Usual General Practitioner Research Articles

Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review

ObjectivesMental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been...

Protocol for a cluster randomised controlled trial to determine the effectiveness and cost-effectiveness of independent pharmacist prescribing in care homes: the CHIPPS study

BackgroundPrescribing, monitoring and administration of medicines in care homes could be improved. Research has identified the need for one person to assume overall responsibility for the management of medicines within each care home. and shown that a pharmacist independent prescriber service is feasible in this context.Aims and objectivesTo conduct a cluster randomised controlled trial to determine the effectiveness and cost-effectiveness of a pharmacist-independent prescribing service in care homes compared to usual general practitioner (GP)-led care.ObjectivesTo perform a definitive randomised controlled trial (RCT) with an internal pilot to determine the intervention’s effectiveness and cost-effectiveness and enable modelling beyond the end of the trial.MethodsThis protocol is for a cluster RCT with a 3-month internal pilot to confirm that recruitment is achievable, and there are no safety concerns. The unit of randomisation is a triad comprising a pharmacist-independent prescriber (PIP) based in a GP practice with sufficient registered patients resident in one or more care homes to allow recruitment of an average of 20 participants. In the intervention group, the PIP will, in collaboration with the GP: assume responsibility for prescribing and managing residents’ medicines including medication review and pharmaceutical care planning; support systematic ordering and administration in the care home, GP practice and supplying pharmacy; train care home and GP practice staff; communicate with GP practice, care home, supplying community pharmacy and study team.The intervention will last 6 months. The primary outcome will be resident falls at 6 months. Secondary outcomes include resident health-related quality of life, falls at 3 months, medication burden, medication appropriateness, mortality and hospitalisations. A full health economic analysis will be undertaken. The target sample size is 880 residents (440) in each arm) from 44 triads. This number is sufficient to detect a decrease in fall rate from 1.5 per individual to 1.178 (relative reduction of 21%) with 80% power and an ICC of 0.05 or less.DiscussionRecruitment is on-going and the trial should complete in early 2020. The trial results will have implications for the future management of residents in care homes and the ongoing implementation of independent pharmacist prescribing.Trial registrationISRCTN, ID: 17847169. Registered on 15 December 2017.

The Fear Reduction Exercised Early (FREE) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial

BackgroundEffective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world’s most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control).Methods and findingsThis pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI −0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices.ConclusionsFindings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.Trial registrationACTRN12616000888460

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria

AimTo assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease.MethodsThe cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients’ experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied.ResultsMore than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care.ConclusionVisiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.

Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial.

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA1c at 12months post-recruitment. The non-inferiority margin was 4.4mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference -0.38mmol/mol [95% CI -4.72, 3.96]; -0.03% [95% CI -0.43, 0.36]) and the intention-to-treat (difference -1.28mmol/mol [95% CI -5.96, 3.40]; -0.12% [95% CI -0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001). In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospital-based specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care. Australian New Zealand Clinical Trials Registry ACTRN12612000380897 FUNDING: The study was funded by the Australian National Health and Medical Research Council (GNT1001157).

Treatment of ambulant patients by a general practitioner within a university hospital's emergency department - follow-up study of patients' behaviour shortly afterwards.

