The cost-effectiveness implications of suboptimal treatment for different severities of Alzheimer's disease in the UK.

OBJECTIVE: This study aims to evaluate the impact of suboptimal treatment, defined in terms of lower population coverage (percentage of total patient population receiving optimal treatment) and delay to treatment on the cost-effectiveness of pharmacological therapies approved for the treatment of different severities of Alzheimer's disease (AD) in the UK. METHODS: A 5-year Markov model was used to simulate transition to full-time care, as delay and coverage were varied for AD patients with mild-to-moderate and moderate-to-severe dementia. The time-varying predictive equations, resource use, utilities, treatment effects and mortality were derived using published sources. RESULTS: For the cohort with moderate-to-severe dementia, cost-effectiveness was optimised when delay was minimised and coverage maximised. For mild-to-moderate dementia, results were similar but varied widely depending on the inputted cost of acetylcholinesterase inhibitors. CONCLUSIONS: The average cost-effectiveness of pharmacological treatments for AD is sensitive to delays to treatment and population coverage. The results of this study can inform future healthcare policy in order to maximise cost-effectiveness of pharmacological therapies for AD

Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed-methods design

BACKGROUND:At least 100,000 patients with schizophrenia receive care from community mental health teams (CMHTs) in England. These patients have regular meetings with clinicians, who assess them, engage them in treatment and co-ordinate care. As these routine meetings are not commonly guided by research evidence, a new intervention, DIALOG, was previously designed to structure consultations. Using a hand-held computer, clinicians asked patients to rate their satisfaction with eight life domains and three treatment aspects, and to indicate whether or not additional help was needed in each area, with responses being graphically displayed and compared with previous ratings. In a European multicentre trial, the intervention improved patients’ quality of life over a 1-year period. The current programme builds on this research by further developing DIALOG in the UK. RESEARCH QUESTIONS:(1) How can the practical procedure of the intervention be improved, including the software used and the design of the user interface? (2) How can elements of resource-oriented interventions be incorporated into a clinician manual and training programme for a new, more extensive ‘DIALOG+’ intervention? (3) How effective and cost-effective is the new DIALOG+ intervention in improving treatment outcomes for patients with schizophrenia or a related disorder? (4) What are the views of patients and clinicians regarding the new DIALOG+ intervention? METHODS:We produced new software on a tablet computer for CMHTs in the NHS, informed by analysis of videos of DIALOG sessions from the original trial and six focus groups with 18 patients with psychosis. We developed the new ‘DIALOG+’ intervention in consultation with experts, incorporating principles of solution-focused therapy when responding to patients’ ratings and specifying the procedure in a manual and training programme for clinicians. We conducted an exploratory cluster randomised controlled trial with 49 clinicians and 179 patients with psychosis in East London NHS Foundation Trust, comparing DIALOG+ with an active control. Clinicians working as care co-ordinators in CMHTs (along with their patients) were cluster randomised 1 : 1 to either DIALOG+ or treatment as usual plus an active control, to prevent contamination. Intervention and control were to be administered monthly for 6 months, with data collected at baseline and at 3, 6 and 12 months following randomisation. The primary outcome was subjective quality of life as measured on the Manchester Short Assessment of Quality of Life; secondary outcomes were also measured. We also established the cost-effectiveness of the DIALOG intervention using data from the Client Service Receipt Inventory, which records patients’ retrospective reports of using health- and social-care services, including hospital services, outpatient services and medication, in the 3 months prior to each time point. Data were supplemented by the clinical notes in patients’ medical records to improve accuracy. We conducted an exploratory thematic analysis of 16 video-recorded DIALOG+ sessions and measured adherence in these videos using a specially developed adherence scale. We conducted focus groups with patients (n = 19) and clinicians (n = 19) about their experiences of the intervention, and conducted thematic analyses. We disseminated the findings and made the application (app), manual and training freely available, as well as producing a protocol for a definitive trial. RESULTS:Patients receiving the new intervention showed more favourable quality of life in the DIALOG+ group after 3 months (effect size: Cohen’s d = 0.34), after 6 months (Cohen’s d = 0.29) and after 12 months (Cohen’s d = 0.34). An analysis of video-recorded DIALOG+ sessions showed inconsistent implementation, with adherence to the intervention being a little over half of the possible score. Patients and clinicians from the DIALOG+ arm of the trial reported many positive experiences with the intervention, including better self-expression and improved efficiency of meetings. Difficulties reported with the intervention were addressed by further refining the DIALOG+ manual and training. Cost-effectiveness analyses found a 72% likelihood that the intervention both improved outcomes and saved costs. LIMITATIONS:The research was conducted solely in urban east London, meaning that the results may not be broadly generalisable to other settings. CONCLUSIONS:(1) Although services might consider adopting DIALOG+ based on the existing evidence, a definitive trial appears warranted; (2) applying DIALOG+ to patient groups with other mental disorders may be considered, and to groups with physical health problems; (3) a more flexible use with variable intervals might help to make the intervention even more acceptable and effective; (4) more process evaluation is required to identify what mechanisms precisely are involved in the improvements seen in the intervention group in the trial; and (5) what appears to make DIALOG+ effective is that it is not a separate treatment and not a technology that is administered by a specialist; rather, it changes and utilises the existing therapeutic relationship between patients and clinicians in CMHTs to initiate positive change, helping the patients to improve their quality of life. FUTURE RESEARCH:Future studies should include a definitive trial on DIALOG+ and test the effectiveness of the intervention with other populations, such as people with depression. TRIAL REGISTRATION:Current Controlled Trials ISRCTN34757603. FUNDING:The National Institute for Health Research Programme Grants for Applied Research programme

