Collaborative Care Framework Research Articles

Neonatal respiratory care practice among level III and IV NICUs in New England.

To assess respiratory care guidelines and explore variations in management of very low birth weight (VLBW) infants within a collaborative care framework. Additionally, to gather clinical leaders' perspectives on guidelines and preferences for ventilation modalities. Leaders from each NICU participated in a practice survey regarding the prevalence of unit clinical guidelines, and management, at many stages of care. Units have an average of 4.3 (±2.1) guidelines, of 9 topics queried. Guideline prevalence was not associated with practice or outcomes. An FiO2 requirement of 0.3-0.4 and a CPAP of 6-7 cmH2O, are the most common thresholds for surfactant administration, which is most often done after intubation, and followed by weaning from ventilatory support. Volume targeted ventilation is commonly used. Extubation criteria vary widely. Results identify trends and areas of variation and suggest that the presence of guidelines alone is not predictive of outcome.

A Call for Integrated Psychiatry-Psychology Collaboration on Consult-Liaison Services: Experiences of a Psychology Extern and Recommendations for Collaborative Care.

Few institutions have integrated psychologists into consult-liaison (CL) psychiatry services caring for patients with medical conditions and comorbid serious mental illnesses (SMI). To our knowledge, no studies have explored the experiences of an integrated pre-doctoral psychologist on a CL psychiatry service and applications of collaborative care. The present study aims to 1) highlight the experiences of a psychology extern on an adult CL psychiatry service in a public academic hospital, and 2) apply a collaborative care framework to provide recommendations for implementing integrated psychiatry-psychology collaboration. A semi-structured qualitative interview was performed with the team's psychology extern to elicit practice goals and setting. As of June 2022, the psychology extern saw 76 inpatient adults over the year-long externship period. Through diverse case vignettes, we illustrate the extern's unique roles in providing psychotherapeutic interventions to enhance patients' coping skills. We further found that embedding a psychology extern within the CL psychiatry service follows the integrated model of collaborative care. We thus apply a collaborative care framework to guide CL services in using multidisciplinary teams to improve care quality for inpatient adults. Leveraging the expertise of a psychology extern in real-time collaboration with CL psychiatry teams can enhance patient-centered care and warrants broader institutional implementation. Future studies are needed to explore the efficacy of integrated psychiatry-psychology collaboration on provider perspectives and clinical outcomes.

Collaborative Care - empowering community in the development of rural primary health workforce and service delivery models.

Across Australia, providing sustainable primary care services in small rural communities (<1000 population) has been increasingly challenging. It is acknowledged that health system planners must take coordinated action to strengthen systems to enable a community-empowered response to such challenges. In partnership with the Australian Government, Collaborative Care is a whole-of-system approach used in five Australian rural sub-regions to align communities, organisations, policy and funding levers with a common purpose in health workforce and service planning (article here). A synthesis of field observations and experiences of community and jurisdictional partners in planning and implementing a Collaborative Care model. In this presentation, we report on the success factors and challenges in developing models for improved rural primary health care access. Successes include sustained community participation, improved community health workforce literacy, coordination of stakeholders and resources across health and community systems combined with health service planning expertise. Challenges include the time and investment to build a coordinated partnership approach and in identifying mechanisms for ongoing financial sustainability. Including community as a partner in design and implementation is a key enabler for achieving a tailored primary health workforce and service delivery model that is acceptable and trusted by communities. The Collaborative Care approach strengthens community through capacity building and integrating existing resources across both primary and acute care services to achieve an innovative and quality rural health workforce model built around the concept of rural generalism. Identifying mechanisms for sustainability will enhance the usefulness of the Collaborative Care Framework.

Nurse champions as leaders for the implementation of CoACT Collaborative Care.

This is the first paper describing the unit level champion role in order to implement the Collaborative Care framework as an evidence-based practice in the province of Alberta. The clear selection criteria of Unit Lead, funding (.2 FTE) that allows for the dedication of the role, support with various education, coaching from the project management team, and community of practices were suggested as important factors for successful utilization of Unit Leads to implement quality improvement initiatives in a large scale. Future initiatives may consider using a peer-leader champion as a change agent who is committed to the change initiative, credible and personally connected to the unit staff, possesses knowledge about the organizational culture, and develops a unit-tailored strategy via performance monitoring data to fully implement an evidence-based practice for quality care.