Aims: Hospital emergency departments (ED) face an increasing number of outpatient cases. Therefore, Hannover Medical School employs general practitioners for the treatment of walk-in patients within the ED. Up to now, little has been reported on how these patients behave after treatment in the ED. This study aims to assess these patients’ behaviour after attending the ED, to find out how many patients consult a physician subsequently, and to explore patients’ utilisation of health care in case of similar health problems.Methods: For this follow-up study, patients treated at Hannover Medical School’s ED during daytime (Monday – Friday) by a general practitioner (GP) within a period of six weeks in 2016 were subsequently followed up by phone interviews 10–15 days after their consultation. Main topics in the semi-structured interview guide were patients’ behaviour after leaving the ED, subsequent contacts with medical care, and how patients would behave in the future given similar symptoms. Data were transferred to a SPSS database, and descriptive data analyses were performed.Results: In total, 171 patients were screened for inclusion, and 91 participated in the study. About half (n=48; 53%) of them were male, and the mean age was 46.6 years. After visiting the GP in the ED, 62 patients (68%) went directly home. Another 14 (15%) took up regular activities (e.g. work, university), while eight patients visited their usual GP practice. Within 10–15 days, 52 patients (57%) had had an appointment with a physician. In most cases this was a GP (n=34; 37%); 12 patients visited a specialist and six patients visited both a GP and a specialist. Physician appointments took place within an average of 3.4 days after treatment in the ED. In case of similar complaints, 37 patients (41%) would visit the ED again rather than visiting the GP, whereas 36% would consult the GP first, and 11% would visit a specialist first.Conclusion: A noteworthy number of patients considered visiting the ED again with similar symptoms instead of visiting a GP in ambulatory care. Consequently our findings suggest that the ED itself plays a minor role in navigating patients’ utilisation of medical treatment.

How common is multiple general practice attendance in Australia?

Australians can seek general practice care from multiple general practitioners (GPs) in multiple locations. This provides high levels of patient choice but may reduce continuity of care. The aim of this study was to estimate the prevalence of attendance at multiple general practices in Australia, and identify patient characteristics associated with multiple practice attendances. A cross-sectional survey of 2477 Australian adults was conducted online in July 2013. Respondents reported whether they had attended more than one general practice in the past year, and whether they had a usual general practice and GP. Demographic information, health service use and practice characteristics were also obtained from the survey. Over one-quarter of the sample reported attending more than one practice in the previous year. Multiple practice attendance is less common with increasing age, and less likely for survey respondents from regional Australia, compared with respondents from metropolitan areas. Multiple practice attenders are just as likely as single practice attenders to have a usual GP. A significant proportion of general practice care is delivered away from usual practices. This may have implications for health policy, in terms of continuity and quality of primary care.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management. To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care. A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible. Sixty-nine general practices in the north of England. A total of 485 participants aged ≥ 65 years with major depressive disorder. A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care. The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months. In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY). Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data). Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant. Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression. Current Controlled Trials ISRCTN45842879. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

Prognosis of cancer in persons with infrequent consultations in general practice: A population-based cohort study.

Cancer survival rates are lower in Denmark than in comparable European countries. This may partly be attributable to subgroups of cancer patients who seek medical attention at late disease stages. It is unknown if differences in usual (i.e. customary) consultation frequency in general practice are associated with cancer prognosis. We aimed to estimate the cancer prognosis of cancer patients stratified by their usual consultation frequency in general practice. We performed a population-based cohort study including 123,943 incident cancer patients aged 50 to 89 years diagnosed in Denmark in 2009 to 2013. We estimated associations between the patient's usual general practitioner (GP) consultation frequency 19 to 36 months before the cancer diagnosis and all-cause mortality by using hazard ratios (HR), estimated by Cox proportional hazards regression. We also estimated the associations between the patient's usual GP consultation frequency and tumour stage, by using logistic regression estimates of odds ratios (ORs). Patients who usually did not see their GP (non-consulters) had higher all-cause mortality [HR = 1.39 (95% CI: 1.33-1.44)] compared to patients who usually saw their GP three to five times during an 18 months period (average consulters). Non-consulters had higher odds of having distant tumour stage [OR = 1.46 (95% CI: 1.38-1.57)] than average consulters. Similar, yet less strong, patterns were seen among patients with low usual GP consultation frequency, yet not statistically significant for all cancer types. In conclusion, the association between usual GP non-consultation and cancer prognosis is a combination of at least two things: a mechanism through more advanced tumour stage and other independent factors.

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial

BackgroundUp to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care.MethodsIn a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P.DiscussionWe expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care.Trial registrationDutch Trial Registry, identifier: NTR4686, Registered on 14 July 2014.

Cost-effectiveness of computerized cognitive-behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial.

