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1.  Service Use, Charge, and Access to Mental Healthcare in a Private Kenyan Inpatient Setting: The Effects of Insurance 
PLoS ONE  2014;9(3):e90297.
The gap in Kenya between need and treatment for mental disorders is wide, and private providers are increasingly offering services, funded in part by private health insurance (PHI). Chiromo, a 30-bed psychiatric hospital in Nairobi, forms part of one of the largest private psychiatric providers in East Africa.
The study evaluated the effects of insurance on service use and charge, questioning implications on access to care. Data derive from invoices for 455 sequential patients, including 12-month follow-up. Multi-linear and binary logistic regressions explored the effect of PHI on readmission, cumulative length of stay, and treatment charge.
Patients were 66.4% male with a mean age of 36.8 years. Half were employed in the formal sector. 70% were admitted involuntarily. Diagnoses were: substance use disorder 31.6%; serious mental disorder 49.5%; common mental disorder 7%; comorbid 7%; other 4.9%. In addition to daily psychiatric consultations, two-thirds received individual counselling or group therapy; half received lab tests or scans; and 16.2% received ECT. Most took a psychiatric medicine. Half of those on antipsychotics were given only brands.
Insurance paid in full for 28.8% of patients. Mean length of stay was 11.8 days and, in 12 months, 16.7 days (median 10.6). 22.2% were readmitted within 12 months. Patients with PHI stayed 36% longer than those paying out-of-pocket and had 2.5 times higher odds of readmission. Mean annual charge per patient was Int$ 4,262 (median Int$ 2,821). Insurers were charged 71% more than those paying out-of-pocket - driven by higher fees and longer stays.
Chiromo delivers acute psychiatric care each year to approximately 450 people, to quality and human rights standards higher than its public counterpart, but at considerably higher cost. With more efficient delivery and wider insurance coverage, Chiromo might expand from its occupancy of 56.6% to reach a larger population in need.
doi:10.1371/journal.pone.0090297
PMCID: PMC3961252  PMID: 24651115
2.  Importance of Social and Cultural Factors for Attitudes, Disclosure and Time off Work for Depression: Findings from a Seven Country European Study on Depression in the Workplace 
PLoS ONE  2014;9(3):e91053.
Objectives
Depression is experienced by a large proportion of the workforce and associated with high costs to employers and employees. There is little research on how the social costs of depression vary by social and cultural context. This study investigates individual, workplace and societal factors associated with greater perceived discomfort regarding depression in the workplace, greater likelihood of employees taking time off of work as a result of depression and greater likelihood of disclosure of depression to one's employer.
Methods
Employees and managers (n = 7,065) were recruited from seven European countries to participate in the IDEA survey. Multivariable logistic regression models were used to examine associations between individual characteristics and country contextual characteristics in relation to workplace perceptions, likelihood of taking time off work and disclosing depression to an employer.
Results
Our findings suggest that structural factors such as benefit systems and flexible working hours are important for understanding workplace perceptions and consequences for employees with depression. However, manager responses that focus on offering help to the employee with depression appear to have stronger associations with positive perceptions in the workplace, and also with openness and disclosure by employees with depression.
Conclusion
This study highlights the importance of individual, workplace and societal factors that may be associated with how people with depression are perceived and treated in the workplace, and, hence, factors that may be associated with openness and disclosure among employees with depression. Some responses, such as flexible working hours, may be helpful but are not necessarily sufficient, and our findings also emphasise the importance of support and openness of managers in addition to flexible working hours.
doi:10.1371/journal.pone.0091053
PMCID: PMC3951284  PMID: 24622046
3.  The Mental Health Consequences of the Recession: Economic Hardship and Employment of People with Mental Health Problems in 27 European Countries 
PLoS ONE  2013;8(7):e69792.
Objectives
A period of economic recession may be particularly difficult for people with mental health problems as they may be at higher risk of losing their jobs, and more competitive labour markets can also make it more difficult to find a new job. This study assesses unemployment rates among individuals with mental health problems before and during the current economic recession.
Methods
Using individual and aggregate level data collected from 27 EU countries in the Eurobarometer surveys of 2006 and 2010, we examined changes in unemployment rates over this period among individuals with and without mental health problems.
