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Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2021; 1:CD006560. [PMID: 33448337 PMCID: PMC8092473 DOI: 10.1002/14651858.cd006560.pub4] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. OBJECTIVES To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. SELECTION CRITERIA Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. MAIN RESULTS We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. AUTHORS' CONCLUSIONS This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.
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Affiliation(s)
- Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, RCSI Medical School, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, RCSI Medical School, Dublin 2, Ireland
| | - Tom O'Dowd
- Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, Dublin, Ireland
| | - Martin Fortin
- Department of Family Medicine, University of Sherbrooke, Quebec, Canada
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Michaelis R, Tang V, Nevitt SJ, Wagner JL, Modi AC, LaFrance WC, Goldstein LH, Gandy M, Bresnahan R, Valente K, Donald KA, Reuber M. Psychological treatments for people with epilepsy. Cochrane Database Syst Rev 2020; 8:CD012081. [PMID: 35653266 PMCID: PMC8409429 DOI: 10.1002/14651858.cd012081.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Given the significant impact epilepsy may have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is increasing clinical interest in evidence-based psychological treatments, aimed at enhancing psychological and seizure-related outcomes for this group. This is an updated version of the original Cochrane Review published in Issue 10, 2017. OBJECTIVES To assess the impact of psychological treatments for people with epilepsy on HRQOL outcomes. SEARCH METHODS For this update, we searched the following databases on 12 August 2019, without language restrictions: Cochrane Register of Studies (CRS Web), which includes randomized or quasi-randomized controlled trials from the Specialized Registers of Cochrane Review Groups including Epilepsy, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to 09 August 2019), and PsycINFO (EBSCOhost, 1887 onwards), and from PubMed, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies. SELECTION CRITERIA We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQOL was the main outcome. For the operational definition of 'psychological treatments', we included a broad range of skills-based psychological treatments and education-only interventions designed to improve HRQOL, seizure frequency and severity, as well as psychiatric and behavioral health comorbidities for adults and children with epilepsy. These psychological treatments were compared to treatment as usual (TAU), an active control group (such as social support group), or antidepressant pharmacotherapy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 36 completed RCTs, with a total of 3526 participants. Of these studies, 27 investigated skills-based psychological interventions. The remaining nine studies were education-only interventions. Six studies investigated interventions for children and adolescents, three studies investigated interventions for adolescents and adults, and the remaining studies investigated interventions for adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from 11 studies (643 participants) that used the Quality of Life in Epilepsy-31 (QOLIE-31) or other QOLIE inventories (such as QOLIE-89 or QOLIE-31-P) convertible to QOLIE-31. We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes in the QOLIE-31 total score (mean improvement of 5.23 points, 95% CI 3.02 to 7.44; P < 0.001), and the overall QoL score (mean improvement of 5.95 points, 95% CI 3.05 to 8.85; P < 0.001) exceeded the threshold of minimally important change (MIC: total score: 4.73 points; QoL score: 5.22 points), indicating a clinically meaningful postintervention improvement in HRQOL. We downgraded the certainty of the evidence provided by the meta-analysis due to serious risks of bias in some of the included studies. Consequently, these results provided moderate-certainty evidence that psychological treatments for adults with epilepsy may enhance overall HRQOL. AUTHORS' CONCLUSIONS Implications for practice: Skills-based psychological interventions improve HRQOL in adults and adolescents with epilepsy. Adjunctive use of skills-based psychological treatments for adults and adolescents with epilepsy may provide additional benefits in HRQOL when these are incorporated into patient-centered management. We judge the evidence to be of moderate certainty. IMPLICATIONS FOR RESEARCH Investigators should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of intervention protocols is necessary to ensure reproducibility. When examining the effectiveness of psychological treatments for people with epilepsy, the use of standardized HRQOL inventories, such as the Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. Unfortunately, there is a critical gap in pediatric RCTs and RCTs including people with epilepsy and intellectual disabilities. Finally, in order to increase the overall quality of RCT study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued. As attrition is often high in research that requires active participation, an intention-to-treat analysis should be carried out. Treatment fidelity and treatment competence should also be assessed. These important dimensions, which are related to 'Risk of bias' assessment, should always be reported.
