Christine Wright

A pragmatic randomised controlled trial to evaluate the cost-effectiveness of a physical activity intervention as a treatment for depression: the treating depression with physical activity (TREAD) trial.

OBJECTIVEnThe TREAting Depression with physical activity (TREAD) study investigated the cost-effectiveness of a physical activity intervention, in addition to usual general practitioner care, as a treatment for people with depression.nnnDESIGNnAn individually randomised, pragmatic, multicentre randomised controlled trial with follow-up at 4, 8 and 12 months. A subset of participants took part in a qualitative study that investigated the acceptability and perceived benefits of the intervention.nnnSETTINGnGeneral practices in the Bristol and Exeter areas.nnnPARTICIPANTSnAged 18-69 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) diagnosis of depression and scoring ≥ 14 on the Beck Depression Inventory (BDI). Those who were unable to complete self-administered questionnaires in English, with medical contraindications to physical activity or with psychosis, bipolar disorder or serious drug abuse were excluded.nnnINTERVENTIONSnWe devised an intervention designed to encourage choice and autonomy in the adoption of physical activity. It consisted of up to three face-to-face and ten telephone contacts delivered by a trained physical activity facilitator over an 8-month period.nnnMAIN OUTCOME MEASURESnThe primary outcome was the BDI score measured at 4 months. Secondary outcomes included depressive symptoms over the 12 months and quality of life, antidepressant use and level of physical activity.nnnRESULTSnThe study recruited 361 patients, with 182 randomised to the intervention arm and 179 to the usual care arm; there was 80% retention at the 4-month follow-up. The intervention group had a slightly lower BDI score at 4 months [-0.54, 95% confidence interval (CI) -3.06 to 1.99] but there was no evidence that the intervention improved outcome for depression. Neither was there any evidence to suggest a difference in the prescription of or self-reported use of antidepressants. However, the amount of physical activity undertaken by those who had received the intervention was increased (odds ratio 2.3, 95% CI 1.3 to 3.9) and was sustained beyond the end of the intervention. From a health-care perspective, the intervention group was more costly than the usual care group, with the cost of the intervention £220 per person on average. It is therefore extremely unlikely that the intervention is cost-effective as a treatment for depression using current willingness-to-pay thresholds.nnnCONCLUSIONSnThis physical activity intervention is very unlikely to lead to any clinical benefit in terms of depressive symptoms or to be a cost-effective treatment for depression. Previous research has reported some benefit and there are three possible reasons for this discrepancy: first, even though the intervention increased self-reported physical activity, the increase in activity was not sufficiently large to lead to a measurable influence; second, only more vigorous activity might be of benefit; and third, previous studies had recruited individuals with a pre-existing commitment to physical activity. Future research is needed to identify and explain the mechanisms by which depression might be effectively treated, including, in particular, specific guidance on the optimum type, intensity and duration of physical activity required to produce a therapeutic effect.nnnTRIAL REGISTRATIONnCurrent Controlled Trials ISRCTN16900744.nnnFUNDINGnThis project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 10. See the HTA programme website for further project information.

Emergency hospital admissions for the elderly: insights from the Devon Predictive Model

BACKGROUNDnIn the UK, people aged 85 and over are the fastest growing population group and are predicted to double in number by 2030. Emergency hospital admissions are also rising.nnnMETHODSnAll emergency admissions for the registered population in Devon to all English hospitals were analysed by age, and admission rates per thousand registered were calculated. The Devon Predictive Model (DPM) was built, using local data, to predict emergency admissions in the following 12 months. This model was compared with the Combined Predictive Model over five risk categories.nnnRESULTSnThe registered Devon population on 31 March 2011 was 761 652 with 65 892 emergency admissions in 2010/2011. The DPM had 89 variables including several local factors which strengthened the model. Three of the four most powerful predictors were age 85-89, 90-94 and 95 and over. The positive predictive value for the DPM was better than the CPMs in all five risk categories. Half (49.6%) of all emergency admissions were from those aged 65 or over. Admissions rose progressively and significantly in each successive elderly age band. At age 85 and over there were 420 emergency admissions per thousand registered.nnnCONCLUSIONSnAge, especially 85 and over, has been undervalued as a risk factor for emergency hospital admissions.

The cost of diagnosing Type 2 diabetes mellitus by clinical opportunistic screening in general practice

Diabet. Med. 29, 863–868 (2012)

Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial

BackgroundAround 17 % of people eligible for UK cardiac rehabilitation programmes following an acute coronary syndrome report moderate or severe depressive symptoms. While maximising psychological health is a core goal of cardiac rehabilitation, psychological care can be fragmented and patchy. This study tests the feasibility and acceptability of embedding enhanced psychological care, composed of two management strategies of proven effectiveness in other settings (nurse-led mental health care coordination and behavioural activation), within the cardiac rehabilitation care pathway.Methods/DesignThis study tests the uncertainties associated with a large-scale evaluation by conducting an external pilot trial with a nested qualitative study. We aim to recruit and randomise eight comprehensive cardiac rehabilitation teams (clusters) to intervention (embedding enhanced psychological care into routine cardiac rehabilitation programmes) or control (routine cardiac rehabilitation programmes alone) arms. Up to 64 patients (eight per team) identified with depressive symptoms upon initial assessment by the cardiac rehabilitation team will be recruited, and study measures will be administered at baseline (before starting rehabilitation) and at 5xa0months and 8xa0months post baseline. Outcomes include depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Trial data on cardiac team and patient recruitment, and the retention and flow of patients through treatment will be used to assess intervention feasibility and acceptability. Qualitative interviews will be undertaken to explore trial participants’ and cardiac rehabilitation nurses’ views and experiences of the trial methods and intervention, and to identify reasons why patients declined to take part in the trial. Outcome data will inform a sample size calculation for a definitive trial.DiscussionThe pilot trial and qualitative study will inform the design of a fully powered cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of the provision of enhanced psychological care within cardiac rehabilitation programmes.Trial registrationISRCTN34701576 (Registered 29 May 2014)

Patients’ use and views of real-time feedback technology in general practice

There is growing interest in real‐time feedback (RTF), which involves collecting and summarizing information about patient experience at the point of care with the aim of informing service improvement.

Development and refinement of a complex intervention within cardiac rehabilitation services: experiences from the CADENCE feasibility study

BackgroundPatients who experience a cardiac event are at higher risk of developing depression than the general population. Despite this, cardiac rehabilitation (CR) programmes do not provide a systematic approach to psychological care for depression. The CADENCE study aimed to develop and pilot an enhanced psychological care (EPC) intervention consisting of behavioural activation (BA) and mental health care coordination. Following original research commissioning guidance, the intervention was planned to be embedded in routine care and delivered by CR nurses to patients with depression attending CR. This paper describes how qualitative methods were used to develop, embed and refine the intervention.MethodsThis feasibility study involved three CR teams. Observations were made of CR nurses delivering usual care, of EPC training given to nurses, and of supervision sessions provided to the CR nurses. Four nurses were interviewed shortly after their EPC training, and three were interviewed again 6–7 months later having delivered EPC to patients. All nine patients recruited to receive EPC were interviewed. Analyses of the observation notes and interview transcripts focused on how the intervention could be improved in terms of its acceptability and implementation.ResultsVariations were found between the CR teams regarding patient waiting list times, how CR was delivered, what facilities were available and how many CR sessions were offered to patients. EPC was acceptable to both nurses and patients. However, nurses struggled to provide this additional care within their existing workload and resources, and patients’ disrupted progression through the CR programme affected EPC delivery. Limited time and availability of private space meant nurses also delivered EPC by telephone, which was viewed as a pragmatic solution but less preferable than face-to-face. Nurses indicated that patients struggled with some of the written materials. Findings were used to revise the intervention to become a protocol of care coordination which included guided self-help BA.ConclusionsInsights gained through conducting interviews and observations enabled us to identify barriers to the implementation of EPC, and to modify the intervention to facilitate its delivery within existing services whilst remaining acceptable to both nurses and patients. The multiple method, iterative approach used was key to the success of this qualitative study.Trial registrationISRCTN34701576 Registered 29/05/2014.

Interpreting multisource feedback: online study of consensus and variation among GP appraisers

BACKGROUNDnGPs collect multisource feedback (MSF) about their professional practice and discuss it at appraisal. Appraisers use such information to identify concerns about a doctors performance, and to guide the doctors professional development plan (PDP).nnnAIMnTo investigate whether GP appraisers detect variation in doctors MSF results, and the degree of consensus in appraisers interpretations of this information.nnnDESIGN AND SETTINGnOnline study of GP appraisers in north-east England.nnnMETHODnGP appraisers were invited to review eight anonymised doctors MSF reports, which represented different patterns of scores on the UK General Medical Councils Patient and Colleague Questionnaires. Participants provided a structured assessment of each doctors report, and recommended actions for their PDP. Appraiser ratings of each report were summarised descriptively. An agreement score was calculated for each appraiser to determine whether their assessments were more lenient than those of other participants.nnnRESULTSnAt least one report was assessed by 101/146 appraisers (69%). The pattern of appraisers ratings suggested that they could detect variation in GPs MSF results, and recommend reasonable actions for the doctors PDP. Increasing appraiser age was associated with more favourable interpretations of MSF results.nnnCONCLUSIONnAlthough preliminary, the finding of broad consensus among GP appraisers in their assessment of MSF reports should be reassuring for GPs, appraisers, and employing organisations. However, if older appraisers are more lenient than younger appraisers in their interpretation of MSF and in the actions they suggest to their appraisees as a result, organisations need to consider what steps could be taken to address such differences.

Enhanced psychological care in cardiac rehabilitation services for patients with new-onset depression: the CADENCE feasibility study and pilot RCT.