A psychological intervention by community pharmacies to prevent depression in adults with subthreshold depression and long-term conditions: the CHEMIST pilot RCT

Background Depression is common in people with long-term health conditions, and this combination can lead to worsened health outcomes and increased health-care costs. Subthreshold depression, a risk factor for major depression, is prevalent in this population, but many people remain untreated due to the demand on services. The community pharmacy may be an alternative setting to offer mental health support; however, insufficient evidence exists to support implementation. Objectives To conduct a feasibility study and pilot randomised controlled trial of a community pharmacy-delivered psychological intervention aimed at preventing depression in adults with long-term health conditions. Design A feasibility study with nested qualitative evaluation and an external pilot, two-arm, 1 : 1 individually randomised controlled trial with nested process and economic evaluations. Setting Community pharmacies in the north of England. Participants Adults aged ≥ 18 years with subthreshold depression and at least one long-term health condition. Intervention A bespoke enhanced support intervention (behavioural activation within a collaborative care framework) involving up to six sessions delivered by trained community pharmacy staff (intervention facilitators) compared with usual care. Main outcome measures Recruitment and retention rates, completeness of outcome measures and intervention engagement. The intended primary outcome was depression severity at 4 months, assessed by the Patient Health Questionnaire-9. Results In the feasibility study, 24 participants were recruited. Outcome measure completeness was 95–100%. Retention at 4 months was 83%. Seventeen participants (71%) commenced intervention sessions and all completed two or more sessions. Depression symptoms reduced slightly at 4 months. The process evaluation suggested that the intervention was acceptable to participants and intervention facilitators. In the pilot randomised controlled trial, 44 participants (target of 100 participants) were randomised (intervention, n = 24; usual care, n = 20). Outcome measure completeness was 100%. Retention at 4 months was 93%. Eighteen participants (75%) commenced intervention sessions and 16 completed two or more sessions. Depression symptoms reduced slightly at 4 months, with a slightly larger reduction in the usual-care arm, although the small sample size limits any conclusions. The process evaluation reported good acceptability of the intervention and identified barriers associated with study implementation and its impact on core pharmacy functions. The economic analysis revealed some indication of reduced resource use/costs associated with the intervention, but this is limited by the small sample size. Intervention costs were low. Limitations The main limitation is the small sample size due to difficulties with recruitment and barriers to implementing the study within existing pharmacy practices. Conclusions The community pharmacy represents a new setting to deliver a depression prevention intervention. Recruitment was a challenge and pharmacy staff encountered barriers to effective implementation of the study within busy pharmacy practice. Despite these challenges, good retention rates and intervention engagement were demonstrated, and process evaluation suggested that the intervention was acceptable in this setting. To the best of our knowledge, this is the first study to demonstrate that community pharmacy staff can be trained to deliver a depression prevention intervention. Future work Further work is needed to address barriers to recruitment, intervention delivery and implementation of psychological interventions in the community pharmacy setting. Trial registration This trial is registered as ISRCTN11290592. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

The feasibility and acceptability of a brief psychological intervention for adults with long-term health conditions and subthreshold depression delivered via community pharmacies: a mixed methods evaluation\u2014the Community Pharmacies Mood Intervention Study (CHEMIST)

