Cost effectiveness of therapist delivered cognitive behavioural therapy and web-based self-management in irritable bowel syndrome: the ACTIB randomised trial

Background: Telephone therapist delivered CBT (TCBT) and web-based CBT (WCBT) have been shown to be significantly more clinically effective than treatment as usual (TAU) at reducing IBS symptom severity and impact at 12 months in adults with refractory IBS. In this paper we assess the cost-effectiveness of the interventions. Methods: Participants were recruited from 74 general practices and three gastroenterology centres in England. Interventions costs were calculated, and other service use and lost employment measured and costed for one-year post randomisation. Quality-adjusted life years (QALYs) were combined with costs to determine cost-effectiveness of TCBT and WCBT compared to TAU. Results: TCBT cost £956 more than TAU (95% CI, £601-£1435) and generated 0.0429 more QALYs. WCBT cost £224 more than TAU (95% CI, - £11 to £448) and produced 0.029 more QALYs. Compared to TAU, TCBT had an incremental cost per QALY of £22,284 while the figure for WCBT was £7724. After multiple imputation these ratios increased to £27,436 and £17,388 respectively. Including lost employment and informal care, TCBT had costs that were on average £866 lower than TAU (95% CI, - £1133 to £2957), and WCBT had costs that were £1028 lower than TAU (95% CI, - £448 to £2580). Conclusions: TCBT and WCBT resulted in more QALYs and higher costs than TAU. Complete case analysis suggests both therapies are cost-effective from a healthcare perspective. Imputation for missing data reduces cost-effectiveness but WCTB remained cost-effective. If the reduced societal costs are included both interventions are likely to be more cost-effective. Trial registration ISRCTN44427879 (registered 18.11.13)

Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial.

To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes

NaChBac: The Long Lost Sodium Channel Ancestor

In excitable cells, the main mediators of sodium conductance across membranes are voltage-gated sodium channels (Na(V)s). Eukaryotic Na(V)s are essential elements in neuronal signaling and muscular contraction and in humans have been causally related to a variety of neurological and cardiovascular channelopathies. They are complex heavily glycosylated intrinsic membrane proteins present in only trace quantities that have proven to be challenging objects of study. However, in recent years, a number of simpler prokaryotic sodium channels have been identified, with NaChBac from Bacillus halodurans being the most well-characterized to date. The availability of a bacterial Na(V) that is amenable to heterologous expression and functional characterization in both bacterial and mammalian systems has provided new opportunities for structure--function studies. This review describes features of NaChBac as an exemplar of this class of bacterial channels, compares prokaryotic and eukaryotic Na(V)s with respect to their structural organization, pharmacological profiling, and functional kinetics, and discusses how voltage-gated ion channels may have evolved to deal with the complex functional demands of higher organisms

Cognitive behavioural therapy (CBT) for irritable bowel syndrome (IBS): 24 month follow-up of ACTIB trial participants

Background: IBS is common, affecting 10-20% of the adult population with many people experiencing ongoing symptoms despite first line therapies. Cognitive behavioural therapy (CBT) is recommended in guidelines for refractory IBS but there is limited access to CBT for IBS and uncertainty whether benefits last in the longer term. ACTIB (Assessing Cognitive behavioural Therapy for IBS) was a large randomised controlled trial of two forms of CBT for patients with refractory IBS. ACTIB results showed, at 12 months, that both forms of CBT for IBS were significantly more effective than treatment as usual (TAU) at reducing IBS symptom severity and impact at 12 months in adults with refractory IBS. This follow-up study aims to evaluate 24 month clinical outcomes of participants recruited to the ACTIB trial. Methods: in the ACTIB three-arm randomised controlled trial, 558 adults with refractory IBS were randomly allocated to therapist-delivered telephone CBT (TCBT), web-based CBT with minimal therapist support (WCBT) or treatment as usual (TAU) and followed up for 12 months. Participants were adults with refractory IBS (clinically significant symptoms for ≥12 months despite first-line therapies), recruited by letter and opportunistically from 74 general practices and three gastroenterology centres in London and South of England between 1st May 2014 and 31st March 2016. Primary outcome measures were IBS Symptom Severity Score (IBS-SSS) and Work and Social Adjustment Scale (WSAS) Intention-to-treat (ITT) analyses with multiple imputation were undertaken. This study was a non-pre-specified naturalistic follow-up and analysis of ACTIB trial participants at 24 months. Findings: 24 months follow-up of outcomes was achieved for 57·9% (323/558) participants, (119/186 in the Telephone CBT arm, 99/185 in the Web CBT arm, 105 /187 in the treatment as usual arm). At 24 months compared to treatment as usual: IBS-SSS was 40·5 (95% CI 15·0 to 66·0) points lower (p=0·002) in the Telephone CBT arm and 12·9 (95% CI -12·9 to 38·8) points lower (p=0·325) in the Web CBT arm. WSAS was 3·1 (95% CI 1·3 to 4·9) points lower (p<0·001) in the Telephone CBT arm and 1·9 (95% CI 0·1 to 3·7) points lower (p=0·036) in the Web WCBT arm. A clinically significant IBS-SSS change (≧50 points), baseline to 24 months, occurred in 84/119 (70·6%) of participants in the Telephone CBT arm , 62/99 (62·6%) in the Web CBT arm and 48/105 (45·7%) in the treatment as usual arm. There were no adverse no adverse events related to treatment. Interpretation: at 24 month follow-up, sustained improvements in IBS were seen in both cognitive behavioural therapy arms compared to treatment as usual, though some previous gains were reduced compared to the 12 month outcomes. IBS-specific CBT has the potential to provide significant long-term improvement in IBS, achievable within a usual clinical setting. Increasing access to CBT for IBS could achieve long-term patient benefit. Funding: UK National Institute for Health Research, trials number ISRCTN4442787