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1.  Epidemiology of frequent attenders: a 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders 
BMC Public Health  2009;9:36.
Background
General Practitioners spend a disproportionate amount of time on frequent attenders. So far, trials on the effect of interventions on frequent attenders have shown negative results. However, these trials were conducted in short-term frequent attenders. It would be more reasonable to target intervention at persistent frequent attenders. Typical characteristics of persistent frequent attenders, as opposed to 1-year frequent attenders and non-frequent attenders, may generate hypotheses regarding modifiable factors on which new randomized trials may be designed.
Methods
We used the data of all 28,860 adult patients from 5 primary healthcare centers. Frequent attenders were patients whose attendance rate ranked in the (age and sex adjusted) top 10 percent during 1 year (1-year frequent attenders) or 3 years (persistent frequent attenders). All other patients on the register over the 3-year period were referred to as non-frequent attenders. The lists of medical problems coded by the GP using the International Classification of Primary Care (ICPC) were used to assess morbidity.
First, we determined which proportion of 1-year frequent attenders was still a frequent attender during the next two consecutive years and calculated the GPs' workload for these patients. Second, we compared morbidity and number of prescriptions for non-frequent attenders, 1-year frequent attenders and persistent frequent attenders.
Results
Of all 1-year frequent attenders, 15.4% became a persistent frequent attender equal to 1.6% of all patients. The 1-year frequent attenders (3,045; 10.6%) were responsible for 39% of the face-to-face consultations; the 470 patients who would become persistent frequent attenders (1.6%) were responsible for 8% of all consultations in 2003. Persistent frequent attenders presented more social problems, more psychiatric problems and medically unexplained physical symptoms, but also more chronic somatic diseases (especially diabetes). They received more prescriptions for psychotropic medication.
Conclusion
One out of every seven 1-year-frequent attenders (15.4%) becomes a persistent frequent attender. Compared with non-frequent attenders, and 1-year frequent attenders, persistent frequent attenders consume more health care and are diagnosed not only with more somatic diseases but especially more social problems, psychiatric problems and medically unexplained physical symptoms.
doi:10.1186/1471-2458-9-36
PMCID: PMC2649070  PMID: 19166622
2.  CHAMP: Cognitive behaviour therapy for health anxiety in medical patients, a randomised controlled trial 
BMC Psychiatry  2011;11:99.
Background
Abnormal health anxiety, also called hypochondriasis, has been successfully treated by cognitive behaviour therapy (CBT) in patients recruited from primary care, but only one pilot trial has been carried out among those attending secondary medical clinics where health anxiety is likely to be more common and have a greater impact on services. The CHAMP study extends this work to examine both the clinical and cost effectiveness of CBT in this population.
Method/Design
The study is a randomized controlled trial with two parallel arms and equal randomization of 466 eligible patients (assuming a 20% drop-out) to an active treatment group of 5-10 sessions of cognitive behaviour therapy and to a control group. The aim at baseline, after completion of all assessments but before randomization, was to give a standard simple explanation of the nature of health anxiety for all participants. Subsequently the control group was to receive whatever care might usually be available in the clinics, which is normally a combination of clinical assessment, appropriate tests and reassurance. Those allocated to the active treatment group were planned to receive between 5 and 10 sessions of an adapted form of cognitive behaviour therapy based on the Salkovskis/Warwick model, in which a set of treatment strategies are chosen aimed at helping patients understand the factors that drive and maintain health anxiety. The therapy was planned to be given by graduate research workers, nurses or other health professionals trained for this intervention whom would also have their competence assessed independently during the course of treatment. The primary outcome is reduction in health anxiety symptoms after one year and the main secondary outcome is the cost of care after two years.
Discussion
This represents the first trial of adapted cognitive behaviour therapy in health anxiety that is large enough to test not only the clinical benefits of treatment but also whether the cost of treatment is offset by savings from reduced use of other health services in comparison to the control group.
Cognitive behaviour therapy for Health Anxiety in Medical Patients (CHAMP)
Trial registration
Current Controlled Trials ISRCTN14565822
doi:10.1186/1471-244X-11-99
PMCID: PMC3141642  PMID: 21672205
3.  Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data 
BMC Family Practice  2013;14:138.
Background
Frequently attending patients to primary care (FA) are likely to cost more in primary care than their non-frequently attending counterparts. But how much is spent on specialist care of FAs? We describe the healthcare expenditures of frequently attending patients during 1, 2 or 3 years and test the hypothesis that additional costs can be explained by FAs’ combined morbidity and primary care physicians’ characteristics.
