Eamon O'Shea

Peer support in type 2 diabetes: a randomised controlled trial in primary care with parallel economic and qualitative analyses: pilot study and protocol

BackgroundDiabetes is a chronic illness, which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self-management training for diabetes has been delivered in a didactic manner. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. This paper describes the pilot study and protocol for a study that aims to evaluate the effectiveness of a peer support intervention for people with type 2 diabetes in a primary care setting.Methods/DesignA pilot study was conducted to access the feasibility of a randomized controlled trial of a peer support intervention. We used the MRC Framework for the evaluation of complex interventions. Elements of the intervention were defined and the study protocol was finalized. In this cluster randomised controlled trial twenty general practices are assigned to control and intervention groups. Each practice compiles a diabetes register and randomly selects 21 patients. All practices implement a standardised diabetes care system. In the intervention group all practices recruit three peer supporters. The peer supporters are trained to conduct nine group meetings in their general practice over a period of two years. Each meeting has a structured component. The primary outcomes are blood pressure, total cholesterol, HBA1c and the Diabetes Well-being score. In addition to biophysical, psychosocial, economic and health service utilization data peer supporter activity and qualitative data are collected.DiscussionPeer support is a complex intervention and evaluating such an intervention presents challenges to researchers. This study will evaluate whether a peer support programme for patients with type 2 diabetes improves biophysical and psychosocial outcomes and whether it is an acceptable, cost effective intervention in the primary care setting.Trial registrationCurrent Controlled Trials ISRCTN42541690

Social capital, life expectancy and mortality: a cross-national examination.

This paper analyses the relationship between social capital and population health. The analysis is carried out within an econometric model of population health in 19 countries in the Organisation for Economic Co-operation and Development countries using panel data covering three different time periods. Social capital is measured by the proportion of people who say that that they generally trust other people and by membership in voluntary associations. The model performs well in explaining health outcomes. We find very little statistically significant evidence that the standard indicators of social capital have a positive effect on population health. By contrast, per capita income and the proportion of health expenditure financed by the government are both significantly and positively associated with better health outcomes. The paper casts doubt upon the widely accepted hypothesis that social capital has a positive effect on health and illustrates the importance of testing this kind of hypothesis in an extended model.

Peer support for patients with type 2 diabetes: cluster randomised controlled trial

Objective To test the effectiveness of peer support for patients with type 2 diabetes. Design Cluster randomised controlled. Setting 20 general practices in the east of the Republic of Ireland. Participants 395 patients (192 in intervention group, 203 in control group) and 29 peer supporters with type 2 diabetes. Intervention All practices introduced a standardised diabetes care system. The peer support intervention ran over a two year period and contained four elements: the recruitment and training of peer supporters, nine group meetings led by peer supporters in participant’s own general practice, and a retention plan for the peer supporters. Main outcome measures HbA1c; cholesterol concentration; systolic blood pressure; and wellbeing score. Results There was no difference between intervention and control patients at baseline. All practices and 85% (337) of patients were followed up. At two year follow-up, there were no significant differences in HbA1c (mean difference −0.08%, 95% confidence interval −0.35% to 0.18%), systolic blood pressure (−3.9 mm Hg, −8.9 to 1.1 mm Hg), total cholesterol concentration (−0.03 mmol/L, −0.28 to 0.22 mmol/L), or wellbeing scores (−0.7, −2.3 to 0.8). While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up, particularly for systolic blood pressure (52% (87/166) >130 mm Hg in intervention v 61% (103/169) >130 mm Hg in control), these changes were not significant. The process evaluation indicated that the intervention was generally delivered as intended, though 18% (35) of patients in the intervention group never attended any group meetings. Conclusions A group based peer support intervention is feasible in general practice settings, but the intervention was not effective when targeted at all patients with type 2 diabetes. While there was a trend towards improvements of clinical outcomes, the results do not support the widespread adoption of peer support. Trial registration Current Controlled Trials ISRCTN42541690.

Do ordering effects matter in willingness-to-pay studies of health care?

Willingness-to-pay studies are increasingly being used in the evaluation of health care programmes. However, there are methodological issues that need to be resolved before the potential of willingness-to-pay can be fully exploited as a tool for the economic evaluation of health care programmes. Of particular methodological interest are the consequences of varying the order in which willingness-to-pay questions are presented to respondents in contingent valuation studies. This paper examines the possibility of ordering effects in willingness-to-pay studies in health care. That is, when asking willingness-to-pay questions about three health care programmes within a single survey, does the order the programmes are presented have an impact on the reported willingness-to-pay? Ordering effects are observed in the ranking of the programmes, in the proportion of zero values reported and in the WTP for one of the programmes. The results suggest that the best explanation for the ordering effects is one of fading glow, whereby the first programme in any sequence captures much of the utility associated with giving.