Computerized cognitive-behavioural therapy (cCBT) forms a core component of stepped psychological care for depression. Existing evidence for cCBT has been informed by developer-led trials. This is the first study based on a large independent pragmatic trial to assess the cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care compared with usual GP care alone and to establish the differential cost-effectiveness of a free-to-use cCBT programme (MoodGYM) in comparison with a commercial programme (Beating the Blues) in primary care. Costs were estimated from a healthcare perspective and outcomes measured using quality-adjusted life years (QALYs) over 2 years. The incremental cost-effectiveness of each cCBT programme was compared with usual GP care. Uncertainty was estimated using probabilistic sensitivity analysis and scenario analyses were performed to assess the robustness of results. Neither cCBT programme was found to be cost-effective compared with usual GP care alone. At a £20 000 per QALY threshold, usual GP care alone had the highest probability of being cost-effective (0.55) followed by MoodGYM (0.42) and Beating the Blues (0.04). Usual GP care alone was also the cost-effective intervention in the majority of scenario analyses. However, the magnitude of the differences in costs and QALYs between all groups appeared minor (and non-significant). Technically supported cCBT programmes do not appear any more cost-effective than usual GP care alone. No cost-effective advantage of the commercially developed cCBT programme was evident compared with the free-to-use cCBT programme. Current UK practice recommendations for cCBT may need to be reconsidered in the light of the results.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness.

Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group. To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression. A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. Thirty-two general practitioner (GP) practices in the north of England. A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression. Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care. The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months. In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003). Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression. Current Controlled Trials ISRCTN02202951. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

Social return on investment analysis of a physiotherapy-led service for managing osteoarthritis in primary care

BackgroundOver 8·75 million people in the UK live with osteoarthritis, which has major social and economic costs. Although the current approach to managing this condition in primary care is suboptimal, any quality improvement must deliver value for money. Social return on investment (SROI) is a cost-benefit analysis that captures wider social benefits. Here, we describe a SROI analysis of a physiotherapy-led service (rather than the usual general practitioner [GP]-led model) delivering National Institute for Health and Care Excellence (NICE) guidance for managing osteoarthritis in six GP practices. MethodsSROI analysis was undertaken to determine the inputs, outputs, and outcomes associated with the intervention. These data were used to calculate a SROI ratio, which determined the level of social value created for every £1 of investment. To mitigate the risk of overclaiming any benefits created by the service, the calculation used conservative values and accounted for deadweight, displacement, drop-off, and attribution. A sensitivity analysis was performed and the SROI was externally validated. FindingsThe SROI analysis showed that a physiotherapy-led service that delivers advice in line with NICE guidance created levels of social value that were greater than the cost of investment. Every £1 invested into the service resulted in a return of £2·43 to £4·03 in social value. The benefits (or outcomes) that patients gained from using the service were increased levels of physical activity, improved physical and mental health, reduced pain, and the saving in money and time spent travelling by accessing a local (GP-based) service. Outcomes for the National Health Service (NHS) were a reduction in health utilisation (eg, fewer GP consultations and secondary referrals) and the saving gained from the levels of weight loss seen in patients (ie, savings dispersed within the wider health system). InterpretationSROI analysis shows that a physiotherapy-led service in primary care that delivers NICE guidance for managing osteoarthritis created an SROI for patients and the NHS. The service delivered benefits to patients, reduced health utilisation elsewhere in the system (eg, GP workload), and delivered value for money. SROI can provide a useful approach to support funding bodies to determine cost-effectiveness for commissioning services in health care. FundingHealth Innovation Network.

Outreach Rehabilitation Program Improves the “Chaotic Journey” After Hip Fracture

