - Amélie Achim
- VITAM Centre de recherche en santé durable, Quebec City, Canada
- Department of Psychiatry, Université Laval, Quebec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Virtue Bajurny
- Person with Lived Experience (Patient Partner), Toronto, Canada
| | | | - Jean-Daniel Carrier
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Nancy Côté
- VITAM Centre de recherche en santé durable, Quebec City, Canada
- Faculty of Social Sciences, Université Laval, Quebec, Canada
| | - Yves Couturier
- School of Social Work, Université de Sherbrooke, Sherbrooke, Canada
| | - Maman Joyce Dogba
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
- VITAM Centre de recherche en santé durable, Quebec City, Canada
| | - Marie-Pierre Gagnon
- VITAM Centre de recherche en santé durable, Quebec City, Canada
- Faculty of Nursing, Université Laval, Quebec, Canada
| | | | | | - Anita Kothari
- Department of Health Studies, Western University, London, Canada
| | - Marie-Thérèse Lussier
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Canada
| | - Frances S Mair
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Susan Smith
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, UK
| | - Brigitte Vachon
- School of Rehabilitation, Université de Montréal, Montreal, Canada
| | - Sabrina Wong
- Faculty of Applied Science, University of British Colombia, Vancouver, Canada
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Harber-Aschan L, Darin-Mattsson A, Fratiglioni L, Calderón-Larrañaga A, Dekhtyar S. Socioeconomic differences in older adults' unplanned hospital admissions: the role of health status and social network. Age Ageing 2023; 52:7127659. [PMID: 37079867 PMCID: PMC10118263 DOI: 10.1093/ageing/afac290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND the socioeconomic distribution of unplanned hospital admissions in older adults is poorly understood. We compared associations of two life-course measures of socioeconomic status (SES) with unplanned hospital admissions while comprehensively accounting for health, and examined the role of social network in this association. METHODS in 2,862 community-dwelling adults aged 60+ in Sweden, we derived (i) an aggregate life-course SES measure grouping individuals into Low, Middle or High SES based on a summative score, and (ii) a latent class measure that additionally identified a Mixed SES group, characterised by financial difficulties in childhood and old age. The health assessment combined measures of morbidity and functioning. The social network measure included social connections and support components. Negative binomial models estimated the change in hospital admissions over 4 years in relation to SES. Stratification and statistical interaction assessed effect modification by social network. RESULTS adjusting for health and social network, unplanned hospitalisation rates were higher for the latent Low SES and Mixed SES group (incidence rate ratio [IRR] = 1.38, 95% confidence interval [CI]: 1.12-1.69, P = 0.002; IRR = 2.06, 95% CI: 1.44-2.94, P < 0.001; respectively; ref: High SES). Mixed SES was at a substantially greater risk of unplanned hospital admissions among those with poor (and not rich) social network (IRR: 2.43, 95% CI: 1.44-4.07; ref: High SES), but the statistical interaction test was non-significant (P = 0.493). CONCLUSION socioeconomic distributions of older adults' unplanned hospitalisations were largely driven by health, although considering SES dynamics across life can reveal at-risk sub-populations. Financially disadvantaged older adults might benefit from interventions aimed at improving their social network.
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Affiliation(s)
- Lisa Harber-Aschan
- Demography Unit, Department of Sociology, Stockholm University, Universitetsvägen 10, 114 18 Stockholm, Sweden
- Stockholm University Demography Unit, Stockholm University, Stockholm, Sweden
| | - Alexander Darin-Mattsson
- Demography Unit, Department of Sociology, Stockholm University, Universitetsvägen 10, 114 18 Stockholm, Sweden
| | - Laura Fratiglioni
- Demography Unit, Department of Sociology, Stockholm University, Universitetsvägen 10, 114 18 Stockholm, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Amaia Calderón-Larrañaga
- Demography Unit, Department of Sociology, Stockholm University, Universitetsvägen 10, 114 18 Stockholm, Sweden
| | - Serhiy Dekhtyar
- Demography Unit, Department of Sociology, Stockholm University, Universitetsvägen 10, 114 18 Stockholm, Sweden
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5
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Shah A, Hussain-Shamsy N, Strudwick G, Sockalingam S, Nolan RP, Seto E. Digital Health Interventions for Depression and Anxiety Among People with Chronic Conditions: Scoping Review (Preprint). J Med Internet Res 2022; 24:e38030. [PMID: 36155409 PMCID: PMC9555324 DOI: 10.2196/38030] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/12/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored. Objective This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions. Methods A scoping review of the literature was conducted using the Arksey and O’Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research. Results Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI. Conclusions As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research.
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Affiliation(s)
- Amika Shah
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
| | - Neesha Hussain-Shamsy
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
| | - Gillian Strudwick
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Sanjeev Sockalingam
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Robert P Nolan
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Cardiac eHealth, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre for Global eHealth Innovation, University Health Network, Toronto, ON, Canada
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6
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Depression and unplanned secondary healthcare use in patients with multimorbidity: A systematic review. PLoS One 2022; 17:e0266605. [PMID: 35390086 PMCID: PMC8989325 DOI: 10.1371/journal.pone.0266605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/23/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Growing numbers of people with multimorbidity have a co-occurring mental health condition such as depression. Co-occurring depression is associated with poor patient outcomes and increased healthcare costs including unplanned use of secondary healthcare which may be avoidable.
Aim
To summarise the current evidence on the association between depression and unplanned secondary healthcare use among patients with multimorbidity.
Methods
We conducted a systematic review by searching MEDLINE, EMBASE, PsychINFO, Web of Science, CINAHL, and Cochrane Library from January 2000 to March 2021. We included studies on adults with depression and at least one other physical long-term condition that examined risk of emergency hospital admissions as a primary outcome, alongside emergency department visits or emergency readmissions. Studies were assessed for risk of bias using The National Institute of Health National Heart, Lung, and Blood Institute quality assessment tool. Relevant data were extracted from studies and a narrative synthesis of findings produced.
Results
Twenty observational studies were included in the review. Depression was significantly associated with different outcomes of unplanned secondary healthcare use, across various comorbidities. Among the studies examining these outcomes, depression predicted emergency department visits in 7 out of 9 studies; emergency hospital admissions in 19 out of 20 studies; and emergency readmissions in 4 out of 4 studies. This effect increased with greater severity of depression. Other predictors of unplanned secondary care reported include increased age, being female, and presence of greater numbers of comorbidities.
Conclusion
Depression predicted increased risk of unplanned secondary healthcare use in individuals with multimorbidity. The literature indicates a research gap in identifying and understanding the impact of complex multimorbidity combinations, and other patient characteristics on unplanned care in patients with depression. Findings indicate the need to improve planned care for patients with moderate-to-severe depression. We suggest regular reviews of care plans, depression severity monitoring and assessment of hospital admission risk in primary care settings.
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7
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Burke L, Littlewood E, Gascoyne S, McMillan D, Chew-Graham CA, Bailey D, Sloan C, Fairhurst C, Baird K, Hewitt C, Henry A, Ryde E, Shearsmith L, Coventry P, Crosland S, Newbronner E, Traviss-Turner G, Woodhouse R, Clegg A, Gentry T, Hill A, Lovell K, Dexter Smith S, Webster J, Ekers D, Gilbody S. Behavioural Activation for Social IsoLation (BASIL+) trial (Behavioural activation to mitigate depression and loneliness among older people with long-term conditions): Protocol for a fully-powered pragmatic randomised controlled trial. PLoS One 2022; 17:e0263856. [PMID: 35324908 PMCID: PMC8947398 DOI: 10.1371/journal.pone.0263856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Depression is a leading mental health problem worldwide. People with long-term conditions are at increased risk of experiencing depression. The COVID-19 pandemic led to strict social restrictions being imposed across the UK population. Social isolation can have negative consequences on the physical and mental wellbeing of older adults. In the Behavioural Activation in Social IsoLation (BASIL+) trial we will test whether a brief psychological intervention (based on Behavioural Activation), delivered remotely, can mitigate depression and loneliness in older adults with long-term conditions during isolation. Methods We will conduct a two-arm, parallel-group, randomised controlled trial across several research sites, to evaluate the clinical and cost-effectiveness of the BASIL+ intervention. Participants will be recruited via participating general practices across England and Wales. Participants must be aged ≥65 with two or more long-term conditions, or a condition that may indicate they are within a ‘clinically extremely vulnerable’ group in relation to COVID-19, and have scored ≥5 on the Patient Health Questionnaire (PHQ9), to be eligible for inclusion. Randomisation will be 1:1, stratified by research site. Intervention participants will receive up to eight intervention sessions delivered remotely by trained BASIL+ Support Workers and supported by a self-help booklet. Control participants will receive usual care, with additional signposting to reputable sources of self-help and information, including advice on keeping mentally and physically well. A qualitative process evaluation will also be undertaken to explore the acceptability of the BASIL+ intervention, as well as barriers and enablers to integrating the intervention into participants’ existing health and care support, and the impact of the intervention on participants’ mood and general wellbeing in the context of the COVID-19 restrictions. Semi-structured interviews will be conducted with intervention participants, participant’s caregivers/supportive others and BASIL+ Support Workers. Outcome data will be collected at one, three, and 12 months post-randomisation. Clinical and cost-effectiveness will be evaluated. The primary outcome is depressive symptoms at the three-month follow up, measured by the PHQ9. Secondary outcomes include loneliness, social isolation, anxiety, quality of life, and a bespoke health services use questionnaire. Discussion This study is the first large-scale trial evaluating a brief Behavioural Activation intervention in this population, and builds upon the results of a successful external pilot trial. Trial registration ClinicalTrials.Gov identifier ISRCTN63034289, registered on 5th February 2021.
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Affiliation(s)
- Lauren Burke
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, United Kingdom
| | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, United Kingdom
| | - Claire Sloan
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Kalpita Baird
- Department of Health Sciences, University of York, York, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Henry
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Leanne Shearsmith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter Coventry
- Department of Health Sciences, University of York, York, United Kingdom
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, United Kingdom
| | | | | | - Rebecca Woodhouse
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Clegg
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Tom Gentry
- Age UK, Tavis House, 1–6 Tavistock Square, London United Kingdom
| | - Andrew Hill
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Sarah Dexter Smith
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | | | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
- * E-mail:
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Schäfer I, Menzel A, Oltrogge JH, Slagman A, Möckel M, Lühmann D, Scherer M. Is subjectively perceived treatment urgency of patients in emergency departments associated with self-reported health literacy and the willingness to use the GP as coordinator of treatment? Results from the multicentre, cross-sectional, observational study PiNo Bund. BMJ Open 2021; 11:e053110. [PMID: 34819288 PMCID: PMC8614139 DOI: 10.1136/bmjopen-2021-053110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Aim of this study was to analyse if subjectively perceived treatment urgency of patients in emergency departments is associated with self-reported health literacy and the willingness to use the general practitioner (GP) as coordinator of treatment. DESIGN A multicentre, cross-sectional, observational study. SETTING Emergency departments in five hospitals. Each hospital was visited 14 times representing two 8-hour shifts on each day of the week. Calendar dates were randomly assigned. PARTICIPANTS All patients of legal age registered at the emergency department or hospital reception desk. Exclusion criteria included immediate or very urgent need of treatment, high level of symptom burden and severe functional impairments in terms of hearing, vision and speech. We conducted standardised personal interviews. Additionally, clinical data were extracted from patient records. PRIMARY AND SECONDARY OUTCOME MEASURES Our target variable was subjectively perceived treatment urgency. Predictor variables included age, sex, education, health-related quality of life (EuroQol Five-Dimension Scale, value set UK), anxiety and depression (Hospital Anxiety and Depression Scale), somatic symptoms (Patient Health Questionnaire, 15 items version), self-reported health literacy (European Health Literacy Questionnaire, 16 questions version) and the commitment to the GP (Fragebogen zur Intensität der Hausarztbindung, 'F-HaBi'). Data were analysed by multilevel, multivariable linear regression adjusted for random effects at the hospital level. RESULTS Our sample comprised 276 patients with a mean age of 50.1 years and 51.8% women. A low treatment urgency (defined as 0-5 points on a Numerical Rating Scale) was reported by 111 patients (40.2%). In the final model, lower subjective treatment urgency was associated with male sex (β=0.84; 95% CI 0.11/1.57, p=0.024), higher health-related quality of life (-2.27 to -3.39/-1.15, p<0.001), lower somatic symptoms score (0.09, 0.004/0.17, p=0.040), higher anxiety score (-0.13 to -0.24/-0.01, p=0.027) and lower commitment to the GP (0.08, 0.01/0.14, p=0.029). CONCLUSIONS A lower level of subjectively perceived treatment urgency was predicted by a lower willingness to use the GP as coordinator of treatment. Self-reported health literacy did not predict the patients' urgency rating.
