Mary Gemma Cherry

A systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour: update 2002-8.

BACKGROUND It has been estimated that violence accounts for more than 1.6 million deaths worldwide each year and these fatal assaults represent only a fraction of all assaults that actually occur. The problem has widespread consequences for the individual and for the wider society in physical, psychological, social and economic terms. A wide range of pharmacological, psychosocial and organisational interventions have been developed with the aim of addressing the problem. This review was designed to examine the effectiveness of these interventions when they are developed in mental health and criminal justice populations. OBJECTIVE To update a previous review that examined the evidence base up to 2002 for a wide range of pharmacological, psychosocial and organisational interventions aimed at reducing violence, and to identify the key variables associated with a significant reduction in violence. DATA SOURCES Nineteen bibliographic databases were searched from January 2002 to April 2008, including PsycINFO (CSA) MEDLINE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), British Nursing Index/Royal College of Nursing, International Bibliography of the Social Sciences (IBSS), Education Resources Information Center (ERIC)/International ERIC, The Cochrane Library (Cochrane reviews, other reviews, clinical trials, methods studies, technology assessments, economic evaluations), Web of Science [Science Citation Index Expanded (SCIE), Social Sciences Citation Index (SSCI), Arts & Humanities Citation Index (A&HCI)]. REVIEW METHODS The assessment was carried out according to accepted procedures for conducting and reporting systematic reviews, including identification of studies, application of inclusion criteria, data extraction and appropriate analysis. Studies were included in meta-analyses (MAs) if they followed a randomised control trial (RCT) design and reported data that could be converted into odds ratios (ORs). For each MA, both a fixed-effects model and a random-effects model were fitted, and both Q statistic and I2 estimates of heterogeneity were performed. RESULTS A total of 198 studies were identified as meeting the inclusion criteria; of these, 51 (26%) were RCTs. Bivariate analyses exploring possible sources of variance in whether a study reported a statistically significant result or not, identified six variables with a significant association. An outcome was less likely to be positive if the primary intervention was something other than a psychological or pharmacological intervention, the study was conducted in an penal institution, the comparator was another active treatment or treatment as usual and if a between-groups design had been used. An outcome was more likely to be positive if it was conducted with people with a mental disorder. The variation attributable to these variables when added to a binary logistic regression was not large (Cox and Snell R(2) = 0.12), but not insignificant given the small number of variables included. The pooled results of all included RCTs suggested a statistically significant advantage for interventions over the various comparators [OR 0.59, 95% confidence interval (CI) 0.53 to 0.65, fixed effects; OR 0.35, 95% CI 0.26 to 0.49 random effects, 40 studies]. However, there was high heterogeneity {I(2) = 86, Q = 279 [degrees of freedom (df) = 39], p < 0.0001}, indicating the need for caution in interpreting the observed effect. Analysis by subgroups showed that most results followed a similar pattern, with statistically significant advantages of treatments over comparators being suggested in fixed- and/or random-effects models but in the context of large heterogeneity. Three exceptions were atypical antipsychotic drugs [OR 0.21, 95% CI 0.16 to 0.27, fixed effects; OR 0.24, 95% CI 0.14 to 0.43, random effects; 10 studies, I(2) = 72.2, Q = 32.4 (df = 9), p < 0.0001], psychological interventions [OR 0.63, 95% CI 0.48 to 0.83, fixed effects; OR 0.53, 95% CI 0.31 to 0.93, random effects; nine studies, I(2) = 62.1, Q = 21.1 (df = 8), p = 0.007] and cognitive behavioural therapy (CBT) as a primary intervention [OR 0.61, 95% CI 0.42 to 0.88, fixed effects; OR 0.61, 95% CI 0.37 to 0.99, random effects; seven studies, I(2) = 21.6, Q = 7.65 (df = 6), p = 0.26]. LIMITATIONS The heterogenity of the included studies inhibits both robust MA and the clear application of findings to establishing improvements in clinical practice. CONCLUSIONS Results from this review show small-to-moderate effects for CBT, for all psychological interventions combined, and larger effects for atypical antipsychotic drugs, with relatively low heterogeneity. There is also evidence that interventions targeted at mental health populations, and particularly male groups in community settings, are well supported, as they are more likely to achieve stronger effects than interventions with the other groups. Future work should focus on improving the quality of evidence available and should address the issue of heterogenity in the literature. FUNDING The National Institute for Health Research Health Technology Assessment programme and the Research for Patient Benefit programme.

Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22

Background: In the United Kingdom, there are approximately 300,000 healthcare-associated infections (HCAI) annually, costing an estimated £1 billion. Up to 30% of all HCAI are potentially preventable by better application of knowledge and adherence to infection prevention procedures. Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained improvements in hand hygiene compliance and reductions in HCAI. Aim: To determine the features of structured educational interventions that impact on compliance with hand hygiene in healthcare professionals within a hospital care setting. Methods: Sixteen electronic databases were searched. Outcomes were assessed using Kirkpatricks hierarchy and included changes in hand hygiene compliance of healthcare professionals, in service delivery and in the clinical welfare of patients involved. Results: A total of 8845 articles were reviewed, of which 30 articles met the inclusion criteria. Delivery of education was separated into six groups. Conclusions: It was not possible to identify individual features of educational interventions due to each study reporting multicomponent interventions. However, multiple, continuous interventions were better than single interventions in terms of eliciting and sustaining behaviour change. Data were not available to determine the time, nature and type of booster sessions with feedback needed for a permanent change in compliance.

A systematic review of risk assessment strategies for populations at high risk of engaging in violent behaviour: update 2002-8.

BACKGROUND This review systematically examines the research literature published in the period 2002-8 on structured violence risk assessment instruments designed for use in mental health services or the criminal justice system. It adopted much broader inclusion criteria than previous reviews in the same area in order to capture and summarise data on the widest possible range of available instruments. OBJECTIVES To address two questions: (1) what study characteristics are associated with a risk assessment instrument score being significantly associated with a violent outcome? and (2) which risk assessment instruments have the highest level of predictive validity for a violent outcome? DATA SOURCES Nineteen bibliographic databases were searched from January 2002 to April 2008, including PsycINFO, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, British Nursing Index, International Bibliography of the Social Sciences, Education Resources Information Centre, The Cochrane Library and Web of Knowledge. REVIEW METHODS Inclusion criteria for studies were (1) evaluation of a structured risk tool; (2) outcome measure of interpersonal violence; (3) participants aged 17 years or over; and (4) participants with a mental disorder and/or at least one offence and/or at least one indictable offence. A series of bivariate analyses using either a chi-squared test or Spearmans rank-order correlation were conducted to explore associations between study characteristics and outcomes. Data from a subset of studies reporting area under the curve (AUC) analysis were combined to provide estimates of mean validity. RESULTS For the overall set of included studies (n = 959), over three-quarters (77%) were conducted in the USA, Canada or the UK. Two-thirds of all studies were conducted with offenders who had either no formal mental health diagnosis (43%) or forensic samples with a formal diagnosis (25%). The Psychopathy Checklist-Revised was tested in the largest number of studies (n = 192). Most studies (78%) reported a statistically significant (p < 0.05) relationship between the instrument score and a violent outcome. Prospective data collection (chi-squared = 4.4, p = 0.035), number of people recruited (U = 27.8, p = 0.012) and number of participants at end point (U = 26.9, p = 0.04) were significantly associated with predictive validity. For those instruments tested in five or more studies reporting AUC values, the General Statistical Information on Recidivism instrument had the highest mean AUC (0.73). LIMITATIONS Agreement between pairs of reviewers in the initial pilot exercises was good but less than perfect, so discrepancies may be present given the complexity and subjectivity of some aspects of violence research. Only five of the seven calendar years (2003-7) are completely covered, with partial coverage of 2002 and 2008. There is no weighting for sample or effect sizes when results from studies are aggregated. CONCLUSIONS A very large number of studies examining the relationship between a structured instrument and a violent outcome were published in this relatively short 7-year period. The general quality of the literature is weak in places (e.g. over-reliance on cross-sectional designs) and a vast range of distinct instruments have been tested to varying degrees. However, there is evidence of some convergence around a small number of high-performing instruments and identification of the components of a high-quality evaluation approach, including AUC analysis. The upper limits (AUC ≥ 0.85) of instrument-based prediction have probably been achieved and are unlikely to be exceeded using instruments alone. FUNDING The National Institute for Health Research Health Technology Assessment and Research for Patient Benefit programmes.