Methods
Record linkage study. Pseudonymised clinical data from the medical records of 16 531 patients from 39 general practices were linked to healthcare insurer’s reimbursements data. Main outcome measures were all reimbursed primary and specialist healthcare costs between 2007 and 2009. Multilevel linear regression analysis was used to quantify the effects of the different durations of frequent attendance on three-year total healthcare expenditures in primary and specialist care, while adjusting for age, sex, morbidities and for primary care physicians characteristics. Primary care physicians’ characteristics were collected through administrative data and a questionnaire.
Results
Unadjusted mean 3-year expenditures were 5044 and 15 824 Euros for non-FAs and three-year-FAs, respectively. After adjustment for all other included confounders, costs both in primary and specialist care remained substantially higher and increased with longer duration of frequent attendance. As compared to non-FAs, adjusted mean expenditures were 1723 and 5293 Euros higher for one-year and three-year FAs, respectively.
Conclusions
FAs of primary care give rise to substantial costs not only in primary, but also in specialist care that cannot be explained by their multimorbidity. Primary care physicians’ working styles appear not to explain these excess costs. The mechanisms behind this excess expenditure remain to be elucidated.
doi:10.1186/1471-2296-14-138
PMCID: PMC3851974  PMID: 24044374
(Persisting) frequent attender; High utilizer; Healthcare expenditure; Primary care; General practice; Primary care physician; General practitioner; Linkage study; Reimbursements data; Multimorbidity
4.  Protocol for Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial: a randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services 
BMC Oral Health  2011;11:27.
Background
Dental caries is a persistent public health problem with little change in the prevalence in young children over the last 20 years. Once a child contracts the disease it has a significant impact on their quality of life. There is good evidence from Cochrane reviews including trials that fluoride varnish and regular use of fluoride toothpaste can prevent caries.
The Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial will compare the costs and effects of a caries preventive package (fluoride varnish, toothpaste, toothbrush and standardised dental health education) with dental health education alone in young children.
Methods/Design
A randomised controlled trial on children initially aged 2 and 3 years old who are regular attenders at the primary dental care services in Northern Ireland. Children will be recruited and randomised in dental practices. Children will be randomised to the prevention package of both fluoride varnish (twice per year for three years), fluoride toothpaste (1,450 ppm F) (supplied twice per year), a toothbrush (supplied twice a year) or not; both test and control groups receive standardised dental health education delivered by the dentist twice per year. Randomisation will be conducted by the Belfast Trust Clinical Research Support Centre ([CRSC] a Clinical Trials Unit).
1200 participants will be recruited from approximately 40 dental practices. Children will be examined for caries by independent dental examiners at baseline and will be excluded if they have caries. The independent dental examiners will examine the children again at 3 years blinded to study group.
The primary end-point is whether the child develops caries (cavitation into dentine) or not over the three years. One secondary outcome is the number of carious surfaces in the primary dentition in children who experience caries. Other secondary outcomes are episodes of pain, extraction of primary teeth, other adverse events and costs which will be obtained from parental questionnaires.
Discussion
This is a pragmatic trial conducted in general dental practice. It tests a composite caries prevention intervention, which represents an evidence based approach advocated by current guidance from the English Department of Health which is feasible to deliver to all low risk (caries free) children in general dental practice. The trial will provide valuable information to policy makers and clinicians on the costs and effects of caries prevention delivered to young children in general dental practice.
Trial registration
EudraCT No: 2009 - 010725 - 39
ISRCTN: ISRCTN36180119
Ethics Reference No: 09/H1008/93:
doi:10.1186/1472-6831-11-27
PMCID: PMC3196725  PMID: 21985746
5.  Evaluation of a primary care adult mental health service: Year 2 
Aims This study aimed to examine the effectiveness of a primary care adult mental health service operating within a stepped care model of service delivery.
Methods Supervised by a principal psychologist manager, psychology graduate practitioners provided one-to-one brief cognitive behavioural therapy (CBT) to service users. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to assess service user treatment outcomes. Satisfaction questionnaires were administered to service users and referring general practitioners (GPs).
Results A total of 43 individuals attended for an initial appointment, of whom 19 (44.2%) completed brief CBT treatment. Of the 13 service users who were in the clinical range pre-treatment, 11 (84.6%) achieved clinical and reliably significant improvement. Of the six service users who were in the non-clinical range pre-treatment, three (50%) achieved reliably significant improvement. Both service users and GPs indicated high levels of satisfaction with the service, although service accessibility was highlighted as needing improvement.
Conclusion The service was effective in treating mild to moderate mental health problems in primary care. Stricter adherence to a stepped care model through the provision of low-intensity, high-throughput interventions would be desirable for future service provision.
PMCID: PMC3822673  PMID: 24381655
brief CBT; service evaluation; stepped care model
6.  Frequent attendance in primary care: comparison and implications of different definitions 
Background
The diversity of definitions of frequent attendance in the literature hampers comparison of their precision, validity, and associated factors.