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Affiliation(s)
- Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Agata Menzel
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hendrik Oltrogge
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Slagman
- Department of Emergency and Acute Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Martin Möckel
- Department of Emergency and Acute Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Dagmar Lühmann
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study. BJGP Open 2021; 5:BJGPO.2021.0044. [PMID: 33910915 PMCID: PMC8450884 DOI: 10.3399/bjgpo.2021.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden. AIM To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions. DESIGN & SETTING Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8). METHOD Factors precipitating admissions were examined using framework analysis. RESULTS Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions. CONCLUSION Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.
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Faisal TI, Khaira N, Veri N, Magfirah M, Dewita D, Alchalidi A, Sari Y. The Effect of Walking Exercise and Consumption of Steeping Chamomile Flowers (Matricaria recutita) on Depression in the Elderly in Langsa City. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: The population of the elderly is increasing rapidly in almost every part of the world. A common problem faced by the elderly is prolonged depression. One of the practical and economic efforts to reduce depression is by walking and consuming chamomile flowers.
AIM: The aim of this study is to analyzing the effect of walking exercise and consumption of chamomile (Matricaria recutita) flower infusion on depression in the elderly in Langsa City.
METHODS: We used a quasi-experimental design with a pretest-posttest control group design. This research was conducted from September to December 2020 in Karang Anyar Village, Langsa City. The population in this study were all elderly who met the inclusion criteria. The sample was selected as many as 24 elderly. The sample size of the study was calculated using the formula for the sample size for experimental research from Federer, namely (t–1) (r–1) ≥15). Data collection techniques in this study were interviews and observations using the Geriatric Depression Scale (GDS) questionnaire instrument, which was carried out twice, namely at the time before treatment and after treatment in four groups, namely, the control group, the walking exercise group, the chamomile flower consumption group and the combination group of walking and exercise. Consume chamomile flowers. Data analysis used paired t-test and one-way analysis of variance test to see the effect of the intervention on depression.
RESULTS: This study’s results indicate that walking can significantly reduce the GDS depression score with a p-value of 0.025. This study indicates that consumption of chamomile Flower can significantly reduce the GDS score of the elderly with a p-value of 0.037. This study showed that the combination of walking and consumption of chamomile tea was able to significantly reduce the GDS depression score with a p-value of 0.017. When viewed from the p-value, this treatment group showed the most significant reduction in the GDS depression score than the other two treatment groups, namely walking and consumption of chamomile tea. In the walking exercise group, the chamomile flowers were the consumption treatment group combined treatment group walking and chamomile tea consumption. All three treatments had the same ability to reduce the GDS score, as evidenced by a p-value of 0.808 (p > 0.05).
CONCLUSION: Walking exercise and consumption of chamomile tea can significantly reduce the GDS score of the elderly in Langsa City.
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Developing a complex intervention whilst considering implementation: the TANDEM (Tailored intervention for ANxiety and DEpression Management) intervention for patients with chronic obstructive pulmonary disease (COPD). Trials 2021; 22:252. [PMID: 33823935 PMCID: PMC8025339 DOI: 10.1186/s13063-021-05203-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/17/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Guidelines now call for a thorough and comprehensive description of the development of healthcare interventions to aid evaluation and understanding of the processes of change. This was the primary aim of this study but we also recognised that effective interventions are commonly not implemented in clinical practice. It is suggested that insufficient attention is given to the implementation process at the development phase of interventions. This study outlines the 5 step iterative process we adopted for considering both implementation and effectiveness issues from the outset of intervention development. We use the development of a complex intervention Tailored intervention for ANxiety and DEpression Management (TANDEM) in patients with chronic obstructive pulmonary disease to illustrate this process. METHODS Intervention development built upon the Medical Research Council framework for developing complex interventions and the person-based approach for development of behavioural interventions. Building an expert team, specifying theory, qualitative data collection and pre-piloting were all critical steps in our intervention development and are described here. RESULTS Contact with experts in the field, and explicitly building on previous work, ensured efficiency of design. Qualitative work suggested guiding principles for the intervention such as introducing mood in relation to breathlessness, and providing flexible tailoring to patients' needs, whilst implementation principles focused on training selected respiratory professionals and requiring supervision to ensure standards of care. Subsequent steps of intervention development, pre-piloting and intervention refinement led to an intervention that was deemed acceptable and if successful will be ready for implementation. CONCLUSIONS The TANDEM study was developed efficiently by building on previous work and considering implementation issues from the outset, with the aim that if shown to be effective it will have more rapid translation in to the health care system with accelerated patient benefits. TRIAL REGISTRATION ISRCTN ISRCTN59537391 . Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.
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12
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Capobianco L, Faija C, Husain Z, Wells A. Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: A systematic review. PLoS One 2020; 15:e0238457. [PMID: 32911486 PMCID: PMC7500039 DOI: 10.1371/journal.pone.0238457] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Anxiety and depression are common among patients with chronic physical illnesses
and have a significant impact on morbidity, quality of life, and health service
utilisation. Psychological treatment of anxiety and depression has small to
moderate efficacy in this group and is not commonly based on a model of causal
mechanisms. A novel approach to understanding and improving mental health
outcomes in physical illnesses is needed. One approach may be to explore the
role of metacognitive beliefs which are reliably associated with anxiety and
depression in individuals with mental health difficulties. The current
systematic review aimed to evaluate the contribution of metacognitive beliefs to
anxiety and depression across physical illnesses. Systematic searches were
conducted on Web of Science, PsychINFO, MEDLINE, Embase, and CINAHL of studies
published between 1997 and January 2019. 13 eligible studies were identified
that in sum comprised 2851 participants. Metacognitive beliefs were found to
have reliable, moderate, positive and significant associations with anxiety and
depression symptoms across a range of physical illnesses. There appeared to be
commonality and some specificity in the relationships. Negative metacognitive
beliefs concerned with uncontrollability and danger of worry were associated
with both anxiety and depression across all physical illnesses assessed, whilst
more specific associations emerged for individual medical conditions where
positive beliefs about worry, cognitive confidence and cognitive
self-consciousness were unique correlates. Negative metacognitive beliefs of
uncontrollability and danger significantly and positively predicted symptoms of
anxiety and depression after controlling for factors including age, gender,
disease factors and cognition (illness perceptions and intolerance of
uncertainty). The results suggest that the metacognitive model of psychological
disorder is applicable to psychological symptoms of anxiety and depression
across a range of chronic medical conditions, implying that metacognitive
therapy might be helpful in improving outcomes in multiple morbidities that
involve poor mental and medical health.
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Affiliation(s)
- Lora Capobianco
- Research and Innovation, Greater Manchester Mental Health NHS Foundation
Trust, Manchester, United Kingdom
- * E-mail:
| | - Cintia Faija
- Division of Nursing, Midwifery & Social Work, Faculty of Biology,
Medicine and Health, Manchester Academic Health Science Centre, The University
of Manchester, Manchester, United Kingdom
| | - Zara Husain
- Research and Innovation, Greater Manchester Mental Health NHS Foundation
Trust, Manchester, United Kingdom
| | - Adrian Wells
- Research and Innovation, Greater Manchester Mental Health NHS Foundation
Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, School of Psychological
Sciences, Manchester Academic Health Science Centre, The University of
Manchester, Manchester, United Kingdom
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13
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Barriers to implementing clinical trials on nonpharmacological treatments in developing countries: lessons learnt from addressing pain in HIV. Pain Rep 2020; 4:e783. [PMID: 31984291 PMCID: PMC6903358 DOI: 10.1097/pr9.0000000000000783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/13/2019] [Accepted: 08/01/2019] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Pain affects over half of the people living with HIV/AIDS (LWHA), and pharmacological treatment has limited efficacy. Preliminary evidence supports nonpharmacological interventions. We previously piloted a multimodal intervention in amaXhosa women LWHA and chronic pain in South Africa with improvements seen in all outcomes, in both intervention and control groups. A multicentre, single-blind randomised controlled trial with 160 participants recruited was conducted to determine whether the multimodal peer-led intervention reduced pain in different populations of both male and female South Africans LWHA. Participants were followed up at weeks 4, 8, 12, 24, and 48 to evaluate effects on the primary outcome of pain, and on depression, self-efficacy, and health-related quality of life. We were unable to assess the efficacy of the intervention due to a 58% loss to follow-up (LTFU). Secondary analysis of the LTFU found that sociocultural factors were not predictive of LTFU. Depression, however, did associate with LTFU, with greater severity of depressive symptoms predicting LTFU at week 8 (P = 0.01). We were unable to evaluate the effectiveness of the intervention due to the high LTFU and the risk of retention bias. The different sociocultural context in South Africa may warrant a different approach to interventions for pain in HIV compared with resource-rich countries, including a concurrent strategy to address barriers to health care service delivery. We suggest that assessment of pain and depression need to occur simultaneously in those with pain in HIV. We suggest investigation of the effect of social inclusion on pain and depression.