Results
Following the onset of the recession, the gap in unemployment rates between individuals with and without mental health problems significantly widened (odds ratio: 1.12, 95% confidence interval: 1.03, 1.34). This disparity became even greater for males, and individuals with low levels of education. Individuals with mental health problems living in countries with higher levels of stigmatizing attitudes regarding dangerousness of people with mental illness were more vulnerable to unemployment in 2010, but not 2006. Greater agreement that people with mental health problems have themselves to blame, was associated with lower likelihood of unemployment for individuals with and without mental health problems.
Conclusion
These findings study suggest that times of economic hardship may intensify social exclusion of people with mental health problems, especially males and individuals with lower education. Interventions to combat economic exclusion and to promote social participation of individuals with mental health problems are even more important during times of economic crisis, and these efforts should target support to the most vulnerable groups.
doi:10.1371/journal.pone.0069792
PMCID: PMC3724888  PMID: 23922801
4.  The cost of schizophrenia in Japan 
Introduction:
Schizophrenia is a disorder that produces considerable burdens due to its often relapsing/remitting or chronic longitudinal course. This burden is felt not only by patients themselves, but also by their families and health care systems. Although the societal burden caused by this disorder has been evaluated in several countries, the magnitude of the societal cost of schizophrenia in Japan has never been estimated. The aim of this study is to clarify the societal burden of schizophrenia by estimating the cost of schizophrenia in Japan in 2008.
Methods:
A human capital approach was adopted to estimate the cost of schizophrenia. The total cost of schizophrenia was calculated as the sum of the direct, morbidity, and mortality costs. Schizophrenia was defined as disorders coded as F20.0–F20.9 according to the International Classification of Diseases-10. The data required to estimate the total cost was collected from publicly available statistics or previously reported studies.
Results:
The total cost of schizophrenia in Japan in 2008 was JPY 2.77 trillion (USD 23.8 billion). While the direct cost was JPY 0.770 trillion (USD 6.59 billion), the morbidity and mortality costs were JPY 1.85 trillion (USD 15.8 billion) and JPY 0.155 trillion (USD 1.33 billion), respectively.
Conclusion:
The societal burden caused by schizophrenia is tremendous in Japan, similar to that in other developed countries where published data exist. Compared with other disorders, such as depression or anxiety disorders, the direct cost accounted for a relatively high proportion of the total cost. Furthermore, absolute costs arising from unemployment were larger, while the prevalence rate was smaller, than the corresponding results for depression or anxiety in Japan.
doi:10.2147/NDT.S41632
PMCID: PMC3682806  PMID: 23785238
cost of illness; schizophrenia; societal burden; cost analysis; societal cost
5.  Goal-oriented cognitive rehabilitation in early-stage dementia: study protocol for a multi-centre single-blind randomised controlled trial (GREAT) 
Trials  2013;14:152.
Background
Preliminary evidence suggests that goal-oriented cognitive rehabilitation (CR) may be a clinically effective intervention for people with early-stage Alzheimer’s disease, vascular or mixed dementia and their carers. This study aims to establish whether CR is a clinically effective and cost-effective intervention for people with early-stage dementia and their carers.
Methods/design
In this multi-centre, single-blind randomised controlled trial, 480 people with early-stage dementia, each with a carer, will be randomised to receive either treatment as usual or cognitive rehabilitation (10 therapy sessions over 3 months, followed by 4 maintenance sessions over 6 months). We will compare the effectiveness of cognitive rehabilitation with that of treatment as usual with regard to improving self-reported and carer-rated goal performance in areas identified as causing concern by people with early-stage dementia; improving quality of life, self-efficacy, mood and cognition of people with early-stage dementia; and reducing stress levels and ameliorating quality of life for carers of participants with early-stage dementia. The incremental cost-effectiveness of goal-oriented cognitive rehabilitation compared to treatment as usual will also be examined.
Discussion
If the study confirms the benefits and cost-effectiveness of cognitive rehabilitation, it will be important to examine how the goal-oriented cognitive rehabilitation approach can most effectively be integrated into routine health-care provision. Our aim is to provide training and develop materials to support the implementation of this approach following trial completion.