A 4-week outreach rehabilitation program for nursing home residents after hip fracture repair appears to have provided hope and self-confidence as well as early mobilization and improved activity levels when compared with the usual care after hospital discharge. These findings come from a small qualitative analysis conducted in parallel to a randomized, controlled trial evaluating the efficacy and cost-effectiveness of the hospital team-led outreach rehabilitation program. Almost all the 28 residents included in the qualitative analysis had severe cognitive impairment. The larger trial recruited 240 older people in three hospitals in South Australia who had been admitted from nursing homes and were recovering from hip fracture surgery. The residents were randomized to receive either the usual care, which included physiotherapy provided by the nursing home staff and medical care provided by the residents’ usual general practitioner, or outreach rehabilitation in addition to the usual care. Outreach rehabilitation involved an average of 14 visits over 4 weeks from the local hospital team, including a geriatrician, physiotherapist, dietician, and, when required, a rehabilitation nurse. The physiotherapist focused on restoration of transfers and mobility, used positive motivational scripts to encourage engagement, and worked with nursing home staff to “encourage a rehabilitation approach between formal therapy sessions.” The qualitative subanalysis — as detailed in the report “The Chaotic Journey: Recovering from Hip Fracture in a Nursing Home” (Arch Gerontol Geriatr 2016;67:106–12) — aimed to understand the experiences and perceptions of 14 residents who returned to “usual care” and 14 residents who received outreach rehabilitation, through interviews and focus groups with family members and nursing home staff. Information on the 28 residents (out of the first 30 recruited for the randomized, controlled trial) was collected on average 5 weeks after each resident had returned from the hospital. The residents had a mean age of 87.5 years (range of 70 to 97 years), and each had been mobile before the fracture. Discharge occurred 2 to 19 days after surgery (a median of 4.5 days). Most of the residents (23 of the 28) had severe cognitive impairment after surgery and three had mild to moderate cognitive impairment, according to the scores on the Mini Mental Score Examination taken at entry to the trial. The challenges “started in the hospital with hospital staff ill-equipped to treat people with dementia and, following discharge home, nursing staff frequently reported poor handovers.” A dearth of information or guidelines from the acute hospital setting about how to handle and manage people after a hip fracture was reported by Maggie Killington of Flanders University and Repatriation General Hospital in Adelaide, Australia, and her associates in the same study. In the usual care group, “the nursing home staff lacked the knowledge and confidence to support [the residents’] recovery following hip fracture repair,” and the physiotherapists were unable to provide timely advice to the nursing home staff and were “unable to provide the intensity of therapy required to promote return of patients’ mobility.” Moreover, ongoing pain, malnourishment, and delirium — and a loss of hope and motivation to engage in activity — were more common among those who received the usual care. Eight of the 14 people who returned to usual care endured either ongoing pain or unacceptable medication side effects. By contrast, the caregivers and families of the residents who received outreach therapy “were positive about the experience and often surprised at the progress,” the investigators wrote. “In addition to good pain management strategies and improved activity levels, [they] were less likely to report anxiety and more often focused on improved quality of life.” Outreach physiotherapy was the most valued aspect of the outreach program, the investigators reported. Residents received psychological support in conjunction with mobility training and strengthening exercises, and the physiotherapists often “worked in conjunction with family members and nursing home staff to provide a safe environment with graduated challenges as the resident attempted to move in bed, get to stand, use stand lifting devices when necessary and undertake stand transfers.” The value of geriatrician input and improved nutritional status were also among the themes that emerged across interviews. “Ways need to be found for the appropriate expertise to follow the patient through post-operative recovery after hip fracture,” the authors said, calling for “integrated care pathways for people with dementia and hip fracture.” Christine Kilgore is a freelance writer in Falls Church, VA.

The second Randomised Evaluation of the Effectiveness, cost-effectiveness and Acceptability of Computerised Therapy (REEACT-2) trial: does the provision of telephone support enhance the effectiveness of computer-delivered cognitive behaviour therapy? A randomised controlled trial.