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Sohanpal R, Pinnock H, Steed L, Heslop Marshall K, Chan C, Kelly M, Priebe S, Roberts CM, Singh S, Smuk M, Saqi-Waseem S, Healey A, Underwood M, White P, Warburton C, Taylor SJC. Tailored, psychological intervention for anxiety or depression in people with chronic obstructive pulmonary disease (COPD), TANDEM (Tailored intervention for ANxiety and DEpression Management in COPD): protocol for a randomised controlled trial. Trials 2020; 21:18. [PMID: 31907074 PMCID: PMC6945421 DOI: 10.1186/s13063-019-3800-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/11/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with chronic obstructive pulmonary disease (COPD) are at increased risk of depression and anxiety, which greatly reduces their quality of life and is associated with worse outcomes; but these psychological co-morbidities are under-recognised and undertreated in COPD patients. Pulmonary rehabilitation (PR) improves mood for up to 6 months but health practitioners under-refer, and patients commonly fail to attend/complete PR. Research suggests that complex non-pharmacological interventions, including both psychological and exercise components, may reduce anxiety and depression in COPD. We have developed a tailored, cognitive behavioural approach (CBA) intervention for patients with COPD and co-morbid anxiety and/or depression ('TANDEM'), which precedes and optimises the benefits of currently offered PR. We hypothesise that such a psychological intervention, delivered by supervised, trained respiratory healthcare professionals, will improve mood in patients with mild to moderate anxiety and/or depression and encourage uptake and completion of PR. METHODS We will conduct a multi-centre, pragmatic, randomised controlled trial of the TANDEM intervention compared to usual care across the Midlands, London, the South East and Bristol, UK. We will train healthcare professionals familiar with COPD to deliver the manualised, tailored, face-to-face, one-to-one intervention weekly for 6-8 weeks. We will recruit 430 participants from primary, community and secondary care with confirmed COPD and moderate to very severe airflow limitation, who are eligible for assessment for PR, and who screen positive for symptoms of mild/moderate depression and/or anxiety using the Hospital Anxiety and Depression scale (HADS). Participants will be randomised 1.25:1 (intervention: usual care). The co-primary outcomes are the HADS anxiety and depression subscale scores at 6 months; participants will be followed up to 12 months. Secondary outcomes include uptake and completion of PR and healthcare resource use. There will be a parallel process evaluation and a health economic evaluation. DISCUSSION The TANDEM intervention has the potential to optimise the unrealised synergy between a psychological intervention and PR. The CBA sessions will precede PR and target individuals' cognitions, behaviours and symptoms associated with anxiety and depression to decrease psychological morbidity and increase effective self-management amongst patients with COPD. TRIAL REGISTRATION ISRCTN, ID: ISRCTN59537391. Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.
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Affiliation(s)
- Ratna Sohanpal
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Liz Steed
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Karen Heslop Marshall
- Newcastle upon Tyne NHS Hospitals Foundation Trust, Chest Clinic, New Victoria Wing RVI Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Claire Chan
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Moira Kelly
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Stefan Priebe
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - C. Michael Roberts
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Sally Singh
- Department of Respiratory Sciences, College of Life Sciences, NIHR Leicester Biomedical Research Centre - Respiratory, Glenfield Hospital, University of Leicester, Groby Road, Leicester, LE3 9QP UK
| | - Melanie Smuk
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Sarah Saqi-Waseem
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - Andy Healey
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, Denmark Hill, London, SE5 8AF UK
| | - Martin Underwood
- Warwick CTU, Warwick Medical School, Gibbet Hill Road, Coventry, CV4 7AL and University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Patrick White
- School of Population Health and Environmental Sciences, King’s College London, Great Maze Pond, London, SE1 1UL UK
| | | | - Stephanie J. C. Taylor
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
| | - On behalf of the TANDEM Investigators
- Institute for Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 58 Turner Street, London, E1 2AB UK
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- Newcastle upon Tyne NHS Hospitals Foundation Trust, Chest Clinic, New Victoria Wing RVI Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
- Department of Respiratory Sciences, College of Life Sciences, NIHR Leicester Biomedical Research Centre - Respiratory, Glenfield Hospital, University of Leicester, Groby Road, Leicester, LE3 9QP UK
- King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, Denmark Hill, London, SE5 8AF UK
- Warwick CTU, Warwick Medical School, Gibbet Hill Road, Coventry, CV4 7AL and University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
- School of Population Health and Environmental Sciences, King’s College London, Great Maze Pond, London, SE1 1UL UK
- London, UK
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15
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Trick L, Watkins ER, Henley W, Gandhi MM, Dickens C. Perseverative negative thinking predicts depression in people with acute coronary syndrome. Gen Hosp Psychiatry 2019; 61:16-25. [PMID: 31733604 DOI: 10.1016/j.genhosppsych.2019.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Depression is common in people who have experienced recent Acute Coronary Syndrome (ACS), and predicts worse medical outcomes. Mechanisms underpinning the development of depression and its association with poor medical outcomes are unclear however. The aim of this study was to investigate the role of perseverative negative thinking (e.g. worry and rumination) in predicting depression in people with recent ACS. METHODS Adults attending specialist inpatient and outpatient cardiology services who had recently experienced ACS were invited to participate in this observational prospective cohort study. Questionnaire assessments were completed within 6months of index ACS (baseline), then 2months and 6months later. RESULTS 169 participants (131 male (78%), median age 68 (±16) years) completed baseline questionnaires, and 111 completed follow-ups. After controlling for the effects of key covariates, baseline rumination was a significant predictor of depression at 6months, accounting for 2% of the variance in depression. This association was partially mediated by poor problem-solving ability and lack of social support. Neither worry nor rumination at baseline were significant predictors of quality of life at 6months. CONCLUSIONS Rumination is a significant independent predictor of depression, and this association may be partially explained by deficits in problem-solving ability and reduced social support. Both rumination and problem solving may provide useful targets for the development of evidence-based interventions to reduce depression among people with coronary heart disease.
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Affiliation(s)
- Leanne Trick
- Mental Health Research Group, University of Exeter Medical School, United Kingdom of Great Britain and Northern Ireland.
| | - Edward R Watkins
- School of Psychology, University of Exeter, United Kingdom of Great Britain and Northern Ireland
| | - William Henley
- Health Statistics Group, University of Exeter Medical School, United Kingdom of Great Britain and Northern Ireland
| | - Manish M Gandhi
- Cardiology Department, Royal Devon and Exeter NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland
| | - Chris Dickens
- Mental Health Research Group, University of Exeter Medical School, United Kingdom of Great Britain and Northern Ireland
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16
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Blakemore A, Dickens C, Chew-Graham CA, Afzal CW, Tomenson B, Coventry PA, Guthrie E. Depression predicts emergency care use in people with chronic obstructive pulmonary disease: a large cohort study in primary care. Int J Chron Obstruct Pulmon Dis 2019; 14:1343-1353. [PMID: 31388297 PMCID: PMC6607976 DOI: 10.2147/copd.s179109] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/18/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care. Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year. Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4–7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds. Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.
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Affiliation(s)
- A Blakemore
- Division of Nursing, Social Work and Midwifery, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - C Dickens
- University of Exeter Medical School, Exeter, St Luke's Campus , Exeter, UK
| | - C A Chew-Graham
- Research Institute, Primary Care and Health Sciences, West Midlands CLAHRC, Keele, University, Newcastle, UK
| | - C W Afzal
- Health Innovation Manchester, Greater Manchester's Academic Health Science Network, Manchester Academic Health Science Centre, Manchester, UK
| | - B Tomenson
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - P A Coventry
- Department of Health Sciences, University of York, York, UK
| | - E Guthrie
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
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Long H, Howells K, Peters S, Blakemore A. Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis. Br J Health Psychol 2019; 24:515-546. [PMID: 31033121 PMCID: PMC6767143 DOI: 10.1111/bjhp.12366] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 03/04/2019] [Indexed: 11/29/2022]
Abstract
Purpose To systematically review the evidence for health coaching as an intervention to improve health‐related quality of life (HRQoL) and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD). Methods We systematically searched MEDLINE, EMBASE, PsycINFO, and CINAHL from database inception to August 2018 to identify all randomized controlled trials (RCTs) of health coaching for people with COPD. Eligible health coaching interventions had to include three components: goal setting, motivational interviewing, and COPD‐related health education. Data were extracted on study characteristics and the effects of the intervention on HRQoL, hospital admissions, physical activity, self‐care behaviour, and mood. Study quality was appraised by two authors using the Cochrane tool for assessing the risk of bias in RCTs. Effect sizes (standardized mean differences [SMD] or odds ratios [OR]) with 95% confidence intervals (CIs) were calculated and pooled using random effects meta‐analyses. Results Of 1578 articles, 10 RCTs were included. Meta‐analysis showed that health coaching has a significant positive effect on HRQoL (SMD = −0.69, 95% CI: −1.28, −0.09, p = .02, from k = 4) and leads to a significant reduction in COPD‐related hospital admissions (OR = 0.46, 95% CI: 0.31, 0.69, p = .0001, from k = 5), but not in all‐cause hospital admissions (OR = 0.70, 95% CI: 0.41–1.12, p = .20, from k = 3). Three of four studies reported significant improvements to self‐care behaviours such as medication adherence and exercise compliance. Conclusions This is the first systematic review to show that health coaching may be a candidate intervention to improve HRQoL and reduce costly hospital admissions in people with COPD. Statement of contribution What is already known on this subject? COPD is a leading cause of death worldwide and considerably reduces HRQoL. In turn, HRQoL is associated with a range of adverse health outcomes in COPD. Health coaching is a self‐management intervention for people with long‐term conditions such as COPD. Studies have examined whether health coaching improves HRQOL and other health outcomes in people with COPD, but no systematic review has been conducted.
What does this study add? The first systematic review and meta‐analysis of RCTs of health coaching for people with COPD. Health coaching may be a candidate intervention for improving HRQoL and reducing COPD‐related hospital admissions in people with COPD. The need to establish the most effective health coaching components, delivery modality, and economic impact.
