Objective An economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain.

Design Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial.

Participants 579 patients with chronic or recurrent low back pain recruited from primary care.

Interventions Normal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse.

Main outcome measures Costs to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves.

Results Intervention costs ranged from £30 for exercise prescription to £596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from £50 for 24 lessons in Alexander technique to £124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value (£61 per point on disability score, £9 per additional pain-free day, £2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional £64 per point on disability score, £43 per additional pain-free day, £5332 per QALY gain).

Conclusions An exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above £20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option.

Background Social and financial environment has an influence on the incidence of depression. We studied perceived financial strain as a risk factor for development of depression among a large cohort of young women in Southampton, UK.

Methods We recruited a large number of young women in Southampton in the Southampton Women's Survey, a longitudinal study looking at factors influencing the health of women and their offspring. Women were asked to complete a baseline questionnaire, which included the GHQ-12 (an assessment of mental health), as well as questions on perceived financial strain and past history of depression. They were followed up two years later through their general practitioner (GP) records for evidence of incident mental illness.

Results A total of 7020 women completed the baseline questionnaire including the GHQ-12. Of these, 5237 (74.6%) had records available for follow-up. Among those developing depression, there was a higher proportion receiving benefits, and a higher level of perceived financial strain. There were also modest elevations in perceived stress, and poorer levels of educational attainment. Among women not depressed at baseline, and with no previous history of depression, those in receipt of state benefits at baseline had a significantly elevated risk of developing the disorder – hazard ratio 1.61 (95% confidence interval (CI) 1.13–2.3). The risk associated with perceived financial strain was 2.16 (95% CI 1.14–4.11), but this did not remain statistically significant after adjustment was made for receipt of benefits, educational qualification, and perceived stress.

Conclusion Financial hardship as evidenced by receipt of benefits is a strong independent predictor for the development of depression. Although perception of financial strain is also a predictor for incident depression, the risk associated with this subjective characteristic does not remain significantly elevated after adjustment. Future studies of the aetiology of depression should incorporate ascertainment of actual financial status.

Objective To assess the effect of brief interventions during the “watchful waiting” period for hypertension.

Design Factorial trial.

Setting General practice.

Methods 296 patients with blood pressure > 160/90 mm Hg were randomised to eight groups defined by three factors: an information booklet; low sodium, high potassium salt; prompt sheets for high fruit, vegetable, fibre; and low fat.

Main outcome measures Blood pressure (primary outcome); secondary outcomes of diet, weight, and dietary biomarkers (urinary sodium:potassium (Na:K) ratio; carotenoid concentrations).

Results Blood pressure was not affected by the booklet (mean difference (diastolic blood pressure) at one month 0.2, 95% confidence interval 1.6 to 2.0), salt (0.13; 1.7 to 2.0), or prompts (0.52; 1.3 to 2.4). The salt decreased Na:K ratio (difference 0.32; 0.08 to 0.56, P = 0.01), and the prompts helped control weight (difference 0.39 (0.85 to 0.05) kg at one month, P = 0.085; 1.2 (0.1 to 2.25) kg at six months, P = 0.03). Among those with lower fruit and vegetable consumption (< 300 g per day), prompts increased fruit and vegetable consumption and also carotenoid concentrations (difference 143 (16 to 269) mmol/l, P < 0.03) but did not decrease blood pressure.

Conclusion During watchful waiting, over and above the effect of brief advice and monitoring, an information booklet, lifestyle prompts, and low sodium salt do not reduce blood pressure. Secondary analysis suggests that brief interventions—particularly lifestyle prompts—can make useful changes in diet and help control weight, which previous research indicates are likely to reduce the long term risk of stroke.

Objective

To assess alternatives to measuring ambulatory pressure, which best predicts response to treatment and adverse outcome.

Setting

Three general practices in England.

Design

Validation study.

Participants

Patients with newly diagnosed high or borderline high blood pressure; patients receiving treatment for hypertension but with poor control.

Main outcome measures

Overall agreement with ambulatory pressure; prediction of high ambulatory pressure (>135/85 mm Hg) and treatment thresholds.

Results

Readings made by doctors were much higher than ambulatory systolic pressure (difference 18.9 mm Hg, 95% confidence interval 16.1 to 21.7), as were recent readings made in the clinic outside research settings (19.9 mm Hg,17.6 to 22.1). This applied equally to treated patients with poor control (doctor v ambulatory 21.4 mm Hg, 17.3 to 25.4). Doctors' and recent clinic readings ranked systolic pressure poorly compared with ambulatory pressure and other measurements (doctor r=0.46; clinic 0.47; repeated readings by nurse 0.60; repeated self measurement 0.73; home readings 0.75) and were not specific at predicting high blood pressure (doctor 26%; recent clinic 15%; nurse 72%; patient in surgery 81%; home 60%), with poor likelihood ratios for a positive test (doctor 1.2; clinic 1.1; nurse 2.1, patient in surgery 4.7; home 2.2). Nor were doctor or recent clinic measures specific in predicting treatment thresholds.

Conclusion

The “white coat” effect is important in diagnosing and assessing control of hypertension in primary care and is not a research artefact. If ambulatory or home measurements are not available, repeated measurements by the nurse or patient should result in considerably less unnecessary monitoring, initiation, or changing of treatment. It is time to stop using high blood pressure readings documented by general practitioners to make treatment decisions.

What is already known on this topicProspective studies indicate that ambulatory blood pressure is a much better predictor of adverse outcome and response to treatment than readings made by a doctorPreliminary evidence suggests that measurements by doctors are likely to be higher than those made by nurses, technicians, or patientsNo study has compared all the available measures in a typical primary care setting with ambulatory blood pressure in patients with newly diagnosed and established hypertensionWhat this study addsThe white coat effect associated with measurements by doctors is not an artefact of research studies; it applies equally in primary care and for both initial diagnosis and assessment of controlIf ambulatory measurement is not possible, repeated measurement by a nurse or by the patient will result in much less unnecessary treatment or change in treatment for high blood pressure

Spatial Data Management (SDMS) is a technique for organizing, viewing and manipulating information by representing it as pictograms and positioning these pictograms in a spatial framework. SDMS can provide uniform access to data from conventional databases, user-created graphical spaces and selected computer-based medical tools. This paper describes the design of the current SDMS and explores two applications in medical care to which SDMS is particularly well-suited — medical administration and management of medical information. When SDMS techniques are applied to resource scheduling, the resulting system assists medical administrators to anticipate and plan for patient flow, staffing levels, and resource utilization. When applied to the management of medical information, SDMS provides a unified interface to diverse patient care and medical history databases.

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Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

Design Factorial randomised trial.

Setting 64 general practices in England.

Participants 579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription.

Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage -0.58, 95% confidence interval -1.94 to 0.77, six lessons -1.40, -2.77 to -0.03, 24 lessons -3.4, -4.76 to -2.03, and exercise -1.29, -2.25 to -0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score -2.98 and -4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons -18, six lessons -10, massage -7) and quality of life improved significantly. No significant harms were reported.

Conclusions One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

Trial registration National Research Register N0028108728.