Non-drug Management Research Articles

Effectiveness and cost-effectiveness of a novel, group self-management course for adults with chronic musculoskeletal pain: study protocol for a multicentre, randomised controlled trial (COPERS)

IntroductionChronic musculoskeletal pain is a common condition that often responds poorly to treatment. Self-management courses have been advocated as a non-drug pain management technique, although evidence for their effectiveness is...

PSS4 The Cost-Effectiveness of Travoprost Preserved With Polyquad® in Newly Treated Open-Angle Glaucoma Patients in 7 Asian Countries

Topical prostaglandin analogues are safe and effective to treat ocular hypertension (OHT) and open-angle glaucoma (OAG). The preservatives used in prostaglandin, however, drops increase the short- to long-term risk of developing ocular surface disease (OSD). We aimed to compare the 10-year costs and clinical outcomes with Polyquad®-preserved travoprost to costs and outcomes with benzalkonium chloride (BAK)-preserved prostaglandins in 7 Asian countries. A semi-Markov health economic model was developed. Treatment-naïve OHT/OAG patients were initiated on treatment with Polyquad®-travoprost, latanoprost or bimatoprost (1st line) with possible timolol adjunct (2nd line, fixed combination). The literature provided information on the increased risks of treatment change and OSD development due to exposure to BAK, and disease evolution. Further treatment lines, including eye laser/surgery, and other medical resource use were obtained using data from a German observational study (COGIS) that were validated and adapted in each country by clinical experts. Local unit costs were collected and applied to each resource (All-Payer perspective, 2011 costs). Country-specific discounting was used. Compared to BAK-preserved prostaglandins, Polyquad-travoprost was dominant (15% less OSD; total costs reductions vs. latanoprost in Singapore −14%, India and Malaysia −13%, South Korea −9% and vs. bimatoprost from −2% in Thailand to −19% in South Korea), or else cost-effective (incremental cost-effectiveness ratios <1,000US$ per OSD-free year gained). In each country, the estimated reductions in glaucoma medical (non-drug) management costs (range from −18 to −22%), and total OSD costs (from −25 to −27%), were significant as per second-order sensitivity analysis. As a long-term consequence of the modeled lower persistence and impaired compliance the presence of OSD was associated with higher total costs. This multi-country model estimated that treating Asian OHT/OAG patients with Polyquad®-preserved travoprost would generate significantly less OSD compared to BAK-preserved prostaglandins, together with savings on glaucoma and OSD management costs.

Effect of ethnicity on the prevalence, severity, and management of COPD in general practice

Chronic obstructive pulmonary disease (COPD) remains a major cause of mortality and hospital use. Little is known in the UK about the variation in COPD prevalence, severity, and management depending on ethnicity. To examine differences by ethnicity in COPD prevalence, severity, and management. Cross-sectional study using routinely collected computerised data from general practice in three east-London primary care trusts (Newham, Tower Hamlets, and City and Hackney) with multiethnic populations of people who are socially deprived. Routine demographic, clinical, and hospital admission data from 140 practices were collected. Crude COPD prevalence was 0.9%; the highest recorded rates were in the white population. Severity of COPD, measured by percentage-predicted forced expiratory volume in 1 second, did not vary by ethnicity. South Asians and black patients were less likely than white patients to have breathlessness, indicated by a Medical Research Council dyspnoea grade of ≥4 (odds ratio [OR] 0.7 [95% confidence interval (CI) = 0.6 to 0.9] and 0.6 [95% CI = 0.4 to 0.8]). Black patients were less likely than white patients to receive inhaled medications. Influenza and pneumococcal vaccine rates were highest among groups of South Asians (OR 3.0 [95% CI = 2.1 to 4.3] and 1.8 [95% CI = 1.4 to 2.3] respectively). Both minority ethnic groups had low referral rates to pulmonary rehabilitation. In Tower Hamlets, black patients were more likely to be admitted to hospital for respiratory causes. Differences in COPD prevalence and severity by ethnicity were identified, and significant differences in drug and non-drug management and hospital admissions observed. Systematic ethnicity recording in general practice is needed to be able to explore such differences and monitor inequalities in healthcare by ethnicity.

