Cost-effectiveness of a disease management program for major depression in elderly primary care patients

Defining usual care comparators when designing pragmatic trials of complex health interventions: a methodology review

BACKGROUND

Pragmatic trials evaluating complex health interventions often compare them to usual care. This comparator should resemble care as provided in everyday practice. However, usual care can differ for the same condition, between patients and practitioners, across clinical sites and over time. Heterogeneity within a usual care arm can raise methodological and ethical issues. To address these it may be necessary to standardise what usual care entails, although doing so may compromise a trial's external validity. Currently, there is no guidance detailing how researchers should decide the content of their usual care comparators. We conducted a methodology review to summarise current thinking about what should inform this decision.

METHODS

MEDLINE, Embase, CINAHL and PsycINFO were searched from inception to January 2022. Articles and book chapters that discussed how to identify or develop usual care comparators were included. Experts in the field were also contacted. Reference lists and forward citation searches of included articles were screened. Data were analysed using a narrative synthesis approach.

RESULTS

One thousand nine hundred thirty records were identified, 1611 titles and abstracts screened, 112 full texts screened, and 16 articles included in the review. Results indicated that the content of a usual care comparator should be informed by the aims of the trial, existing care practices, clinical guidelines, and characteristics of the target population. Its content should also be driven by the trial's requirements to protect participants, inform practice, and be methodologically robust, efficient, feasible and acceptable to stakeholders. When deciding the content of usual care, researchers will need to gather information about these drivers, balance tensions that might occur when responding to different trial objectives, and decide how usual care will be described and monitored in the trial.

DISCUSSION

When deciding the content of a usual care arm, researchers need to understand the context in which a trial will be implemented and what the trial needs to achieve to address its aim and remain ethical. This is a complex decision-making process and trade-offs might need to be made. It also requires research and engagement with stakeholders, and therefore time and funding during the trial's design phase.

TRIAL REGISTRATION

PROSPERO CRD42022307324.

Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression

Background

Depression is a common mental health disorder for which clinical practice guidelines have been developed. Prior systematic reviews have identified complex organizational interventions, such as collaborative care, as effective for guideline implementation; yet, many healthcare delivery organizations are interested in less resource-intensive methods to increase provider adherence to guidelines and guideline-concordant practices. The objective of this systematic review was to assess the effectiveness of healthcare provider interventions that aim to increase adherence to evidence-based treatment of depression in routine clinical practice.

Methods

We searched five databases through August 2017 using a comprehensive search strategy to identify English-language randomized controlled trials (RCTs) in the quality improvement, implementation science, and behavior change literature that evaluated outpatient provider interventions, in the absence of practice redesign efforts, to increase adherence to treatment guidelines or guideline-concordant practices for depression. We used meta-analysis to summarize odds ratios, standardized mean differences, and incidence rate ratios, and assessed quality of evidence (QoE) using the GRADE approach.

Results

Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline-concordant practices met inclusion criteria. Studies evaluated diverse provider interventions, including distributing guidelines to providers, education/training such as academic detailing, and combinations of education with other components such as targeting implementation barriers. Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies. There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes. We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies. Effects on patients’ health in these RCTs were inconsistent across studies and outcomes.

Conclusions

Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines. Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research. Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence-based treatment for depression.

Trial registration

PROSPERO record CRD42017060460 on 3/29/17

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0788-8) contains supplementary material, which is available to authorized users.

Consistency and sources of divergence in recommendations on screening with questionnaires for presently experienced health problems or symptoms: a comparison of recommendations from the Canadian Task Force on Preventive Health Care, UK National Screening Committee, and US Preventive Services Task Force

BACKGROUND

Recently, health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include "screening" for presently experienced health problems and symptoms using self-report questionnaires. We examined recommendations from three major national guideline organizations to determine the consistency of recommendations, identify sources of divergent recommendations, and determine if guideline organizations have identified any direct randomized controlled trial (RCT) evidence for the effectiveness of questionnaire-based screening.

METHODS

We reviewed recommendation statements listed by the Canadian Task Force on Preventive Health Care (CTFPHC), the United Kingdom National Screening Committee (UKNSC), and the United States Preventive Services Task Force (USPSTF) as of 5 September 2016. Eligible recommendations focused on using self-report questionnaires to identify patients with presently experienced health problems or symptoms. Within each recommendation and accompanying evidence review we identified screening RCTs.

