Josie Sandercock

The clinical effectiveness of different parenting programmes for children with conduct problems: a systematic review of randomised controlled trials

BackgroundConduct problems are common, disabling and costly. The prognosis for children with conduct problems is poor, with outcomes in adulthood including criminal behaviour, alcoholism, drug abuse, domestic violence, child abuse and a range of psychiatric disorders.There has been a rapid expansion of group based parent-training programmes for the treatment of children with conduct problems in a number of countries over the past 10 years. Existing reviews of parent training have methodological limitations such as inclusion of non-randomised studies, the absence of investigation for heterogeneity prior to meta-analysis or failure to report confidence intervals.The objective of the current study was to systematically review randomised controlled trials of parenting programmes for the treatment of children with conduct problems.MethodsStandard systematic review methods were followed including duplicate inclusion decisions, data extraction and quality assessment. Twenty electronic databases from the fields of medicine, psychology, social science and education were comprehensively searched for RCTs and systematic reviews to February 2006.Inclusion criteria were: randomised controlled trial; of structured, repeatable parenting programmes; for parents/carers of children up to the age of 18 with a conduct problem; and at least one measure of child behaviour. Meta-analysis and qualitative synthesis were used to summarise included studies.Results57 RCTs were included. Studies were small with an average group size of 21. Meta-analyses using both parent (SMD -0.67; 95% CI: -0.91, -0.42) and independent (SMD -0.44; 95% CI: -0.66, -0.23) reports of outcome showed significant differences favouring the intervention group. There was insufficient evidence to determine the relative effectiveness of different approaches to delivering parenting programmes.ConclusionParenting programmes are an effective treatment for children with conduct problems. The relative effectiveness of different parenting programmes requires further research.

Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]

BackgroundCardiac rehabilitation following myocardial infarction reduces subsequent mortality, but uptake and adherence to rehabilitation programmes remains poor, particularly among women, the elderly and ethnic minority groups. Evidence of the effectiveness of home-based cardiac rehabilitation remains limited. This trial evaluates the effectiveness and cost-effectiveness of home-based compared to hospital-based cardiac rehabilitation.Methods/designA pragmatic randomised controlled trial of home-based compared with hospital-based cardiac rehabilitation in four hospitals serving a multi-ethnic inner city population in the United Kingdom was designed. The home programme is nurse-facilitated, manual-based using the Heart Manual. The hospital programmes offer comprehensive cardiac rehabilitation in an out-patient setting.PatientsWe will randomise 650 adult, English or Punjabi-speaking patients of low-medium risk following myocardial infarction, coronary angioplasty or coronary artery bypass graft who have been referred for cardiac rehabilitation.Main outcome measuresSerum cholesterol, smoking cessation, blood pressure, Hospital Anxiety and Depression Score, distance walked on Shuttle walk-test measured at 6, 12 and 24 months. Adherence to the programmes will be estimated using patient self-reports of activity.In-depth interviews with non-attendees and non-adherers will ascertain patient views and the acceptability of the programmes and provide insights about non-attendance and aims to generate a theory of attendance at cardiac rehabilitation. The economic analysis will measure National Health Service costs using resource inputs. Patient costs will be established from the qualitative research, in particular how they affect adherence.DiscussionMore data are needed on the role of home-based versus hospital-based cardiac rehabilitation for patients following myocardial infarction and revascularisation, which would be provided by the Birmingham Rehabilitation Uptake Maximisation Study (BRUM) study and has implications for the clinical management of these patients. A novel feature of this study is the inclusion of non-English Punjabi speakers.

The clinical effectiveness of pre-hospital intravenous fluid replacement in trauma patients without head injury: a systematic review

Traditionally, the management of bleeding trauma patients has included early rapid fluid replacement on scene. However, evidence shows that a delay to definitive treatment (control of bleeding) may be harmful and UK policy advocates minimal delay on scene with intravenous fluids being administered in transit to hospitals. This paper systematically reviews the evidence for administering fluids in pre-hospital trauma patients with no head injury. Randomized controlled trials comparing immediate and delayed fluid replacement were sought using formal search strategies. Study selection, quality assessment and data extraction were performed independently by two reviewers using pre-defined criteria. We found no evidence to suggest that pre-hospital fluid administration is beneficial. There is some evidence that it may be harmful and that patients do comparatively well when fluids are withheld. However, this evidence is not conclusive, particularly for blunt trauma, and is not sufficient to disprove current UK policy, which recommends hypotensive resuscitation.

Decision-making under conditions of uncertainty–what can we learn from palivizumab?

When we make healthcare decisions, whether it be about the treatment of an individual or a policy decision about what should be provided by a health service, there are always uncertainties in the information available. Uncertainties can include: What is the true effectiveness of a proposed treatment? Are there important adverse effects? Is the evidence applicable to this patient? What are the true costs? What is the opportunity cost? Making sensible and responsible decisions where significant uncertainty exists poses a challenge for clinicians and managers trying to optimize outcomes for their patients or populations. Palivizumab use in premature infants represents just such a challenge and is interesting to observe the evolving policy response where it has taken nearly 10 years from launch for national-level recommendations to reflect cost-effectiveness. In this journal, there is an economic evaluation by Neovius et al. (1) that uses Swedish cohort data to address this question. Palivizumab (Synagis ) is a monoclonal antibody that provides passive immunity against respiratory syncytial virus (RSV) infection. It is given by intramuscular injection once a month for five months during the RSV season. There is little doubt that palivizumab is effective at reducing the risk of serious disease from RSV infection as shown in the original trials in high-risk infants(2,3) and confirmed in clinical practice (4,5). The problem is RSV is common, nearly all children have been infected by the age of two, and palivizumab is expensive. Neovius et al.(1) estimate the mean drug acquisition cost per child treated to be 29k SEK (approximately £3k at current exchange rates). This average figure is of the same order as estimates from other economic evaluations (6,7). Since its launch palivizumab has been used extensively and worldwide sales exceeded US

Recombinant Human Erythropoietins and Cancer Patients: Updated Meta-Analysis of 57 Studies Including 9353 Patients

1 billion in each of the last 3 years(8), but does using palivizumab in premature infants represent a good use of money or an irresponsibly high opportunity cost? We were first asked to address the issue of its cost-effectiveness by local (West Midlands) health service managers, shortly after palivizumab’s launch in 1999. We calculated that the cost per hospital admission prevented was around £43k (9). There was no direct evidence that palivizumab saved lives – a good example of the uncertainty that decision makers face: the trials were not powered to detect mortality differences, but, is it not reasonable to expect a reduction in deaths if we can reduce the incidence of serious illness and hospital admissions? We thought so, and modelled a reduction in mortality mirroring the reduction in hospital admissions which gave an estimated incremental cost per life-year gained (LYG) of £96k when used in all children who meet the licensed indication (well above the level considered to represent good value for money in the UK). Palivizumab is used prophylactically and cost is incurred for all children treated not just those who would have been seriously ill. It follows, therefore, that the cost-effectiveness will vary according to the probability that a child will Invited Commentary for Kristian Neovius et al. Cost-effectiveness analysis of palivizumab as respiratory syncytial virus prophylaxis in preterm infants in Sweden, pages 1306–1314. Acta Pædiatrica ISSN 0803–5253