Trial registration
Current Controlled Trials ISRCTN21027481
doi:10.1186/1745-6215-14-152
PMCID: PMC3680175  PMID: 23710796
Alzheimer’s disease; Vascular dementia; Mixed dementia; Re-ablement; Quality of life; Cost-effectiveness
6.  Cost-effectiveness of adherence therapy versus health education for people with schizophrenia: randomised controlled trial in four European countries 
Background
Non-adherence to anti-psychotics is common, expensive and affects recovery. We therefore examine the cost-effectiveness of adherence therapy for people with schizophrenia by multi-centre randomised trial in Amsterdam, London, Leipzig and Verona.
Methods
Participants received 8 sessions of adherence therapy or health education. We measured lost productivity and use of health/social care, criminal justice system and informal care at baseline and one year to estimate and compare mean total costs from health/social care and societal perspectives. Outcomes were the Short Form 36 (SF-36) mental component score (MCS) and quality-adjusted life years (QALYs) gained (SF-36 and EuroQoL 5 dimension (EQ5D)). Cost-effectiveness was examined for all cost and outcome combinations using cost-effectiveness acceptability curves (CEACs).
Results
409 participants were recruited. There were no cost or outcome differences between adherence therapy and health education. The probability of adherence therapy being cost-effective compared to health education was between 0.3 and 0.6 for the six cost-outcome combinations at the willingness to pay thresholds we examined.
Conclusions
Adherence therapy appears equivalent to health education. It is unclear whether it would have performed differently against a treatment as usual control, whether such an intervention can impact on quality of life in the short-term, or whether it is likely to be cost-effective in some sites but not others.
Trial registration
Trial registration: Current Controlled Trials ISRCTN01816159
doi:10.1186/1478-7547-11-12
PMCID: PMC3668244  PMID: 23705862
Cost effectiveness; Quality-adjusted life year; Antipsychotic; Adherence; Schizophrenia; Psychological therapy
7.  Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial 
Age and Ageing  2013;42(4):501-508.
Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial.
Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England.
Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat.
Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service.
Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs.
Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75–1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant.
Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.
International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
doi:10.1093/ageing/aft008
PMCID: PMC3684109  PMID: 23443509
telecare; assistive technology; randomised controlled trial; administrative data; older people
8.  Feasibility study of an optimised person-centred intervention to improve mental health and reduce antipsychotics amongst people with dementia in care homes: study protocol for a randomised controlled trial 
Trials  2013;14:13.
Background
People living in care homes often have complex mental and physical health problems, disabilities and social needs which are compounded by the use of psychiatric and other drugs. In the UK dementia care is a national priority with a vast impact on services. WHELD combines the most effective elements of existing approaches to develop a comprehensive but practical intervention. This will be achieved by training care staff to provide care that is focused on an understanding of the individual and their needs; and by using additional components such as exercise, activities and social interaction to improve mental health and quality of life (QoL) and reduce the use of sedative drugs.
Design
Work Package 3 (WP3) is the pilot randomised trial and qualitative evaluation to help develop a future definitive randomised controlled clinical trial. The study design is a cluster randomised 2x2x2 factorial design with two replications in 16 care homes. Each care home is randomized to receive one of the eight possible permutations of the four key interventions, with each possible combination delivered in two of the 16 homes. Each cluster includes a minimum of 12 participants (depending upon size of the care home, the number of people with dementia and the number consenting).
Discussion
The overarching goal of the programme is to provide an effective, simple and practical intervention which improves the mental health of, and reduces sedative drug use in, people with dementia in care homes and which can be implemented nationally in all UK care homes as an NHS intervention.
Trial Registration
Current controlled trials ISRCTN40313497
doi:10.1186/1745-6215-14-13
PMCID: PMC3617007  PMID: 23305152
Dementia; Care homes; Quality of life; Antipsychotic medication; Behavioural symptoms; Cost-effectiveness; Implementation; Person-centred care; Exercise; Social interaction
9.  An organisational analysis of the implementation of telecare and telehealth: the whole systems demonstrator 
Background
To investigate organisational factors influencing the implementation challenges of redesigning services for people with long term conditions in three locations in England, using remote care (telehealth and telecare).
Methods
Case-studies of three sites forming the UK Department of Health’s Whole Systems Demonstrator (WSD) Programme. Qualitative research techniques were used to obtain data from various sources, including semi-structured interviews, observation of meetings over the course programme and prior to its launch, and document review. Participants were managers and practitioners involved in the implementation of remote care services.