RESULTS

We identified 22 separate recommendations on questionnaire-based screening, including three CTFPHC recommendations against screening, eight UKNSC recommendations against screening, four USPSTF recommendations in favor of screening (alcohol misuse, adolescent depression, adult depression, intimate partner violence), and seven USPSTF recommendations that did not recommend for or against screening. In the four cases where the USPSTF recommended screening, either the CTFPHC, the UKNSC, or both recommended against. When recommendations diverged, the USPSTF expressed confidence in benefits based on indirect evidence, evaluated potential harms as minimal, and did not consider cost or resource use. CTFPHC and UKNSC recommendations against screening, on the other hand, focused on the lack of direct evidence of benefit and raised concerns about harms to patients and resource use. Of six RCTs that directly evaluated screening interventions, five did not report any statistically significant primary or secondary health outcomes in favor of screening, and one trial reported equivocal results.

CONCLUSIONS

Only the USPSTF has made any recommendations for screening with questionnaires for presently experienced problems or symptoms. The CTFPHC and UKNSC recommended against screening in all of their recommendations. Differences in recommendations appear to reflect differences in willingness to assume benefit from indirect evidence and different approaches to assessing possible harms and resource consumption. There were no examples in any recommendations of RCTs with direct evidence of improved health outcomes.

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

Background

To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective.

Methods

A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping.

Results

In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained.

Conclusion

The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention.

Dutch trial register NTR1519

A randomised controlled trial of the effectiveness of a program for early detection and treatment of depression in primary care

OBJECTIVE

There is considerable uncertainty about whether depression screening programs in primary care may improve outcomes and what specific features of such programs may contribute to success. We tested the effectiveness of a program involving substantial commitment from local mental health services.

METHODS

Prospective, randomised, patient- and evaluator-masked, parallel-group, controlled study. Participants were recruited in several urban primary care practices where they completed the PC-SAD screener and WHOQOL-Bref. Those who screened positive and did not report suicidal ideation (N=115) were randomised to an intervention group (communication of the result and offer of psychiatric evaluation and treatment free of charge; N=56) or a control group (no feedback on test result for 3 months; N=59). After 3 months, 100 patients agreed to a follow-up telephone interview including the administration of the PC-SAD5 and WHOQOL-Bref.

RESULTS

Depression severity and quality of life improved significantly in both groups. Intent-to-treat analysis showed no effect of the intervention. As only 37% of patients randomised to the intervention group actually contacted the study outpatient clinic, we performed a per-protocol analysis to determine whether the intervention, if delivered as planned, had been effective. This analysis revealed a significant positive effect of the intervention on severity of depressive symptoms, and on response and remission rate. Complier average causal effect analysis yielded similar results.

CONCLUSION

Due to the relatively small sample size, our findings should be regarded as preliminary and have limited generalizability. They suggest that there are considerable barriers on the part of many patients to the implementation of depression screening programs in primary care. While such programs can be effective, they should be designed based on the understanding of patients' perspectives.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Utility Values for Adults with Unipolar Depression: Systematic Review and Meta-Analysis

BACKGROUND

Unipolar depression is a mental illness with a substantial health-related and economic burden. Health interventions for depression predominately focus on improving sufferers' health-related quality of life (HRQoL). Utility is a measure of HRQoL that is required for use in model-based cost-utility analyses to assess the added value of health interventions. This review aimed to identify, summarize, and where feasible, synthesize published utilities for unipolar depression.

METHODS

A structured electronic search combining common terms for unipolar depression and utility was conducted in MEDLINE, EMBASE, and PsycINFO. Utility values identified were summarized, and the study designs were appraised in terms of the patient population and valuation method used to generate utilities. Random-effect meta-analyses were applied to pool mean utilities identified for 3 depressive health states (mild, moderate, and severe) elicited from direct and indirect valuation methods separately.

RESULTS

Thirty-five studies were identified that reported utilities for various levels of depression severity. The most commonly used direct valuation method for eliciting utilities was standard gamble (SG) (n = 5), and the most commonly used indirect valuation method was EQ-5D (n = 20). The pooled mean (standard deviation) utilities from studies using SG as a direct valuation method were mild = 0.69 (0.14), moderate = 0.52 (0.28), and severe = 0.27 (0.26). The pooled utilities from studies using EQ-5D as an indirect valuation method were mild = 0.56 (0.16), moderate = 0.45 (0.18), and severe = 0.25 (0.15).

CONCLUSIONS

This systematic review is a useful resource for decision analysts who need health-related utility values to populate model-based cost-utility analyses of health interventions for the management of unipolar depression. Further research is necessary to understand whether direct or indirect valuation methods are the most robust sources for utilities in depression.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.