BackgroundAdults with long-term health conditions (LTCs) are more likely to experience depressive symptoms which can worsen health outcomes and quality of life, and increase healthcare costs. Subthreshold depression may go undetected and/or untreated.The Community Pharmacies Mood Intervention Study (CHEMIST) explored whether community pharmacies represent a suitable setting to offer brief psychological support to people with LTCs and comorbid subthreshold depression.MethodsA feasibility intervention study with a nested mixed methods evaluation was employed. Adults with subthreshold depression and a minimum of one LTC were recruited from community pharmacies/local general practices and offered a brief psychological support intervention (‘Enhanced Support Intervention’ (ESI)), based on behavioural activation within a Collaborative Care framework. The intervention included up to six sessions supported by pharmacy staff (‘ESI facilitators’) trained to deliver the ESI within the community pharmacy setting.Recruitment, retention rates and engagement with the ESI were assessed. Semi-structured, one-to-one interviews with pharmacy staff and study participants, and a focus group with pharmacy staff, explored experiences and acceptability of the study and the ESI. Themes were mapped onto constructs of the Theoretical Framework of Acceptability.ResultsRecruitment of ESI participants was challenging and slower than anticipated despite the varied methods of recruitment employed; although, this was useful in identifying barriers and enabling factors for participation. Engagament with the ESI was good with n=17 (71%) recruited participants commencing the ESI. The ESI was found to be acceptable to participants and ESI facilitators. Retention rate at 4 months was good n=20 (87.0%).The main barriers to identifying potential participants for pharmacy staff were lack of time, resources and limited experience in research. The ESI training and support manual were acceptable to ESI facilitators. The ESI and supporting patient workbook were acceptable to people with LTCs and subthreshold depression.ConclusionsCommunity pharmacies were viewed as an acceptable setting in which to deliver preventative brief psychological support to people with LTCs at risk of depression.This feasibility study provided important data to inform the design of a pilot randomised controlled trial in this setting and highlighted important considerations for future pharmacy-based research.Trial registrationISRCTN11290592

Impact of Integrated Care Pathways Within the Framework of Collaborative Care on Older Adults With Anxiety, Depression, or Mild Cognitive Impairment

To evaluate the impact of an Integrated Care Pathway (ICP) within a collaborative care framework for anxiety, depression and mild cognitive impairment (MCI) on clinical outcomes, quality of life, and time to treatment initiation. Prospective Cohort study. Primary care practices in Toronto and Hamilton, Ontario, Canada. Patients of participating primary care practices born in the years 1950 to 1958. Target 150 participants, 75 in ICP and 75 in Treatment-As-Usual (TAU) arm. ICP within a collaborative care framework and TAU. One hundred forty-five participants with anxiety, depression or MCI, from five primary care practices were enrolled: 69 were managed as per ICP and 76 as per TAU. All underwent outcome assessments at 6, 12, 18, and 24 months. Compared to TAU, ICP participants had a significantly higher rate of improvement in depression symptoms (β=-0.620, F (1, 256)=4.10, p=0.044), anxiety symptoms (β=-0.593, F (1, 223)=4.00, p=0.047), and quality of life (β=1.351, F(1, 358)=6.58, p=0.011). The ICP group had also a significantly higher "hazard" of treatment initiation (HR=3.557; 95% CI: [2.228, 5.678]; p < 0.001) after controlling for age, gender and baseline severity of symptoms compared to TAU group. Use of an ICP within a collaborative care framework in primary care settings for anxiety, depression and MCI among older adults, results in faster reductions in clinical symptoms and improvement in quality of life compared to usual care, as well as faster access to recommended treatments.

Collaborative care: Primary health workforce and service delivery in Western New South Wales-A case study.

ObjectiveTo explore how four small towns in rural New South Wales known as the 4Ts are addressing challenges accessing quality care and sustainable health services through a collaborative approach to workforce planning using the collaborative care framework.DesignDescriptive case study approach.SettingThe collaborative care project was developed as a result of ongoing partnerships between 2 rural Local Health Districts, 2 Primary Health Networks and a non‐governmental health workforce organisation. The collaboration works with 5 subregions each comprising 2 or more rural communities. This paper focuses on the 4Ts subregion.ParticipantsStakeholders of the collaborative design including organisations and the community.InterventionA place‐based approach to co‐designing health services with community in one sub‐region of Western New South Wales.Main outcome measuresA synthesis of field observations and experiences of community and jurisdictional partners in implementation of the 4Ts subregional model. Mapping of implementation processes against the collaborative care framework.ResultsThe collaborative care framework is a useful planning and community engagement tool to build health workforce literacy and to impact on system change at the local level. We identify key elements of effectiveness in establishing the 4Ts model, including the need for coordinated health system planning, better integrating existing resources to deliver services, community engagement, building health workforce literacy and town‐based planning.ConclusionThis study adds to the body of knowledge about how to successfully develop a collaborative primary health care workforce model in practice. The findings demonstrate that the implementation of a collaborative primary health care workforce model using the collaborative care framework can improve service access and quality, which in turn might facilitate workforce sustainability.