Results
The implementation of remote care was nested within a large pragmatic cluster randomised controlled trial (RCT), which formed a core element of the WSD programme. To produce robust benefits evidence, many aspect of the trial design could not be easily adapted to local circumstances. While remote care was successfully rolled-out, wider implementation lessons and levels of organisational learning across the sites were hindered by the requirements of the RCT.
Conclusions
The implementation of a complex innovation such as remote care requires it to organically evolve, be responsive and adaptable to the local health and social care system, driven by support from front-line staff and management. This need for evolution was not always aligned with the imperative to gather robust benefits evidence. This tension needs to be resolved if government ambitions for the evidence-based scaling-up of remote care are to be realised.
doi:10.1186/1472-6963-12-403
PMCID: PMC3532839  PMID: 23153014
Telecare; Telehealth; Whole system redesign; Organisational change; Adoption; Implementation; Ethnographic methods
10.  Individual Cognitive Stimulation Therapy for dementia (iCST): study protocol for a randomized controlled trial 
Trials  2012;13:172.
Background
Improving the quality of care for people with dementia and their carers has become a national priority in many countries. Cognitive Stimulation Therapy (CST) groups can be beneficial in improving cognition and quality of life for people with dementia. The aim of the current study is to develop and evaluate a home-based individual Cognitive Stimulation Therapy (iCST) programme for people with dementia which can be delivered by their family carer.
Methods
This multi-centre, pragmatic randomised controlled trial (RCT) will compare the effectiveness and cost-effectiveness of iCST for people with dementia with a treatment as usual control group. The intervention consists of iCST sessions delivered by a carer for 30 minutes, 3 times a week over 25 weeks.
For people with dementia the primary outcome measures are cognition assessed by the ADAS-Cog, and quality of life assessed by QoL-AD. For carers, quality of life using the SF-12 is the primary outcome measure. Using a 5% significance level, comparison of 306 participants will yield 80% power to detect an effect size of 0.35 for cognition as measured by the ADAS-Cog, and quality of life as measured by the QoL-AD. Quality of life for the carer will be measured using the SF-12. The trial will include a cost-effectiveness analysis from a public sector perspective.
Discussion
The UK Department of Health has recently stressed that improving access to psychological therapies is a national priority, but many people with dementia are unable to access psychological interventions. The development of a home-based individual version of CST will provide an easy to use, widely available therapy package that will be evaluated for effectiveness and cost-effectiveness in a multi centre RCT.
doi:10.1186/1745-6215-13-172
PMCID: PMC3522062  PMID: 22998983
11.  Adaptive Pacing, Cognitive Behaviour Therapy, Graded Exercise, and Specialist Medical Care for Chronic Fatigue Syndrome: A Cost-Effectiveness Analysis 
PLoS ONE  2012;7(8):e40808.
Background
The PACE trial compared the effectiveness of adding adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET), to specialist medical care (SMC) for patients with chronic fatigue syndrome. This paper reports the relative cost-effectiveness of these treatments in terms of quality adjusted life years (QALYs) and improvements in fatigue and physical function.
Methods
Resource use was measured and costs calculated. Healthcare and societal costs (healthcare plus lost production and unpaid informal care) were combined with QALYs gained, and changes in fatigue and disability; incremental cost-effectiveness ratios (ICERs) were computed.
Results
SMC patients had significantly lower healthcare costs than those receiving APT, CBT and GET. If society is willing to value a QALY at £30,000 there is a 62.7% likelihood that CBT is the most cost-effective therapy, a 26.8% likelihood that GET is most cost effective, 2.6% that APT is most cost-effective and 7.9% that SMC alone is most cost-effective. Compared to SMC alone, the incremental healthcare cost per QALY was £18,374 for CBT, £23,615 for GET and £55,235 for APT. From a societal perspective CBT has a 59.5% likelihood of being the most cost-effective, GET 34.8%, APT 0.2% and SMC alone 5.5%. CBT and GET dominated SMC, while APT had a cost per QALY of £127,047. ICERs using reductions in fatigue and disability as outcomes largely mirrored these findings.