An Overview of the Recent European Federation of Neurological Societies Guidelines on the Treatment of Tension-type Headache

Tension-type headache (TTH) is the most prevalent headache type and causes a high degree of disability. This paper provides an overview of the recently published European Federation of Neurological Societies guideline on the treatment of TTH, which recommended that non-drug management should always be considered for this condition. For example: information, reassurance and identification of trigger factors may be rewarding; electromyograph biofeedback has a documented effect in TTH; cognitive-behavioural therapy and relaxation training most likely also are effective; and physical therapy and acupuncture may be valuable options for patients with frequent TTH. Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Excessive use of analgesics should be avoided to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the first choice for prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine may be used second line.

The content of talk about health conditions and medications during appointments involving interpreters

Interpreters often join immigrants and physicians to permit communication. To describe the content of talk about health problems and medications during clinical encounters involving interpreters [professionals (PI) or family members (FI)]. We analysed one regularly scheduled encounter for each of 16 adult patients with his family physician and their usual interpreter (10 with a PI and 6 with a FI). A different PI, not involved in the consultations, translated the non-English or French parts. We coded all utterances about each medical problem and each medication using six health problem and 16 medication topics from MEDICODE, a validated coding scheme. Physicians and patients addressed an average of 3.6 problems and 3 medications per encounter. No psychosocial problems were discussed in encounters involving FIs. On average, three topics were discussed per problem. In order of frequency, they were follow-up, explanations of the condition, non-drug management, consequences, self-management and emotions about the problem. Encounters involving PIs were more likely than encounters with FIs to include discussions of emotions about the problem (42% versus 4%, P = 0.001) and indications for follow-up (88% versus 28%, P < 0.001). An average of 6.5 topics was discussed per medication. Commonest topics discussed were medication class, how the drug was being used, achieved effect and expected effect. One can address multiple problems and share vital information even in the presence of a language barrier. When FIs are interpreting, physicians would do well to make a particular effort to bring the patient's psychological and emotional issues into the interaction.

P238 Characteristics, treatment patterns and outcomes of patients with non-CF bronchiectasis: a single institution district general hospital (DGH) analysis

IntroductionNon-CF bronchiectasis has been the subject of analysis for several years with limited guidelines available regarding appropriate investigation and management strategies to optimise patient care. Non-CF bronchiectasis is common and,...

EFNS guideline on the treatment of tension‐type headache – Report of an EFNS task force

Tension-type headache (TTH) is the most prevalent headache type and is causing a high degree of disability. Treatment of frequent TTH is often difficult. To give evidence-based or expert recommendations for the different treatment procedures in TTH based on a literature search and the consensus of an expert panel. All available medical reference systems were screened for the range of clinical studies on TTH. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points. Non-drug management should always be considered although the scientific basis is limited. Information, reassurance and identification of trigger factors may be rewarding. Electromyography (EMG) biofeedback has a documented effect in TTH, whilst cognitive-behavioural therapy and relaxation training most likely are effective. Physical therapy and acupuncture may be valuable options for patients with frequent TTH, but there is no robust scientific evidence for efficacy. Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for the treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice for the prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are drugs of second choice. The efficacy of the prophylactic drugs is often limited, and treatment may be hampered by side effects.

Non-drug management of chronic low back pain

Non-drug management of chronic low back pain

Non-drug management of chronic low back pain

Estimates suggest that, at any one time, 12–33% of the population have back pain.1 About 5% of a GP's workload involves consultations for the condition,2,3 and around 32% of patients...

Factors contributing to nonadherence to oral hypoglycemic medications among ambulatory type 2 diabetes patients in Southwestern Nigeria.