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Affiliation(s)
- Rosa Michaelis
- Department of Neurology Gemeinschaftskrankenhaus Herdecke, University of Witten/Herdecke, Herdecke, Germany
| | - Venus Tang
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Hospital Authority, Hong Kong
- Department of Clinical Psychology, Prince of Wales Hospital, Hospital Authority, Hong Kong
| | - Sarah J Nevitt
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Janelle L Wagner
- College of Nursing, Medical University of South Carolina, Charleston, USA
| | - Avani C Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, USA
| | - William Curt LaFrance
- Departments of Psychiatry and Neurology, Brown University, Providence, Rhode Island, USA
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Milena Gandy
- Department of Psychology, Macquarie University, Sydney, Australia
| | - Rebecca Bresnahan
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Kette Valente
- Faculty of Medicine, University of São Paulo (HCFMUSP), Sao Paulo, Brazil
| | - Kirsten A Donald
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
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Edward KL, Cook M, Stephenson J, Giandinoto JA. The impact of brief lifestyle self-management education for the control of seizures. ACTA ACUST UNITED AC 2019; 28:348-354. [PMID: 30925235 DOI: 10.12968/bjon.2019.28.6.348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM: this study examined a brief lifestyle self-management intervention, based on self-determination theory, to manage seizure frequency, and its effects on health-related quality of life and resilience in people with epilepsy aged over 18 years. BACKGROUND: most people with epilepsy can identify factors that may trigger seizures and may try to avoid these; however, education from clinicians on this varies. DESIGN: a cohort study with control design. METHOD: sixty participants were purposively sampled and allocated to an intervention or a control group. RESULTS: moderate correlations were found, particularly between: resilience and satisfaction with life; medication adherence and psychological quality of life; and psychological quality of life and satisfaction with life. The mean seizure occurrences between the control and intervention groups were 12.71 (SD 24.55) and 6.76 (SD 13.40) respectively after the intervention. While the study was not powered to assess this, the intervention may be most effective regarding medication adherence and physical health quality of life. CONCLUSION: the relationship between self-efficacy and seizure management appeared to be strengthened by the programme. This study is the first known to measure resilience in relation to lifestyle self-management for seizure control in people with epilepsy. Relevance to practice: nurses are well placed to work with patients' strengths towards self-efficacy and potentially resilient coping.
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Affiliation(s)
- Karen-Leigh Edward
- Professor of Nursing and Practice Based Research, Faculty of Health, Arts and Design, Swinburne University of Technology, Visiting Professor, School of Human and Health Sciences, University of Huddersfield, UK, Visiting Professor of Practice Based Research, St Vincent's Private Hospital Melbourne, Australia
| | - Mark Cook
- Chair of Medicine, University of Melbourne, Professor and Director of Neurology, St Vincent's Hospital Melbourne, Australia
| | - John Stephenson
- Senior Lecturer in Biomedical Statistics, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Jo-Ann Giandinoto
- PhD Student, School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Australia
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Seyer F, Witt JA, Taube J, Helmstaedter C. The efficacy of a short-term multidisciplinary epilepsy program. Epilepsy Behav 2018; 86:98-101. [PMID: 30030086 DOI: 10.1016/j.yebeh.2018.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022]
Abstract
RATIONALE Epilepsy is more than having seizures. Therefore, specialized epilepsy centers in Germany offer multidisciplinary programs for inpatients with pharmacoresistant epilepsies. This monocentric study evaluated the efficacy of a short-term program that is based on a biopsychosocial model of health and conceptualized by occupational therapists, physical therapists, neuropsychologists, and social workers. METHODS Of the 1573 patients treated between 2008 and 2014, 1339 were rated using a 7-tiered predefined category system. Outcome domains are compliance, affect, activity, autonomy, communication, fine motor skills, and mobility. Based on a total score, the patients were classified as impaired, functional, or highly functional. Functionality at baseline and changes after the treatment were analyzed and related to demographics, medical, and neuropsychological data. RESULTS At baseline, 80.8% of the patients were rated as impaired according to the total score. Impairments were predominantly observed in the domains affect, autonomy, and communication. A better total score at baseline was significantly related to a better neuropsychological functioning and a lower number of concurrent antiepileptic drugs. After the intervention 50.3% of the patients showed significant improvements regarding the total score. Compliance, activity, and affect were the most responsive domains. CONCLUSION This study provides promising results with regard to the efficacy of a short-term multidisciplinary epilepsy program. Positive effects could be achieved referring to compliance, activity, and affect. The findings support the relevance of such programs. Subsequent research should focus on the transfer to everyday life.