BACKGROUNDnAround 19% of people screened by UK cardiac rehabilitation programmes report having moderate or severe symptoms of depression. These individuals are at an increased risk of cardiac mortality and morbidity, reduced quality of life and increased use of health resources compared with their non-depressed counterparts. Maximising psychological health is a goal of cardiac rehabilitation, but psychological care is patchy.nnnOBJECTIVE(S)nTo examine the feasibility and acceptability of embedding enhanced psychological care (EPC) within cardiac rehabilitation, we tested the feasibility of developing/implementing EPC and documented the key uncertainties associated with undertaking a definitive evaluation.nnnDESIGNnA two-stage multimethods study; a feasibility study and a qualitative evaluation, followed by an external pilot cluster randomised controlled trial (RCT) with a nested qualitative study.nnnSETTINGnUK comprehensive cardiac rehabilitation teams.nnnPARTICIPANTSnAdults eligible for cardiac rehabilitation following an acute coronary syndrome with new-onset depressive symptoms on initial nurse assessment. Patients who had received treatment for depression in the preceding 6 months were excluded.nnnINTERVENTIONSnThe EPC intervention comprised nurse-led mental health-care co-ordination and behavioural activation within cardiac rehabilitation. The comparator was usual cardiac rehabilitation care.nnnMAIN OUTCOME MEASURESnMeasures at baseline, and at the 5- (feasibility and pilot) and 8-month follow-ups (pilot only). Process measures related to cardiac team and patient recruitment, and participant retention. Outcomes included depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Interviews explored participant and nurses views and experiences.nnnRESULTSnBetween September 2014 and May 2015, five nurses from four teams recruited participants into the feasibility study. Of the 203 patients screened, 30 were eligible and nine took part (the target was 20 participants). At interview, participants and nurses gave valuable insights into the EPC intervention design and delivery. Although acceptable, the EPC delivery was challenging for nurses (e.g. the ability to allocate sufficient time within existing workloads) and the intervention was modified accordingly. Between December 2014 and February 2015, 8 out of 20 teams approached agreed to participate in the pilot RCT [five were randomised to the EPC arm and three were randomised to the usual-care (UC) arm]. Of the 614 patients screened, 55 were eligible and 29 took part (the target was 43 participants). At baseline, the trial arms were well matched for sex and ethnicity, although the EPC arm participants were younger, from more deprived areas and had higher depression scores than the UC participants. A total of 27 out of 29 participants were followed up at 5 months. Interviews with 18 participants (12 in the EPC arm and six in the UC arm) and seven nurses who delivered EPC identified that both groups acknowledged the importance of receiving psychological support embedded within routine cardiac rehabilitation. For those experiencing/delivering EPC, the intervention was broadly acceptable, albeit challenging to deliver within existing care.nnnLIMITATIONSnBoth the feasibility and the pilot studies encountered significant challenges in recruiting patients, which limited the power of the pilot study analyses.nnnCONCLUSIONSnCardiac rehabilitation nurses can be trained to deliver EPC. Although valued by both patients and nurses, organisational and workload constraints were significant barriers to implementation in participating teams, suggesting that future research may require a modified approach to intervention delivery within current service arrangements. We obtained important data informing definitive research regarding participant recruitment and retention, and optimal methods of data collection.nnnFUTURE RESEARCHnConsideration should be given to the delivery of EPC by dedicated mental health practitioners, working closely with cardiac rehabilitation services.nnnTRIAL REGISTRATIONnCurrent Controlled Trials ISRCTN34701576.nnnFUNDINGnThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 30. See the NIHR Journals Library website for further project information.

Diagnosing type 2 diabetes and identifying high-risk individuals using the new glycated haemoglobin (HbA1c) criteria

In the February 2013 issue of the BJGP there are several interesting and useful articles about aspects of diabetes, but I would like to question just one aspect stated in the Clinical Intelligence article by Gholap and colleagues.1nnBasing diagnosis on an HbA1c result has significant advantages, which are outlined in the article. They say that the HbA1c level reflects average glucose levels over the preceding 6–8 weeks (later giving the clinical situations in which that may not be the case). And they say that in a patient without symptoms any ‘diagnostic’ level test result needs to be repeated, or supported by another kind of test, to confirm a diagnosis with such important long-term implications. So-far-so-good. But I think it is incorrect …

Type 2 Diabetes Mellitus in Family Practice: Prevention and Screening

There is now a worldwide epidemic of Type 2 Diabetes Mellitus. It is a condition associated with numerous complications, which may well be present even at the time of diagnosis. Effective treatments are available but there is no known cure. The focus therefore is on both prevention and early detection by screening, with a view to preventing or delaying complications. This chapter gives a brief overview of the evidence for prevention of Type 2 Diabetes (behavioural and pharmacological) and describes various approaches to screening, from an international perspective, together with their relative advantages and disadvantages. Clinical opportunistic screening will be discussed and compared with population screening. The international guidance for screening for Type 2 Diabetes will be reviewed and a summary of the evidence relating to the psychological effects of screening, as well as the costs and cost-effectiveness of the various types of screening programmes, will be presented.