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Affiliation(s)
- Hannah Long
- Manchester Centre of Health Psychology, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Kelly Howells
- National Institute for Health Research, School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sarah Peters
- Manchester Centre of Health Psychology, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Amy Blakemore
- Division of Nursing, Social Work and Midwifery, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, UK
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Richards SH, Campbell JL, Dickens C, Anderson R, Gandhi M, Gibson A, Kessler D, Knight L, Kuyken W, Richards DA, Taylor RS, Turner K, Ukoumunne OC, Davey A, Warren FC, Winder RE, Wright CA. Enhanced psychological care in cardiac rehabilitation services for patients with new-onset depression: the CADENCE feasibility study and pilot RCT. Health Technol Assess 2019; 22:1-220. [PMID: 29856312 DOI: 10.3310/hta22300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Around 19% of people screened by UK cardiac rehabilitation programmes report having moderate or severe symptoms of depression. These individuals are at an increased risk of cardiac mortality and morbidity, reduced quality of life and increased use of health resources compared with their non-depressed counterparts. Maximising psychological health is a goal of cardiac rehabilitation, but psychological care is patchy. OBJECTIVE(S) To examine the feasibility and acceptability of embedding enhanced psychological care (EPC) within cardiac rehabilitation, we tested the feasibility of developing/implementing EPC and documented the key uncertainties associated with undertaking a definitive evaluation. DESIGN A two-stage multimethods study; a feasibility study and a qualitative evaluation, followed by an external pilot cluster randomised controlled trial (RCT) with a nested qualitative study. SETTING UK comprehensive cardiac rehabilitation teams. PARTICIPANTS Adults eligible for cardiac rehabilitation following an acute coronary syndrome with new-onset depressive symptoms on initial nurse assessment. Patients who had received treatment for depression in the preceding 6 months were excluded. INTERVENTIONS The EPC intervention comprised nurse-led mental health-care co-ordination and behavioural activation within cardiac rehabilitation. The comparator was usual cardiac rehabilitation care. MAIN OUTCOME MEASURES Measures at baseline, and at the 5- (feasibility and pilot) and 8-month follow-ups (pilot only). Process measures related to cardiac team and patient recruitment, and participant retention. Outcomes included depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Interviews explored participant and nurses' views and experiences. RESULTS Between September 2014 and May 2015, five nurses from four teams recruited participants into the feasibility study. Of the 203 patients screened, 30 were eligible and nine took part (the target was 20 participants). At interview, participants and nurses gave valuable insights into the EPC intervention design and delivery. Although acceptable, the EPC delivery was challenging for nurses (e.g. the ability to allocate sufficient time within existing workloads) and the intervention was modified accordingly. Between December 2014 and February 2015, 8 out of 20 teams approached agreed to participate in the pilot RCT [five were randomised to the EPC arm and three were randomised to the usual-care (UC) arm]. Of the 614 patients screened, 55 were eligible and 29 took part (the target was 43 participants). At baseline, the trial arms were well matched for sex and ethnicity, although the EPC arm participants were younger, from more deprived areas and had higher depression scores than the UC participants. A total of 27 out of 29 participants were followed up at 5 months. Interviews with 18 participants (12 in the EPC arm and six in the UC arm) and seven nurses who delivered EPC identified that both groups acknowledged the importance of receiving psychological support embedded within routine cardiac rehabilitation. For those experiencing/delivering EPC, the intervention was broadly acceptable, albeit challenging to deliver within existing care. LIMITATIONS Both the feasibility and the pilot studies encountered significant challenges in recruiting patients, which limited the power of the pilot study analyses. CONCLUSIONS Cardiac rehabilitation nurses can be trained to deliver EPC. Although valued by both patients and nurses, organisational and workload constraints were significant barriers to implementation in participating teams, suggesting that future research may require a modified approach to intervention delivery within current service arrangements. We obtained important data informing definitive research regarding participant recruitment and retention, and optimal methods of data collection. FUTURE RESEARCH Consideration should be given to the delivery of EPC by dedicated mental health practitioners, working closely with cardiac rehabilitation services. TRIAL REGISTRATION Current Controlled Trials ISRCTN34701576. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Christopher Dickens
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Rob Anderson
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Manish Gandhi
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andy Gibson
- Department of Health and Social Sciences, University of the West of England, Bristol, UK
| | - David Kessler
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Luke Knight
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Willem Kuyken
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - David A Richards
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Rod S Taylor
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK.,Institute of Health Service Research, University of Exeter Medical School, Exeter, UK
| | - Katrina Turner
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Obioha C Ukoumunne
- NIHR Collaborations for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Antoinette Davey
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Fiona C Warren
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Rachel E Winder
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Christine A Wright
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
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Moayeri F, Dunt D, Hsueh YSA, Doyle C. Cost-utility analysis of telephone-based cognitive behavior therapy in chronic obstructive pulmonary disease (COPD) patients with anxiety and depression comorbidities: an application for willingness to accept concept. Expert Rev Pharmacoecon Outcomes Res 2018; 19:331-340. [PMID: 30324818 DOI: 10.1080/14737167.2019.1536550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND This study evaluated the cost-utility of telephone-based cognitive behavioral therapy (TB-CBT) (experimental arm) in comparison with a placebo-befriending (control arm) program in COPD participants with mild to severe depression and/or anxiety. METHODS The decision rule was based on willingness-to-pay if there is an increased unit of effectiveness (a quality-adjusted life year [QALY] gain) and an increase in cost, and willingness-to-accept (WTA) if there is a reduced unit of effectiveness (a QALY loss) and decrease in cost (a cost-saving). RESULTS TB-CBT group was associated with a reduction in the incremental cost of AUS-$407.3 (p < 0.001, SE:34.1) plus a negative, nonsignificant incremental QALY gain of -0.008 (SE:0.011) per patient compared to control group. The point estimate of the mean incremental cost-utility ratio was AUS$50,284.0 cost saving per QALY sacrificed (the high value associated with small QALY value in the denominator). Ninety-five percent CI was AUS$13,426 cost sacrificed to AUS$32,018 cost gain (lower values associated with larger QALY values in the denominator). If the societal's minimum (flooring threshold) WTA is AUS$64,000 per QALY forgone, the probability of TB-CBT being cost-effective was 42% Conclusions: This study showed that TB-CBT can be recommended as a cost-saving and preventive approach over usual care plus befriending program.
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Affiliation(s)
- Foruhar Moayeri
- a Centre for Health Policy, Melbourne School of Population and Global Health , The University of Melbourne , Carlton Victoria , Australia
| | - David Dunt
- a Centre for Health Policy, Melbourne School of Population and Global Health , The University of Melbourne , Carlton Victoria , Australia
| | - Ya-Seng Arthur Hsueh
- a Centre for Health Policy, Melbourne School of Population and Global Health , The University of Melbourne , Carlton Victoria , Australia
| | - Colleen Doyle
- b Australian Catholic University, Faculty of Health Sciences , School of Behavioural and Health Sciences (VIC), Villa Maria Catholic Homes , Kew Victoria , Australia
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Leutgeb R, Berger S, Szecsenyi J, Laux G. Patients with somatoform disorders: More frequent attendance and higher utilization in primary Out-of-Hours care? PLoS One 2018; 13:e0202546. [PMID: 30161150 PMCID: PMC6116940 DOI: 10.1371/journal.pone.0202546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/05/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND One significant health policy challenge in many European countries at present is developing strategies to deal with the increase in patient attendance at Out-of-Hours care (OOHC), whether this is at OOHC-Centres in primary care settings or hospital emergency departments (ED). FAs (FAs) presenting in OOHC are a known challenge and previous studies have shown that FAs present more often with psychological problems and psychiatric comorbidities rather than severe physical complaints. FAs may be also contributing to the rising workload in OOHC-Centres in primary care. The aim of this study was to determine attendance frequencies and health problem presentation patterns for patients with and without somatoform disorders (ICD-10 F45 diagnoses) in OOHC-Centres in primary care. Some of these somatoform disorders may have a psychiatric character. Moreover, we wanted to compare health care utilization patterns (pharmacotherapy and hospitalizations) between these patients groups. METHODS Routine OOHC data from a large German statutory health insurance company in the federal state of Baden-Wuerttemberg were evaluated. 3,813,398 health insured persons were included in the data set from 2014. The data were initially made available for our study group in order to evaluate a comprehensive evaluation programme in German primary care, the "Hausarztzentrierte Versorgung" (HZV), loosely translated as "family doctor coordinated care". We used the ICD-10 codes F45.0-F45.9 in regular care to identify patients with somatoform disorders and compared their health care utilization patterns (attendance rates, diagnoses, prescriptions, hospitalization rates) in OOHC to patients without somatoform disorders. Attendance rates were calculated with multivariable regression models in order to adjust for age, gender, comorbidities and for participation in the HZV intervention. RESULTS 350,528 patients (9.2%) of the 3,813,398 insured persons had an F45-diagnosis. In comparison with the whole study-sample, patients with an F45-diagnosis were on average seven years older (51.7 vs. 44.0 years; p<0,0001) and the percentage of women was significantly higher (70.1% vs 53.3%; p<0,0001). In OOHC, as opposed to normal office hours, the adjusted rate of patients with an F45-diagnosis was 60.6% higher (adjusted for age, gender and co-morbidity) than in the general study-sample. Accordingly, in OOHC, prescriptions for antidepressants, hypnotics, anxiolytics but also opioids were significantly higher than in the general study population i.e. those without F45- diagnoses. However, an F45 diagnosis was only made in 3.45% of all F45 patients seen in OOHC in 2014. CONCLUSIONS Patients with somatoform disorders were more FAs in both regular office hours and in OOHC in primary care settings. In OOHC, they are normally not identified as such because the somatoform illness is secondary to other acutely presenting symptoms such as pain. While it is acknowledged that it is difficult to make an exact diagnosis in this complex group of somatoform disorders in an OOHC setting, it is still important to develop continuing education programmes for medical staff working in OOHC, to support effective recognition and response to the specific needs of this complex patient group.
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Affiliation(s)
- Ruediger Leutgeb
- University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany
- * E-mail:
| | - Sarah Berger
- University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany
| | - Joachim Szecsenyi
- University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany
| | - Gunter Laux
- University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany
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21
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Camacho EM, Davies LM, Hann M, Small N, Bower P, Chew-Graham C, Baguely C, Gask L, Dickens CM, Lovell K, Waheed W, Gibbons CJ, Coventry P. Long-term clinical and cost-effectiveness of collaborative care (versus usual care) for people with mental-physical multimorbidity: cluster-randomised trial. Br J Psychiatry 2018; 213:456-463. [PMID: 29761751 PMCID: PMC6429252 DOI: 10.1192/bjp.2018.70] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Collaborative care can support the treatment of depression in people with long-term conditions, but long-term benefits and costs are unknown.AimsTo explore the long-term (24-month) effectiveness and cost-effectiveness of collaborative care in people with mental-physical multimorbidity. METHOD A cluster randomised trial compared collaborative care (integrated physical and mental healthcare) with usual care for depression alongside diabetes and/or coronary heart disease. Depression symptoms were measured by the symptom checklist-depression scale (SCL-D13). The economic evaluation was from the perspective of the English National Health Service. RESULTS 191 participants were allocated to collaborative care and 196 to usual care. At 24 months, the mean SCL-D13 score was 0.27 (95% CI, -0.48 to -0.06) lower in the collaborative care group alongside a gain of 0.14 (95% CI, 0.06-0.21) quality-adjusted life-years (QALYs). The cost per QALY gained was £13 069. CONCLUSIONS In the long term, collaborative care reduces depression and is potentially cost-effective at internationally accepted willingness-to-pay thresholds.Declaration of interestNone.
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Affiliation(s)
- Elizabeth M. Camacho
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK,Correspondence: Elizabeth M. Camacho, PhD, Centre for Health Economics, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Linda M. Davies
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | - Mark Hann
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | - Nicola Small
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research, The University of Manchester, Manchester Academic Health Science Centre, UK
| | - Carolyn Chew-Graham
- Primary Care & Health Sciences, University of Keele, UK, Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UKand NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, UK
| | | | - Linda Gask
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester Academic Health Science Centre, UK
| | - Waquas Waheed
- Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | - Chris J. Gibbons
- The Psychometrics Centre, University of Cambridge, UKand Division of Population Health, Health Services Research, and Primary Care, The University of Manchester, UK
| | - Peter Coventry
- Department of Health Sciences, University of York, UKand Centre for Reviews and Dissemination, University of York, UK
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Taylor AK, Gilbody S, Bosanquet K, Overend K, Bailey D, Foster D, Lewis H, Chew-Graham CA. How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial. BMC FAMILY PRACTICE 2018; 19:116. [PMID: 30021506 PMCID: PMC6052715 DOI: 10.1186/s12875-018-0813-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/29/2018] [Indexed: 04/27/2023]
Abstract
Background Depression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients. Methods A qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients’ and professionals’ views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory. Results Thirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation. Conclusions A telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs’ understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.