The overall goal of the study was to evaluate the probable reasons for patients' nonadherence to prescribed oral hypoglycemic medications in an ambulatory care setting in Nigeria with a view to identifying points for necessary intervention to improve adherence and treatment outcomes. Also, the recommended non-drug management options for diabetes patients with emphasis on self monitoring of blood glucose were assessed. A cross-sectional study was conducted at a 200-bed secondary health care facility in Southwestern Nigeria between 2(nd) April and 31(st) May 2008. Copies of pre-tested questionnaire were administered directly to 121 ambulatory patients with type 2 diabetes at the study site. Information on socio-demographic characteristic, probable barriers that affect adherence to prescribed oral hypoglycemic medications, non-drug treatment options for diabetes, and patients' self management efforts were obtained. Descriptive and chi-square statistics were used to evaluate the distribution of respondents' opinion. The response rate was almost 100%. The commonly cited intentional nonadherence practice included dose omission (70.2%). Almost 50% respondents were fed up with daily ingestion of drugs and 19.8% were inconvenienced with taking medications outside home and gave these as reasons for the dose omission. Forgetfulness (49.6%) and high cost of medication (35.5%) were mentioned as major non-intentional reasons for nonadherence. Aside oral medications, 82.6% and 95.0% of respondents respectively, reported moderate exercise and dietary restrictions as part of the prescribed treatment modalities. More than two third of respondents (81.8%) had never monitored blood glucose by themselves. Significant association exist between sex, occupation and patients' tendencies to forget doses of prescribed oral medications (p<0.05). Nonadherence behaviors among ambulatory patients with type 2 diabetes occur mostly, as omission and forgetfulness of doses of medication. Efforts are needed to increase the medication adherence and self management practices of these patients in Nigeria so they can realize the full benefits of prescribed therapies.

Review: Drug and nondrug treatment in tension-type headache

Tension-type headache (TTH) is a common primary headache with tremendous socioeconomic impact. Establishment of an accurate diagnosis is important before initiation of any treatment. Nondrug management is crucial. Information, reassurance and identification of trigger factors may be rewarding. Psychological treatments with scientific evidence for efficacy include relaxation training, EMG biofeedback and cognitive-behavioural therapy. Physical therapy and acupuncture are widely used, but the scientific evidence for efficacy is sparse. Simple analgesics are the mainstays for treatment of episodic TTH. Combination analgesics, triptans, muscle relaxants and opioids should not be used, and it is crucial to avoid frequent and excessive use of simple analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice for the prophylactic treatment of chronic TTH. The efficacy is modest and treatment is often hampered by side effects. Thus, treatment of frequent TTH is often difficult and multidisciplinary treatment strategies can be useful. The development of specific nonpharmacological and pharmacological managements for TTH with higher efficacy and fewer side effects is urgently needed. Future studies should also examine the relative efficacy of the various treatment modalities; for example, psychological, physical and pharmacological treatments, and clarify how treatment programs should be optimized to best suit the individual patient.

Evaluation of the effect of the introduction of a hypertension club on the management of hypertension at a community health centre in the Cape Town Metropole

