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PubMed2002

Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder.

BACKGROUND: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. METHODS: We randomly assigned 115 primary care patients with panic disorder to a CC intervention that included systematic patient education and approximately 2 visits with an on-site consulting psychiatrist, compared with usual primary care. Telephone assessments of clinical outcomes were performed at 3, 6, 9, and 12 months. Use of health care services and costs were assessed using administrative data from the primary care clinics and self-report data. RESULTS: Patients receiving CC experienced a mean of 74.2 more anxiety-free days during the 12-month intervention (95% confidence interval [CI], 15.8-122.0). The incremental mental health cost of the CC intervention was $205 (95% CI, -$135 to $501), with the additional mental health costs of the intervention explained by expenditures for antidepressant medication and outpatient mental health visits. Total outpatient cost was $325 (95% CI, -$1460 to $448) less for the CC than for the usual care group. The incremental cost-effectiveness ratio for total ambulatory cost was -$4 (95% CI, -$23 to $14) per anxiety-free day. Results of a bootstrap analysis suggested a 0.70 probability that the CC intervention was dominant (eg, lower costs and greater effectiveness). CONCLUSION: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care.

Adult↗
PubMed2006

Can a costly intervention be cost-effective?: An analysis of violence prevention.

OBJECTIVES: To examine the cost-effectiveness of the Fast Track intervention, a multi-year, multi-component intervention designed to reduce violence among at-risk children. A previous report documented the favorable effect of intervention on the highest-risk group of ninth-graders diagnosed with conduct disorder, as well as self-reported delinquency. The current report addressed the cost-effectiveness of the intervention for these measures of program impact. DESIGN: Costs of the intervention were estimated using program budgets. Incremental cost-effectiveness ratios were computed to determine the cost per unit of improvement in the 3 outcomes measured in the 10th year of the study. RESULTS: Examination of the total sample showed that the intervention was not cost-effective at likely levels of policymakers' willingness to pay for the key outcomes. Subsequent analysis of those most at risk, however, showed that the intervention likely was cost-effective given specified willingness-to-pay criteria. CONCLUSIONS: Results indicate that the intervention is cost-effective for the children at highest risk. From a policy standpoint, this finding is encouraging because such children are likely to generate higher costs for society over their lifetimes. However, substantial barriers to cost-effectiveness remain, such as the ability to effectively identify and recruit such higher-risk children in future implementations.

Adolescent↗
PubMed1999

Spontaneous rupture of hepatocellular carcinoma: conservative management and selective intervention.

HYPOTHESIS: A conservative approach using selective intervention is better than an aggressive approach using nonselective intervention for ruptured hepatocellular carcinoma. DESIGN: Nonrandomized controlled trial. SETTING: A university hospital. PATIENTS AND INTERVENTIONS: From 1984 to 1990, an aggressive approach was adopted in which 29 and 8 of a total of 40 patients underwent surgical intervention or attempted transarterial embolization (TAE), respectively. From 1991 to 1997, a more conservative approach was used. The initial treatment for 72 patients was conservative with close monitoring. Additional hemostatic procedures consisting of TAE (n = 13) or surgical intervention (n = 9) were given, depending on the clinical progress, disease status, and liver function of the patients. MAIN OUTCOME MEASURES: In-hospital mortality, survival. RESULTS: In-hospital mortality rate was 62% (25 of 40 patients) in the first period and 51% (37 of 72 patients) in the second period. The respective median survival times were 7 and 12 days. If 36 patients with end-stage malignant neoplasms were excluded, the in-hospital mortality rate became 60% (18 of 30 patients) in the first period and 35% (16 of 46 patients) in the second period (P = .03, chi2 test). The respective median survival times became 8 and 72 days (P = .02, log rank test). In the second period, 7 (54%) of 13 patients who underwent TAE and 1 (11%) of 9 patients who underwent surgical intervention died within the same hospital admission (P = .07, Fisher exact test). CONCLUSIONS: Selective intervention was cost-effective and gave better results than an aggressive approach. When intervention was indicated for hemostasis, surgery seemed better than TAE although the difference was not statistically significant.

