Testing hypotheses associated with bird responses to wildfire.

Disturbance is a key ecological process influencing the distribution and abundance of many elements of the earth's biota. Predicting the response of biota to disturbance is therefore important, but it nevertheless remains difficult to make accurate forecasts of response. We tested predictions from disturbance-related theories and concepts in 10 vegetation types at Booderee National Park (southeastern Australia) using a retrospective study of bird responses to fire history (over 35 years) on 110 sites and a prospective study following a single wildfire event in 2003 at 59 of these sites. Our data did not support predictions from the intermediate-disturbance hypothesis; observed bird species richness at a site was significantly (F(1,99) = 6.30, P = 0.014) negatively related to the number of fires since 1972 and was 8.7% lower (95% CI, 1.8-15.1%) for each additional fire. In contrast to fire history effects, we found that after the 2003 fire, the vast majority of individual species and the bird assemblage per se in most vegetation types recovered within two years. Thus, recovery after a single fire did not reflect long-term effects of multiple fires on overall bird species richness at a site. We postulated that the recovery of bird species richness and bird assemblage composition after the 2003 fire would be fastest in structurally simple vegetation types and slowest in structurally complex vegetation, but observed the opposite. Although observed bird species richness in vertically heterogeneous forest and woodland had returned to prefire levels by 2006, bird species richness in structurally simple vegetation types (e.g., sedgeland) had not. Postfire vegetation regeneration, together with a paucity of early-successional specialists, would explain the speed of recovery of the bird assemblage and why it changed relatively little during our investigation.

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial.

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.

Economic evaluation of treatments for children with severe behavioural problems.

BACKGROUND: Disruptive behaviour disorders, including conduct disorder, affect at least 10% of children and are the most common reasons for referral to children's mental health services. The long-term economic impact on society of unresolved conduct disorder can exceed pound sterling 1 million for one individual over their lifetime. AIMS OF THE STUDY: The aim of this study was to estimate, from a multi-sectoral service perspective, the longer term cost-effectiveness of an intensive practice based parenting programme for children with severe behavioural problems as compared to a standard treatment, on a pilot basis. METHODS: A six-month pragmatic controlled trial was conducted involving forty-two families who had been referred to a Child and Adolescent Mental Health Service (CAMHS) because of severe child behavioural problems. The families were randomly allocated into either the standard or intensive, practice-based treatment arms of the trial. At baseline, children were aged 2 to 10 years. The externalising T-scale of the Child Behaviour Check List (CBCL) was used as the primary outcome measure. Follow-up studies were conducted at 6 months and four years post-intervention. At the four-year follow up point the two treatments were subjected to an incremental cost-effectiveness analysis. This analysis was enabled by the collection of cost data with respect to the provision of the intensive and standard treatments in terms of therapeutic contact time and also participants' use of health, special educational and social services usage by means of a Client Service Receipt Inventory. RESULTS: Both groups exhibited improved behaviour at six month follow-up, but only the practice based treatment group showed sustained improvement at the four-year follow-up. An independent t-test revealed a significant difference between group mean scores at four-year follow-up (p = 0.027). The research found a median bootstrap ICER estimate of pound sterling 224 From the cost-effectiveness acceptability curve (CEAC) it was found that 89.6% of the cost-effectiveness plane represented a cost saving over the control intervention while 99.9% represented an improvement in effect. Therefore the intensive intervention could not be said to differ significantly from the control intervention on the basis of costs or effects. However under certain circumstances requiring judgement the intensive intervention could be cost-effective. DISCUSSION: Training interventions for the parents of children with severe conduct disorders currently take the form of a number of behavioural strategies provided by a CAMHS team including the reinforcement of appropriate behaviours and parent record-keeping. An alternative treatment was then considered that included all the aspects provided by the standard treatment (with the exception of agreeing written goals) and also added five-hour sessions of unit-based treatment during which videotaped recording of parent-child interactions were used to give feedback to parents and to provide the opportunity for behavioural rehearsal. The findings of the current research indicate that this alternative treatment may be more cost-effective than the standard intervention under certain circumstances. CONCLUSIONS: It can be concluded on a pilot basis that while the CEAC failed to show a significant difference between costs and effects for the intensive treatment, under circumstances of resource/effect trade offs the treatment could be said to be cost-effective. IMPLICATIONS FOR HEALTH CARE PROVISION, USE AND POLICIES: Health and social care policy and commissioning must be evidence based. Although the analysis in this paper should be considered a pilot due to the small sample size our results suggest that investment by health services and social services in practice-based parenting interventions may well be less costly and more effective in the longer-run than the standard practice involving giving management advice to parents. IMPLICATIONS FOR FURTHER RESEARCH: It would be of interest for further research to continue to follow up the work done in this study with a larger cohort of subjects to further establish the effective components of parenting programmes and their relative costs and benefits both at intervention and over time.

Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care.

BACKGROUND: Spinal pain is common and frequently disabling. Management guidelines have encouraged referral from primary care for spinal manipulation. However, the evidence base for these recommendations is weak. More pragmatic trials and economic evaluations have been recommended. OBJECTIVES: Our aim was to assess the effectiveness and health care costs of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A pragmatic randomized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. A total of 201 patients with neck or back pain of 2-12 weeks duration were allocated at random between usual GP care and an additional three sessions of osteopathic spinal manipulation. The primary outcome measure was the Extended Aberdeen Spine Pain Scale (EASPS). Secondary measures included SF-12, EuroQol and Short-form McGill Pain Questionnaire. Health care costs were estimated from the records of referring GPs. RESULTS: Outcomes improved more in the osteopathy group than the usual care group. At 2 months, this improvement was significantly greater in EASPS [95% confidence interval (CI) 0.7-9.8] and SF-12 mental score (95% CI 2.7-10.7). At 6 months, this difference was no longer significant for EASPS (95% CI -1.5 to 10.4), but remained significant for SF-12 mental score (95% CI 1.0-9.9). Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group (95% CI 32-155 UK pounds). Though osteopathy also cost 22 UK pounds more in mean total health care cost, this was not significant (95% CI - 159 to 142 UK pounds). CONCLUSION: A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes, at little extra cost. Rigorous multicentre studies are now needed to assess the generalizability of this approach.