The effect of collaborative care on treatment outcomes of newly diagnosed tuberculosis patients with Type-2 diabetes mellitus and adverse drug reaction presentations: A prospective study.

The burdens of tuberculosis (TB) and diabetes mellitus (DM) in Nigeria are high. DM often goes unrecognized in TB patients, resulting in poorer treatment outcomes compared with TB patients only. This study set out to compare TB treatment outcomes and associated factors in TB only and TBDM patients when a collaborative care (CC) model is in place. A prospective quasi-experimental study, modeled after the World Health Organization and The Union's Collaborative Framework for Care and Control of TB and DM was carried out among TB patients in two chest clinics in Lagos state. Patients were grouped into TB only, who received the usual TB care, directly observed treatment, short course (DOTS), and TBDM, who received DOTS and CC. Data were analyzed with IBM Statistical Package for the Social Sciences, version 23.0. Chi-square and multivariate analysis determined the association between treatment success and CC. Statistical tests were calculated at 95% confidence intervals and considered significant when P value is < 0.05. Of 671 participants in the study, 52 (7.7%) had DM. At TB treatment completion, there was no statistically significant difference in outcomes between TBDM and TB-only patients (P = 0.40). Patients who received CC were about 32 (OR: 31.60, 95% CI: 3.38-293), and 5 times (OR: 5.08, 95% CI: 1.35-19.17) more likely to achieve success and cure, respectively, compared to those who did not. Provision of CC with DOTS ensured improved TB treatment outcomes in TBDM patients. Recommendations of WHO/The Union are feasible in our setting.

A Collaborative Framework With Artificial Intelligence for Long-Term Care

The trend of aging population among working families has made health care services for sub-healthy people more important. In Taiwan, caregivers are often hired by human resource agencies to provide long-term care, and they are the main supervisors responsible for the care of the sub-healthy people. However, most agencies only consider the cost of their caregivers and have insufficient staff to take care of the sub-healthy people, leading to the failure of the long-term care system. The lack of an effective collaborative framework for long-term care leads to sub-healthy people being at high risks. Existing frameworks for long-term care are still in the early stages of capturing suitability information dynamically. This paper proposes a new framework that includes all possible features suitable to support the needs of all sub-healthy people and provides a solution for the issue of determining suitable features for collaboration. This study applies association rules to long-term care to handle the mapping process and uses artificial intelligence technology to solve the issues of adjusting human variability dynamically based on the mapping result of sub-healthy people.

How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial

BackgroundDepression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.MethodsA qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients’ and professionals’ views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory.ResultsThirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation.ConclusionsA telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs’ understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.

Payment Reform to Enhance Collaboration of Primary Care and Cardiology

The US health care system faces an unsustainable trajectory of high costs and inconsistent outcomes. The fee-for-service payment model has contributed to inefficiency, and new payment methods are a promising approach to improving value. Health reforms are needed to increase patient access, reduce costs, and improve health care quality, and the landmark Medicare Access and CHIP Reauthorization Act presents a roadmap for reform. The product of a collaboration between primary care and cardiology clinicians, this review describes a conceptual approach to delivery and payment reforms that aim to better support primary care-cardiology comanagement of chronic cardiovascular disease (CVD). Few existing alternative payment models specifically address long-term management of CVD. Primary care medical homes and accountable care organizations come closest, but both emphasize primary care, and cardiologists have often not been well engaged. A collaborative care framework should articulate distinct roles and responsibilities for primary care and cardiology in CVD comanagement. Finally, a series of payment models aim to better support clinicians in providing accountable, seamless, and patient-centered cardiac care. Clinical leadership is essential during this time of change in the health care system. Patients often struggle to navigate a fragmented and expensive system, whereas clinicians often practice with incomplete information about tests, treatments, and recommendations by their colleagues. The payment models described in this review offer an opportunity to create more satisfying approaches to patient care while improving value. These models have potential to support more effective coordination and to facilitate broader health care system transformation.

Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions.

BackgroundPractice nurses (PNs) deliver much of the chronic disease management in primary care and have been highlighted as appropriately placed within the service to manage patients with long-term physical conditions (LTCs) and co-morbid depression.This nested qualitative evaluation within a service development pilot provided the opportunity to examine the acceptability of a Brief Behavioural Activation (BBA) intervention within a collaborative care framework. Barriers and facilitators to engaging with the intervention from the patient and clinician perspective will be used to guide future service development and research.MethodsThe study was conducted across 8 practices in one Primary Care Trust 1 in England. Through purposive sampling professionals (n = 10) taking part in the intervention (nurses, GPs and a mental health gateway worker) and patients (n = 4) receiving the intervention participated in semi-structured qualitative interviews. Analysis utilised the four Normalisation Process Theory (NPT) concepts of coherence, cognitive participation, collective action and reflexive monitoring to explore the how this intervention could be implemented in practice.ResultsAwareness of depression and the stigma associated with the label of depression meant that, from a patient perspective a PN being available to ‘listen’ was perceived as valuable. Competing practice priorities, perceived lack of time and resources, and lack of engagement by the whole practice team were considered the greatest barriers to the implementation of this intervention in routine primary care.ConclusionLack of understanding of, participation in, and support from the whole practice team in the collaborative care model exacerbated the pressures perceived by PNs. The need for formal supervision of PNs to enable them to undertake the role of case manager for patients with depression and long-term conditions is emphasised.Electronic supplementary materialThe online version of this article (doi:10.1186/s12912-016-0190-2) contains supplementary material, which is available to authorized users.

Addressing diabetes mellitus as part of the strategy for ending TB.

As we enter the new era of Sustainable Development Goals, the international community has committed to ending the TB epidemic by 2030 through implementation of an ambitious strategy to reduce TB-incidence and TB-related mortality and avoiding catastrophic costs for TB-affected families. Diabetes mellitus (DM) triples the risk of TB and increases the probability of adverse TB treatment outcomes such as failure, death and recurrent TB. The rapidly escalating global epidemic of DM means that DM needs to be addressed if TB-related milestones and targets are to be achieved. WHO and the International Union Against Tuberculosis and Lung Disease's Collaborative Framework for Care and Control of Tuberculosis and Diabetes, launched in 2011, provides a template to guide policy makers and implementers to combat the epidemics of both diseases. However, more evidence is required to answer important questions about bi-directional screening, optimal ways of delivering treatment, integration of DM and TB services, and infection control. This should in turn contribute to better and earlier TB case detection, and improved TB treatment outcomes and prevention. DM and TB collaborative care can also help guide the development of a more effective and integrated public health approach for managing non-communicable diseases.

Revealing hidden depression in older people: a qualitative study within a randomised controlled trial

BackgroundThe prevalence of depressive symptoms in older people may be as high as 20 %. Depression in older people is associated with loss, loneliness and physical co-morbidities; it is known to be under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.MethodsA nested qualitative study in a randomised controlled trial for older people with moderate to severe depression: the CASPER Plus Trial (Collaborative Care for Screen Positive Elders). We interviewed GPs, case managers (CM) and patient participants to explore perspectives and experiences of delivering and receiving a psychosocial intervention, developed specifically for older adults in primary care, within a collaborative care framework. Transcripts were analysed thematically using principles of constant comparison.ResultsThirty three interviews were conducted and, across the three data-sets, four main themes were identified: revealing hidden depression, reducing the ‘blind spots’, opportunity to talk outside the primary care consultation and ‘moving on’ from depression.ConclusionsDepression in older people is commonly hidden, and may coexist with physical conditions that are prioritised by both patients and GPs. Being invited to participate in a trial about depression may allow older people to disclose their feelings, name the problem, and seek help. Offering older people an opportunity to talk outside the primary care consultation is valued by patients and GPs. A psychosocial intervention delivered by a case manager in the primary care setting may fill the gap in the care of older people with depression.Trial registrationCurrent Controlled Trials ISRCTN45842879.