METHODS

We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.

RESULTS

Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.

CONCLUSIONS

The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

Cost effectiveness of telecare management for pain and depression in patients with cancer: results from a randomized trial

OBJECTIVE

Pain and depression are prevalent and treatable symptoms among patients with cancer, yet they are often undetected and undertreated. The Indiana Cancer Pain and Depression (INCPAD) trial demonstrated that telecare management can improve pain and depression outcomes. This article investigates the incremental cost effectiveness of the INCPAD intervention.

METHODS

The INCPAD trial was conducted in 16 community-based urban and rural oncology practices in Indiana. Of the 405 participants, 202 were randomized to the intervention group and 203 to the usual-care group. Intervention costs were determined, and effectiveness outcomes were depression-free days and quality-adjusted life years.

RESULTS

The intervention group was associated with a yearly increase of 60.3 depression-free days (S.E. = 15.4; P < 0.01) and an increase of between 0.033 and 0.066 quality-adjusted life years compared to the usual care group. Total cost of the intervention per patient was US$1189, which included physician, nurse care manager and automated monitoring set-up and maintenance costs. Incremental cost per depression-free day was US$19.72, which yields a range of US$18,018 to US$36,035 per quality-adjusted life year when converted to that metric. When measured directly, the incremental cost per quality-adjusted life year ranged from US$10,826 based on the modified EQ-5D to US$73,286.92 based on the SF-12.

CONCLUSION

Centralized telecare management, coupled with automated symptom monitoring, appears to be a cost effective intervention for managing pain and depression in cancer patients.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part I: Risk Factors, Screening, Suicide Risk Diagnosis and Assessment in Patients with a Depression Diagnosis]

INTRODUCTION

Depression is an important cause of morbidity and disability in the world; however, it is under-diagnosed at all care levels.

OBJECTIVE

The purpose here is to present recommendations based on the evidence gathered to answer a series of clinical questions concerning risk factors, screening, suicide risk diagnosis and evaluation in patients undergoing a depressive episode and recurrent depressive disorder. Emphasis has been made upon the approach used at the primary care level so as to grant adult diagnosed patients the health care guidelines based on the best and more updated evidence available thus achieving minimum quality standards.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from guides NICE90 and CANMAT were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 1-22 corresponding to screening, suicide risk and depression diagnosis were presented. The corresponding degree of recommendation is included.

The depression treatment cascade in primary care: a public health perspective

Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a "treatment cascade": the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.

Analysis of decisions made in meta-analyses of depression screening and the risk of confirmation bias: a case study

BACKGROUND

Depression is common in primary care and clinicians are encouraged to screen their patients. Meta-analyses have evaluated the effectiveness of screening, but two author groups consistently reached completely opposite conclusions.

METHODS

We identified five systematic reviews on depression screening conducted between 2001 and 2009, three by Gilbody and colleagues and two by the United States Preventive Task Force. The two author groups consistently reached completely opposite conclusions. We analyzed two contemporaneous systematic reviews, applying a stepwise approach to unravel their methods. Decision points were identified, and discrepancies between systematic reviews authors' justification of choices made were recorded.

RESULTS

Two systematic reviews each addressing three research questions included 26 randomized controlled trials with different combinations in each review. For the outcome depression screening resulting in treatment, both reviews undertook meta-analyses of imperfectly overlapping studies. Two in particular, pooled each by only one of the reviews, influenced the recommendations in opposite directions. Justification for inclusion or exclusion of studies was obtuse.

CONCLUSION

Systematic reviews may be less objective than assumed. Based on this analysis of two meta-analyses we hypothesise that strongly held prior beliefs (confirmation bias) may have influenced inclusion and exclusion criteria of studies, and their interpretation. Authors should be required to declare a priori any strongly held prior beliefs within their hypotheses, before embarking on systematic reviews.

Does GP training in depression care affect patient outcome? - A systematic review and meta-analysis

Background

Primary care practices provide a gate-keeping function in many health care systems. Since depressive disorders are highly prevalent in primary care settings, reliable detection and diagnoses are a first step to enhance depression care for patients. Provider training is a self-evident approach to enhance detection, diagnoses and treatment options and might even lead to improved patient outcomes.

Methods

A systematic literature search was conducted reviewing research studies providing training of general practitioners, published from 1999 until May 2011, available on the electronic databases Medline, Web of Science, PsycINFO and the Cochrane Library as well as national guidelines and health technology assessments (HTA).