Background: Hypertension is a widespread problem of immense economic importance in sub-Saharan Africa because of its high prevalence in urban areas, its frequent under-diagnosis, and the severity of its complications. A systematic review of interventions used to improve the management of hypertension in primary care showed that effective delivery of hypertensive care requires a systematic approach in the community. The rationale for establishing a hypertension club at the Mitchell’s Plain Community Health Centre (MPCHC), Cape Town, South Africa is based on the findings of and recommendations made by a study done previously at MPCHC by the Chronic Diseases of Lifestyle Programme of the Medical Research Council. This study found that the blood pressure of hypertensive patients was not optimally controlled and both the drug and non-drug management of hypertension needed to be improved. The patients had asked for the introduction of a dedicated hypertension club. Methods: A dedicated hypertension club was started at MPCHC and hypertensive patients were enrolled. A booking system with an appointment register was initiated. A hypertension record sheet was kept in the patient’s folder. Observations like blood pressure (BP), weight, and urinalysis were recorded by the club’s nurses. Health information officers were used to educate the patients about hypertension, its treatment and complications. The doctors’ role was to fully assess the patients’ risk profiles and to develop a management plan. To audit the club, a questionnaire was conducted on an initial group of 100 patients at the inception of the club and repeated on a group of 100 patients after six months. The aim was to assess the patients’ knowledge of issues affecting the management of hypertension and their satisfaction with the service received at MPCHC. A folder review was done on the second group of patients. The intention was to evaluate whether there had been a change in the patients’ BP over the preceding six months, whether the patients were compliant and whether observations were made regularly. Results: The average age of the study population was early sixties. More women than men were studied. The knowledge of the follow-up group regarding factors affecting hypertension control was slightly better than that of the initial group, but remained poor. The knowledge of the consequences of poor hypertension control did not improve after six months. Salt use stayed the same. The patients were satisfied with the service received, although shorter waiting times were desired. About 64% of the patients had collected their medication as per schedule. In the initial group, 48% of the patients had a BP > 140/90 mmHg. After six months, 33% of the patients had a BP > 140/90 mmHg. Conclusions: The study did not show much change in the patients’ knowledge in the first six months after the institution of the hypertension club. Compliance was poor, although BP control improved somewhat. The benefit was in setting up the system.

The Effects of the Introduction of a Hypertension Club on the Management of Hypertension at a Community Health Centre

Background: Hypertension is a widespread problem of immense economic importance in sub-Saharan Africa because of its high prevalence in urban areas, its frequent under-diagnosis, and the severity of its complications. A systematic review of interventions used to improve the management of hypertension in primary care showed that effective delivery of hypertensive care requires a systematic approach in the community. The rationale for establishing a hypertension club at the Mitchell’s Plain Community Health Centre (MPCHC), Cape Town, South Africa is based on the findings of and recommendations made by a study done previously at MPCHC by the Chronic Diseases of Lifestyle Programme of the Medical Research Council. This study found that the blood pressure of hypertensive patients was not optimally controlled and both the drug and non-drug management of hypertension needed to be improved. The patients had asked for the introduction of a dedicated hypertension club. Methods: A dedicated hypertension club was started at MPCHC and hypertensive patients were enrolled. A booking system with an appointment register was initiated. A hypertension record sheet was kept in the patient’s folder. Observations like blood pressure (BP), weight, and urinalysis were recorded by the club’s nurses. Health information officers were used to educate the patients about hypertension, its treatment and complications. The doctors’ role was to fully assess the patients’ risk profiles and to develop a management plan. To audit the club, a questionnaire was conducted on an initial group of 100 patients at the inception of the club and repeated on a group of 100 patients after six months. The aim was to assess the patients’ knowledge of issues affecting the management of hypertension and their satisfaction with the service received at MPCHC. A folder review was done on the second group of patients. The intention was to evaluate whether there had been a change in the patients’ BP over the preceding six months, whether the patients were compliant and whether observations were made regularly. Results: The average age of the study population was early sixties. More women than men were studied. The knowledge of the follow-up group regarding factors affecting hypertension control was slightly better than that of the initial group, but remained poor. The knowledge of the consequences of poor hypertension control did not improve after six months. Salt use stayed the same. The patients were satisfied with the service received, although shorter waiting times were desired. About 64% of the patients had collected their medication as per schedule. In the initial group, 48% of the patients had a BP > 140/90 mmHg. After six months, 33% of the patients had a BP > 140/90 mmHg. Conclusions: The study did not show much change in the patients’ knowledge in the first six months after the institution of the hypertension club. Compliance was poor, although BP control improved somewhat. The benefit was in setting up the system.