The design and relevance of a computerised therapy program for indigenous Māori adolescents.

Background: Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression. Objective: The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach. Methods: There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data. Results: SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery. Conclusions: SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people

Scottish theme towns: have new identities enhanced development?

Three small towns in southwest Scotland have recently been branded as distinct theme towns, based on books, artists and food. This is an attempt to make them more attractive to visitors and thereby improve their economy. The objective of this research is to establish whether the new identities possessed by the towns have enhanced their development. It is argued, using data reviewing the past decade, that they have all developed, albeit at different rates, in terms of the economy and culture. Moreover, it is maintained that social capital has been enhanced and is a factor whose importance has been under-appreciated by planners and observers of this type of process. The relevance of the new identity to the pre-branding identity is also seen as a factor in successful development and ideas of authenticity and heritage are brought to bear on the relationship

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT.

BACKGROUND: Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor. OBJECTIVES: The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested. DESIGN: This was a three-arm, single-blind, parallel randomised controlled trial. SETTING: A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited. PARTICIPANTS: A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised. INTERVENTIONS: The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC. RANDOMISATION: Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation. MAIN OUTCOME MEASURES: The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. RESULTS: The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective. CONCLUSIONS: Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84864870. FUNDING: 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. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London

Following the Francis report: investigating patient experience of mental health in-patient care

BACKGROUND: The Francis report highlights perceptions of care that are affected by different factors including ward structures. AIMS: To assess patient and staff perceptions of psychiatric in-patient wards over time. METHOD: Patient and staff perceptions of in-patient psychiatric wards were assessed over 18 months. We also investigated whether the type of ward or service structure affected these perceptions. We included triage and routine care. The goal was to include at least 50% of eligible patients and staff. RESULTS: The most dramatic change was a significant deterioration in all experiences over the courseof the study. Systems of care or specific wards did not affect patient experience but staff were more dissatisfied in the triage system. CONCLUSIONS: This is the first report of deterioration in perceptions of the therapeutic in-patient environment that has been captured in a rigorous way. It may reflect contemporaneous experiences across the National Health Service of budget reductions and increased throughput. The ward systems we investigated did not improve patient experience and triage may have been detrimental to staff

Modelling the cost-effectiveness of pharmacotherapy compared with cognitive–behavioural therapy and combination therapy for the treatment of moderate to severe depression in the UK

Background. The National Institute of Health and Care Excellence (NICE) in England and Wales recommends the combination of pharmacotherapy and psychotherapy for the treatment of moderate to severe depression. However, the cost-effectiveness analysis on which these recommendations are based have not included psychotherapy as monotherapy as a potential option. For this reason, we aimed to update, augment and refine the existing economic evaluation. Methods. We constructed a decision analytic model with a 27-month time horizon. We compared pharmacotherapy with cognitive behavioural therapy (CBT) and combination treatment for moderate to severe depression in secondary care from a healthcare service perspective. We reviewed the literature to identify relevant evidence and, where possible, synthesised evidence from clinical trials in a meta-analysis to inform model parameters. Results. The model suggested that CBT as monotherapy was most likely to be the most cost-effective treatment option a cost per QALY threshold above £22,000. It dominated combination treatment and had an incremental cost-effectiveness ratio of £20,039 per quality-adjusted life year compared to pharmacotherapy. There was significant decision uncertainty in the probabilistic and deterministic sensitivity analyses. Conclusions. Contrary to previous NICE guidance, the results indicated that even for those patients for whom pharmacotherapy is acceptable, CBT as monotherapy may be a cost-effective treatment option. However, this conclusion was based on a limited evidence base, particularly for combination treatment. In addition, this evidence cannot easily be transferred to a primary care setting

Reducing weight and increasing physical activity in people at high risk of cardiovascular disease: a randomised controlled trial comparing the effectiveness of enhanced motivational interviewing intervention with usual care.