Carcinoma, Hepatocellular↗
PubMed1999

Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults.

CONTEXT: The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due, in part, to the excessive use of antibiotics for acute respiratory tract infections. OBJECTIVE: To decrease total antibiotic use for uncomplicated acute bronchitis in adults. DESIGN: Prospective, nonrandomized controlled trial, including baseline (November 1996-February 1997) and study (November 1997-February 1998) periods. SETTING: Four selected primary care practices belonging to a group-model health maintenance organization in the Denver, Colo, metropolitan area. PARTICIPANTS: Consecutive adults diagnosed as having uncomplicated acute bronchitis. A total of 2462 adults were included at baseline and 2027 adults were included in the study. Clinicians included 56 physicians, 28 physician assistants or nurse practitioners, and 9 registered nurses. INTERVENTION: The full intervention site received household and office-based patient educational materials, as well as a clinician intervention consisting of education, practice-profiling, and academic detailing. A limited intervention site received only office-based educational materials, and control sites provided usual care. MAIN OUTCOME MEASURE: Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods. RESULTS: Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period. During the study period, there was a substantial decline in antibiotic prescription rates at the full intervention site (from 74% to 48% [P = .003]), but not at the control and limited intervention sites (78% to 76% [P = .81] and 82% to 77% [P = .68], respectively). Compared with control sites, changes in nonantibiotic prescriptions (inhaled bronchodilators, cough suppressants, and analgesics) were not significantly different for intervention sites. Return office visits (within 30 days of the incident visit) for bronchitis or pneumonia did not change significantly for any of the sites. CONCLUSIONS: Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions.

Acute Disease↗
PubMed2005

Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial.

CONTEXT: Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings. OBJECTIVE: To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States. INTERVENTION: Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients' depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment. MAIN OUTCOME MEASURES: Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. Secondary outcomes were mental health-related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale. RESULTS: Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean [SD] CES-D scores, 19.0 [11.9] vs 21.4 [13.1]; P = .02), higher mental health-related quality of life (mean [SD] MCS-12 scores, 44.6 [11.3] vs 42.8 [12.9]; P = .03), and greater satisfaction with mental health care (mean [SD] scores, 3.8 [0.9] vs 3.5 [1.0]; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007). CONCLUSIONS: A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.

Adolescent↗
PubMed2000

Interventions to promote collaboration between nurses and doctors.

BACKGROUND: Lack of nurse-doctor collaboration contributes to problems in quality and efficiency of patient care. OBJECTIVES: To assess the effects of interventions designed to improve nurse-doctor collaboration. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register and database of studies awaiting assessment, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, the Database of Abstracts of Reviews of Effectiveness, MEDLINE, and reference lists of articles up to the end of October 1999. SELECTION CRITERIA: Randomised trials, controlled before-and-after studies and interrupted time series of interventions to improve collaboration between nursing and medical professionals sharing patient care in primary or hospital care settings. DATA COLLECTION AND ANALYSIS: One reviewer assessed the eligibility of potentially relevant studies, extracted data and assessed the quality of included studies; a second reviewer undertook duplicate assessments on the eligibility of some articles and data abstraction on all included studies. MAIN RESULTS: Two trials involving 1945 people were included. One six month trial involving 1102 admissions evaluated daily, structured, team ward rounds, in which nurses, doctors and other professionals made care decisions jointly. There was shortened average length of hospital stay (LOS) from 6.06 to 5.46 days, and reduced hospital charges from US$ 8090 to 6681. There were no differences in mortality rates or the type of care to which patients were discharged. Another three month trial involving 843 admissions compared two female wards and evaluated a four times per week round. There were no significant differences between the intervention and control wards in total average length of stay for all patients (11.7 days in intervention ward versus 11.6 in the control ward). Excluding patients who died in hospital revealed shortened length of stay in the intervention ward (intervention ward 10.5 days, control ward 11.9). Mortality rates were not significantly different. REVIEWER'S CONCLUSIONS: Increasing collaboration improved outcomes of importance to patients and to health care managers. These gains were moderate and affected health care processes rather than outcomes. Further research is needed to confirm these findings. The logistic challenge presented by the complexity of the interventions and the need for large sample sizes due to the likely modest impact and rarity of outcome events may best be met by multi-centre studies. Before launching such studies qualitative research is needed to identify barriers to collaboration. Interventions other than nurse-doctor ward rounds and team meetings should also be tested.