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Affiliation(s)
- Frank Seyer
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany.
| | - Juri-Alexander Witt
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Julia Taube
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
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Michaelis R, Tang V, Goldstein LH, Reuber M, LaFrance WC, Lundgren T, Modi AC, Wagner JL. Psychological treatments for adults and children with epilepsy: Evidence-based recommendations by the International League Against Epilepsy Psychology Task Force. Epilepsia 2018; 59:1282-1302. [PMID: 29917225 DOI: 10.1111/epi.14444] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2018] [Indexed: 12/12/2022]
Abstract
Given the significant impact that psychosocial factors and epilepsy treatments can have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness-based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.
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Affiliation(s)
- Rosa Michaelis
- Department of Neurology, Herdecke Community Hospital, University of Witten/Herdecke, Herdecke, Germany.,Integrated Curriculum for Anthroposophical Medicine (ICURAM), Witten/Herdecke University, Herdecke, Germany.,Department of Neurology, Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Venus Tang
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong.,Department of Clinical Psychology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - William Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Tobias Lundgren
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institute, Stockholm, Sweden
| | - Avani C Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janelle L Wagner
- College of Nursing and Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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Michaelis R, Tang V, Wagner JL, Modi AC, LaFrance WC, Goldstein LH, Lundgren T, Reuber M. Cochrane systematic review and meta-analysis of the impact of psychological treatments for people with epilepsy on health-related quality of life. Epilepsia 2018; 59:315-332. [DOI: 10.1111/epi.13989] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Rosa Michaelis
- Department of Neurology; Herdecke Community Hospital; University of Witten/Herdecke; Herdecke Germany
- Department of Psychiatry; St. Marien-Hospital Hamm; Hamm Germany
| | - Venus Tang
- Department of Clinical Psychology; Prince of Wales Hospital; Hong Kong
- Division of Neurosurgery; Department of Surgery; Faculty of Medicine; Chinese University of Hong Kong; Hong Kong
| | - Janelle L. Wagner
- College of Nursing and Department of Pediatrics; Medical University of South Carolina; Charleston SC USA
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - W. Curt LaFrance
- Departments of Psychiatry and Neurology; Rhode Island Hospital; Brown University; Providence RI USA
| | - Laura H. Goldstein
- Department of Psychology; Institute of Psychiatry, Psychology, and Neuroscience; King's College London; London UK
| | - Tobias Lundgren
- Department of Clinical Neuroscience; Center for Psychiatry Research; Karolinska Institute; Stockholm Sweden
| | - Markus Reuber
- Academic Neurology Unit; Royal Hallamshire Hospital; University of Sheffield; Sheffield UK
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Michaelis R, Tang V, Wagner JL, Modi AC, LaFrance Jr WC, Goldstein LH, Lundgren T, Reuber M. Psychological treatments for people with epilepsy. Cochrane Database Syst Rev 2017; 10:CD012081. [PMID: 29078005 PMCID: PMC6485515 DOI: 10.1002/14651858.cd012081.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Given the significant impact epilepsy can have on the health-related quality of life (HRQoL) of individuals with epilepsy and their families, there is great clinical interest in evidence-based psychological treatments, aimed at enhancing psychological well-being in people with epilepsy. A review of the current evidence was needed to assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes, in order to inform future therapeutic recommendations and research designs. OBJECTIVES To assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes. SEARCH METHODS We searched the following databases on 20 September 2016, without language restrictions: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE PsycINFO, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies. SELECTION CRITERIA We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQoL was the main outcome measure. For the operational definition of 'psychological treatments', we included a broad range of treatments that used psychological or behavioral techniques designed to improve HRQoL, seizure frequency and severity, and psychiatric comorbidities for adults and children with epilepsy, compared to treatment as usual (TAU) or an active control group. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration. MAIN RESULTS We included 24 completed RCTs, with a total of 2439 participants. Eleven studies investigated psychological interventions, such as cognitive, behavioral, and mindfulness-based interventions. The remaining studies were classified as educational interventions (N = 7), self-management interventions (N = 3), adherence interventions (N = 1), and mixed interventions (N = 2). Two studies investigated interventions for children and adolescents, and five studies investigated interventions for adolescents and adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from six adult studies, two studies on adolescents and adults, and one on adolescents and young adults (468 participants) for HRQoL, measured with the Quality of Life in Epilepsy-31 (QOLIE-31). We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes of the QOLIE-31 total score (mean improvement of 5.68 points (95% CI 3.11 to 8.24; P < 0.0001), and three subscales, emotional well-being (mean improvement of 7.03 points (95% CI 2.51 to 11.54; P = 0.002); energy and Fatigue (mean improvement of 6.90 points (95% CI 3.49 to 10.31; P < 0.0001); and overall QoL (mean improvement of 6.47 points (95% CI 2.68 to 10.25; P = 0.0008) exceeded the threshold of minimally important change (MIC), indicating a clinically meaningful post-intervention improvement of QoL. We downgraded the quality of the evidence provided by the meta-analysis because of serious risk of bias in some of the included studies. Consequentially, these results provided evidence of moderate quality that psychological treatments for adults with epilepsy may enhance overall QoL in people with epilepsy. AUTHORS' CONCLUSIONS Implications for practice: Psychological interventions and self-management interventions improved QoL, and emotional well-being, and reduced fatigue in adults and adolescents with epilepsy. Adjunctive use of psychological treatments for adults and adolescents with epilepsy may provide additional benefits to QoL in those who incorporate patient-centered management. IMPLICATIONS FOR RESEARCH Authors should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of the intervention protocol is necessary to ensure reproducibility.When researching psychological treatments for people with epilepsy, the use of Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. There is a critical gap in pediatric RCTs for psychological treatments, particularly those that use an epilepsy-specific measure of HRQoL.Finally, in order to increase the overall quality of study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued when conducting RCTs. As attrition is often high in research that requires active participant participation, an intention-to-treat analysis should be carried out.
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Affiliation(s)
- Rosa Michaelis
- Gemeinschaftskranhaus Herdecke University of Witten/HerdeckeDepartment of NeurologyHerdeckeHerdeckeGermany
| | | | - Janelle L Wagner
- Medical University of South CarolinaCollege of Nursing & Department of Pediatrics99 Johnathan Lucas StreetMSC 160CharlestonUSASC 29425‐1600
| | - Avani C Modi
- University of Cincinnati College of MedicineDivision of Behavioral Medicine and Clinical PsychologyCincinnatiUSA
| | | | - Laura H Goldstein
- Institute of Psychiatry, Psychology and Neuroscience, King's College LondonDepartment of PsychologyDe Crespigny ParkLondonUKSE5 8AF
| | - Tobias Lundgren
- Karolinska InstitutetCenter for Psychiatry Reseach, Department of Clinical NeuroscienceStockholm Health Care ServicesStockholm County CouncilStockholmSweden
| | - Markus Reuber
- University of Sheffield, Royal Hallamshire HospitalAcademic Neurology UnitGlossop RoadSheffieldUKS10 2JF
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8
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Modi AC, Wagner J, Smith AW, Kellermann TS, Michaelis R. Implementation of psychological clinical trials in epilepsy: Review and guide. Epilepsy Behav 2017; 74:104-113. [PMID: 28734195 DOI: 10.1016/j.yebeh.2017.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/11/2017] [Indexed: 01/15/2023]
Abstract
The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.