OBJECTIVE: The epidemic of obesity is contributing to the increasing prevalence of people at high risk of cardiovascular disease (CVD), negating the medical advances in reducing CVD mortality. We compared the clinical and cost-effectiveness of an intensive lifestyle intervention consisting of enhanced motivational interviewing in reducing weight and increasing physical activity for patients at high risk of CVD. METHODS: A three-arm, single-blind, parallel-group randomised controlled trial was conducted in consenting primary care centres in south London. We recruited patients aged 40-74 years with a QRisk2 score ≥20.0%, which indicates the probability of having a CVD event in the next 10 years. The intervention was enhanced motivational interviewing which included additional behaviour change techniques and was delivered by health trainers in 10 sessions over 1 year, in either group (n=697) or individual (n=523) format. The third arm received usual care (UC; n=522). The primary outcomes were physical activity (mean steps/day) and weight (kg). Secondary outcomes were changes in low-density lipoprotein cholesterol and CVD risk score. We estimated the relative cost-effectiveness of each intervention. RESULTS: At 24 months, the group and individual interventions were not more effective than UC in increasing physical activity (mean difference=70.05 steps, 95% CI -288.00 to 147.90 and mean difference=7.24 steps, 95% CI -224.01 to 238.50, respectively), reducing weight (mean difference=-0.03 kg, 95% CI -0.49 to 0.44 and mean difference=-0.42 kg, 95% CI -0.93 to 0.09, respectively) or improving any secondary outcomes. The group and individual interventions were not cost-effective at conventional thresholds. CONCLUSIONS: Enhancing motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in those at high CVD risk

Concepts of mental disorders in the United Kingdom : Similarities and differences between the lay public and psychiatrists

BACKGROUND: The lay public often conceptualise mental disorders in a different way to mental health professionals, and this can negatively impact on outcomes when in treatment. AIMS: This study explored which disorders the lay public are familiar with, which theoretical models they understand, which they endorse and how they compared to a sample of psychiatrists. METHODS: The Maudsley Attitude Questionnaire (MAQ), typically used to assess mental health professional's concepts of mental disorders, was adapted for use by a lay community sample (N = 160). The results were compared with a sample of psychiatrists (N = 76). RESULTS: The MAQ appeared to be accessible to the lay public, providing some interesting preliminary findings: in order, the lay sample reported having the best understanding of depression followed by generalised anxiety, schizophrenia and finally antisocial personality disorder. They best understood spiritualist, nihilist and social realist theoretical models of these disorders, but were most likely to endorse biological, behavioural and cognitive models. The lay public were significantly more likely to endorse some models for certain disorders suggesting a nuanced understanding of the cause and likely cure, of various disorders. Ratings often differed significantly from the sample of psychiatrists who were relatively steadfast in their endorsement of the biological model. CONCLUSION: The adapted MAQ appeared accessible to the lay sample. Results suggest that the lay public are generally aligned with evidence-driven concepts of common disorders, but may not always understand or agree with how mental health professionals conceptualise them. The possible causes of these differences, future avenues for research and the implications for more collaborative, patient-clinician conceptualisations are discussed.Peer reviewedFinal Accepted Versio

Cricket, migration and diasporic communities

Ever since different communities began processes of global migration, sport has been an integral feature in how we conceptualise and experience the notion of being part of a diaspora. Sport provides diasporic communities with a powerful means for creating transnational ties, but also shapes ideas of their ethnic and racial identities. In spite of this, theories of diaspora have been applied sparingly to sporting discourses. Due mainly to its central role in spreading dominant white racial narratives within the British Empire, and the various ways different ethnic groups have ‘played’ with the meanings and associations of the sport in the (post-)colonial period, cricket is an interesting focus for academic research. Despite W.G. Grace’s claim that cricket advances civilisation by promoting a common bond, binding together peoples of vastly different backgrounds, to this day cricket operates strict symbolic boundaries; defining those who do, and equally, do not belong. C.L.R. James’ now famous metaphor of looking ‘beyond the boundary’ captures the belief that, to fully understand the significance of cricket, and the sport’s roles in changing and shaping society, one must consider the wider social and political contexts within which the game is played. The collection of papers in this special issue does just that. Cricket acts as the point of departure in each, but the way in which ideas of power, representation and inequality are ‘played out’ is unique in each