Cooperative Behavior↗
PubMed2006

Interventions for preventing oral mucositis for patients with cancer receiving treatment.

BACKGROUND: Treatment of cancer is increasingly more effective but is associated with short and long-term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). OBJECTIVES: To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. SEARCH STRATEGY: The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Date of most recent searches: April 2004. SELECTION CRITERIA: Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral mucositis; outcomes - prevention of mucositis, pain, amount of analgesia, dysphagia, systemic infection, length of hospitalisation, cost and patient quality of life. DATA COLLECTION AND ANALYSIS: Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models. MAIN RESULTS: Two hundred and two studies were eligible. One hundred and thirty two were excluded for various reasons, usually as there was no useable information on mucositis. Of the 71 useable studies all had data for mucositis comprising 5217 randomised patients. Interventions evaluated were: acyclovir, allopurinol mouthrinse, aloe vera, amifostine, antibiotic pastille or paste, benzydamine, beta carotene, calcium phosphate, camomile, chlorhexidine, clarithromycin, folinic acid, glutamine, GM-CSF, honey, hydrolytic enzymes, ice chips, iseganan, keratinocyte GF, misonidazole, oral care, pentoxifylline, povidone, prednisone, propantheline, prostaglandin, sucralfate, traumeel and zinc sulphate. Of the 29 interventions included in trials, 10 showed some evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis. Interventions where there was more than one trial in the meta-analysis finding a significant difference when compared with a placebo or no treatment were: amifostine which provided minimal benefit in preventing moderate and severe mucositis RR = 0.84 (95% confidence interval (CI) 0.75 to 0.95) and 0.60 (95% CI 0.37 to 0.97), antibiotic paste or pastille demonstrated a moderate benefit in preventing mucositis RR = 0.87 (95% CI 0.79 to 0.97), hydrolytic enzymes reduced moderate and severe mucositis with RRs = 0.52 (95% CI 0.36 to 0.74) and 0.17 (95% CI 0.06 to 0.52), and ice chips prevented mucositis at all levels RR = 0.63 (95% CI 0.44 to 0.91), 0.43 (95% CI 0.23 to 0.81), 0.27 (95% CI 0.11 to 0.68). Other interventions showing some benefit with only one study were: benzydamine, calcium phosphate, honey, oral care protocols, povidone and zinc sulphate. The number needed to treat (NNT) to prevent one patient experiencing moderate or severe mucositis over a baseline incidence of 60% for amifostine is 10 (95% CI 7 to 33), antibiotic paste or pastille 13 (95% CI 8 to 56), hydrolytic enzyme 4 (95% CI 3 to 6) and ice chips 5 (95% CI 3 to 19). When the baseline incidence is 40%/90% the NNTs for amifostine are 16/7, for antibiotic paste or pastille 19/7, for hydrolytic enzyme 5/3 and for ice chips 7/3. The general reporting of RCTs was poor. However, the assessments of the quality of the randomisation improved when the authors provided additional information. AUTHORS' CONCLUSIONS: Several of the interventions were found to have some benefit at preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for well designed and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Antifungal Agents↗
PubMed2004

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery.