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Affiliation(s)
- Anna Kathryn Taylor
- Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK.
| | - Simon Gilbody
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Katharine Bosanquet
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Karen Overend
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Della Bailey
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Deborah Foster
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Helen Lewis
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Carolyn Anne Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,West Midlands CLAHRC (Collaboration for Leadership in Applied Health Research and Care), Warwick, UK
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23
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Fraher EP, Richman EL, Zerden LDS, Lombardi B. Social Work Student and Practitioner Roles in Integrated Care Settings. Am J Prev Med 2018; 54:S281-S289. [PMID: 29779553 DOI: 10.1016/j.amepre.2018.01.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/31/2018] [Accepted: 01/31/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Social workers are increasingly being deployed in integrated medical and behavioral healthcare settings but information about the roles they fill in these settings is not well understood. This study sought to identify the functions that social workers perform in integrated settings and identify where they acquired the necessary skills to perform them. METHODS Master of social work students (n=21) and their field supervisors (n=21) who were part of a Health Resources and Services Administration-funded program to train and expand the behavioral health workforce in integrated settings were asked how often they engaged in 28 functions, where they learned to perform those functions, and the degree to which their roles overlapped with others on the healthcare team. RESULTS The most frequent functions included employing cultural competency, documenting in the electronic health record, addressing patient social determinants of health, and participating in team-based care. Respondents were least likely to engage in case conferences; use Screening, Brief Intervention and Referral to Treatment; use stepped care to determine necessary level of treatment; conduct functional assessments of daily living skills; use behavioral activation; and use problem-solving therapy. A total of 80% of respondents reported that their roles occasionally, often, very often, or always overlapped with others on the healthcare team. Students reported learning the majority of skills (76%) in their Master of Social Work programs. Supervisors attributed the majority (65%) of their skill development to on-the-job training. CONCLUSIONS Study findings suggest the need to redesign education, regulatory, and payment to better support the deployment of social workers in integrated care settings. SUPPLEMENT INFORMATION This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
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Affiliation(s)
- Erin P Fraher
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Program on Health Workforce Research and Policy, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Erica Lynn Richman
- Program on Health Workforce Research and Policy, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lisa de Saxe Zerden
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brianna Lombardi
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Choi SKY, Boyle E, Cairney J, Grootendorst P, Gardner S, Collins EJ, Kendall C, Rourke SB. Impact of depression and recreational drug use on emergency department encounters and hospital admissions among people living with HIV in Ontario: A secondary analysis using the OHTN cohort study. PLoS One 2018; 13:e0195185. [PMID: 29630615 PMCID: PMC5891004 DOI: 10.1371/journal.pone.0195185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/19/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Nearly half of HIV-positive patients experience mental health and substance use problems, but many do not receive adequate or ongoing mental health or addiction care. This lack of ongoing care can result in the use of costly acute care services. Prospective evaluations of the relationship between psychiatric and substance use disorders and acute care services use are lacking, and this information is needed to understand unmet needs and improve access to appropriate services. Methods We conducted a secondary data analysis from a multicenter, longitudinal, prospective cohort study (n = 3,482 adults) between October 1, 2007 and March 31, 2013. We used explanatory extended Cox proportional hazard regression models to examine the impact of current depression and recreational drug use on acute care services use, and to explore whether current depression and recreational drug use were associated with potentially avoidable acute care services use. Results Over our 5.5 year study period, HIV-positive participants with current depression-only (aHR [95% CI]:1.2[1.1–1.4]), recreational drug use-only (1.3[1.1–1.6]), or co-occurring depression and recreational drug use (1.4[1.2–1.7]) were associated with elevated hazard of emergency department (ED) encounters compared to participants without these conditions. Over half of ED encounters were potentially avoidable. Participants with current depression-only (1.3[1.1–1.5];1.3[1.03–1.6]), recreational drug use-only (1.3[1.04–1.6];1.5[1.1–1.9]), or co-occurring depression and recreational drug use (1.3[1.04–1.7];1.4[1.06–1.9]) were associated with elevated hazard of low-acuity or repeated ED encounters respectively. Conclusions We found a significant increase in ED services use and potentially avoidable ED encounters (including low-acuity or repeated ED encounters), particularly among those with either current depression or recreational drug use. These findings emphasize the challenges in managing HIV and mental health/addiction co-morbidities in the current HIV care model. Future research should evaluate integrated and collaborative care programs for improving the coordination of care and effectively treat mental health and addiction problems among HIV-positive patients in Ontario.
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Affiliation(s)
- Stephanie K. Y. Choi
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Eleanor Boyle
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - John Cairney
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Infant and Child Health Lab, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Ontario, Canada
| | - Paul Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
- School of Public Policy and Governance, University of Toronto, Ontario, Canada
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Gardner
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Rotman Research Institute, Baycrest Hospital, Ontario, Canada
| | - Evan J. Collins
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Claire Kendall
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- University of Ottawa, Ontario, Canada
- The Ottawa Hospital, Ontario, Canada
| | - Sean B. Rourke
- Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- * E-mail:
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Richards SH, Dickens C, Anderson R, Richards DA, Taylor RS, Ukoumunne OC, Turner KM, Gandhi M, Kuyken W, Gibson A, Davey A, Warren F, Winder R, Campbell J. Assessing the effectiveness of Enhanced Psychological Care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): a pilot cluster randomised controlled trial. Trials 2018; 19:211. [PMID: 29609644 PMCID: PMC5880097 DOI: 10.1186/s13063-018-2576-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 03/08/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation. METHODS An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed. RESULTS Eight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI - 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI - 1.4 to 10.2; N = 17) at 8 months. DISCUSSION While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions. TRIAL REGISTRATION ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).
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Affiliation(s)
- Suzanne H. Richards
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
- University of Leeds Institute of Health Sciences, University of Leeds, Level 10 Worsley Building, Leeds, LS2 9JN UK
| | - Chris Dickens
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Rob Anderson
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - David A. Richards
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Rod S. Taylor
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Obioha C. Ukoumunne
- NIHR Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Katrina M. Turner
- Population Health Sciences, University of Bristol, Canynge Hall, Whatley Road, Bristol, BS8 2PS UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Manish Gandhi
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW UK
| | - Willem Kuyken
- University Department of Psychiatry, University of Oxford, Warneford Hospital, 0X3 7JX, Oxford, UK
| | - Andrew Gibson
- Health and Social Sciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol, BS16 1QY UK
| | - Antoinette Davey
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Fiona Warren
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - Rachel Winder
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | - John Campbell
- University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
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Prior A, Vestergaard M, Larsen KK, Fenger-Grøn M. Association between perceived stress, multimorbidity and primary care health services: a Danish population-based cohort study. BMJ Open 2018; 8:e018323. [PMID: 29478014 PMCID: PMC5855234 DOI: 10.1136/bmjopen-2017-018323] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental-physical multimorbidity. DESIGN Population-based cohort study. SETTING Primary healthcare in Denmark. PARTICIPANTS 118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers. OUTCOME MEASURES General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers. RESULTS Perceived stress levels were associated with primary care activity in a dose-response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services. CONCLUSION Persons with high stress levels generally had higher use of primary healthcare, 4-6 times higher use of mental health-related services (most often in the form of psychotropic drug prescriptions), but less timely use of chronic care services.
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Affiliation(s)
- Anders Prior
- Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Mogens Vestergaard
- Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Karen Kjær Larsen
- Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Morten Fenger-Grøn
- Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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Martínez P, Castro A, Alonso D, Vöhringer PA, Rojas G. Effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases: a protocol for a systematic review and meta-analysis. BMJ Open 2017; 7:e011249. [PMID: 28729304 PMCID: PMC5541516 DOI: 10.1136/bmjopen-2016-011249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Depression is a global-scale public health problem, and a significant association has been established between depression and chronic physical diseases. This growing comorbidity poses a challenge to healthcare systems. We aim to assess the effectiveness of the management of major depressive episodes/disorder in adults with comorbid chronic physical diseases. METHODS AND ANALYSIS We will conduct a systematic review and meta-analysis of randomised clinical trials. Two databases MEDLINE and Cochrane Library (Cochrane Database for Systematic Reviews and CENTRAL), as well as the reference lists of the included articles, will be searched for studies either in English or Spanish with published results within the 2005-2015 period. Studies must fulfil the following conditions: (1) participants aged 18 years or older, diagnosed as having a major depressive episodes/disorder according to standardised criteria and chronic physical diseases; (2)interventions (be it pharmacological, psychological, psychosocial or a combination) must be compared with control conditions (other 'active' intervention, treatment as usual, waiting list or placebo); (3)and must report reduction in depressive symptoms after treatment, response to treatment, remission of major depressive episodes/disorder and significant improvement in quality of life. Data extraction, risk of bias evaluation, results summarisation and quality of the evidence (GRADE) will be performed as recommended by the Cochrane Collaboration. A qualitative synthesis and a random effects meta-analysis will be carried out. Effect sizes will be calculated (relative risk and Cohen's d), I2 and Q statistics will be employed to study heterogeneity and publication bias analysis will be performed. Subgroup analyses and meta-regression will be carried out. ETHICS AND DISSEMINATION Results are expected to be published in specialised peer-reviewed journals (preferred topics: Mental Health, Psychology, Psychiatry and/or Systematic Reviews) and dissemination activities will be targeted to all the healthcare providers. TRIAL REGISTRATION NUMBER International Prospective Register of Systematic Reviews (CRD42016029166) submitted on 11 January 2016.
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Affiliation(s)
- Pablo Martínez
- Department of Psychiatry and Mental Health, Clinical Hospital, Universidad de Chile, Santiago de Chile, Chile
- Information Technology Innovation Centre for Social Applications (CITIAPS), Universidad de Santiago de Chile, Santiago, Chile
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
- School of Psychology, Faculty of Humanities, Universidad de Santiago de Chile, Santiago, Chile
| | - Ariel Castro
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Diego Alonso
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Paul A Vöhringer
- Department of Psychiatry and Mental Health, Clinical Hospital, Universidad de Chile, Santiago de Chile, Chile
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
- Mood Disorders Program, Tufts Medical Center, Tufts University, Boston, Massachusetts, USA
| | - Graciela Rojas
- Department of Psychiatry and Mental Health, Clinical Hospital, Universidad de Chile, Santiago de Chile, Chile
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
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Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Lees C, Hutchison T, O'Brien S. Introducing community integrated nursing teams: How one Clinical Commissioning Group applied an evidence-based approach. Br J Community Nurs 2017; 22:289-294. [PMID: 28570114 DOI: 10.12968/bjcn.2017.22.6.289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The present day collection of financial and demographic challenges confronted by health and social care mean that integrated services are undoubtedly essential to sustain adequate care. However, the impact of integrated care upon healthcare staff and patients as well as new ways of working will need to be demonstrated, with collaboration and engagement throughout any transition. This paper provides an overview of the evidence relating to the delivery of effective, integrated out-of-hospital care, with a discussion of the literature. It also considers how one Clinical Commissioning Group has begun the process of integration with the focus on community nursing services for the provision of better care for patients with an evidence-based approach.
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Affiliation(s)
- Carolyn Lees
- Senior Lecturer, Liverpool John Moores University
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Oliveras I, Losilla JM, Vives J. Methodological quality is underrated in systematic reviews and meta-analyses in health psychology. J Clin Epidemiol 2017; 86:59-70. [DOI: 10.1016/j.jclinepi.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 12/09/2016] [Accepted: 05/02/2017] [Indexed: 01/09/2023]
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Panagioti M, Blakeman T, Hann M, Bower P. Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study. BMJ Open 2017; 7:e013524. [PMID: 28559454 PMCID: PMC5729978 DOI: 10.1136/bmjopen-2016-013524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions. METHODS The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents. RESULTS Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97). CONCLUSIONS We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents.