Aim
To examine different definitions of frequent attendance in order to identify the sociodemographic and clinical factors associated with frequent attendance in primary care, according to each definition.
Design of study
One-phase cross-sectional study.
Setting
Seventy-seven primary care centres in Catalonia, Spain.
Method
A total of 3815 primary care patients were interviewed between October 2005 and March 2006. Three definitions of frequent attendance were tested: (1) frequent attenders as the top 25% and the top 10% consulting patients; (2) frequent attenders as the top 25% and the top 10% consulting patients stratified by age and sex; and (3) frequent attenders as the top 25% and the top 10% consulting patients stratified by the presence of physical/mental conditions (patients with only mental disorders, with only chronic physical conditions, with comorbid conditions, and with no condition). Multilevel logistic regressions were used.
Results
The following factors were systematically related to frequent attender status: being on sick leave, being born outside of Spain, reporting mental health problems as the main reason for consulting, and having arthritis/rheumatism, or bronchitis. Major depression was related to frequent attendance in two of the three definitions. The factor ‘GP’ was related to frequent attendance when the top decile cut-off point was used. The models with a 10% cut-off point were more discriminative than those with a 25% cut-off point: the area under the receiver operating characteristic curve for models with a 25% cut-off and a 10% cut-off ranged between 0.71 (95% confidence interval [CI] = 0.70 to 0.73) and 0.75 (95% CI = 0.74 to 0.77) and between 0.79 (95% CI = 0.78 to 0.81) and 0.85 (95% CI = 0.83 to 0.86), respectively.
Conclusion
The way frequent attendance is defined is of crucial importance. It is recommended that a more discriminative definition of frequent attendance is used (the top 10%).
doi:10.3399/bjgp10X483139
PMCID: PMC2814289  PMID: 20132693
chronic illness; frequent attendance; health services; mental disorders; primary health care; utilisation
7.  Cognitive Behavioural Therapy for Depressed Youth: Predictors of Attendance in a Pilot Study 
Objective:
Of the many forms of psychotherapy offered to treat depression in youth, Cognitive Behavioural Therapy (CBT) has been shown to be efficacious. Nonetheless, a high degree of apparent non-responsiveness, failure to remit post-treatment, and lack of long term benefit are all problematic. Given that regular participation is critical to treatment success, child and family predictors of attendance were researched.
Method:
Twenty-nine depressed Canadian youth (aged 10–17) participated in a youth only or youth plus parent CBT group. Child and parent predictors of attendance were examined.
Results:
Youth who were younger, less anxious (by maternal report), and had more formally educated parents attended CBT more consistently. Further, mothers who perceived their children’s depressive symptoms as more severe, whose children reported more depressive and anxious symptoms, and who reported more life stressors attended more parent sessions.
Conclusions:
This study identifies key factors influencing youth and parent attendance in group CBT for depressed youth. Addressing these factors at the outset of treatment may decrease attrition in this form of psychotherapy.
PMCID: PMC2868553  PMID: 20467543
cognitive behavioural therapy; depression; youth; attendance; thérapie cognitivo-comportementale; dépression; adolescents; présence
8.  Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial 
BMC Psychiatry  2010;10:54.
Background
Internet administered cognitive behaviour therapy (CBT) is a promising new way to deliver psychological treatment, but its effectiveness in regular care settings and in relation to more traditional CBT group treatment has not yet been determined. The primary aim of this study was to compare the effectiveness of Internet-and group administered CBT for panic disorder (with or without agoraphobia) in a randomised trial within a regular psychiatric care setting. The second aim of the study was to establish the cost-effectiveness of these interventions.
Methods
Patients referred for treatment by their physician, or self-referred, were telephone-screened by a psychiatric nurse. Patients fulfilling screening criteria underwent an in-person structured clinical interview carried out by a psychiatrist. A total of 113 consecutive patients were then randomly assigned to 10 weeks of either guided Internet delivered CBT (n = 53) or group CBT (n = 60). After treatment, and at a 6-month follow-up, patients were again assessed by the psychiatrist, blind to treatment condition.
Results
Immediately after randomization 9 patients dropped out, leaving 104 patients who started treatment. Patients in both treatment conditions showed significant improvement on the main outcome measure, the Panic Disorder Severity Scale (PDSS) after treatment. For the Internet treatment the within-group effect size (pre-post) on the PDSS was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group effect sizes were low and treatment effects were maintained at 6-months follow-up. We found no statistically significant differences between the two treatment conditions using a mixed models approach to account for missing data. Group CBT utilised considerably more therapist time than did Internet CBT. Defining effect as proportion of PDSS responders, the cost-effectiveness analysis concerning therapist time showed that Internet treatment had superior cost-effectiveness ratios in relation to group treatment both at post-treatment and follow-up.