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Affiliation(s)
- Avani C Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039, USA.
| | - Janelle Wagner
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA; Comprehensive Epilepsy Program, Medical University of South Carolina, Charleston, SC, USA; Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Aimee W Smith
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039, USA
| | - Tanja S Kellermann
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rosa Michaelis
- Department of Psychiatry, St. Marien-Hospital, Hamm, Germany; Integrative Curriculum for Anthroposophic Medicine (ICURAM), University Witten/Herdecke, Witten, Germany
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9
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Wijnen BFM, van Mastrigt GAPG, Evers SMAA, Gershuni O, Lambrechts DAJE, Majoie MHJM, Postulart D, Aldenkamp BAP, de Kinderen RJA. A systematic review of economic evaluations of treatments for patients with epilepsy. Epilepsia 2017; 58:706-726. [PMID: 28098939 DOI: 10.1111/epi.13655] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2016] [Indexed: 11/29/2022]
Abstract
The increasing number of treatment options and the high costs associated with epilepsy have fostered the development of economic evaluations in epilepsy. It is important to examine the availability and quality of these economic evaluations and to identify potential research gaps. As well as looking at both pharmacologic (antiepileptic drugs [AEDs]) and nonpharmacologic (e.g., epilepsy surgery, ketogenic diet, vagus nerve stimulation) therapies, this review examines the methodologic quality of the full economic evaluations included. Literature search was performed in MEDLINE, EMBASE, NHS Economic Evaluation Database (NHS EED), Econlit, Web of Science, and CEA Registry. In addition, Cochrane Reviews, Cochrane DARE and Cochrane Health Technology Assessment Databases were used. To identify relevant studies, predefined clinical search strategies were combined with a search filter designed to identify health economic studies. Specific search strategies were devised for the following topics: (1) AEDs, (2) patients with cognitive deficits, (3) elderly patients, (4) epilepsy surgery, (5) ketogenic diet, (6) vagus nerve stimulation, and (7) treatment of (non)convulsive status epilepticus. A total of 40 publications were included in this review, 29 (73%) of which were articles about pharmacologic interventions. Mean quality score of all articles on the Consensus Health Economic Criteria (CHEC)-extended was 81.8%, the lowest quality score being 21.05%, whereas five studies had a score of 100%. Looking at the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), the average quality score was 77.0%, the lowest being 22.7%, and four studies rated as 100%. There was a substantial difference in methodology in all included articles, which hampered the attempt to combine information meaningfully. Overall, the methodologic quality was acceptable; however, some studies performed significantly worse than others. The heterogeneity between the studies stresses the need to define a reference case (e.g., how should an economic evaluation within epilepsy be performed) and to derive consensus on what constitutes "standard optimal care."
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Affiliation(s)
- Ben F M Wijnen
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Ghislaine A P G van Mastrigt
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Olga Gershuni
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Danielle A J E Lambrechts
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marian H J M Majoie
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands.,MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands.,School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Debby Postulart
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Bert A P Aldenkamp
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands.,MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands.,Department of Behavioral Sciences, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Reina J A de Kinderen
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016; 3:CD006560. [PMID: 26976529 PMCID: PMC6703144 DOI: 10.1002/14651858.cd006560.pub3] [Citation(s) in RCA: 291] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. OBJECTIVES To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. SELECTION CRITERIA Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. MAIN RESULTS We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -2.23, 95% confidence interval (CI) -2.52 to -1.95). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence) although two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. AUTHORS' CONCLUSIONS This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.
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Affiliation(s)
- Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Emma Wallace
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Tom O'Dowd
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareAdelaide and Meath Hosptials, Incorporating the National Children's HospitalTallaghtDublinIreland24
| | - Martin Fortin
- University of SherbrookeDepartment of Family MedicineUnite de Medicine de famille de Chicoutimi305, St‐Vallier ChicoutimiQuebecCanadaG7H 5H6
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