Translating Best Practices in Nondrug Postoperative Pain Management

The research-to-practice gap is at the heart of the problem in the underuse of nondrug complementary methods to manage postoperative pain. To show how the six steps of the Collaborative Research Utilization (CRU) model can be used to translate research into practice, using an example of nondrug pain management protocols. The CRU model was used to translate empirically tested nondrug interventions for surgical pain management enhancement into cost-effective, easy-to-use, best-practice nursing interventions, using tailored patient teaching. The preliminary findings of the substudy in the context of the CRU model are reported. The CRU model was successful in changing patients' knowledge, attitudes, and use of nondrug interventions for pain management. Further research is needed in heterogeneous populations. Organization receptivity to research and a well-integrated computerized documentation system for cueing clinicians' pain management practices are key for effectiveness of change.

Nurses and midwives pain knowledge improves under the influence of an acute pain service

Abstract A recent survey of nurses’ and midwives’ pain knowledge and attitudes demonstrated that those working regularly with an acute pain service were more knowledgeable about analgesics, non-drug pain management and addiction issues. An acute pain service was shown to have a positive influence on pain management practice. A 29-item pain knowledge and attitudes questionnaire which also included questions relating to the impact of an acute pain service was distributed to 600 nurses and midwives. A response rate of 48% (286 valid responses) was achieved. Nurses and midwives who were unaware of an acute pain service in their organisation had significantly lower scores on knowledge about pain management, particularly in relation to the analgesia choices made. This data indicates that an acute pain service has an important influence within health care organisations and can be utilised to lead advancement in pain management practice.

What's new in… Heart failure

Chronic heart failure continues to be an exciting field of clinical research. Up to 5% of the population have heart failure or symptoms suggestive of the condition, and the mortality is high (up to 30% within 3 months of diagnosis and 10% per year thereafter), but current therapy approximately doubles life expectancy. The National Institute for Clinical Excellence (NICE) has published guidance on the diagnosis and management of heart failure, providing an authoritative overview of therapeutics and emphasizing the importance of non-drug management and the need for good communication, education and follow-up.

New approaches to atrial fibrillation management: a critical review of a rapidly evolving field.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, the prevalence of which is increasing with the aging of the population. Because of its clinical importance and the lack of highly satisfactory management approaches, AF is the subject of active clinical and research efforts. This paper reviews recent and on-going developments in pharmacological and non-drug management of AF. The ideal therapeutic goal for AF is the production and maintenance of sinus rhythm. Comparative studies suggest that available class I and III drugs have comparable and modest efficacy for sinus rhythm maintenance. Amiodarone, with actions of all antiarrhythmic classes, has recently been shown to have clearly superior efficacy compared with other available drugs. Newer agents are in development, but their advantages are as yet unclear and appear limited. A potentially interesting approach is the prescription of drugs upon the occurrence of an attack, rather than on a continuous basis. Recent insights into AF mechanisms may permit therapy to prevent development of the AF substrate. An alternative to sinus rhythm maintenance is a rate control approach, with no attempt to prevent AF. Drugs to effect rate control include digitalis, beta-blockers and calcium channel antagonists. Digitalis has limited value for control of exercise heart rate and for paroxysmal AF, but is particularly well suited for patients with concomitant AF and congestive heart failure. AV-nodal ablation and pacing is an effective alternative for rate control but leaves the patient pacemaker dependent. The relative merits of rate versus rhythm control are being evaluated in ongoing trials, preliminary results of which indicate no statistically significant differences in primary endpoints but highlight the risks of rhythm control therapy. In patients requiring pacemakers, physiological pacing (dual chamber devices or atrial pacing) has an advantage over purely ventricular pacemakers in AF prevention. Newer pacing modalities that produce more synchronised atrial activation, as well as pacemakers that prevent excessive atrial rate swings, show promise in AF prevention and may soon see wider use. The usefulness of automatic atrial defibrillators is presently limited by discomfort during shocks. Targeted destruction of pulmonary vein foci by radiofrequency catheter ablation suppresses paroxysmal AF. Efficacy in persistent AF is lower and still under study. Problems include potential recurrence in other veins and a small but nontrivial risk of pulmonary vein stenosis. Surgical division of the atria into zones with limited electrical connection, the MAZE procedure, is highly effective in AF prevention but is a major intervention that is not applicable to most patients. In conclusion, significant advances are being made in the management of patients with AF but much more work remains to be done.