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Affiliation(s)
- Maria Panagioti
- NIHR School for Primary Care Research Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Thomas Blakeman
- NIHR School for Primary Care Research Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, University of Manchester, Manchester, UK
| | - Mark Hann
- NIHR School for Primary Care Research Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), Manchester Academic Health Science Centre University of Manchester, Manchester, UK
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Trick L, Watkins E, Windeatt S, Dickens C. The association of perseverative negative thinking with depression, anxiety and emotional distress in people with long term conditions: A systematic review. J Psychosom Res 2016; 91:89-101. [PMID: 27894469 DOI: 10.1016/j.jpsychores.2016.11.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/08/2016] [Accepted: 11/10/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Depression is common in people with long term conditions, and is associated with worse medical outcomes. Previous research shows perseverative negative thinking (e.g. worry, rumination) predicts subsequent depression and worse medical outcomes, suggesting interventions targeting perseverative negative thinking could improve depression and medical outcomes. Previous studies recruited healthy individuals, however. This review aimed to determine the temporal relationship and strength of prospective association of perseverative negative thinking with depression, anxiety and emotional distress in people with long term conditions. METHOD Four electronic databases were searched for studies including standardised measures of perseverative negative thinking and depression, anxiety or emotional distress, and which presented prospective associations. Findings were narratively synthesized. RESULTS Thirty studies were identified in a range of long term conditions. Perseverative negative thinking and subsequent depression, anxiety or emotional distress were significantly correlated in the majority of studies (bivariate r=0.23 to r=0.73). 25 studies controlled for confounders, and in 15 perseverative negative thinking predicted subsequent depression, anxiety or emotional distress. Results varied according to condition and study quality. Six of 7 studies found bivariate associations between depression, anxiety or emotional distress and subsequent perseverative negative thinking, though 2 studies controlling for key covariates found no association. Few studies assessed the impact of perseverative negative thinking on medical outcomes. CONCLUSION Strongest evidence supported perseverative negative thinking predicting subsequent depression, anxiety and emotional distress in people with long term conditions. Further prospective research is warranted to clarify the association of perseverative negative thinking with subsequent poor medical outcomes.
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Affiliation(s)
- Leanne Trick
- University of Exeter Medical School, College House, St Lukes Campus, Heavitree Road, Exeter EX1 2LU, United Kingdom.
| | - Edward Watkins
- University of Exeter Medical School, College House, St Lukes Campus, Heavitree Road, Exeter EX1 2LU, United Kingdom
| | - Stacey Windeatt
- University of Exeter Medical School, College House, St Lukes Campus, Heavitree Road, Exeter EX1 2LU, United Kingdom
| | - Chris Dickens
- University of Exeter Medical School, College House, St Lukes Campus, Heavitree Road, Exeter EX1 2LU, United Kingdom
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Guthrie EA, Dickens C, Blakemore A, Watson J, Chew-Graham C, Lovell K, Afzal C, Kapur N, Tomenson B. Depression predicts future emergency hospital admissions in primary care patients with chronic physical illness. J Psychosom Res 2016; 82:54-61. [PMID: 26919799 PMCID: PMC4796037 DOI: 10.1016/j.jpsychores.2014.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/12/2014] [Accepted: 10/03/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE More than 15 million people currently suffer from a chronic physical illness in England. The objective of this study was to determine whether depression is independently associated with prospective emergency hospital admission in patients with chronic physical illness. METHOD 1860 primary care patients in socially deprived areas of Manchester with at least one of four exemplar chronic physical conditions completed a questionnaire about physical and mental health, including a measure of depression. Emergency hospital admissions were recorded using GP records for the year before and the year following completion of the questionnaire. RESULTS The numbers of patients who had at least one emergency admission in the year before and the year after completion of the questionnaire were 221/1411 (15.7%) and 234/1398 (16.7%) respectively. The following factors were independently associated with an increased risk of prospective emergency admission to hospital: having no partner (OR 1.49, 95% CI 1.04 to 2.15); having ischaemic heart disease (OR 1.60, 95% CI 1.04 to 2.46); having a threatening experience (OR 1.16, 95% CI 1.04 to 1.29); depression (OR 1.58, 95% CI 1.04 to 2.40); and emergency hospital admission in the year prior to questionnaire completion (OR 3.41, 95% CI 1.98 to 5.86). CONCLUSION To prevent potentially avoidable emergency hospital admissions, greater efforts should be made to detect and treat co-morbid depression in people with chronic physical illness in primary care, with a particular focus on patients who have no partner, have experienced threatening life events, and have had a recent emergency hospital admission.
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Affiliation(s)
- Elspeth A Guthrie
- Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK.
| | - Chris Dickens
- Institute of Health Service Research, University of Exeter Medical School, Exeter, UK; Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Veysey Building, Room 007, Salmon Pool Lane, Exeter, UK.
| | - Amy Blakemore
- Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK; National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK.
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, The University of Manchester, Room 6.322a, Jean McFarlane Building, University Place, Oxford Road, Manchester, UK.
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK.
| | - Navneet Kapur
- Centre for Suicide Prevention, University Place, The University of Manchester, Oxford Road, Manchester, UK.
| | - Barbara Tomenson
- Biostatistics Unit, Institute of Population Health, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, UK.
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Richards SH, Dickens C, Anderson R, Richards DA, Taylor RS, Ukoumunne OC, Kessler D, Turner K, Kuyken W, Gandhi M, Knight L, Gibson A, Davey A, Warren F, Winder R, Wright C, Campbell J. Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial. Trials 2016; 17:59. [PMID: 26830029 PMCID: PMC4736496 DOI: 10.1186/s13063-016-1184-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/16/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Around 17% of people eligible for UK cardiac rehabilitation programmes following an acute coronary syndrome report moderate or severe depressive symptoms. While maximising psychological health is a core goal of cardiac rehabilitation, psychological care can be fragmented and patchy. This study tests the feasibility and acceptability of embedding enhanced psychological care, composed of two management strategies of proven effectiveness in other settings (nurse-led mental health care coordination and behavioural activation), within the cardiac rehabilitation care pathway. METHODS/DESIGN This study tests the uncertainties associated with a large-scale evaluation by conducting an external pilot trial with a nested qualitative study. We aim to recruit and randomise eight comprehensive cardiac rehabilitation teams (clusters) to intervention (embedding enhanced psychological care into routine cardiac rehabilitation programmes) or control (routine cardiac rehabilitation programmes alone) arms. Up to 64 patients (eight per team) identified with depressive symptoms upon initial assessment by the cardiac rehabilitation team will be recruited, and study measures will be administered at baseline (before starting rehabilitation) and at 5 months and 8 months post baseline. Outcomes include depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Trial data on cardiac team and patient recruitment, and the retention and flow of patients through treatment will be used to assess intervention feasibility and acceptability. Qualitative interviews will be undertaken to explore trial participants' and cardiac rehabilitation nurses' views and experiences of the trial methods and intervention, and to identify reasons why patients declined to take part in the trial. Outcome data will inform a sample size calculation for a definitive trial. DISCUSSION The pilot trial and qualitative study will inform the design of a fully powered cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of the provision of enhanced psychological care within cardiac rehabilitation programmes. TRIAL REGISTRATION ISRCTN34701576 (Registered 29 May 2014).
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Affiliation(s)
- Suzanne H Richards
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Chris Dickens
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Rob Anderson
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - David A Richards
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Rod S Taylor
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Obioha C Ukoumunne
- NIHR Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK.
| | - Katrina Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Whatley Road, Bristol, BS8 2PS, UK.
| | - Willem Kuyken
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, 0X3 7JX, UK.
| | - Manish Gandhi
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
| | - Luke Knight
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
| | - Andrew Gibson
- Health and Social Sciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol, BS16 1QY, UK.
| | - Antoinette Davey
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Fiona Warren
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Rachel Winder
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Christine Wright
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - John Campbell
- University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
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Illness perceptions of people with long-term conditions are associated with frequent use of the emergency department independent of mental illness and somatic symptom burden. J Psychosom Res 2016; 81:38-45. [PMID: 26800637 DOI: 10.1016/j.jpsychores.2016.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 12/15/2015] [Accepted: 01/04/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether illness perceptions of patients with long-term conditions (LTCs) are associated with urgent healthcare use and whether this association is independent from mental illness and somatic symptom burden. METHODS Illness perceptions (B-IPQ) and somatic symptom severity (PHQ-15) were assessed in 304 patients with diabetes, rheumatological disorders and COPD attending an Accident and Emergency Department (AED) in Greece over a one year period. The presence of mental illness was determined by the Mini International Neuropsychiatric Interview. A Generalized Linear Model (Negative Binomial) regression was used to determine the associations of illness perceptions with AED use after adjusting for mental illness, somatic symptom severity, disease parameters and demographics. RESULTS Eighty-six patients (28.3%) reported at least one visit to the AED during the previous year and 75 (24.7%) twice or more. 124 patients (40.8%) had some form of mental disorder with 85 (28.0%) meeting criteria for major depressive disorder. The degree to which the patients had an understanding of their illness (illness comprehensibility) (p<0.01) along with younger age (p<0.05), additional comorbidities (p<0.05) and greater somatic symptom burden (p<0.001) was strongly associated with AED use; AED visits were expected to be reduced by 9.1% for each unit increase in illness comprehensibility. CONCLUSIONS The way people perceive their illness influences urgent healthcare seeking behavior independent of somatic symptom burden. This finding indicates that information provision may prove effective in reducing urgent healthcare use and encourage the design of psycho-educational interventions targeting disease-related cognitions in an attempt to prevent unnecessary healthcare utilization.
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Diaz R, Behr J, Kumar S, Britton B. MODELING CHRONIC DISEASE PATIENT FLOWS DIVERTED FROM EMERGENCY DEPARTMENTS TO PATIENT-CENTERED MEDICAL HOMES. IIE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2016; 5:268-285. [PMID: 26770663 PMCID: PMC4709841 DOI: 10.1080/19488300.2015.1095824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic Disease is defined as a long lasting health condition, which can develop and/or worsen over an extended time, but which can also be controlled. The monetary and budgetary toll due to its persistent nature has become unsustainable and requires pressing actions to limit their incidence and burden. This paper demonstrates the utility of the System Dynamics approach to simulate the behavior of key factors involved in the implementation of chronic disease management. We model the patient flow diversion from emergency departments (ED) to patient-centered medical homes (PCMH), with emphasis on the visit rates, as well as the effect of insurance coverage, in an effort to assure continuity of quality care for Asthma patients at lower costs. The model is used as an evaluative method to identify conditions of a maintained health status through adequate policy planning, in terms of resources and capacity. This approach gives decision makers the ability to track the level of implementation of the intervention and generate knowledge about dynamics between population demands and the intervention effectiveness. The functionality of the model is demonstrated through the consideration of hypothetical scenarios executed using sensitivity analysis.
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Affiliation(s)
- Rafael Diaz
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Norfolk, United States
| | - Joshua Behr
- Old Dominion University, Virginia Modeling, Analysis, and Simulation Center, Suffolk, 23435 United States
| | - Sameer Kumar
- University of St. Thomas, Minneapolis, United States
| | - Bruce Britton
- Eastern Virginia Medical School, Norfolk, United States
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Coventry PA, Small N, Panagioti M, Adeyemi I, Bee P. Living with complexity; marshalling resources: a systematic review and qualitative meta-synthesis of lived experience of mental and physical multimorbidity. BMC FAMILY PRACTICE 2015; 16:171. [PMID: 26597934 PMCID: PMC4657350 DOI: 10.1186/s12875-015-0345-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 09/22/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Multimorbidity poses a major health burden worldwide yet most healthcare is still orientated towards the management of single diseases. Literature on the experience of living with multimorbidity is accumulating but has not yet been synthesised in a manner conducive to informing the design of self-management interventions for this population. This study aimed to systematically review and synthesise findings from published, in-depth qualitative studies about the experience of multimorbidity, with a view to identifying the components and motivation for successful self-management in this population. METHODS Systematic review of and meta-synthesis of qualitative studies that evaluated patient experience of living with and/or self-managing mental and/or physical multimorbidity. MEDLINE, Embase, PsycINFO, CINAHL, and ASSIA along with reference lists of existing reviews and content pages of non-indexed specialists comorbidity journals were searched. RESULTS Nineteen studies from 23 papers were included. A line of argument synthesis was articulated around three third-order constructs: 1) Encounters with complexity; 2) Marshalling medicines, emotions, and resources; and 3) Self-preservation and prevention. Our interpretation revealed how mental and physical multimorbidity is experienced as moments of complexity rather than mere counts of illnesses. Successful self-management of physical symptoms was contingent upon the tactical use of medicines, whilst emotional health was more commonly managed by engaging in behavioural strategies, commonly with a social or spiritual component. Motivations for self-management were underpinned by a sense of moral purpose to take responsibility for their health, but also by a desire to live a purposeful life beyond an immediate context of multimorbidity. CONCLUSIONS Understanding how people experience the complexities of mental and physical multimorbidity may be crucial to designing and delivering interventions to support successful self-management in this population. Future self-management interventions should aim to support patients to exert responsibility and autonomy for medical self-management and promote agency and self-determination to lead purposeful lives via improved access to appropriate social and psychological support.