Computerised cognitive behaviour therapy (cCBT) is an efficient form of therapy potentially improving access to psychological care. Indirect evidence suggests that the uptake and effectiveness of cCBT can be increased if facilitated by telephone, but this is not routinely offered in the NHS. To compare the clinical effectiveness and cost-effectiveness of telephone-facilitated free-to-use cCBT [e.g. MoodGYM (National Institute for Mental Health Research, Australian National University, Canberra, ACT, Australia)] with minimally supported cCBT. This study was a multisite, pragmatic, open, two-arm, parallel-group randomised controlled trial with a concurrent economic evaluation. Participants were recruited from GP practices in Bristol, Manchester, Sheffield, Hull and the north-east of England. Potential participants were eligible to participate in the trial if they were adults with depression scoring ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9). Participants were randomised using a computer-generated random number sequence to receive minimally supported cCBT or telephone-facilitated cCBT. Participants continued with usual general practitioner care. The primary outcome was self-reported symptoms of depression, as assessed by the PHQ-9 at 4 months post randomisation. Secondary outcomes were depression at 12 months and anxiety, somatoform complaints, health utility (as assessed by the European Quality of Life-5 Dimensions questionnaire) and resource use at 4 and 12 months. Clinical effectiveness: 182 participants were randomised to minimally supported cCBT and 187 participants to telephone-facilitated cCBT. There was a difference in the severity of depression at 4 and 12 months, with lower levels in the telephone-facilitated group. The odds of no longer being depressed (defined as a PHQ-9 score of < 10) at 4 months were twice as high in the telephone-facilitated cCBT group [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.23 to 3.42]. The benefit of telephone-facilitated cCBT was no longer significant at 12 months (OR 1.63, 95% CI 0.98 to 2.71). At 4 months the between-group difference in PHQ-9 scores was 1.9 (95% CI 0.5 to 3.3). At 12 months the results still favoured telephone-facilitated cCBT but were no longer statistically significant, with a difference in PHQ-9 score of 0.9 (95% CI -0.5 to 2.3). When considering the whole follow-up period, telephone-facilitated cCBT was asssociated with significantly lower PHQ-9 scores than minimally supported cCBT (mean difference -1.41, 95% CI -2.63 to -0.17; p = 0.025). There was a significant improvement in anxiety scores over the trial period (between-group difference 1.1, 95% CI 0.1 to 2.3; p = 0.037). In the case of somatic complaints (assessed using the Patient Health Questionnaire-15), there was a borderline statistically significant difference over the trial period (between-group difference 1.1, 95% CI 0.0 to 1.8; p = 0.051). There were gains in quality-adjusted life-years at reduced cost when telephone facilitation was added to MoodGYM. However, the results were subject to uncertainty. The results showed short-term benefits from the addition of telephone facilitation to cCBT. The effect was small to moderate and comparable with that of other primary care psychological interventions. Telephone facilitation should be considered when offering cCBT for depression. Participants' depression was assessed with the PHQ-9, cCBT use was quite low and there was a slightly greater than anticipated loss to follow-up. Improve the acceptability of cCBT and its capacity to address coexisting disorders. Large-scale pragmatic trials of cCBT with bibliotherapy and telephone-based interventions are required. Current Controlled Trials ISRCTN55310481. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 89. See the NIHR Journals Library website for further project information.

Détection par le médecin généraliste des troubles psychiatriques courants selon l’auto-questionnaire diagnostique le Patient Health Questionnaire : dix ans après, le dispositif du médecin traitant a-t-il modifié la donne ?