The economic and social cost of dementia in Ireland

The economic and social burden of dementia on society is the value of all the resources used to prevent, diagnose, treat, and generally cope with the illness. There is increasing pressure to define the cost components of dementia with a view to improving resource allocation and accountability in this area in the future. We have assessed the overall resource implications of dementia in Ireland. Six main areas are covered in the cost analysis as follows: mortality and life years lost, in‐patient acute care, in‐patient psychiatric care, residential long‐stay care, family care, and primary and social care in the community. While the results indicate that the baseline cost of illness associated with dementia is substantial at just under IR£250 million, the most important aspect of the work is the distribution of the burden. The critical role of carers in maintaining people with dementia in their own home is reflected in the results showing that family care accounts for almost 50% of the overall resource burden, based on an opportunity cost valuation of carer time. Copyright

Male mortality differentials by socio-economic group in Ireland

There is very little information on differences in mortality by socio-economic group in Ireland. Only one major study has been done in this area. That study was based on data for 1981 and confined to aggregate deaths for males aged between 15 and 64. The objective of this paper is to extend the previous work along a number of important dimensions. Combined deaths data for males for the period 1986-1991 are used, thereby allowing differentials to be estimated with more precision. Mortality differentials for males by cause of death are also explored using this data. Methodological issues associated with trend analysis are highlighted in the paper. There is some discussion on both causal relationships and policy implications arising from analysis of the data. The results confirm international trends in this area: poorer people have higher mortality relative to people in more advantaged circumstances.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

OBJECTIVES The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. METHODS Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. RESULTS The intervention strategy resulted in mean cost savings per patient of euro512.77 (95 percent confidence interval [CI], -1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, -0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay euro45,000 per additional QALY. CONCLUSIONS Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice.

Eliciting preferences for resource allocation in mental health care in Ireland

The proportion of total health care expenditure devoted to mental health care in Ireland, at just below 7%, is low relative to other countries. There have been few studies that have examined the relationship between public preferences for different kinds of health care expenditure and priority setting as undertaken by policy-makers and governments. This paper examines citizens rankings and willingness to pay for a community-based mental health care programme in Ireland relative to two other programmes: cancer and elderly care. Respondents rank cancer as the most important programme, followed by elderly care and then mental health care. The contingent valuation survey demonstrated that people are willing to make significant tax contributions to new community-based services for people with mental health problems, counteracting the view sometimes expressed that people do not care at all about mental health care provision. However, the survey also found that people tend to value additional spending on mental health care lower than cancer and elderly care programmes.

The impact of reminiscence on the quality of life of residents with dementia in long‐stay care

There is increasing recognition of the potential use of reminiscence in maintaining or improving the quality of life of people with dementia. Despite being used widely in dementia care, evidence on the effectiveness of reminiscence remains uncertain.

The effectiveness of a structured education pulmonary rehabilitation programme for improving the health status of people with moderate and severe chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial

Objective To evaluate the effectiveness of a structured education pulmonary rehabilitation programme on the health status of people with chronic obstructive pulmonary disease (COPD). Design Two-arm, cluster randomised controlled trial. Setting 32 general practices in the Republic of Ireland. Participants 350 participants with a diagnosis of moderate or severe COPD. Intervention Experimental group received a structured education pulmonary rehabilitation programme, delivered by the practice nurse and physiotherapist. Control group received usual care. Main outcome measure Health status as measured by the Chronic Respiratory Questionnaire (CRQ) at baseline and at 12–14 weeks postcompletion of the programme. Results Participants allocated to the intervention group had statistically significant higher mean change total CRQ scores (adjusted mean difference (MD) 1.11, 95% CI 0.35 to 1.87). However, the CI does not exclude a smaller difference than the one that was prespecified as clinically important. Participants allocated to the intervention group also had statistically significant higher mean CRQ Dyspnoea scores after intervention (adjusted MD 0.49, 95% CI 0.20 to 0.78) and CRQ Physical scores (adjusted MD 0.37, 95% CI 0.14 to 0.60). However, CIs for both the CRQ Dyspnoea and CRQ Physical subscales do not exclude smaller differences as prespecified as clinically important. No other statistically significant differences between groups were seen. Conclusions A primary care based structured education pulmonary rehabilitation programme is feasible and may increase local accessibility to people with moderate and severe COPD. Trial registration ISRCTN52403063.