BACKGROUND: Post-operative atrial fibrillation is a common complication of cardiac surgery and has been associated with increased incidence of other complications including post-operative stroke, increased hospital length of stay and increased cost of hospitalisation. Prevention of atrial fibrillation is a reasonable clinical goal and, consequently, many randomised trials have evaluated the effectiveness of pharmacological and non-pharmacological interventions. We systematically reviewed the literature and prepared meta-analyses to better understand the role and effects of various prophylactic therapies against post-operative atrial fibrillation. OBJECTIVES: To assess the effects of pharmacological and non-pharmacological interventions for preventing post-cardiac surgery atrial fibrillation. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE and CINAHL from earliest achievable date to June 2003. We hand searched references from reports and earlier reviews. We searched abstract books and CD-ROMs from annual scientific meetings of American College of Cardiology, American Heart Association, North American Society of Pacing and Electrophysiology and European Heart Organization between 1997-2003. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials comparing pharmacological interventions or non-pharmacological interventions with control treatment, placebo or usual care for the prevention of post-operative atrial fibrillation in post-coronary artery bypass grafting or combined CABG and valvular surgery. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Fifty eight studies were included with a total of 8565 participants. Interventions included were amiodarone, beta blockers, solatol and pacing. Results favoured treatment for post-operative atrial fibrillation. The data for stroke favoured treatment by a non-significant effect size of 0.81, 95% confidence interval 0.51 to 1.28. Similarly, a positive indication for length of stay was derived but it too was not significant with a weighted mean difference of -0.66, 95% confidence interval -0.95 to -0.37. A positive result for cost of hospitalisation in favour of treatment was achieved, but the statistic is not significant due to low power and large standard deviations: a weighted mean difference of -2717, 95% confidence interval 7518 to 2084. Beta-blockers had the greatest magnitude of effect across 28 trials (4074 patients) with an odds ratio (random) of 0.35, 95% confidence interval 0.26 to 0.49. Across all treatment, the odds ratio favoured treatment with a ratio (random) of 0.43, 95% confidence interval 0.37 to 0.51. REVIEWERS' CONCLUSIONS: Intervention is favoured across the three pharmacological interventions studied and the one non-pharmacological intervention, pacing. The length of stay data favoured treatment (-0.66, 95% confidence interval -0.95 to -0.37).

Adrenergic beta-Antagonists↗
PubMed2004

Interventions to improve adherence to lipid lowering medication.

BACKGROUND: Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this review we focus on interventions, which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly. OBJECTIVES: To assess the effect of interventions aiming at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycInfo and CINAHL. Date of most recent search was in February 2003. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials of adherence-enhancing interventions to lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data independently and assessed studies according to criteria outlined by the Cochrane Reviewers' Handbook. MAIN RESULTS: The eight studies found contained data on 5943 patients. Interventions could be stratified into four categories : 1. simplification of drug regimen, 2. patient information/education, 3. intensified patient care such as reminding and 4. complex behavioural interventions such as group sessions. Change in adherence ranged from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Three studies reported significantly improved adherence through simplification of drug regimen (category 1), improved patient information/education (category 2) and reminding (category 3). The fact that the successful interventions were evenly spread across the categories, does not suggest any advantage of one particular type of intervention. The methodological and analytical quality was generally low and results have to be considered with caution. Combining data was not appropriate due to the substantial heterogeneity between included randomised controlled trials (RCTs). REVIEWERS' CONCLUSIONS: At this stage, no specific intervention aimed at improving adherence to lipid lowering drugs can be recommended. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow-up. Increased patient-centredness with emphasis on the patient's perspective and shared-decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.

Cardiovascular Diseases↗
PubMed2004

Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings.