ObjectivesThe general practitioner (GP) is the most frequently consulted health professional by patients with common mental disorders (CMD). Yet approximately half of cases are not detected by the GP. Many factors linked to the patient, the doctor and the health care system influence detection. For example, detection rates are higher when patients are better known to their GP. On the other hand, patients visiting a different GP for reasons of dissatisfaction with previous care are more likely to be detected on the survey-day. In France, a form of gatekeeping was introduced in 2005 to encourage patients to register with a doctor (most often a GP) of their choice (known as the Preferred Doctor), responsible for care coordination and referral if necessary to secondary care. Visiting a different GP, other than for non-avoidable reasons (for e.g. GP unreachable, patient on holiday), is still possible but financially sanctioned with lower reimbursement rates. We aimed to compare GP detection rates before and after the introduction of this gatekeeping scheme. Patient service use behaviour such as doctor-shopping and GP referral to secondary care were also compared. MethodsTwo cross-sectional surveys using the same study methods were carried out 10 years apart. In 2003, 46 GPs and 1151 patients participated (approximately 25 patients per GP), with a 32.7% GP participation rate. In 2013, 38 GPs participated (of which 29 had participated in the previous study, with a 85.3% “recapture” rate) and 1133 patients (approximately 30 patients per GP). Patient participation rates were 89.8% and 67%, respectively. Patients completed self-report questionnaires in the waiting room of which the DSM-IV diagnostic criteria Patient Health Questionnaire (PHQ) and an adapted version of the Client Service Receipt Inventory (CSRI) on contacts with health care services in the previous six months. For each patient, the GP completed a questionnaire giving his rating of psychiatric illness on a five-point scale with his/her diagnosis for cases, and action undertaken. ResultsOf the patients, 27% and 25.4% had a CMD according to the PHQ (defined as a diagnosis of minor or major depression, panic attack, anxiety or somatoform disorder) in 2003 and 2013 respectively. Corresponding detection rates were 51% and 52.6%. Rates were highest for threshold disorders: panic disorder (69.4% and 79.9% in 2003 and 2013, respectively), major depression (75% and 63.3% in 2003 and 2013, respectively) and other anxiety disorders (69.1% and 78.8% in 2003 and 2013, respectively). In 2003, the GPs declared seeing 15.5% for the first time on the survey-day, compared to 9.6% in 2013 (P=0.006). Doctor-shopping declined between the two studies, from 18.4% to 12.1% for practical and mostly unavoidable reasons, and from 9.8% to 4.2% for dissatisfaction reasons (P<0.0001). Referral to specialist doctors increased from 9.7% in 2003 to 14.7% in 2013 (P=0.014). In 2013, on the survey-day, 94.8% of patients had registered with a Preferred Doctor and 81.2% were seeing this Preferred Doctor. In 2003, 93.5% of patients declared having a usual GP and 79.9% were visiting this GP on the survey-day. ConclusionsThis is one of the first studies to report data from two repeated surveys carried out before and after a change in the health service organisation, with data collected from both the patient and the GP. We report relatively high GP detection rates for the two periods, with about 50% of CMDs, including subsyndromic conditions, detected by the GP. Rates are considerably higher for the threshold disorders. The overall detection rate did not increase as expected between the two studies. Detection is a complex topic, involving issues such as the suitability of applying categorical DSM-IV criteria diagnoses to primary care, the relevance of detecting subthreshold conditions and the ability of cross-sectional studies to correctly assess the ability of GPs to recognise cases. The introduction of gatekeeping with the choice of a Preferred Doctor has led to a decline in the frequency of doctor-shopping, whatever its reason, with patients no doubt being better known to the GP. Yet it appears most patients had already chosen a GP they were loyal to before the scheme, with a similar proportion of patients consulting their chosen GP or Preferred Doctor on both survey-days in 2003 and 2013, suggesting the scheme may to some extent only have officialised what already existed with respect to having a usual GP. The French reform still allows for doctor-shopping which can be considered as a positive aspect of the scheme: patients either dissatisfied with previous care or needing to change GP are thus able to “test” and choose the doctor that best suits their needs.

Physical activity and mental health: evidence is growing.

Physical activity and mental health: evidence is growing.

The significance of relational continuity of care for Māori patient engagement with predominantly non‐Māori doctors: findings from a qualitative study

ObjectiveThis qualitative study explored self‐reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non‐Māori general practitioners (GPs). MethodsThe study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in‐depth interviews, which were transcribed and analysed thematically. ResultsAnalysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non‐discriminatory care from predominantly non‐Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non‐regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare. ConclusionsFacilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface. ImplicationsReducing significant health disparities between Māori and non‐Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter‐ethnic health outcomes in primary healthcare settings is an important consideration.

Computerised cognitive behaviour therapy for major depression: a reply to the REEACT trial

Computerised cognitive behavioural therapy (CCBT) has been shown to be an efficacious treatment for depression. A recent meta-analysis of 9 studies showed a large mean effect size superiority over control...

An evaluation of the additional benefit of population screening for dementia beyond a passive case-finding approach.

General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the "Ageing in General Practice" study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding. Patients were classified as "case-finding" (n = 425) or "screening" (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome. The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected. There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.