Communicable and non-communicable diseases: connections, synergies and benefits of integrating care.

Communicable and non-communicable diseases: connections, synergies and benefits of integrating care.

Diabetes mellitus and tuberculosis: programmatic management issues.

SUMMARYIn August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

CASPER plus (CollAborative care in Screen-Positive EldeRs with major depressive disorder): study protocol for a randomised controlled trial.

BackgroundDepression accounts for the greatest disease burden of all mental health disorders, contributes heavily to healthcare costs, and by 2020 is set to become the second largest cause of global disability. Although 10% to 16% of people aged 65 years and over are likely to experience depressive symptoms, the condition is under-diagnosed and often inadequately treated in primary care. Later-life depression is associated with chronic illness and disability, cognitive impairment and social isolation. With a progressively ageing population it becomes increasingly important to refine strategies to identity and manage depression in older people. Currently, management may be limited to the prescription of antidepressants where there may be poor concordance; older people may lack awareness of psychosocial interventions and general practitioners may neglect to offer this treatment option.Methods/designCASPER Plus is a multi-centre, randomised controlled trial of a collaborative care intervention for individuals aged 65 years and over experiencing moderate to severe depression. Selected practices in the North of England identify potentially eligible patients and invite them to participate in the study. A diagnostic interview is carried out and participants with major depressive disorder are randomised to either collaborative care or usual care. The recruitment target is 450 participants.The intervention, behavioural activation and medication management in a collaborative care framework, has been adapted to meet the complex needs of older people. It is delivered over eight to 10 weekly sessions by a case manager liaising with general practitioners.The trial aims to evaluate the clinical and cost effectiveness of collaborative care in addition to usual GP care versus usual GP care alone. The primary clinical outcome, depression severity, will be measured with the Patient Health Questionnaire-9 (PHQ-9) at baseline, 4, 12 and 18 months. Cost effectiveness analysis will assess health-related quality of life using the SF-12 and EQ-5D and will examine cost-consequences of collaborative care.A qualitative process evaluation will be undertaken to explore acceptability, gauge the extent to which the intervention is implemented and to explore sustainability beyond the clinical trial.DiscussionResults will add to existing evidence and a positive outcome may lead to the commissioning of this model of service in primary care.Trial registrationISRCTN45842879 (24 July 2012).

Prevalence of diabetes mellitus among tuberculosis patients in Urban Puducherry

Background:Diabetes and Tuberculosis often present together and complicate each other at many levels. A collaborative framework for care and control of diabetes and tuberculosis developed by World Health Organisation and International Union against Tuberculosis and Lung Diseases emphasizes routine bi-directional screening for the two diseases.Aims:The study was to assess the prevalence of diabetes in tuberculosis patients currently on treatment.Materials and Methods:This facility-based cross-sectional study was undertaken in four randomly selected peripheral health institutions providing directly observed treatment short-course, treatment for tuberculosis patients. All cases of tuberculosis, more than 18 years of age were screened for diabetes. Risk factors like age, sex, family history of diabetes, alcohol, smoking and obesity were assessed.Results:The prevalence of diabetes in tuberculosis patients was found to be 29% (known diabetics - 20.7%, new Diabetes cases - 8.3%). Diabetes was significantly associated with older age, family history of diabetes, consumption of alcohol and sputum positivity.Conclusions:Screening patients with Tuberculosis for fasting blood sugar estimation will help in early detection of diabetes

Collaborative stepped care for anxiety disorders in primary care: aims and design of a randomized controlled trial.

BackgroundPanic disorder (PD) and generalized anxiety disorder (GAD) are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual.Methods/designThe study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC) or care as usual (CAU). In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1) guided self-help, 2) cognitive behavioral therapy and 3) antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI). Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months.DiscussionIt is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options for GAD and PD in the primary care setting. Results will become available in 2011.Trial registrationNTR1071