Motivational enhancement therapy with and without cognitive behaviour therapy for Type 1 diabetes: economic evaluation from a randomized controlled trial

AIMS

  To assess the cost-effectiveness of motivational enhancement therapy and cognitive behaviour therapy for poorly controlled Type 1 diabetes.

METHODS

  Within-trial prospective economic evaluation from (i) health and social care and (ii) societal perspectives. Three hundred and forty-four adults with Type 1 diabetes for at least 2 years and persistent, suboptimal glycaemic control were recruited to a three-arm multi-centre randomized controlled trial in London and Manchester, UK. They were randomized to (i) usual care plus four sessions of motivational enhancement therapy (ii) usual care plus four sessions of motivational enhancement therapy and eight sessions of cognitive behaviour therapy or (iii) usual care alone. Outcomes were (i) costs, (ii) Quality-Adjusted Life Year gains measured by the EuroQol 5-dimensional health state index and the 36-item Short Form and (iii) diabetes control measured by change in HbA(1c) level at 1 year.

RESULTS

  Both intervention groups had significantly higher mean health and social care costs (+ £535 for motivational enhancement therapy and + £790 for combined motivational enhancement and cognitive behavioural therapy), but not societal costs compared with the usual-care group. There were no differences in Quality Adjusted Life Years. There was a significantly greater HbA(1c) improvement in the combined motivational enhancement and cognitive behavioural therapy group (+ 0.45%; incremental cost-effectiveness ratio = £1756), but the not in the motivational enhancement therapy group. Cost-effectiveness acceptability curves suggested that both interventions had low probabilities of cost-effectiveness based on Quality Adjusted Life Years (but high based on HbA(1c) improvements). Imputing missing costs and outcomes confirmed these findings.

CONCLUSIONS

  Neither therapy was undisputedly cost-effective compared with usual care alone, but conclusions vary depending on the relative importance of clinical and quality-of-life outcomes.

A randomised controlled trial of cognitive behaviour therapy and motivational interviewing for people with Type 1 diabetes mellitus with persistent sub-optimal glycaemic control: a Diabetes and Psychological Therapies (ADaPT) study

OBJECTIVES

To determine whether (i) motivational enhancement therapy (MET) + cognitive behaviour therapy (CBT) compared with usual care, (ii) MET compared with usual care, (iii) or MET + CBT compared with MET was more effective in improving glycaemic control when delivered by general nurses with additional training in these techniques.

DESIGN

A three-arm parallel randomised controlled trial as the gold standard design to test the effectiveness of psychological treatments.

SETTING

The recruiting centres were diabetes clinics in seven acute trusts in south-east London and Greater Manchester.

PARTICIPANTS

Adults (18-65 years) with a confirmed diagnosis of type 1 diabetes for a minimum duration of 2 years and a current glycated (or glycosylated) haemoglobin (HbA1c) value between 8.2% and 15.0%.

INTERVENTIONS

The control arm consisted of usual diabetes care which varied between the hospitals, but constituted at least three monthly appointments to diabetes clinic. The two treatments arms consisted of usual care with MET and usual care with MET + CBT.

MAIN OUTCOME MEASURES

The primary outcome was HbA1c at 12 months from randomisation. Secondary outcome measures were 1-year costs measured by the Client Service Receipt Inventory at baseline, 6 months and 12 months; quality of life-years [quality-adjusted life-years (QALYs)] measured by the SF-36 (Short Form-36 Health Survey Questionnaire) and EQ-5D (European Quality of Life-5 Dimensions) at baseline and 12 months.

RESULTS

One thousand six hundred and fifty-nine people with type 1 diabetes were screened and 344 were randomised to MET + CBT (n = 106), MET (n = 117) and to usual care (n = 121). The 12-month follow-up rate for HbA1c was 88% (n = 305). The adjusted mean 12-month HbA1c was 0.45% lower in those treated with MET + CBT [95% confidence interval (CI) 0.16% to 0.79%, p = 0.008] than for usual care; 0.16% lower in those treated with MET (95% CI 0.20% to 0.51%, p = 0.38) than for usual care; and 0.30% lower with MET + CBT than with MET (95% CI -0.07% to 0.66%, p = 0.11). The higher the HbA1c, and the younger the participant at baseline, the greater was the reduction in HbA1c. The interventions had no effect on secondary outcomes such as depression and quality of life. The economic evaluation was inconclusive. Both interventions were associated with increased health care costs than for usual care alone. There was no significant difference in social costs. Cost effectiveness ratios, up to one year, varied considerably according to whether QALY estimates were based on EQ-5D or SF-36 and whether imputed or complete data were used in the analyses.

CONCLUSIONS

A combination of MET and CBT may be useful for patients with persistent sub-optimal diabetic control. MET alone appears less effective than usual care. Economic evaluation was inconclusive.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044517.

The psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: 6-month follow-up

State anxiety (S-STAI-6), distress (GHQ-12), concern and quality of life (EuroQoL-EQ-5D) 6 months after human papillomavirus (HPV) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospective questionnaire study, with 6-month follow-up after the smear test result. Two centres participated in an English pilot study of HPV testing. Participants included two groups of women receiving abnormal smear test results: (tested for HPV and found to be (a) HPV positive (n=369) or (b) HPV negative (n=252)) and two groups not tested for HPV (those receiving (c) abnormal smear test results (n=102) or (d) normal smear test results (n=288)). There were no differences in anxiety, distress or health-related quality of life between the four study groups at 6 months. Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result, and were highest in the group untested for HPV. Predictors of concern across all groups receiving an abnormal smear test were perceived risk of developing cancer, being HPV positive or untested for HPV, sexual health worries and the smear being a woman's first smear test. The raised anxiety and distress observed in women immediately after being informed of an abnormal smear test result and that they are HPV positive was no longer evident at 6 months. Concern about the smear test result was however still raised in these women and those who tested negative for HPV, and particularly among those who did not undergo HPV testing.

Psychological costs of inadequate cervical smear test results

The purpose of the study is to investigate, for the first time, the psychological impact of an inadequate smear test result. A prospective questionnaire design was used, and the setting was a single English cervical screening laboratory. Two groups of women receiving either a normal test result (n=226) or either a first or nonconsecutive inadequate smear test result (n=180) participated. The main outcome measures included State anxiety (STAI) and concern about test result, assessed within 4 weeks of receipt of results, and attendance for a repeat cervical smear within 3 months. Compared to women with normal test results, women with inadequate smear test results had higher state anxiety (P=0.025), were more concerned about their results (P<0.001), perceived themselves to be at higher risk of cervical cancer (P=0.016), and felt less satisfied with the information they had received about their test results (P<0.001). The only predictor of attendance for a repeat smear test following an inadequate smear test result was state anxiety (P=0.011): nonattenders had higher levels of state anxiety in response to their initial test results. In conclusion, in this first study to assess the psychological impact of receiving an inadequate smear test result, we have shown that it raises state anxiety and concern to levels similar to those found in women with abnormal smear test results. Of particular concern is that anxious women are less likely to attend for a repeat smear test within the recommended time frame. Given the millions of women each year receiving this test result, research is now needed to ascertain how the anxiety associated with this result can be avoided.