ABC of heart failure: Non-drug management

Effective counselling and education of patients, and of the relatives or carers, is important and may enhance long term adherence to management strategies. Simple explanations about the symptoms and signs of heart failure, including details on drug and other treatment strategies, are valuable. Emphasis should be placed on self help strategies for each patient; these should include information on the need to adhere to drug treatment. Some patients can be instructed how to monitor their weight at home on a daily basis and how to adjust the dose of diuretics as advised; sudden weight increases ( > 2 kg in 1-3 days), for example, should alert a patient to alter his or her treatment or seek advice.

Pharmacists' ability to influence outcomes of hypertension therapy.

We measured the impact of pharmaceutical care on outcomes of antihypertensive therapy for patients with elevated baseline blood pressures who were attending an urban university-affiliated internal medicine clinic. The intervention group received education about hypertension, drug and nondrug management, and assistance to enhance compliance. The pharmacist made recommendations to physicians regarding pharmacotherapy. The control group received no such education, and interventions relating to pharmacotherapy were only physician initiated. Over an average follow-up of 5 months, significant-decreases in mean blood pressures were noted for the intervention group from baseline to final assessment (156.5/144.5 mm Hg systolic, p = 0.001; 91.6/86.9 mm Hg diastolic, p = 0.01), with insignificant changes in mean pressures in the control group (153.7/151.0 mm Hg systolic, p = 0.48; 90.4/87.8 mm Hg diastolic, p = 0.29). Comparing the groups, the change in diastolic pressures was insignificant (4.7 vs 2.6 mm Hg intervention vs control, p = 0.49), but the change in systolic pressure was more impressive (12.0 vs 2.7 mm Hg, respectively, p = 0.05). There was no significant difference in SF-36 Health Survey scores between groups. A significant decrease (p = 0.03) in the SF-36 physical functioning domain was seen in the intervention group, but no other significant changes in health-related quality of life scores. Pharmaceutical care contributed to improved blood pressure control in these patients.

Benzodiazepine prescribing in general practice: dispelling some myths.

The objective was to analyse clinical and non-clinical factors associated with the receipt of a prescription for a benzodiazepine among general practice patients. A survey of 110 consecutive patient encounters (consultations) as recorded by a representative sample of general practitioners in inner urban, outer urban and rural settings was designed. A total of 286 general practitioners took part during 1991-2. 31,256 patients (10,683 male; 34%) were surveyed and the odds of receiving a benzodiazepine script measured. Insomnia, unlike anxiety, was almost routinely managed with a benzodiazepine alone (insomnia 89.6%; anxiety 49.4%), whereas anxiety was more likely to be managed with non-drug management (insomnia 7.2%; anxiety 38.3%). In multiple logistic regression, the variables significantly associated with the prescription of a benzodiazepine included being a female patient, being an older patient and being an established patient, who attends a GP working in a busy practice in an inner urban area. A second regression model was run with the addition of three variables, namely the presenting problems of anxiety and insomnia, and the number of health problems. The only predictors of benzodiazepine prescribing in the full model were these three clinical variables together with patient age. There is a need to educate doctors about the non-drug management of insomnia. The stereotype of the doctor over-prescribing a benzodiazepine without an appropriate problem/diagnosis should be questioned. On the other hand, there is concern that patient age continues to be associated with a prescription of these medications, when all other clinical and non-clinical factors are taken into account.