Results

108 articles were fully assessed and 11 articles met the inclusion criteria and were included. Training of providers alone (even in a specific interventional method) did not result in improved patient outcomes. The additional implementation of guidelines and the use of more complex interventions in primary care yield a significant reduction in depressive symptomatology. The number of studies examining sole provider training is limited, and studies include different patient samples (new on-set cases vs. chronically depressed patients), which reduce comparability.

Conclusions

This is the first overview of randomized controlled trials introducing GP training for depression care. Provider training by itself does not seem to improve depression care; however, if combined with additional guidelines implementation, results are promising for new-onset depression patient samples. Additional organizational structure changes in form of collaborative care models are more likely to show effects on depression care.

Clinical effectiveness of using an integrated model to treat depressive symptoms in veterans affairs primary care clinics and its impact on health care utilization

OBJECTIVE

To determine if veterans treated in an integrated mental health program within a Veterans Affairs (VA) primary care clinic sustained long-term improvement in depressive symptoms and changed their use of health care.

METHOD

In this pilot program, 72 veterans were offered short-term treatment for depressive symptoms by a colocated psychiatrist who was integrated into a VA primary care team (October 1, 1997, through September 30, 1999). Patients were assessed initially and at their final session using the Hamilton Depression Rating Scale. Veterans who completed treatment were referred back to their primary care provider or to specialty mental health services. Patients were contacted and invited to be reevaluated 3 to 5 years later using the same measure (December 1, 2001, through November 30, 2002). Health care utilization data were collected for 1 year preintervention and 2 years postintervention. Outcomes for treatment completers were compared to outcomes for those who declined or dropped out of treatment.

RESULTS

Of 48 patients who agreed to participate in the study, 27 completed treatment and showed a significant decline in symptoms from pretreatment to follow-up (P = .008) compared to 16 noncompleters, as well as a moderate-to-large between-group effect size (d = 0.78) and trends for higher remission and response rates. Completers ranked significantly higher in the number of antidepressant prescriptions filled before (P = .002) and after treatment (P = .001) and in the number of medical visits postintervention (year 1: P = .021; year 2: P = .023), without an associated cost increase.

CONCLUSIONS

Colocated mental health care integrated into VA primary care is associated with sustained improvement of depressive symptoms in a heterogeneous patient population with a high incidence of psychiatric comorbidities. This finding compares favorably with the results of earlier controlled clinical trials and suggests a potential effect on health care utilization.

Development of the hepatitis C self-management program

OBJECTIVE

Chronic hepatitis C infection (HCV) is a major health problem that disproportionately affects people with limited resources. Many people with HCV are ineligible or refuse antiviral treatment, but less curative treatment options exist. These options include adhering to follow-up health visits, lifestyle changes, and avoiding hepatotoxins like alcohol. Herein, we describe a recently developed self-management program designed to assist HCV-infected patients with adherence and improve their health-related quality of life (HRQOL).

METHODS

The development of the Hepatitis C Self-Management Program (HCV-SMP) was informed by scientific literature, qualitative interviews with HCV-infected patients, self-management training, and feedback from HCV clinical experts.

RESULTS

The Hepatitis C Self-Management Program (HCV-SMP) is a multi-faceted program that employs cognitive-behavioral principles and is designed to provide HCV-infected people with knowledge and skills for improving their HRQOL. The program consists of six 2-h workshop sessions which are held weekly. The sessions consist of a variety of group activities, including disease-specific information dissemination, action planning, and problem-solving.

CONCLUSION

The intervention teaches skills for adhering to challenging treatment recommendations using a validated theoretical model. A randomized trial will test the efficacy of this novel HCV self-management program for improving HRQOL in a difficult to reach population.

Integrating mental health parity for homebound older adults under the medicare home health care benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.

The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients

Background

Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department.

Methods/Design

An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.

The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.

The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.

Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle.

Discussion

This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety.

Trial registration

Dutch trial register: NTR1519

Review: the net benefits of depression management in primary care

Depression is often diagnosed and treated in primary care settings. Organizational and systems interventions that restructure primary care practices and train staff have been shown to be cost-effective strategies for treating depression. Funders are increasingly calling for a cost-benefit assessment of such programs. In this study, the authors review existing cost-effectiveness studies of primary care depression treatments, classify them into categories, translate the results into net benefit terms, and assess whether more costly programs generate greater net benefit. The authors find that interventions that provide training to primary care teams in how to manage depression most consistently produce net benefits, with more costly interventions of this type generating larger net benefits than less costly interventions. Collaborative care interventions, which add specialized staff to primary care practices, and therapy interventions, in which clinicians are trained to provide therapy, also generate net social benefits at conventional valuations of quality-adjusted life years.