Conclusions
This study provides support for the effectiveness of Internet CBT in a psychiatric setting for patients with panic disorder, and suggests that it is equally effective as the more widely used group administered CBT in reducing panic-and agoraphobic symptoms, as well as being more cost effective with respect to therapist time.
Trial registration
ClinicalTrials.gov NCT00845260
doi:10.1186/1471-244X-10-54
PMCID: PMC2910662  PMID: 20598127
9.  Predictability of persistent frequent attendance: a historic 3-year cohort study 
Background
Few patients who attend GP consultations frequently continue to do so long term. While transient frequent attendance may be readily explicable, persistent frequent attendance often is not. It increases GPs' workload while reducing work satisfaction. It is neither reasonable, nor efficient to target diagnostic assessment and intervention at transient frequent attenders.
Aim
To develop a prediction rule for selecting persistent frequent attenders, using readily available information from GPs' electronic medical records.
Design of study
A historic 3-year cohort study.
Method
Data of 28 860 adult patients from 2003 to 2005 were examined. Frequent attenders were patients whose attendance rate ranked in the (age- and sex-adjusted) top 10% during 1 year (1-year frequent attenders) or 3 years (persistent frequent attenders). Bootstrapped multivariable logistic regression analysis was used to determine which predictors contained information on persistent frequent attendance.
Results
Of 3045 1-year frequent attenders, 470 (15.4%) became persistent frequent attenders. The prediction rule could update this prior probability to 3.3% (lowest value) or 43.3% (highest value). However, the 10th and 90th centiles of the posterior probability distribution were 7.4% and 26.3% respectively, indicating that the model performs modestly. The area under the receiver operating characteristic curve was 0.67 (95% confidence limits 0.64 and 0.69).
Conclusion
Among 1-year frequent attenders, six out of seven are transient frequent attenders. With the present indicators, the rule developed performs modestly in selecting those more likely to become persistent frequent attenders.
doi:10.3399/bjgp09X395120
PMCID: PMC2629841  PMID: 19192367
cohort study; frequent attender; family practice; mental disorders; prognosis; staff workload
10.  Factors affecting the use of primary health care clinics for children. 
Factors affecting the attendance at primary health care clinics in Lagos were studied at Oguntolu Clinic and Randle Road Health Centre among 120 Nigerian children. The level of immunisation was a measure of the frequency (regularity) of attendance at the clinics. Certain socioeconomic, psychological, and demographic factors were the major factors affecting attendance. Among those fully immunised, the family sizes were low, the mothers and fathers were educated, the mothers were younger, and a higher proportion of the children were boys. The family health workers were responsible for earlier and regular attendance at the clinic. The perception of the severity of symptoms of disease was a major psychological factor affecting attendance. A predictive model for the identification of high need but low users and low need but high users is presented to facilitate the formulation of more realistic primary health care programme priorities and policies.
PMCID: PMC1052240  PMID: 7166690
11.  Primary care patients with mental health problems: outcome of a randomised clinical trial 
Background
The prevalence of patients with mental health problems in general practice is high, and at least one-third of these problems last for 6 months or longer. Patients with these problems take up more time during a consultation and attend more frequently.
Aim
This study investigated the effectiveness of problem-solving treatment for primary care patients with mental health problems. The hypothesis was that patients receiving problem-solving treatment from a nurse would have fewer symptoms after 3 months, or a lower attendance rate, compared with patients receiving the usual care from the GP.
Design of the study
Randomised clinical trial.
Setting
Twelve general practices in Amsterdam and 12 nurses from a mental healthcare institution.
Method
A sample of patients aged ≥18 years were screened for mental health problems with the general health questionnaire (GHQ–12) in the waiting room of the general practices, and were randomised. Patients receiving the problem-solving treatment were required to complete four to six treatment sessions, while patients in the control group were treated as usual by the GP.
Results
No significant difference was found between the groups in terms of improved psychopathology or a decrease in attendance rate. Post-hoc analyses showed a sub-group of patients with more severe pathology who may benefit from problem-solving treatment.
Conclusion
The main results show that problem-solving treatment provided by a nurse adds little to the usual care from the GP for frequent attenders with mental health problems. Post-hoc analyses show that there may be a sub-group of more severely depressed patients who could benefit from problem-solving treatment.
PMCID: PMC2169312  PMID: 17976289
anxiety; depression; family practice; nurses; problem-solving; treatment
12.  Sexual Risk Behaviour Among HIV-Positive Persons in Kumasi, Ghana 
Ghana Medical Journal  2012;46(1):27-33.
Summary
Objectives
To assess the prevalence and predictors of sexual risk behaviours among HIV-positive individuals in clinical care in Kumasi, Ghana.
Design
Cross-sectional survey of 267 (43 males and 224 females) HIV-positive individuals attending Kumasi South Regional Hospital.