Conclusions
Comparing the four treatments using a health care perspective, CBT had the greatest probability of being the most cost-effective followed by GET. APT had a lower probability of being the most cost-effective option than SMC alone. The relative cost-effectiveness was even greater from a societal perspective as additional cost savings due to reduced need for informal care were likely.
doi:10.1371/journal.pone.0040808
PMCID: PMC3411573  PMID: 22870204
12.  Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study 
Background
Telehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial.
Methods
Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes.
Results
Barriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.
Conclusions
These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.
doi:10.1186/1472-6963-12-220
PMCID: PMC3413558  PMID: 22834978
Telehealth; Telecare; Patients’ perspectives; Non-adoption; Non-participation; Barriers; Qualitative research; Whole System Demonstrator
13.  Cost-effectiveness of telehealth in people with social care needs: the Whole Systems Demonstrator cluster randomised trial 
Introduction
The Whole Systems Demonstrator pilots introduced telehealth and telecare into three local authority areas using an integrated approach to deliver health and social care to those with high care needs and long-term conditions. Proponents of these technologies have given cost savings as one rationale for advocating their introduction and widespread implementation; proponents have also advocated their potential to improve the quality of life for their users. Until recently, evaluations of telehealth and telecare in high-income countries have been based on relatively small-scale pilots; few such evaluations have been designed as randomised controlled trials. The WSD study was a pragmatic cluster-randomised control trial, representing the largest-scale trial of telehealth and telecare to be carried out in the UK. This presentation focuses on the results of the WSD telecare questionnaire study.
Objectives
To examine the costs and cost-effectiveness of telecare compared to standard support and treatment.
Methods
Economic evaluation conducted in parallel with a pragmatic cluster-randomised controlled trial of Telecare. 2600 people with social care needs participated in a trial of a community-based telecare intervention in three English local authority areas. Approximately half of the participants in the telecare trial also consented to participate in the WSD telecare questionnaire study, which collected information on a number of patient-reported outcome measures and also on the self-reported use of a range of health and social services. Health and social costs were calculated by attaching nationally applicable unit costs to self-reported service use data. The unit costs of telecare support and treatment provided were calculated drawing on administrative and financial data sources and interviews with key informants. The primary outcome for the cost-effectiveness analysis was the quality-adjusted life year (QALY). Secondary outcomes included measures of health-related quality of life and well-being. We employed multivariate analyses to explore the cost-effectiveness of the intervention
Results
The presentation will describe the results of the economic evaluation of telecare, addressing the cost of care and treatment packages used by those participating in the telecare questionnaire study and the results of the cost-effectiveness analysis. These results will be available by the time of the presentation.
Conclusions
These will be available by the time of the presentation.
PMCID: PMC3571183
economic evaluation; social care; cost analysis; telecare
14.  The MonAMI project: the social benefits of telecare 
Introduction
There are widespread concerns around the accessibility of mainstream technology which remains underdeveloped for the needs of many older people 1. The Mainstreaming on Ambient Intelligence (MonAMI) project 2, funded under the EU FP6 framework in the area of e-Inclusion, developed an open technology platform and series of ‘telecare’ services designed to be accessed using mainstreamed devices (e.g. mobile telephones, personal computers). A field trial was conducted to evaluate the technology in the homes of disabled older people in three communities across Europe.
Aims
The primary aim of the MonAMI trial was to evaluate the acceptability and usefulness of the services in terms of whether they enable older people with needs to live independently and maintain a good quality of life. The secondary aim was to validate the technical and economic feasibility of delivering telecare services, using an open platform, in living community contexts.
Methods
The MonAMI system was evaluated in a three-month field trial in the cities of Kosice (Slovakia), Stockholm (Sweden) and Zaragoza (Spain). Trial participants (users) included people over 65 years, with a varying range of physical, cognitive and sensorial impairments. In each of the users’ homes a bouquet of alert, home monitoring and home control services were installed and configured to users’ individual needs and lifestyle. Face-to-face, semi-structured interviews were held at baseline and at post-trial follow-up, collecting data on users’ level of independence, health and wellbeing status, social networking, perceptions of safety, and acceptance of the services. Significance tests and regression analyses were performed to measure the impact of the services on users’ quality of life.