Immunotherapy for Hymenoptera venom allergy: too expensive for European health care?

To the Editor: Insect venom allergy is the most frequent elicitor of severe anaphylaxis in central Europe (1), accounting for the majority of anaphylactic reactions in adults, and being second as elicitor of anaphylaxis in children (2). The prevalence of insect-sting anaphylaxis varies widely between children and adults ranging from 1.5% to 3.3% and more depending on the geographic and socioeconomic background (3). Venom immunotherapy (VIT) is highly effective to cure Hymenoptera venom allergy (4) and does also improve this disease-specific quality of life (5,6). Recently, a focus has been put on the cost-effectiveness of VIT used for treating bee and wasp venom allergy. Stimulated by the English National Health Service, the British National Institute for Health and Clinical Excellence (NICE) commissioned a study analysing the economic burden caused by VIT (7). A central aspect of this analysis was the calculation of additional costs arising from potential life-saving effects of VIT. To adjust to quality of life in gained years, Hockenhull et al. (7) used the age-dependent European Quality of Life-5 Dimensions (EQ-5D) Weighted Health Status Index population norms. Key finding of the analysis was that, compared to avoidance advice and supply with emergency kits only, VIT may cost up to £18 million per year gained if the focus is put on life-saving aspect of VIT. With this commentary, we would like to express our concerns regarding the authors’ strategy to focus on fatal reactions possibly prevented by VIT. How can it be explained that – when referred to qualityadjusted years of life – VIT results in such astronomical costs? In medicine, economic issues include the evaluation of therapy costs. As some treated patients will live longer without getting well again, it is also essential to refer the number of years gained to the resulting quality of life. To combine both variables, a QALY (quality-adjusted life year) is calculated by multiplying the number of years gained with score points reflecting the quality of life during these years. If, for example, a therapy would gain 10 extra years for a patient not suffering from any long-term morbidity (1 score point for optimal quality of life), a QALY of 10 would be calculated. With only 2 years gained and with a significant longterm morbidity (e.g. 0.5 score points for reduced quality of life), the QALY would be 1. To calculate cost-effectiveness, treatment costs arising from an additional therapy (incremental cost-effectiveness ratio, ICER) are then referred to one QALY. Thus, for example, in comparison with a wait-and-see strategy, after a lay cardiopulmonary resuscitation, up to US

Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals

500.000 will be required per QALY (8). Compared to the numbers above calculated for VIT, this sum seems to be actually quite favourable. If, however, a disease is comparably common (and if many affected patients need a long-term therapy thereby further increasing costs), and if, simultaneously, the same disease (such as Hymenoptera venom allergy) is rarely lethal (with a low potential of saving lives), then it will be awfully expensive to gain even one extra year. The incidence of insect-sting mortality due to early anaphylaxis is known to be low ranging from 0.03 to 0.48 fatalities per 1000.000 inhabitants per year (3). These facts must have already been clear in advance of the above-mentioned analysis, which calculated a death rate following severe anaphylaxis of 1.25% (7), and make one wonder about the reasons making the initiators of the analysis commission such an evaluation of which catastrophic results for VIT were predictable. We acknowledge the fact that Hockenhull et al. (7) also performed a subgroup analysis, where VIT was found to be cost-effective in terms of preventing fatal reactions. This subgroup contained patients stung at least five times a year. Such a patient classification, however, is quite unrealistic, because there are – fortunately – hardly or even no patients who are stung that often each year. The approach to refer cost-effectiveness of a therapy just to survival and to a normalized quality of life (ICER per QALY) must be regarded as inappropriate for many therapies. Numerous, even very expensive, therapeutic measures are not primarily aiming at a prolongation of life, but rather at a specific improvement of quality of life. VIT also falls under this category, and assessment of cost-effectiveness is only justified against this background. It is important to note that the above NICE analysis initially assumed no VIT-related change in utility due to anxiety (1). There is, however, some evidence that VIT significantly improves quality of life (5,6). Unfortunately, there are no results obtained by a validated utility measure of quality of life. Consequently, Hockenhull et al. (7) concluded that any health benefit from VIT is entirely due to its effectiveness in reducing systemic reactions from sting and resulting deaths. We welcome the fact that the NICE analysis also contains a separate subgroup analysis assuming that fear of sting does affect the utility of some people and that VIT reduces this anxiety and so negates this loss in quality of life. For this specific subgroup (patients with sting anxiety), it was calculated that, compared to avoidance advice and supply with emergency kits only, VIT may cost up to £23,868 per QALY. These numbers are in the range of those derived, for example, for statins used to reduce cholesterol concentrations (9).

