Simon Leigh

App-based psychological interventions: friend or foe?

In a time of increasing demand for psychological services and continually decreasing resources, unmet need with respect to National Health Service (NHS) mental health services is reaching an unprecedented level.1 While monthly referrals to community mental health teams increased 13% in 2013, and 16% in the case of crisis services, investment in mental health services has fallen in real terms for three successive years,2 not helped by the governments £22 billion target for efficiency savings. As such, the resulting loss of over 200 full-time mental health doctors and 3600 nurses1 has meant that despite a £450 million investment in reducing waiting times3 and increasing access to psychological therapies (IAPT), 1 in 10 patients experience waiting lists of over a year before receiving any form of treatment, with 1 in 2 waiting over 3 months.4 One in 6 of those on waiting lists for mental health services are expected to attempt suicide, 4 in 10 are expected to self-harm and two-thirds are likely to see their condition deteriorate before having the opportunity to see a mental health professional.1 ,5 As such, approximately 70 million sick days6 and 170 000 self-harm related accident and emergency attendances7 can be attributed to underlying mental health issues in the UK every year; with these individuals also exhibiting double the rate of both inpatient and outpatient hospital attendances compared to the UK general population.8 Unfortunately long-term prospects for those with mental health issues are not much better. Those suffering from serious mental illness face twice the risk of diabetes and death from heart disease,9 three times the risk of hypertension and a fourfold increase in all-cause premature mortality when compared with the UK general population; all of which contributing to the £105billion that mental distress costs the …

Comparing applets and oranges: barriers to evidence-based practice for app-based psychological interventions

Poor-quality pharmaceuticals and medical devices rarely make it to market; however, the same cannot be said for app-based interventions. With a high availability but low evidence base for mHealth, apps are an increasingly uncertain prospect to users and healthcare professionals alike. Although in a first-best situation, the burden of proof concerning app safety, clinical and cost-effectiveness ‘should’ ultimately lie with app developers; a number of barriers to evidence generation, including the fact that ‘acceptable evidence’ itself is largely open to interpretation, mean that it may be folly to expect this paucity of real-world effectiveness research to improve. While the health technology assessment of established therapeutic modalities including pharmaceuticals and talking therapies benefits from the existence of approved evaluative guidelines, unfortunately the same cannot be said for app-based interventions, specifically with regard to outcomes measurement. As such, it would seem that in order to prevent the comparative assessment of apps simply becoming an exercise comparing apples and oranges, there is a clear need for consensus and guidance for app developers, as to which patient-reported outcome measures, among the hundreds available, are of clinical use to those making decisions, and should therefore be used when developing app-based interventions. By negating the fear that any evidence collected may be of poor quality, we can reincentivise developers to engage in evidence generation, and in doing so, maximise the likelihood of evidence-based decision-making taking a firm hold. However, only by dispelling the ambiguity around what acceptable evidence can and should look like, can we begin to do so.

The incidence and implications of cerebral palsy following potentially avoidable obstetric complications: a preliminary burden of disease study

To determine the extent of cerebral palsy attributable to adverse obstetric events, and estimate the lifetime mortality and morbidity expectations of these individuals relative to age‐matched members of the UK general population.

Promoting health and reducing costs: a role for reform of self-monitoring of blood glucose provision within the National Health Service.

To determine the cost‐effectiveness of all options for the self‐monitoring of blood glucose funded by the National Health Service, providing guidance for disinvestment and testing the hypothesis that advanced meter features may justify higher prices.

Effective? Engaging? Secure? Applying the ORCHA-24 framework to evaluate apps for chronic insomnia disorder

Background Mobile health offers many opportunities; however, the ‘side-effects’ of health apps are often unclear. With no guarantee health apps first do no harm, their role as a viable, safe and effective therapeutic option is limited. Objective To assess the quality of apps for chronic insomnia disorder, available on the Android Google Play Store, and determine whether a novel approach to app assessment could identify high-quality and low-risk health apps in the absence of indicators such as National Health Service (NHS) approval. Methods The Organisation for the Review of Care and Health Applications- 24 Question Assessment (ORCHA-24), 24 app assessment criteria concerning data privacy, clinical efficacy and user experience, answered on a ‘yes’ or ‘no’ and evidence-driven basis, was applied to assess 18 insomnia apps identified via the Android Google Play Store, in addition to the NHS-approved iOS app Sleepio. Findings 63.2% of apps (12/19) provided a privacy policy, with seven (36.8%) stating no user data would be shared without explicit consent. 10.5% (2/19) stated they had been shown to be of benefit to those with insomnia, with cognitive behavioural therapy apps outperforming hypnosis and meditation apps (p=0.046). Both the number of app downloads (p=0.29) and user-review scores (p=0.23) were unrelated to ORCHA-24 scores. The NHS-approved app Sleepio, consistently outperformed non-accredited apps across all domains of the ORCHA-24. Conclusions Apps for chronic insomnia disorder exhibit substantial variation in adherence to published data privacy, user experience and clinical efficacy standards, which are not clearly correlated with app downloads or user-review scores. Clinical implications In absence of formal app accreditation, the ORCHA-24 could feasibly be used to highlight the risk–benefit profiles of health apps prior to downloading.

The cost-effectiveness of seven behavioural interventions to prevent drug misuse in vulnerable populations

BACKGROUND The National Institute for Health and Care Excellence (NICE) developed a guideline on drug misuse prevention in vulnerable populations. Part of the guideline development process involved evaluating cost-effectiveness and determining which interventions represented good value for money. METHODS Economic models were developed for seven interventions which aimed to prevent drug use in vulnerable populations. The models compared the costs (to the health and crime sectors) and health benefits (in quality-adjusted life years (QALYs)) of each intervention and its comparator. Sensitivity analysis explored the uncertainty associated with the cost of each intervention and duration of its effect. RESULTS The reduction in drug use for each intervention partly offset the costs of the intervention, and improved health outcomes (QALYs). However, with high intervention costs and low QALY gains, none of the interventions were estimated to be cost-effective in the base case. Sensitivity analysis found that some of the interventions could be cost-effective if they could be delivered at a lower cost, or if the effect could be sustained for more than two years. CONCLUSIONS For drug misuse prevention to be prioritised by funders, the consequences of drug misuse need to be understood, and interventions need to be shown to be effective and cost-effective. Quantifying the wider harms of drug misuse and wider benefits of prevention interventions poses challenges in evaluating the cost-effectiveness of drug misuse prevention interventions. A greater understanding of the consequences of drug misuse and causal factors could facilitate development of cost-effective interventions to prevent drug misuse.

Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost‐consequence analysis alongside a clinical trial

To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low‐resource settings.