Methods
An interviewer-administered questionnaire was used to asses demographic and health characteristics, HIV/AIDS knowledge, attitudes, and beliefs and sexual risk behaviours.
Results
Forty-four percent of the sample reported having sex after testing positive for HIV. Of the 175 participants with regular sex partners, 24% had HIV-positive partners. Majority (67%) had HIV-negative partners (serodiscordant couples) or partners of unknown status. More than half (51%) of the study population with regular sex partners reported that they had unprotected anal or vaginal sex. Participants who scored < 50% on the HIV/AIDS knowledge scale were 90% less likely to have used condoms during their last sexual intercourse. Disclosure of HIV status was associated with protective patterns of condom use (OR=2.2; 95% CI: 1.3–12.9). Participants on ARV were 80% less likely to have used condoms during the last sexual intercourse (OR=0.2; 95% CI: 0.04–0.6).
Conclusion
The high rates of sexual risk behaviour among HIV-positive individuals in this sample place others at risk of HIV infection. It also places these HIV positive individuals at risk for infection with sexually transmitted infections and super-infection with other HIV strains. These findings highlight the need to integrate HIV prevention in routine medical care in Ghana.
PMCID: PMC3353501  PMID: 22605886
HIV-seropositivity; sexual behaviour; Ghana; antiretroviral therapy; condom use
13.  Design considerations in a clinical trial of a cognitive behavioural intervention for the management of low back pain in primary care: Back Skills Training Trial 
Background
Low back pain (LBP) is a major public health problem. Risk factors for the development and persistence of LBP include physical and psychological factors. However, most research activity has focused on physical solutions including manipulation, exercise training and activity promotion.
Methods/Design
This randomised controlled trial will establish the clinical and cost-effectiveness of a group programme, based on cognitive behavioural principles, for the management of sub-acute and chronic LBP in primary care. Our primary outcomes are disease specific measures of pain and function. Secondary outcomes include back beliefs, generic health related quality of life and resource use. All outcomes are measured over 12 months. Participants randomised to the intervention arm are invited to attend up to six weekly sessions each of 90 minutes; each group has 6–8 participants. A parallel qualitative study will aid the evaluation of the intervention.
Discussion
In this paper we describe the rationale and design of a randomised evaluation of a group based cognitive behavioural intervention for low back pain.
doi:10.1186/1471-2474-8-14
PMCID: PMC2147057  PMID: 17316434
14.  Successful GP intervention with frequent attenders in primary care: randomised controlled trial 
Background
Frequent attenders to GP clinics can place an unnecessary burden on primary care. Interventions to reduce frequent attendance have had mixed results.
Aim
To assess the effectiveness of a GP intervention to reduce frequent-attender consultations.
Design of study
Randomised controlled trial with frequent attenders divided into an intervention group and two control groups (one control group was seen by GPs also providing care to patients undergoing the intervention).
Setting
A health centre in southern Spain.
Method
Six GPs and 209 randomly-selected frequent attenders participated. Three GPs were randomly allocated to perform the new intervention: of the 137 frequent attenders registered with these three GPs, 66 were randomly allocated to receive the intervention (IG) and 71 to a usual care control group (CG2). The other three GPs offered usual care to the other 72 frequent attenders (CG1). The main outcome measure was the total number of consultations 1 year post-intervention. Baseline measurements were recorded of sociodemographic characteristics, provider–user interface, chronic illnesses, and psychosocial variables. GPs allocated to the new intervention received 15 hours' training which incorporated biopsychosocial, organisational, and relational approaches. After 1 year of follow-up frequent attenders were contacted. An intention-to-treat analysis was used.
Results
A multilevel model was built with three factors: time, patient, and doctor. After adjusting for covariates, the mean number of visits at 1 year in IG was 13.10 (95% confidence interval [CI] = 11.39 to 14.94); in the CG1 group was 19.37 (95% CI = 17.31 to 21.55); and in the CG2 group this was 16.72 (95% CI =14.84 to 18.72).
Conclusion
The new intervention with GPs resulted in a significant and relevant reduction in frequent-attender consultations. Although further trials are needed, this intervention is recommended to GPs interested in reducing consultations by their frequent attenders.
doi:10.3399/bjgp08X280182
PMCID: PMC2435670  PMID: 18482486
primary health care; utilisation; randomised controlled trial
15.  Caregiver- and Patient-Directed Interventions for Dementia 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:
Introduction
Caregiver-Directed Interventions for Dementia
Patient-Directed Interventions for Dementia
Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia
Caregiver-Directed Interventions for Dementia
Objective
To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.
Clinical Need: Target Population and Condition
Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.
Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.
Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.
It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.
Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.
Description of Interventions
The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.
Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.
Methods of Evidence-Based Analysis
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.