BACKGROUND: Lack of adherence to blood pressure lowering medication is a major reason for poor control of hypertension worldwide. Interventions to improve adherence to antihypertensive medication have been evaluated in randomised trials but it is unclear which interventions are effective. OBJECTIVES: To determine the effectiveness of interventions aiming to increase adherence to blood pressure lowering medication in adults with high blood pressure SEARCH STRATEGY: All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, and CINAHL in April 2002. SELECTION CRITERIA: RCTs of interventions to increase adherence to blood pressure lowering medication in adults with essential hypertension in primary care, with adherence to medication and blood pressure control as outcomes DATA COLLECTION AND ANALYSIS: Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook. MAIN RESULTS: We included 38 studies testing 58 different interventions and containing data on 15519 patients. The studies were conducted in nine countries between 1975 and 2000. The duration of follow-up ranged from two to 60 months. Due to heterogeneity between studies in terms of interventions and the methods used to measure adherence, we did not pool the results. Simplifying dosing regimens increased adherence in seven out of nine studies, with a relative increase in adherence of 8 per cent to 19.6 per cent. Motivational strategies were successful in 10 out of 24 studies with generally small increases in adherence up to a maximum of 23 per cent. Complex interventions involving more than one technique increased adherence in eight out of 18 studies, ranging from 5 per cent to a maximum of 41 per cent. Patient education alone seemed largely unsuccessful. REVIEWERS' CONCLUSIONS: Reducing the number of daily doses appears to be effective in increasing adherence to blood pressure lowering medication and should be tried as a first line strategy, although there is less evidence of an effect on blood pressure reduction. Some motivational strategies and complex interventions appear promising, but we need more evidence on their effect through carefully designed RCTs.

Antihypertensive Agents↗
PubMed2005

Policy interventions implemented through sporting organisations for promoting healthy behaviour change.

BACKGROUND: Sporting organisations provide an important setting for health promotion strategies that involve policies, communication of healthy messages and creation of health promoting environments. The introduction of policy interventions within sporting organisations is one strategy to target high risk behaviours such as smoking, alcohol consumption, excess sun exposure, unhealthy eating and discrimination. OBJECTIVES: To review all controlled evaluation studies of policy interventions organised through sporting settings to increase healthy behaviour (related to smoking, alcohol, healthy eating, sun protection, discrimination, safety and access). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsyclNFO, CINAHL, SPORTDiscus, Sociological Abstracts, Dissertation Abstracts, freely available online health promotion and sports-related databases hosted by leading agencies, and the internet using sport and policy-related key words. We identified further studies in the bibliographies of articles and by contacting authors of key articles in the area. SELECTION CRITERIA: We aimed to identify research that had used study designs that incorporated an evaluated intervention and comparison. Uncontrolled studies, meeting other inclusion criteria, were to be reported in an annex to the review. Types of studies: Studies in which sporting organisations were allocated to a policy intervention or control/comparison group. No minimum follow-up required. TYPES OF PARTICIPANTS: People of all ages. Types of interventions: Any policy intervention implemented through sporting organisations to instigate and/or sustain healthy behaviour change, intention to change behaviour, or changes in attitudes, knowledge or awareness of healthy behaviour. Policies must address any of the following: smoking, alcohol, healthy eating, sun protection, access for disadvantaged groups, physical safety (not including injuries), and social and emotional health (e.g.. anti-vilification, anti-discrimination). Types of outcome measures: Behaviour change, intention to change behaviour, change in attitudes, knowledge or awareness of healthy behaviour, and policy presence. DATA COLLECTION AND ANALYSIS: We assessed whether identified citations were controlled evaluation studies and investigated the use of policy implemented in sporting settings. Abstracts were independently inspected by two reviewers and full papers were obtained where necessary. As no controlled evaluation studies were located, no data collection or analysis was undertaken. No uncontrolled studies meeting other inclusion criteria were identified and therefore no annex is presented. MAIN RESULTS: No rigorous studies were located to test the effectiveness of policy interventions organised through sporting organisations to increase healthy behaviours, attitudes, knowledge or inclusion of health oriented policies within the organisations. AUTHORS' CONCLUSIONS: We were unable to find any controlled studies to guide the use of policy interventions used in sporting settings. The search process revealed a number of case studies with anecdotal reporting of outcomes. We strongly recommend that rigorous evaluation techniques are employed more commonly in this field to illuminate the impact of health promoting policy on outcomes, and the contexts and processes which are likely to be effective in reducing harmful behaviours.