Results
Sixty-eight users were recruited to the trial. The mean age was 78 years, 74% were women and 93% lived alone. Most users reported disabilities related to their legs and knees and the mean self-rated EQ5D-VAS3 health score was 63.8. In general, users with better self-rated independence 4 and health scores at baseline found the services more helpful compared to users with poorer ratings. However, specific analyses revealed the services had positive effects on perceptions of safety for users with a greater number of disabilities as compared to those with fewer disabilities (Odds ratio 2.51, p<0.05). Users with leg impairments conveyed feeling more energetic as compared to those without such impairments (Odds ratio 7.49, p<0.05); while users living alone confirmed that the services were helpful for their social networking5 as compared to users living with others (Odds ratio 2.49, p<0.1). Collectively, significantly more than 50% of users (70.6% p<0.001) rated the acceptability and usefulness of MonAMI services highly. Moreover many users stated that if possible, they would continue using the MonAMI system beyond the trial.
Conclusions
Overall, the trial results are promising; demonstrating that the MonAMI telecare services are beneficial for older people with needs. The trial also confirmed the potential of deploying and providing continuous services using MonAMI technology across diverse health and social care systems in Europe, lending support to MonAMI’s proof of concept of an open core platform approach for delivering care services.
PMCID: PMC3571186
telecare; older people; accessibility; disability; quality of life
15.  Developing the evidence base for adult social care practice: The NIHR School for Social Care Research 
In a foreword to Shaping the Future of Care Together, Prime Minister Gordon Brown says that a care and support system reflecting the needs of our times and meeting our rising aspirations is achievable, but ‘only if we are prepared to rise to the challenge of radical reform’. A number of initiatives will be needed to meet the challenge of improving social care for the growing older population. Before the unveiling of the green paper, The National Institute for Health Research (NIHR) announced that it has provided £15m over a five-year period to establish the NIHR School for Social Care Research. The School’s primary aim is to conduct or commission research that will help to improve adult social care practice in England. The School is seeking ideas for research topics, outline proposals for new studies and expert advice in developing research methods.
doi:10.1179/175016810X12670238442101
PMCID: PMC3191519  PMID: 22003363
social care; research; England; National Institute for Health Research
16.  Peer support for family carers of people with dementia, alone or in combination with group reminiscence in a factorial design: study protocol for a randomised controlled trial 
Trials  2011;12:205.
Background
Peer support interventions can improve carer wellbeing and interventions that engage both the carer and person with dementia can have significant mutual benefits. Existing research has been criticised for inadequate rigour of design or reporting. This paper describes the protocol for a complex trial that evaluates one-to-one peer support and a group reminiscence programme, both separately and together, in a factorial design.
Design
A 2 × 2 factorial multi-site randomised controlled trial of individual peer support and group reminiscence interventions for family carers and people with dementia in community settings in England, addressing both effectiveness and cost-effectiveness.
Discussion
The methods described in this protocol have implications for research into psychosocial interventions, particularly complex interventions seeking to test both individual and group approaches.
Trial Registration
ISRCTN37956201
doi:10.1186/1745-6215-12-205
PMCID: PMC3180397  PMID: 21917187
17.  The Economic Costs of Progressive Supranuclear Palsy and Multiple System Atrophy in France, Germany and the United Kingdom 
PLoS ONE  2011;6(9):e24369.
Progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) are progressive disabling neurological conditions usually fatal within 10 years of onset. Little is known about the economic costs of these conditions. This paper reports service use and costs from France, Germany and the UK and identifies patient characteristics that are associated with cost. 767 patients were recruited, and 760 included in the study, from 44 centres as part of the NNIPPS trial. Service use during the previous six months was measured at entry to the study and costs calculated. Mean six-month costs were calculated for 742 patients. Data on patient sociodemographic and clinical characteristics were recorded and used in regression models to identify predictors of service costs and unpaid care costs (i.e., care from family and friends). The mean six-month service costs of PSP were €24,491 in France, €30,643 in Germany and €25,655 in the UK. The costs for MSA were €28,924, €25,645 and €19,103 respectively. Unpaid care accounted for 68–76%. Formal and unpaid costs were significantly higher the more severe the illness, as indicated by the Parkinson's Plus Symptom scale. There was a significant inverse relationship between service and unpaid care costs.
doi:10.1371/journal.pone.0024369
PMCID: PMC3169589  PMID: 21931694
18.  A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial 
Background
It is expected that increased demands on services will result from expanding numbers of older people with long-term conditions and social care needs. There is significant interest in the potential for technology to reduce utilisation of health services in these patient populations, including telecare (the remote, automatic and passive monitoring of changes in an individual's condition or lifestyle) and telehealth (the remote exchange of data between a patient and health care professional). The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact.