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Affiliation(s)
- Peter A Coventry
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Nicola Small
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Maria Panagioti
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Isabel Adeyemi
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Penny Bee
- School of Nursing, Midwifery and Social Work and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Boland MRS, Kruis AL, Tsiachristas A, Assendelft WJJ, Gussekloo J, Blom CMG, Chavannes NH, Rutten-van Mölken MPMH. Cost-effectiveness of integrated COPD care: the RECODE cluster randomised trial. BMJ Open 2015; 5:e007284. [PMID: 26525419 PMCID: PMC4636669 DOI: 10.1136/bmjopen-2014-007284] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To investigate the cost-effectiveness of a chronic obstructive pulmonary disease (COPD) disease management (COPD-DM) programme in primary care, called RECODE, compared to usual care. DESIGN A 2-year cluster-randomised controlled trial. SETTING 40 general practices in the western part of the Netherlands. PARTICIPANTS 1086 patients with COPD according to GOLD (Global Initiative for COPD) criteria. Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse and inability to fill in Dutch questionnaires. Practices were included if they were willing to create a multidisciplinary COPD team. INTERVENTIONS A multidisciplinary team of caregivers was trained in motivational interviewing, setting up individual care plans, exacerbation management, implementing clinical guidelines and redesigning the care process. In addition, clinical decision-making was supported by feedback reports provided by an ICT programme. MAIN OUTCOME MEASURES We investigated the impact on health outcomes (quality-adjusted life years (QALYs), Clinical COPD Questionnaire, St. George's Respiratory Questionnaire and exacerbations) and costs (healthcare and societal perspective). RESULTS The intervention costs were €324 per patient. Excluding these costs, the intervention group had €584 (95% CI €86 to €1046) higher healthcare costs than did the usual care group and €645 (95% CI €28 to €1190) higher costs from the societal perspective. Health outcomes were similar in both groups, except for 0.04 (95% CI -0.07 to -0.01) less QALYs in the intervention group. CONCLUSIONS This integrated care programme for patients with COPD that mainly included professionally directed interventions was not cost-effective in primary care. TRIAL REGISTRATION NUMBER Netherlands Trial Register NTR2268.
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Affiliation(s)
- Melinde R S Boland
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Apostolos Tsiachristas
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Coert M G Blom
- Stichting Zorgdraad foundation, Oosterbeek, The Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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Overend K, Bosanquet K, Bailey D, Foster D, Gascoyne S, Lewis H, Nutbrown S, Woodhouse R, Gilbody S, Chew-Graham C. Revealing hidden depression in older people: a qualitative study within a randomised controlled trial. BMC FAMILY PRACTICE 2015; 16:142. [PMID: 26481581 PMCID: PMC4617777 DOI: 10.1186/s12875-015-0362-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/07/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND The prevalence of depressive symptoms in older people may be as high as 20 %. Depression in older people is associated with loss, loneliness and physical co-morbidities; it is known to be under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients. METHODS A nested qualitative study in a randomised controlled trial for older people with moderate to severe depression: the CASPER Plus Trial (Collaborative Care for Screen Positive Elders). We interviewed GPs, case managers (CM) and patient participants to explore perspectives and experiences of delivering and receiving a psychosocial intervention, developed specifically for older adults in primary care, within a collaborative care framework. Transcripts were analysed thematically using principles of constant comparison. RESULTS Thirty three interviews were conducted and, across the three data-sets, four main themes were identified: revealing hidden depression, reducing the 'blind spots', opportunity to talk outside the primary care consultation and 'moving on' from depression. CONCLUSIONS Depression in older people is commonly hidden, and may coexist with physical conditions that are prioritised by both patients and GPs. Being invited to participate in a trial about depression may allow older people to disclose their feelings, name the problem, and seek help. Offering older people an opportunity to talk outside the primary care consultation is valued by patients and GPs. A psychosocial intervention delivered by a case manager in the primary care setting may fill the gap in the care of older people with depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN45842879 .
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Affiliation(s)
| | | | - Della Bailey
- University of York, Heslington, York, YO10 5DD, UK.
| | | | | | - Helen Lewis
- University of York, Heslington, York, YO10 5DD, UK.
| | | | | | | | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, NIHR CLAHRC West Midlands, Keele, Staffordshire, ST5 5BG, UK.
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Dickens C. Depression in People with Coronary Heart Disease: Prognostic Significance and Mechanisms. Curr Cardiol Rep 2015; 17:83. [DOI: 10.1007/s11886-015-0640-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lower PHQ-9 cutpoint accurately diagnosed depression in people with long-term conditions attending the Accident and Emergency Department. J Affect Disord 2015; 176:155-63. [PMID: 25721612 DOI: 10.1016/j.jad.2015.01.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Major Depressive Disorder (MDD) is frequent in the Accident and Emergency Department (AED) but is often unrecognized. We aimed to assess the prevalence of MDD and determine the psychometric properties of the PHQ-9 in diagnosing MDD in patients with long-term medical conditions attending an AED. METHODS The PHQ-9 was administered to 349 patients with diabetes, COPD and chronic inflammatory rheumatic diseases, mainly rheumatoid arthritis and spondyloarthropathies, visiting an AED. The MINI interview was used as the criterion standard for MDD. Receiver operator characteristic (ROC) curve analysis was performed to determine the optimal PHQ-9 cutpoint for MDD. Construct validators included psychological distress (SCL-90-R), illness perceptions (B-IPQ) and Health-Related Quality of Life (WHOQOL-BREF). RESULTS The prevalence of MDD was 27.2%. At an optimal cutpoint of 8, PHQ-9 had a sensitivity of 90.5% and specificity of 89.4%. The area under the curve (0.96) was excellent. Convergent validity was established by the strong associations between PHQ-9 scores and functional status, SCL-90-R depression, illness perceptions and AED visits during the previous year. LIMITATIONS The sample consisted of multiple rather a single disease group, preventing us from accounting for illness severity using specific disease severity indices. CONCLUSION MDD is frequent in patients with long-term medical conditions attending the AED and the PHQ-9, at a cutpoint of 8, is an accurate, reliable and valid measure for MDD screening in this patient population.
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Coventry P, Lovell K, Dickens C, Bower P, Chew-Graham C, McElvenny D, Hann M, Cherrington A, Garrett C, Gibbons CJ, Baguley C, Roughley K, Adeyemi I, Reeves D, Waheed W, Gask L. Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ 2015; 350:h638. [PMID: 25687344 PMCID: PMC4353275 DOI: 10.1136/bmj.h638] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2014] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions. DESIGN Cluster randomised controlled trial. SETTING 36 general practices in the north west of England. PARTICIPANTS 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥ 10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial. INTERVENTIONS Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses. MAIN OUTCOME MEASURES The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF). RESULTS 19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval -0.41 to -0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support. CONCLUSIONS Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity. TRIAL REGISTRATION ISRCTN80309252.
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Affiliation(s)
- Peter Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Chris Dickens
- Institute of Health Service Research, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - Peter Bower
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, University of Keele, Keele ST5 5BG, UK
| | - Damien McElvenny
- NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Mark Hann
- Centre for Biostatistics and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Andrea Cherrington
- Research Institute, Primary Care and Health Sciences, University of Keele, Keele ST5 5BG, UK
| | - Charlotte Garrett
- Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Chris J Gibbons
- Manchester Centre for Health Psychology, University of Manchester, Manchester M13 9PL, UK
| | - Clare Baguley
- NHS Health Education North West, Manchester M1 3BN, UK
| | - Kate Roughley
- Division of Clinical Psychology, University of Liverpool, Liverpool L69 3GB, UK
| | - Isabel Adeyemi
- NIHR Collaboration for Leadership in Applied Health Research and Care, Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - David Reeves
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Waquas Waheed
- Lancashire Care NHS Foundation Trust, Preston PR5 6AW, UK
| | - Linda Gask
- Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
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Blakemore A, Dickens C, Anderson R, Tomenson B, Woodcock A, Guthrie E. Complex interventions reduce use of urgent healthcare in adults with asthma: systematic review with meta-regression. Respir Med 2014; 109:147-56. [PMID: 25433953 DOI: 10.1016/j.rmed.2014.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/15/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Asthma accounts for considerable healthcare expenditure, a large proportion of which is attributable to use of expensive urgent healthcare. This review examines the characteristics of complex interventions that reduce urgent healthcare use in adults with asthma. METHOD Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to January 2013 were conducted. Studies were eligible for inclusion if they: i) included adults with asthma ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. Data on participants recruited, methods, characteristics of complex interventions and the effects of the intervention on urgent healthcare use were extracted. RESULTS 33 independent studies were identified resulting in 39 comparisons altogether. Pooled effects indicated that interventions were associated with a reduction in urgent healthcare use (OR = 0.79, 95% CI = 0.67, 0.94). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.77, 95% CI = 0.64, 0.91), skills training (OR = 0.64, 95% CI = 0.48, 0.86) and relapse prevention (OR = 0.75, 95% CI = 0.57, 0.98). In multivariate meta-regression analysis, only skills training remained significant. CONCLUSIONS Complex interventions reduced the use of urgent healthcare in adults with asthma by 21%. Those complex interventions including skills training, education and relapse prevention may be particularly effective in reducing the use of urgent healthcare in adults with asthma.