Alcohol Drinking↗
PubMed2005

Interventions implemented through sporting organisations for increasing participation in sport.

BACKGROUND: There is now compelling scientific evidence that increased levels of physical activity can bring wide-ranging health benefits. These benefits can extend beyond physical health and include other positive impacts relating to mental health and personal development. The sport and recreation sector is viewed as a priority area for increasing rates of physical activity. Participation rates have been shown to be lower in females, decline with age, and are reduced in lower socio-economic and minority groups. It is important to determine the most effective interventions that sporting organisations can use to increase participation. OBJECTIVES: To review all controlled evaluation studies of interventions organised through sporting settings to increase participation. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsyclNFO, CINAHL, SPORTDiscus, Sociological Abstracts, Dissertation Abstracts, and a number of freely-available online health promotion and sports-related databases. The internet was used extensively to search for studies and locate information generated by sporting bodies throughout the world. SELECTION CRITERIA: Types of studies: Controlled evaluation studies. No minimum follow-up required. Uncontrolled studies, meeting other inclusion criteria, were to be reported in an annex to the review. TYPES OF PARTICIPANTS: People of all ages. Types of interventions: Any intervention designed to increase active and/ or non-active participation in sport. These could include: mass media campaigns; information or education sessions; management or organisational change strategies; policy changes, for example to improve the socio-cultural environment to encourage people of specific age, gender or ethnicity to participate; changes to traditional or existing programs, for example club or association-initiated rule modification programs; provision of activities beyond traditional or existing programs, for example 'Come and Try' initiatives (teaser or taster programs); skill improvement programs; volunteer encouragement programs. Types of outcome measures: Change in the number of (active and non-active) participants in organised sport, change in status from non-participating to non-active or active participation, change in status from non-active to active participation. DATA COLLECTION AND ANALYSIS: We assessed whether identified citations were controlled evaluation studies which investigated the use of interventions implemented in sporting settings to increase participation. Two reviewers independently inspected abstracts. We obtained full papers where necessary. As no controlled evaluation studies were located, no data collection or analysis was undertaken. No uncontrolled studies meeting other inclusion criteria were identified and therefore no annex is presented. MAIN RESULTS: Despite a thorough review of the published and unpublished literature, we were unable to locate any rigorous studies which tested the effects of interventions organised through sporting organisations to increase participation in sport. AUTHORS' CONCLUSIONS: There is an absence of high quality evidence to support interventions designed and delivered by sporting organisations to increase participation in sport. Interventions funded and conducted in this area must be linked to a rigorous evaluation strategy in order to examine overall effectiveness, sociodemographic differentials in participation and cost-effectiveness of these strategies.

Exercise↗
PubMed2006

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted. OBJECTIVES: To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests. SELECTION CRITERIA: Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software. MAIN RESULTS: Twenty eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (on self-reported pain, SMD -0.24 (95% CI -0.45 to -0.04), combined cognitive-behavioral interventions--reduced other-reported distress (SMD -0.88, 95% CI -1.65 to -0.12; and behavioral measures of distress (SMD -0.67, 95% CI -0.95 to -0.38) with hypnosis being the most promising--self-reported pain (SMD -1.47, 95% CI -2.67 to -0.27), with promising but limited evidence for the efficacy of numerous other psychological interventions, such as information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion. AUTHORS' CONCLUSIONS: Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

Adolescent↗
PubMed2005

Psychosocial interventions for conversion disorder.