Methods/Design
We are conducting a large scale, multi-site study of the implementation, impact and acceptability of these new technologies. A major part of the evaluation is a cluster-randomised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs. The trial involves a number of outcomes, including health care utilisation and quality of life. We describe the broad evaluation and the methods of the cluster randomised trial
Discussion
If telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need.
Trial Registration
Current Controlled Trials ISRCTN43002091
doi:10.1186/1472-6963-11-184
PMCID: PMC3169462  PMID: 21819569
20.  Design of an internet-based health economic evaluation of a preventive group-intervention for children of parents with mental illness or substance use disorders 
BMC Public Health  2010;10:470.
Background
Preventive interventions are developed for children of parents with mental and substance use disorders (COPMI), because these children have a higher risk of developing a psychological or behavioral disorder in the future. Mental health and substance use disorders contribute significantly to the global burden of disease. Although the exact number of parents with a mental illness is unclear, the subject of mentally ill parents is gaining attention. Moreover there is a lack of interventions for COPMI-children, as well of (cost-) effectiveness studies evaluating COPMI interventions. Innovative interventions such as e-health provide a new field for exploration. There is no knowledge about the opportunities for using the internet to prevent problems in children at risk. In the current study we will focus on the (cost-) effectiveness of an online health prevention program for COPMI-children.
Methods/Design
We designed a randomized controlled trial to examine the (cost-) effectiveness of the Kopstoring intervention. Kopstoring is an online intervention for COPMI-children to strengthen their coping skills and prevent behavioral and psychological problems. We will compare the Kopstoring intervention with (waiting list) care as usual. This trial will be conducted entirely over the internet. An economic evaluation, from a societal perspective will be conducted, to examine the trial's cost-effectiveness. Power calculations show that 214 participants are needed, aged 16-25. Possible participants will be recruited via media announcements and banners on the internet. After screening and completing informed consent procedures, participants will be randomized. The main outcome is internalizing and externalizing symptoms as measured by the Youth Self Report. For the economic evaluation, healthcare costs and costs outside the healthcare sector will be measured at the same time as the clinical measures, at baseline, 3, 6 and 9 months. An extended measure for the intervention group will be provided at 12 months, to examine the long-term effects. In addition, a process evaluation will be conducted.
Discussion
Recent developments, such as international conferences and policy discussions, show the pressing need to study the (cost-) effectiveness of interventions for vulnerable groups of children. This study will shed light on the (cost-) effectiveness of an online preventive intervention.
Trial registration
NTR1982
doi:10.1186/1471-2458-10-470
PMCID: PMC2928203  PMID: 20698962
21.  Interleukin 8 (IL-8) - a universal biomarker? 
Many clinical conditions including various types of cancers are complex and generally require invasive, laborious, expensive and time-consuming investigations for their diagnosis, treatment and follow-up. There is therefore a general need for exploring non-invasive markers in clinical medicine. Interleukin 8 (IL-8) is currently being applied in various subspecialties of medicine either for the purpose of rapid diagnosis or as a predictor of prognosis. Nevertheless, there is need for large-scale studies to substantiate accuracy and outcome. This article will summarize current evidence suggesting that Interleukin 8 (IL-8) may serve as a useful biomarker.
doi:10.1186/1755-7682-3-11
PMCID: PMC2893518  PMID: 20550702
22.  Maintenance Cognitive Stimulation Therapy (CST) for dementia: A single-blind, multi-centre, randomized controlled trial of Maintenance CST vs. CST for dementia 
Trials  2010;11:46.