A realist review of educational interventions to improve the delivery of nutrition care by doctors and future doctors

Objective To determine what, how, for whom, why, and in what circumstances educational interventions improve the delivery of nutrition care by doctors and other healthcare professionals work. Design Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched MEDLINE, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations. Results Over half of the 46 studies from which we extracted data originated from the USA. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included feeling competent, feeling confident and comfortable, having greater self-efficacy, being less inhibited by barriers in healthcare systems and feeling that nutrition care was accepted and recognised. Conclusions These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients’ health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

Attachment, mentalisation and expressed emotion in carers of people with long-term mental health difficulties

BackgroundDietary interventions are considered an important aspect of clinical practice, more so in the face of the rising prevalence of obesity, diabetes and cardiovascular diseases globally. Routinely, most doctors do not provide such intervention to their patients, and several barriers, present during both training and clinical practice, have been identified. Educational interventions to improve nutrition care competencies and delivery have been implemented but with variable success, probably, due to the complex nature of such interventions. Using traditional methods only to investigate whether interventions are effective or not could not provide appropriate lessons. It is therefore pertinent to conduct a realist review that investigates how the interventions work. This realist review aims at determining what sort of educational interventions work, how, for whom, and in what circumstances, to improve the delivery of nutrition care by doctors and future doctors.Methods/designThis realist review will be conducted according to Pawson’s five practical steps for conducting a realist review: (1) clarifying the scope of the review, (2) determining the search strategy, including adopting broad inclusion/exclusion criteria and purposive snowballing techniques, (3) ensuring proper article selection and study quality assessment using multiple methods, (4) extracting and organising data through the process of note taking, annotation and conceptualization and (5) synthesising the evidence and drawing conclusions through a process of reasoning. This realist review protocol has not been registered in any database before now.DiscussionFindings will be reported according to the publication criteria outlined by the realist and meta-narrative evidence synthesis (RAMESES) group.

Venom immunotherapy for preventing allergic reactions to insect stings

BackgroundExpressed emotion (EE) is a global index of familial emotional climate, which is comprised of emotional over-involvement (EOI) and critical comments (CC)/hostility. Although EE is an established predictor of negative outcomes for both people with long-term mental health difficulties and their family carers, its psychological underpinnings remain relatively poorly understood. This paper examined associations between attachment, mentalisation ability and aspects of EE.MethodsCarers of people with long-term mental health difficulties (n = 106) completed measures of adult attachment (the Experiences in Close Relationships-Short Form questionnaire), mentalisation (the Reading the Mind in the Eyes Test and the Emotional Self-Efficacy Scale) and EE (the Family Questionnaire). Data were analysed using hierarchical multiple regression.ResultsAttachment avoidance and facets of mentalisation were directly and uniquely positively associated with CC/hostility, with attachment avoidance and other-directed emotional self-efficacy (one facet of mentalisation) each significantly predicting CC/hostility scores after controlling for the effects of EOI and demographic variables. However, no associations were observed between EOI, attachment anxiety and mentalisation. Furthermore, no indirect effects from attachment to EE via mentalisation was found.ConclusionsAlthough it would be premature to propose firm clinical implications based on these findings, data indicate that it may be beneficial for clinicians to consider attachment and mentalisation in their conceptualisation of carers’ criticism and hostility. However, further research is needed to clarify the magnitude of these associations and their direction of effect before firm conclusions can be drawn.