An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background: Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs). Aim: To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk. Methods Development: We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs. Implementation: The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence. Evaluation: The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment. Trial results Depression trial: In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5; p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence. CVD risk trial: In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9; p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management. The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement. Conclusion: The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs

Evidence-based health care

Box binder containing six items: produced with Milton Keynes Primary Care Trust (GB): originally published in 1999SIGLEAvailable from British Library Document Supply Centre-DSC:Vm02/50402 / BLDSC - British Library Document Supply Centre2. ed.GBUnited Kingdo

Reviewing studies with diverse designs: the development and evaluation of a new tool

RATIONALE, AIMS & OBJECTIVE: Tools for the assessment of the quality of research studies tend to be specific to a particular research design (e.g. randomized controlled trials, or qualitative interviews). This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches. The aim of this paper is to describe the development and preliminary evaluation of a quality assessment tool that can be applied to a methodologically diverse set of research articles. METHODS: The 16-item quality assessment tool (QATSDD) was assessed to determine its reliability and validity when used by health services researchers in the disciplines of psychology, sociology and nursing. Qualitative feedback was also gathered from mixed-methods health researchers regarding the comprehension, content, perceived value and usability of the tool. RESULTS: Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of 'good research technique' being assessed. Face validity was subsequently established through feedback from a sample of nine health researchers. Inter-rater reliability was established through substantial agreement between three reviewers when applying the tool to a set of three research papers (kappa = 71.5%), and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability. CONCLUSIONS: The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies, and may be an extremely useful tool for reviewers to standardize and increase the rigour of their assessments in reviews of the published papers which include qualitative and quantitative work

The therapeutic effectiveness of creative activities on mental well-being: a systematic review of the literature

The aim of this paper was to investigate the literature to ascertain the effectiveness of creative activities on mental well-being within the mental health context. Creative activities have always been evident within the context of mental health and there is increasing recognition that the arts have an important role to play in improving the health and well-being of individuals. Medline, Cinahl and PsycINFO were searched utilizing the keywords art, therap, well-being and mental health. The arts council data base was accessed and the Department of Health review of Arts for Health Working Group. Eleven studies were appraised by one reviewer utilizing the Critical Appraisal Skills Programme tool. It was difficult to make comparisons of the papers accessed as a result of the majority of studies being evaluative in nature and untaken within local projects therefore lacking in generalization. The evidence suggests that creative activities can have a healing and protective effect on mental well-being. Their therapeutic effects promote relaxation, provide a means of self-expression, reduce blood pressure while boosting the immune system and reducing stress. However, the evidence to support these claims is weak and assumptions were made that lacked reliability and validity. Establishing the benefit of participating in creative arts is difficult because of a lack of consistency of a clear definition, but it is important to identify the potential of creative arts as a therapeutic and transformational tools and not an intervention for therapeutic diversio