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Affiliation(s)
- Amy Blakemore
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK; National Institute for Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Chris Dickens
- Institute of Health Research, University of Exeter Medical School and Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Veysey Building, Room 007, Salmon Pool Lane, Exeter, EX2 4SG, UK
| | - Rebecca Anderson
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Barbara Tomenson
- Biostatistics Unit: Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Ashley Woodcock
- Institution of Inflammation and Repair, University of Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - Else Guthrie
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity. BMC Health Serv Res 2014; 14:536. [PMID: 25367263 PMCID: PMC4226873 DOI: 10.1186/s12913-014-0536-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/17/2014] [Indexed: 11/10/2022] Open
Abstract
Background Primary care is increasingly focussed on the care of people with two or more long-term conditions (multimorbidity). The UK Department of Health strategy for long term conditions is to use self-management support for the majority of patients but there is evidence of limited engagement among primary care professionals and patients with multimorbidity. Furthermore, multimorbidity is more common in areas of socioeconomic deprivation but deprivation may act as a barrier to patient engagement in self-management practices. Background Effective self-management is considered critical to meet the needs of people living with long term conditions but achieving this is a significant challenge in patients with multimorbidity. This study aimed to explore patient and practitioner views on factors influencing engagement in self-management in the context of multimorbidity. Methods A qualitative study using individual semi-structured interviews with 20 patients and 20 practitioners drawn from four general practices in Greater Manchester situated in areas of high and low social deprivation. Patients were purposively sampled on socioeconomic deprivation (defined by Index of Multiple Deprivation (IMD) score), number and type of long term conditions (2 or more of: coronary heart disease, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease and depression), age and gender. Practitioners were sampled by deprivation status of the practice area; role (i.e. salaried GP, GP principal, practice nurse); and number of years’ experience. Interviews were audio-recorded and transcribed verbatim. Analysis used a thematic approach based on Framework. Results Three main factors were identified as influencing patient engagement in self-management: capacity (access and availability of socio-economic resources and time; knowledge; and emotional and physical energy), responsibility (the degree to which patients and practitioners agreed about the division of labour about chronic disease management, including self-management) and motivation (willingness to take-up types of self-management practices). Socioeconomic deprivation negatively impacted on all three factors. Motivation was especially reduced in the presence of mental and physical multimorbidity. Conclusion Full engagement in self-management practices in multimorbidity was only present where patients’ articulated a sense of capacity, responsibility, and motivation. Patient ‘know-how’ or interpretive capacity to self-manage multimorbidity is potentially an important precursor to responsibility and motivation, and might be a critical target for intervention. However, individual and social resources are needed to generate capacity, responsibility, and motivation for self-management, pointing to a balanced role for health services and wider enabling networks. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0536-y) contains supplementary material, which is available to authorized users.
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Langer S, Chew-Graham CA, Drinkwater J, Afzal C, Keane K, Hunter C, Guthrie E, Salmon P. A motivational intervention for patients with COPD in primary care: qualitative evaluation of a new practitioner role. BMC FAMILY PRACTICE 2014; 15:164. [PMID: 25284048 PMCID: PMC4286939 DOI: 10.1186/1471-2296-15-164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long-term conditions such as chronic obstructive pulmonary disease (COPD) are growing challenges for health services. Psychosocial co-morbidity is associated with poorer quality of life and greater use of health care in these patients but is often un-diagnosed or inadequately treated in primary care, where most care for these patients is provided. We developed a brief intervention, delivered by 'liaison health workers' (LHWs), to address psychosocial needs in the context of an integrated approach to physical and mental health. We report a qualitative study in which we characterize the intervention through the experience of the patients receiving it and examine how it was incorporated into primary care. METHODS Qualitative study using patient and practice staff informants. We audio-recorded interviews with 29 patients offered the intervention (three had declined it or withdrawn) and 13 practice staff (GPs, nurses and administrators). Analysis used a constant comparative approach. RESULTS Most patients were enthusiastic about the LHWs, describing the intervention as mobilizing their motivation for self-management. By contrast with other practitioners, patients experienced the LHWs as addressing their needs holistically, being guided by patient needs rather than professional agendas, forming individual relationships with patients and investing in patients and their capacity to change. Practices accommodated and accepted the LHWs, but positioned them as peripheral to and separate from the priority of physical care. CONCLUSIONS Despite being a short-term intervention, patients described it as having enduring motivational benefits. The elements of the intervention that patients described map onto the key features of motivating interventions described by Self-Determination Theory. We suggest that the LHWs motivated patients to self-management by: (i) respecting patients' competence to decide on needs and priorities; (ii) forming relationships with patients as individuals; and (iii) fostering patients' sense of autonomy. While truly integrated primary care for patients with long-term conditions such as COPD remains elusive, existing practice staff might adopt elements of the LHWs' approach to enhance motivational change in patients with long-term conditions such as COPD.
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Affiliation(s)
| | | | | | | | | | | | | | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool L69 3GB, UK.
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Coventry PA, Hudson JL, Kontopantelis E, Archer J, Richards DA, Gilbody S, Lovell K, Dickens C, Gask L, Waheed W, Bower P. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One 2014; 9:e108114. [PMID: 25264616 PMCID: PMC4180075 DOI: 10.1371/journal.pone.0108114] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/14/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication). METHODS AND FINDINGS Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient -0.11, 95% CI -0.20 to -0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. CONCLUSION Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.
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Affiliation(s)
- Peter A. Coventry
- Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Joanna L. Hudson
- Health Psychology Section, Psychology Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Janine Archer
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - David A. Richards
- Institute of Health Service Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Simon Gilbody
- Mental Health Research Group, Department of Health Sciences and Hull York Medical School, University of York, York, United Kingdom
| | - Karina Lovell
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Chris Dickens
- Institute of Health Service Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Linda Gask
- Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Waquas Waheed
- Lancashire Care NHS Foundation Trust, Preston, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Blakeley C, Blakemore A, Hunter C, Guthrie E, Tomenson B, Dickens C. Does anxiety predict the use of urgent care by people with long term conditions? A systematic review with meta-analysis. J Psychosom Res 2014; 77:232-9. [PMID: 25149033 PMCID: PMC4153376 DOI: 10.1016/j.jpsychores.2014.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The role of anxiety in the use of urgent care in people with long term conditions is not fully understood. A systematic review was conducted with meta-analysis to examine the relationship between anxiety and future use of urgent healthcare among individuals with one of four long term conditions: diabetes; coronary heart disease, chronic obstructive pulmonary disease and asthma. METHODS Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library were conducted These searches were supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts within the field about relevant studies. Studies were eligible for inclusion if they: a) used a standardised measure of anxiety, b) used prospective cohort design, c) included adult patients diagnosed with coronary heart disease (CHD), asthma, diabetes or chronic obstructive pulmonary disease (COPD), d) assessed urgent healthcare use prospectively. Data regarding participants, methodology, and association between anxiety and urgent care use was extracted from studies eligible for inclusion. Odds ratios were calculated for each study and pooled using random effects models. RESULTS 8 independent studies were identified for inclusion in the meta-analysis, with a total of 28,823 individual patients. Pooled effects indicate that anxiety is not associated with an increase in the use of urgent care (OR=1.078, p=0.476), regardless of the type of service, or type of medical condition. CONCLUSIONS Anxiety is not associated with increased use of urgent care. This finding is in contrast to similar studies which have investigated the role of depression as a risk factor for use of urgent care.
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Affiliation(s)
- Claire Blakeley
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK.
| | - Amy Blakemore
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK; NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Sciences Centre, University of Manchester, Williamson Building, Oxford Road, M13 9WL, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Else Guthrie
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK
| | - Barbara Tomenson
- Biostatistics Unit, Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK
| | - Chris Dickens
- Mental Health Research Group, University of Exeter Medical School, UK; National Institute for Health Research (NIHR), Collaboration for Leadership in Applied Health Research & Care (CLAHRC) for the South West Peninsula (PenCLAHRC), UK
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Hunter C, Chew-Graham C, Langer S, Stenhoff A, Drinkwater J, Guthrie E, Salmon P. A qualitative study of patient choices in using emergency health care for long-term conditions: the importance of candidacy and recursivity. PATIENT EDUCATION AND COUNSELING 2013; 93:335-341. [PMID: 23906651 DOI: 10.1016/j.pec.2013.06.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 05/27/2013] [Accepted: 06/07/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis. METHODS Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach. RESULTS Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners. CONCLUSION Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of 'candidacy' for specific emergency care services, was recursively shaped by previous experiences. PRACTICE IMPLICATIONS Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients' judgements of candidacy and their perceptions of accessible expertise in alternative services.
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Affiliation(s)
- Cheryl Hunter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Kenning C, Fisher L, Bee P, Bower P, Coventry P. Primary care practitioner and patient understanding of the concepts of multimorbidity and self-management: A qualitative study. SAGE Open Med 2013; 1:2050312113510001. [PMID: 26770690 PMCID: PMC4687771 DOI: 10.1177/2050312113510001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The aim of this article is to offer insight into how professionals and patients understand and experience multimorbidity and how these accounts differ, and how they affect attitudes and engagement with self-management. METHODS Semi-structured interviews with 20 primary healthcare practitioners and 20 patients with at least 2 long-term conditions (including coronary heart disease, diabetes, osteoarthritis, chronic obstructive pulmonary disease and depression). Thematic analysis was used, and themes were identified using an open-coding method. RESULTS Practitioners associated multimorbidity with complexity and uncertainty in the clinic, leading to emotional strain and 'heart sink'. Patient accounts differed. Some described multimorbidity as problematic when it exacerbated their symptoms and caused emotional and psychological strain. Others did not perceive multimorbidity as problematic. Self-management was seen by practitioners and patients to be a key element of managing multiple conditions, but drivers for prompting and engaging in self-management differed between patients and practitioners. CONCLUSION This study suggests that recommendations for clinical practice for multimorbid patients should take into account the gap in perceptions between practitioner and patients about experiences of multimorbidity. Not least, practice would need to reflect the tension between practitioners' and patients' accounts about the role and benefits of self-management in the presence of multimorbidity.
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Affiliation(s)
- Cassandra Kenning
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, UK
| | - Louise Fisher
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Penny Bee
- Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, UK; School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, UK
| | - Peter Coventry
- Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, UK; NIHR Collaboration for Applied Health Research and Care for Greater Manchester (GM-CLAHRC), University of Manchester, Manchester, UK
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Dickens C, Katon W, Blakemore A, Khara A, Tomenson B, Woodcock A, Fryer A, Guthrie E. Complex interventions that reduce urgent care use in COPD: a systematic review with meta-regression. Respir Med 2013; 108:426-37. [PMID: 23806286 DOI: 10.1016/j.rmed.2013.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 05/24/2013] [Accepted: 05/25/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Chronic obstructive pulmonary disease is common and accounts for considerable healthcare expenditure. A large proportion of this healthcare expenditure is attributable to the use of expensive urgent healthcare. The characteristics of interventions that reduce the use of urgent healthcare remain unclear. OBJECTIVE To examine the characteristics of complex interventions intended to reduce the use of urgent and unscheduled healthcare among people with COPD. DATA SOURCES Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to 25th January 2013 were conducted. These were supplemented by hand-searching bibliographies and citation tracing identified reviews and eligible studies. STUDY SELECTION Studies were eligible for inclusion if they: i) included adults with chronic obstructive pulmonary disease, ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. DATA EXTRACTION Data on the subjects recruited, trial methods used, the characteristics of complex interventions and the effects of the intervention on urgent healthcare utilisation were extracted from eligible studies. RESULTS 32 independent studies were identified. Pooled effects indicated that interventions were associated with a 32% reduction in the use of urgent healthcare (OR = 0.68, 95% CI = 0.57, 0.80). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.66, 95% CI = 0.55, 0.81), Exercise (OR = 0.60, 95% CI = 0.48, 0.76) and relaxation therapy (OR = 0.48, 95% CI = 0.33, 0.70). CONCLUSIONS Use of urgent healthcare in patients with COPD was significantly reduced by complex interventions. Complex interventions among people with COPD may reduce the use of urgent care, particularly those including education, exercise and relaxation.
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Affiliation(s)
- Chris Dickens
- Institute of Health Service Research, University of Exeter Medical School and Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), Universities of Exeter, Veysey Building, Room 007, Salmon Pool Lane, Exeter EX2 4SG, UK
| | - Wayne Katon
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA
| | - Amy Blakemore
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; Centre for Primary Care, Institute of Population Health, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK.
| | - Angee Khara
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Barbara Tomenson
- Biostatistics Unit, Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK
| | - Ashley Woodcock
- Institute of Inflammation and Repair, University of Manchester, 2nd Floor Education and Research Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK
| | - Anna Fryer
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Else Guthrie
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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