Questions
Section 2.1
Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Do respite care services impact on rates of institutionalization of these seniors?
Section 2.2
Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Which interventions reduce the risk for institutionalization of seniors with dementia?
Outcomes of Interest
any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;
rate of institutionalization; and
cost-effectiveness.
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.
Summary of Conclusions on Caregiver-Directed Interventions
There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.
There is considerable qualitative evidence of the perceived benefits of respite care.
Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.
Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)
There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.
There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.
RCT indicates randomized controlled trial.
Patient-Directed Interventions for Dementia
Objective
The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:
3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention
What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?
3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention
What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?
3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention
Can exercise decrease the risk of subsequent cognitive decline/dementia?
3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention
Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?
Clinical Need: Target Population and Condition
Secondary Prevention2
Exercise
Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.
Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.
Nonpharmacologic and Nonexercise Interventions
Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.
Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.
Primary Prevention3
Exercise
Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).
Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.
Nonpharmacologic and Nonexercise Interventions
Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.
Description of Interventions
Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.
Questions
Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?
Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?
Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?
Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:
Summary of Findings
Table 2 summarizes the conclusions from Sections 3.1 through 3.4.
Summary of Conclusions on Patient-Directed Interventions*
Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.
A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.
Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).
Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).
Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).
Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.
Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.
1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.
Benefit/Risk Analysis
As per the GRADE Working Group, the overall recommendations consider 4 main factors:
the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;
the quality of the evidence;
translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and
uncertainty about the baseline risk for the population of interest.
The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).
Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*
Economic Analysis
Budget Impact Analysis of Effective Interventions for Dementia
Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.
Annual Budget Impact (2008 Canadian Dollars)
Assumed 7% prevalence of dementia aged 65+ in Ontario.
Assumed 8 weekly sessions plus 4 monthly phone calls.
Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).
Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.
Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.
PMCID: PMC3377513  PMID: 23074509
16.  Invitation to attend a health check in a general practice setting: comparison of attenders and non-attenders 
A sample of 1570 men and women aged 20-45 years registered with an inner-city Cardiff practice were offered the opportunity by their general practitioner to have a health check at the surgery. The demographic characteristics, attitudes, beliefs and preventive health behaviour and past contact with the practice were compared for a sample of 259 non-attenders and 216 attenders. The results showed that attenders were generally better educated, better motivated to look after their health, had fewer ties and commitments, performed more healthapproved practices, had had more recent contact with their own practice and accepted the legitimacy of a general practitioner's interest in his patients' lifestyle. Offering cohorts of patients additional screening services is unlikely to be efficient or effective since it is the low-risk people already known to the doctor who are most likely to attend. The onus lies on primary health care to provide services in a way which permits appropriate screening of the high-risk groups as they attend for other reasons.
PMCID: PMC1711284  PMID: 3204565
17.  Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: Design of a randomised trial 
BMC Public Health  2008;8:224.
Background
Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care.
Methods/Design
In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18–65) will be recruited in the general population by means of a large-scale Internet-based screening (N = 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life.
Discussion
Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed.
Trial registration
The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).
doi:10.1186/1471-2458-8-224
PMCID: PMC2474681  PMID: 18590518
18.  Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy. 
BACKGROUND: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue. AIM: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue. DESIGN OF STUDY: A randomised controlled trial incorporating a cost-consequences analysis. SETTING: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months. METHOD: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale. RESULTS: Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score). CONCLUSIONS: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.
PMCID: PMC1313893  PMID: 11271867
19.  The Financial Burden of Morbidity in HIV-Infected Adults on Antiretroviral Therapy in Côte d'Ivoire 
PLoS ONE  2010;5(6):e11213.
Background
Large HIV care programs frequently subsidize antiretroviral (ARV) drugs and CD4 tests, but patients must often pay for other health-related drugs and services. We estimated the financial burden of health care for households with HIV-infected adults taking antiretroviral therapy (ART) in Côte d'Ivoire.
Methodology/Principal Findings
We conducted a cross-sectional survey. After obtaining informed consent, we interviewed HIV-infected adults taking ART who had consecutively attended one of 18 HIV care facilities in Abidjan. We collected information on socioeconomic and medical characteristics. The main economic indicators were household capacity-to-pay (overall expenses minus food expenses), and health care expenditures. The primary outcome was the percentage of households confronted with catastrophic health expenditures (health expenditures were defined as catastrophic if they were greater than or equal to 40% of the capacity-to-pay). We recruited 1,190 adults. Median CD4 count was 187/mm3, median time on ART was 14 months, and 72% of subjects were women. Mean household capacity-to-pay was $213.7/month, mean health expenditures were $24.3/month, and 12.3% of households faced catastrophic health expenditures. Of the health expenditures, 75.3% were for the study subject (ARV drugs and CD4 tests, 24.6%; morbidity events diagnosis and treatment, 50.1%; transportation to HIV care centres, 25.3%) and 24.7% were for other household members. When we stratified by most recent CD4 count, morbidity events related expenses were significantly lower when subjects had higher CD4 counts.