Background
Psychological treatments for dementia are widely used in the UK and internationally, but only rarely have they been standardised, adequately evaluated or systematically implemented. There is increasing recognition that psychosocial interventions may have similar levels of effectiveness to medication, and both can be used in combination. Cognitive Stimulation Therapy (CST) is a 7-week cognitive-based approach for dementia that has been shown to be beneficial for cognition and quality of life and is cost-effective, but there is less conclusive evidence for the effects of CST over an extended period.
Methods/Design
This multi-centre, pragmatic randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of Maintenance CST groups for dementia compares a intervention group who receive CST for 7 weeks followed by the Maintenance CST programme once a week for 24 weeks with the control group who receive CST for 7 weeks, followed by treatment as usual for 24 weeks.
The primary outcome measures are quality of life of people with dementia assessed by the QoL-AD and cognition assessed by the ADAS-Cog. Secondary outcomes include the person with dementia's mood, behaviour, activities of daily living, ability to communicate and costs; as well as caregiver health-related quality of life. Using a 5% significance level, comparison of 230 participants will yield 80% power to detect a standardised difference of 0.39 on the ADAS-Cog between the groups. The trial includes a cost-effectiveness analysis from a public sector perspective.
Discussion
A pilot study of longer-term Maintenance CST, offering 16 weekly sessions of maintenance following the initial CST programme, previously found a significant improvement in cognitive function (MMSE) for those on the intervention group. The study identified the need for a large-scale, multi-centre RCT to define the potential longer-term benefits of continuing the therapy. This study aims to provide definitive evidence of the potential efficacy of maintenance CST and establish how far the long-term benefits can be compared with antidementia drugs such as cholinesterase inhibitors.
Trial Registration
ISRCTN26286067
doi:10.1186/1745-6215-11-46
PMCID: PMC2867981  PMID: 20426866
24.  Emerging applications of fluorescence spectroscopy in medical microbiology field 
There are many diagnostic techniques and methods available for diagnosis of medically important microorganisms like bacteria, viruses, fungi and parasites. But, almost all these techniques and methods have some limitations or inconvenience. Most of these techniques are laborious, time consuming and with chances of false positive or false negative results. It warrants the need of a diagnostic technique which can overcome these limitations and problems. At present, there is emerging trend to use Fluorescence spectroscopy as a diagnostic as well as research tool in many fields of medical sciences. Here, we will critically discuss research studies which propose that Fluorescence spectroscopy may be an excellent diagnostic as well as excellent research tool in medical microbiology field with high sensitivity and specificity.
doi:10.1186/1479-5876-7-99
PMCID: PMC2787503  PMID: 19941643
25.  Financial incentives to improve adherence to anti-psychotic maintenance medication in non-adherent patients - a cluster randomised controlled trial (FIAT) 
BMC Psychiatry  2009;9:61.
Background
Various interventions have been tested to achieve adherence to anti-psychotic maintenance medication in non-adherent patients with psychotic disorders, and there is no consistent evidence for the effectiveness of any established intervention. The effectiveness of financial incentives in improving adherence to a range of treatments has been demonstrated; no randomised controlled trial however has tested the use of financial incentives to achieve medication adherence for patients with psychotic disorders living in the community.
Methods/Design
In a cluster randomised controlled trial, 34 mental health teams caring for difficult to engage patients in the community will be randomly allocated to either the intervention group, where patients will be offered a financial incentive for each anti-psychotic depot medication they receive over a 12 month period, or the control group, where all patients will receive treatment as usual. We will recruit 136 patients with psychotic disorders who use these services and who have problems adhering to antipsychotic depot medication, although all conventional methods to achieve adherence have been tried. The primary outcome will be adherence levels, and secondary outcomes are global clinical improvement, number of voluntary and involuntary hospital admissions, number of attempted and completed suicides, incidents of physical violence, number of police arrests, number of days spent in work/training/education, subjective quality of life and satisfaction with medication. We will also establish the cost effectiveness of offering financial incentives.
Discussion
The study aims to provide new evidence on the effectiveness and cost effectiveness of offering financial incentives to patients with psychotic disorders to adhere to antipsychotic maintenance medication. If financial incentives improve adherence and lead to better health and social outcomes, they may be recommended as one option to improve the treatment of non-adherent patients with psychotic disorders.
Trial Registration
Current controlled trials ISRCTN77769281.
doi:10.1186/1471-244X-9-61
PMCID: PMC2760548  PMID: 19785727

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