Remission from depressive symptoms among older adults with mood disorders: findings of a representative community sample

OBJECTIVE

To determine factors associated with remission in a community-dwelling sample of older Canadians with mood disorders.

METHODS

We used a representative community survey conducted in 6 Canadian provinces. Data were gathered by telephone and in-person interviews. The response rate was 79%. Those in institutions were excluded from the sampling frame. Our sample was limited to community-dwelling individuals, aged 55 and over, who reported that they had been diagnosed by a health professional with a mood disorder at some point in their life. Only those with mood disorders that lasted 6 months or more were included in the sample (n = 1,161). Remission from depression was calculated using the Composite International Diagnostic Interview-Short Form (CIDI-SF). Individuals were classified as in remission if CIDI-SF < 0.9.

RESULTS

Three-quarters (76%) of older adults with mood disorders had been symptom-free for the preceding year. The logistic regression analyses indicated that the married, those aged 65 and over, those in good to excellent health, and those who reported minimal stress had the highest odds of remission. Gender, immigration status, education level, household income, number of chronic conditions, activities of daily living limitations, comorbid anxiety disorders, and physical activity level were not associated with the likelihood of remission.

CONCLUSION

Remission rates in this community sample of older adults with mood disorders were much higher than in previous clinical samples. Strategies to improve identification and outreach to those least likely to be in remission from depression are discussed.

Primary care management of major depression in patients aged > or =55 years: outcome of a randomised clinical trial

BACKGROUND

Late-life depression is associated with chronic illness, disability, and a poor prognosis. Primary care management may be in need of improvement.

AIM

To compare the effects of an intervention programme that aims to improve the identification, diagnosis, and treatment of depression in patients aged > or =55 years with the effects of usual care.

DESIGN OF STUDY

Cluster randomised controlled trial.

SETTING

General practices in the Netherlands.

METHOD

Trained GPs performed the intervention and their practice assistants conducted the screenings. Patients were screened with the 15-item Geriatric Depression Scale (GDS-15) and given a consultation with the GP who diagnosed depression with the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Antidepressant treatment was proposed. Primary outcomes were measured with the Montgomery Asberg Depression Rating Scale (MADRS). Trained independent research assistants performed independent evaluations in both arms.

RESULTS

Eighteen practices (23 GPs) were allocated to the intervention and 16 practices (20 GPs) to usual care. From June 2000 to September 2002, 3937 patients were screened; 579 patients had a positive score on the GDS-15, 178 had major depression, of whom 145 participated in the trial. MADRS scores for the intervention group dropped from 21.66 at baseline to 9.23 at 6 months, and the usual care group from 20.94 at baseline to 11.45 at 6 months. MADRS scores decreased during the year in both arms. For the intervention group, these scores increased between 6 and 12 months.

CONCLUSION

The programme resulted in lower MADRS scores in the intervention group than in the usual care group, but only at the end of the intervention, at 6 months after baseline.

Patient education and group counselling to improve the treatment of depression in primary care: a randomized controlled trial

BACKGROUND

The Contactus program for depressed patients in primary care, consists of six lectures about depression, each followed by a group discussion. The aim of this study was to investigate if Contactus can improve treatment outcome in comparison to a control group.

METHODS

Forty-six primary care centres in Sweden, each randomly allocated either to the Contactus group or to the control group, included depressed patients, 205 in the Contactus group and 114 in the control group. Besides regular treatment of depression, the Contactus group participated in the educational program. At start and after 6 weeks, patients filled in a questionnaire and the self-reports: HADS (Hospital Anxiety and Depression Scale) and GAF-self (Global Assessment of Functioning).

RESULTS

After 6 weeks, clinically depressed patients (HAD-depression score >10) had a mean improvement in HAD-D of 4.6 in Contactus vs. 3.0 in controls (p=0.02), and 72% vs. 47% considered themselves to feel better (p=0.01). Increase in GAF score was 11.8 vs. 5.8 (p=0.04), respectively. According to HADS, 55% in Contactus were responders vs. 29% among controls (p=0.006), and 42% vs. 21% (p=0.02) were in remission.

LIMITATIONS

Only 40% of the patients in Contactus and 35% among controls were clinically depressed according to the HADS (>10 points) at inclusion.

CONCLUSIONS

Patient education and group counselling contributes significantly to better improvement among depressed patients. Group treatment is inexpensive and could be implemented in the routine care of depressed patients in primary care.