Conclusions/Significance
Many households in Côte d'Ivoire face catastrophic health expenditures that are not attributable to ARV drugs or routine follow-up tests. Innovative schemes should be developed to help HIV-infected patients on ART face the cost of morbidity events.
doi:10.1371/journal.pone.0011213
PMCID: PMC2887850  PMID: 20585454
20.  Cost-effectiveness of cognitive behaviour therapy versus talking and usual care for depressed older people in primary care 
Background
Whilst evidence suggests cognitive behaviour therapy (CBT) may be effective for depressed older people in a primary care setting, few studies have examined its cost-effectiveness. The aim of this study was to compare the cost-effectiveness of cognitive behaviour therapy (CBT), a talking control (TC) and treatment as usual (TAU), delivered in a primary care setting, for older people with depression.
Methods
Cost data generated from a single blind randomised controlled trial of 204 people aged 65 years or more were offered only Treatment as Usual, or TAU plus up to twelve sessions of CBT or a talking control is presented. The Beck Depression Inventory II (BDI-II) was the main outcome measure for depression. Direct treatment costs were compared with reductions in depression scores. Cost-effectiveness analysis was conducted using non-parametric bootstrapping. The primary analysis focussed on the cost-effectiveness of CBT compared with TAU at 10 months follow up.
Results
Complete cost data were available for 198 patients at 4 and 10 month follow up. There were no significant differences between groups in baseline costs. The majority of health service contacts at follow up were made with general practitioners. Fewer contacts with mental health services were recorded in patients allocated to CBT, though these differences were not significant. Overall total per patient costs (including intervention costs) were significantly higher in the CBT group compared with the TAU group at 10 month follow up (difference £427, 95% CI: £56 - £787, p < 0.001). Reductions in BDI-II scores were significantly greater in the CBT group (difference 3.6 points, 95% CI: 0.7-6.5 points, p = 0.018). CBT is associated with an incremental cost of £120 per additional point reduction in BDI score and a 90% probability of being considered cost-effective if purchasers are willing to pay up to £270 per point reduction in the BDI-II score.
Conclusions
CBT is significantly more costly than TAU alone or TAU plus TC, but more clinically effective. Based on current estimates, CBT is likely to be recommended as a cost-effective treatment option for this patient group if the value placed on a unit reduction in BDI-II is greater than £115.
Trial Registration
isrctn.org Identifier: ISRCTN18271323
doi:10.1186/1472-6963-11-33
PMCID: PMC3046916  PMID: 21314920
21.  Prompt letters to reduce non-attendance: applying evidence based practice 
BMC Psychiatry  2008;8:90.
Background
Non-attendance rates in psychiatric outpatient clinics have been a topic of considerable interest. It is measured as an indicator of quality of service provision. Failed attendances add to the cost of care as well as having an adverse impact on patients leading to missing medications, delay in identifying relapses and increasing waiting list time. Recent trials have demonstrated that prompting letters sent to patients led to a decrease in non-attendance rates. We applied this evidence based practice in our community mental health setting to evaluate its impact.
Methods
Using a before and after study design, we sent prompting letters to all patients due to attend outpatient clinic appointments for a period of six months in 2007. Non-attendance rates were compared with the corresponding period in 2006. We also looked at trends of non-attendance prior to this intervention and compared results with other parts of our service where this intervention had not been applied.
Results
1433 prompting letters were sent out to all out-patient appointments made from June to November 2007. This resulted in an average non-attendance rate of 17% which was significantly less compared to 27% between June and November 2006 (RR 0.65, 95% CI 0.56 to 0.76, NNT 11). No downward trend in non-attendance rate was identified either prior to the intervention or when compared with similar teams across the city.
Conclusion
Prompt letters have been shown to reduce non-attendance rates in previous RCTs and systematic reviews. Our findings demonstrate a reduction in non-attendance rates with prompting letters even under non-trial conditions. Majority of the patients were constant during the two periods compared although there were some changes in medical personnel. This makes it difficult to attribute all the change, solely to the intervention alone. Perhaps our work shows that the results of pragmatic randomised trials are easily applicable and produce similar results in non-randomised settings. We found that prompting letters are a useful and easy to apply evidence based intervention to reduce non-attendance rates with a potential to achieve significant cost savings.
doi:10.1186/1471-244X-8-90
PMCID: PMC2621156  PMID: 19014606
22.  Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital 
Introduction
Nonattendance at scheduled outpatient appointments for primary care is a major health care problem worldwide. Our aim was to estimate the prevalence of nonattendance at scheduled appointments for outpatients seeking primary care, to identify associated factors and build a model that predicts nonattendance at scheduled appointments.