BACKGROUND: Conversion disorder is an alteration or loss of physical functioning suggestive of a physical disorder that is thought to be due to a psychological stressor or conflict. The fact that many theories about the cause of conversion disorder focus on psychological and social factors would suggest that a psychosocial intervention might be of most benefit. OBJECTIVES: To investigate the efficacy of psychosocial interventions on people diagnosed with conversion disorder compared with standard care, a biological intervention or another psychosocial intervention. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety and Neurosis Group Trials Register (May 2004), various databases on OVID (February 2004), handsearched reference lists and textbooks on conversion disorder and contacted relevant authors. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion disorder with standard care or other interventions (biological or psychosocial). DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and extracted data from the studies. For dichotomous outcomes we calculated a relative risk with its associated 95% confidence interval and a number needed to treat. For continuous data we calculated a weighted mean difference. MAIN RESULTS: The search identified 260 references, 217 were clearly not relevant to this review and excluded on the basis of their titles and abstracts, 40 more were excluded after reading the full papers (the reasons are given in the excluded studies tables) and only three studies (total n =119) met the inclusion criteria. One study was concerned with paradoxical injunction therapy and the other two studied the value of hypnosis. The three studies had different interventions and control groups so the results could not be combined. All of the studies were of poor methodological quality and it is therefore difficult to place much value on the results of the studies. We were unable to include some data because of poor reporting. AUTHORS' CONCLUSIONS: Randomised studies are possible in this field. The use of psychosocial interventions for conversion disorder requires more research and it is not possible to draw any conclusions about their potential benefits or harms from the included studies.

Anti-Anxiety Agents↗
PubMed2005

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes.

BACKGROUND: Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers. OBJECTIVES: To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included. SELECTION CRITERIA: Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken. MAIN RESULTS: We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant. AUTHORS' CONCLUSIONS: Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

Humans↗
PubMed2007

Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review.

BACKGROUND: Wandering occurs in 15-60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices. OBJECTIVE: To determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia. DESIGN: A systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought. RESULTS: (i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable. CONCLUSIONS: In order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials.

Aged↗
PubMed2006

A Bayesian approach to analysing the cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening.

AIMS: To assess the cost-effectiveness of two primary care interventions, a letter and a flag, aimed at improving attendance for breast screening among (i) all women invited for breast screening and (ii) non-attenders. METHODS: A probabilistic decision analytic model was developed using Markov chain Monte Carlo simulation implemented in WinBUGS. The model was populated using economic and effectiveness data collected alongside two randomised controlled trials. RESULTS: For all women invited, the incremental cost-effectiveness ratio (ICER) for the letter compared with no intervention is 27 pounds per additional attendance, and the ICER for the combined letter and flag intervention compared to the letter alone is 171 pounds. The corresponding ICERs for non-attenders are 41 pounds and 90 pounds. The flag intervention is an inefficient option in both settings. A large proportion of the costs fall on the practices (25-67%), depending on the intervention and target population. The total costs incurred do not, however, seem prohibitive. Expected value of perfect information suggests that there is greater value in carrying out further research on the intervention implemented among all women invited for breast screening rather than on non-attenders. CONCLUSIONS: The flag intervention alone does not appear to be an efficient option. The choice between the letter and both interventions combined is subjective, depending on the willingness to pay for an additional screening attendance.

Bayes Theorem↗
PubMed2005

Group-based HIV risk reduction intervention for adolescent girls: evidence of feasibility and efficacy.

The purposes of this pilot study were (a) to assess the feasibility of a community-based, small group HIV risk reduction intervention with adolescent girls, and (b) to obtain preliminary evidence of the efficacy of this theoretically-guided intervention using a controlled design. The feasibility of the intervention was demonstrated by successfully implementing it with 33 sexually-active, single girls. Preliminary evidence of the efficacy of the intervention was obtained using a randomized trial with 62 sexually-active, single girls. Data obtained at a 3-month follow-up assessment showed that girls who received the HIV-related intervention improved their HIV-related knowledge and enhanced their motivation for risk reduction compared to girls who received a control (health promotion) intervention. Effect sizes suggest that the HIV intervention also reduced several risk behaviors (e.g., vaginal sex without a condom, giving oral sex, and alcohol and drug use before sex). Challenges to implementation and suggestions for intervention enhancement are discussed.

Adolescent↗