Methods
A cohort study of adult patients, who had a scheduled outpatient appointment for primary care, was conducted between January 2010 and July 2011, at the Italian Hospital of Buenos Aires. We evaluated the history and characteristics of these patients, and their scheduling and attendance at appointments. Patients were divided into two groups: those who attended their scheduled appointments, and those who did not. We estimated the odds ratios (OR) and corresponding 95% confidence intervals (95% CI), and generated a predictive model for nonattendance, with logistic regression, using factors associated with lack of attendance, and those considered clinically relevant. Alternative models were compared using Akaike’s Information Criterion. A generation cohort and a validation cohort were assigned randomly.
Results
Of 113,716 appointments included in the study, 25,687 were missed (22.7%; 95% CI: 22.34%–22.83%). We found a statistically significant association between nonattendance and age (OR: 0.99; 95% CI: 0.99–0.99), number of issues in the personal health record (OR: 0.98; 95% CI: 0.98–0.99), time between the request for and date of appointment (OR: 1; 95% CI: 1–1), history of nonattendance (OR: 1.07; 95% CI: 1.07–1.07), appointment scheduled later than 4 pm (OR: 1.30; 95% CI: 1.24–1.35), and specific days of the week (OR: 1.00; 95% CI: 1.06–1.1). The predictive model for nonattendance included characteristics of the patient requesting the appointment, the appointment request, and the actual appointment date. The area under the receiver operating characteristic curve of the predictive model in the generation cohort was 0.892 (95% CI: 0.890–0.894).
Conclusion
Evidence related to patient characteristics, and the identification of appointments with a higher likelihood of nonattendance, should promote guided strategies to reduce the rate of nonattendance, as well as to future research on this topic. The use of predictive models could further guide management strategies to reduce the rate of nonattendance.
doi:10.2147/PPA.S51841
PMCID: PMC3826940  PMID: 24235820
nonattendance; appointments; schedules
23.  A comparison of sexual behaviour and risk behaviour for HIV infection between women in three clinical settings. 
Genitourinary Medicine  1993;69(6):441-445.
OBJECTIVE--To compare sexual behaviour and HIV risk behaviour between women in three clinical settings and to investigate the effect of socio-economic status and ethnic origin upon these behaviours. SUBJECTS AND METHODS--A questionnaire was administered to 1,950 women attending clinics for genitourinary medicine (GUM) family planning and termination of pregnancy (TOP), all in inner London. RESULTS--A quarter of women attending the GUM and TOP clinics were not using any regular form of contraception. Differences in the median numbers of sexual partners in the past year (1-2) and over lifetime (4-6) between the three groups were slight. Amongst the women in all three groups: more than half (54.8-64.9%) had had a non-regular partner in the preceding twelve months; fewer than one-fifth (10.4-17.1%) reported always using condoms with their regular partners, and fewer than two-fifths (31.3-39.7%) always used them with their non-regular partners; approximately one in five women (18.6-23.9%) reported one or more major HIV risk behaviours. Some parameters of sexual behaviour were found to be influenced by socio-economic status and/or ethnic origin. CONCLUSIONS--The behaviour of women attending these three clinics is very similar. Women attending clinics for family planning or termination of pregnancy need advice on sexually transmitted diseases and HIV infection, and women attending genitourinary medicine or termination clinics need advice on contraception. Closer integration between disciplines is required to provide a comprehensive sexual health service for women.
PMCID: PMC1195148  PMID: 8282297
24.  Effectiveness of Cognitive-Behavioral Therapy Modified for Inpatients with Depression 
ISRN Psychiatry  2011;2012:461265.
The effectiveness among inpatients with depression of a modified cognitive behavior therapy (CBT) program was examined. A group of 300 inpatient admissions with a primary diagnosis of depression attending a private psychiatric clinic were assessed at the beginning and end of a two-week CBT program. The effectiveness of the treatment was demonstrated by improvements on the Beck depression inventory (BDI), the health of the nation outcome scales, locus of control of behaviour scale, and the global assessment of function. The changes on the BDI for patients with depression were benchmarked against estimates generated from published studies. The degree of change in a two-week period for inpatients with depression was similar to that observed in efficacy studies of CBT that typically run over a more extended time. Implications for integrating CBT with inpatient services are discussed.
doi:10.5402/2012/461265
PMCID: PMC3667638  PMID: 23738192
25.  Cognitive Mediation of Cognitive-Behavioural Therapy Outcomes for Anxiety-Based School Refusal 
Background
Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms.
Aims
Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal.
Method
Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up.
Results
Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up.
Conclusions
These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.
doi:10.1017/S1352465812000756
PMCID: PMC3772992  PMID: 23017774
CBT; mediators; school refusal; anxiety; self-efficacy

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