Outcome Quality of Inpatient and Day-Clinic Treatment in Child and Adolescent Psychiatry-A Naturalistic Study.

BACKGROUND: Child and adolescent psychiatry has only recently been established as a separate specialty and is practiced in different settings. The epidemiology of psychological problems in childhood is high and varied, thus qualitative work is essential. Assessment of outcome as part of quality management is central to assure the service of psychiatric care to be effective. METHOD: Over a three-year period consecutively admitted patients from inpatient and day-clinic treatment were prospectively evaluated. A total of 200 from 442 patients (m = 80, f = 120; age 15.1 ± 2.8 y) agreed to participate. Patients, caregivers, and therapists answered a range of questionnaires to provide a multi-personnel rating. Questionnaires used for outcome assessment were Child Behavior Checklist (CBCL) and Youth-Self-Report (YSR) (at admission, discharge, and 6 weeks after discharge) and the problem score of the Inventory of Quality of Life for children (ILK), treatment satisfaction, and process quality by the Questionnaire for Treatment Satisfaction (FBB, at discharge) and as real-life outcome control assessment of quality of life (ILK) was added (admission, discharge, and 6 wks after discharge). RESULTS: There was a significant reduction in psychopathologicalsymptoms (CBCL, YSR) and in the problem score. Furthermore, there was a significant increase in quality of life. QoL score and YSR/CBCL scores returned to normal levels. Treatment satisfaction was high and so was satisfaction with process quality. Factors significantly influencing outcome were severity of disease and the relationship to the therapist. No differences were found for gender and setting. CONCLUSION: The quality management analysis revealed significant improvements of symptom load, a significant increase in QoL and a high treatment satisfaction. Furthermore, process quality was scored highly by parents and therapists.

A systematic Analysis of Evaluation Methods for Inpatient Children and Adolescents Rehabilitation Programs.

Increasing chronic diseases in children and adolescents such as obesity, asthma bronchiale, or mental disorders, result in a growing importance of rehabilitation programs and subsequent program evaluations. We conducted a systematic literature search in 5 databases and provided an overview of methods for evaluating inpatient child and adolescent rehabilitation programs. This included an identification of generic and indication-specific outcomes and standardized measuring instruments. Eighteen studies covering 8 indication groups were considered for the qualitative analysis according to the pre-defined inclusion and exclusion criteria. Overall, the 18 studies included eight generic outcomes: (1) quality of life, (2) psychological well-being, (3) perceived changes, (4) functionality, (5) rehabilitation satisfaction, (6) self-management/-efficacy, (7) days of absence and (8) self-esteem. Eighteen standardized measuring instruments and 6 self-developed questionnaires were used to assess the 8 generic outcomes. Besides, indication-specific outcomes for 5 indications namely traumatic brain injury, obesity, diabetes, eating disorders and neurodermatitis, were reported. Overall, the present systematic review summarizes essential content (8 generic outcomes) and methods for evaluations of children and adolescent rehabilitation programs; however, before choosing a generic measuring tool during an evaluation, the psychometric validity of the instruments should be evaluated. In addition to the generic perspective, the evaluation of disease-specific outcomes is recommended.

Assessment of public health interventions for decision support: methods & processes of the evaluation of the Austrian screening programme for pregnant women & children.

BACKGROUND: In 2010, the Austrian Ministry of Health (MoH) commissioned the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) to prepare decision support for the reorientation of the national screening programme for pregnant women and children ("Mutter-Kind-Pass"). This is one of several reports aimed at giving an overview of recommended screening measures. METHODS: By conducting a guideline synopsis, we summarised screening recommendations from guidelines of high methodological quality. To facilitate contextualisation of the recommendations, the MoH initiated a transparent appraisal process. RESULTS: We identified 101 guidelines dealing with screenings during pregnancy and 75 guidelines providing screening recommendations for children. From 2014 to 2018, an interdisciplinary and multi-professional expert group discussed these results and formulated recommendations for a new Austrian screening programme. CONCLUSION: Following the multi-step process of Health Technology Assessment (assessment-appraisal-decision), this methodological approach bridges evidence and national expert knowledge and represents a novel path towards a new screening programme in Austria.

Services Use of Children and Adolescents before Admission to Psychiatric Inpatient Care.

BACKGROUND: Although 20% of children and adolescents in Europe suffer from overt mental health problems, their illness-related service utilisation is often unknown. If at all, existing research has only addressed the health care sector while services requirements in mental health care go far beyond the health care system, including the social, the educational and the criminal justice system. AIMS OF STUDY: This paper aims at describing the service contact patterns of children and adolescents within and outside the health care sector before they are admitted to a child and adolescent mental health hospital. Additionally, we evaluate the private out-of-pocket payments that occur for primary carers. METHOD: A cohort of consecutive admissions to a child and adolescent hospital in Austria was prospectively analysed. We collected data on service use and out-of-pocket expenses before hospital admission from primary carers through face-to-face interviews using an adapted version of the European Child and Adolescent Mental Health Service Receipt Inventory (EU-CAMHSRI). Clinical data came from validated questionnaires (CBCL, YSR) and from the anamnestic documentation. RESULT: Ninety percent from a cohort of 441 patients had some contact with services or took medication before they were admitted to hospital. Most often, services in the health care outpatient setting were used. Outside of the health care system, support in school, as well as counselling services, were used most frequently, whereas the persons hardly sought support in living or employment. Roughly 32,400 per 100 patients was spent privately, yet these out-of pocket expenses were very unevenly distributed. Service use and out-of-pocket spending increased with social status and were gender-specific. The more severe external behaviour symptoms were, the more non-health care services were used. DISCUSSION: Mentally ill children and adolescents use a broad range of services across sectors before admission to hospital. Service use is associated with specific symptoms of the disease, yet not with the diagnosis. For some carers, this is linked to considerable financial burden because many of those services are only partly publicly funded or are not part of the health sector. A limitation of the study is the uncertainty of self-reports. Furthermore, we do not know whether the services used were needs-based and effective, and what the utilisation patterns of non-hospitalised children and adolescents are. IMPLICATIONS FOR HEALTH POLICIES: Mental health policy for children and adolescents in Austria needs to focus on how to organise a needs-oriented and coordinated services mix across different sectors that is equally accessible regardless of the patients' socio-economic background. IMPLICATIONS FOR FUTURE RESEARCH: To support planning, further research on the factors that predict service use and on the cost-effectiveness of services is required.

[Outcome quality in the mental health rehabilitation of children and adolescents ]. / Ergebnisqualität in der Mental Health Rehabilitation für Kinder und Jugendliche.

The range of mental health rehabilitation (MHR) available to children and adolescents with mental health disorders differs internationally. While MHR programs have been already implemented for this target group in Germany, in Austria such services are still in the planning phase. With regard to the quality assurance of potential MHR programs, however, ongoing evaluation approaches are needed already in the course of program design. This review focuses on indicators and measurement methods used in MHR program evaluations. Through a systematic literature search, we identified six studies providing information on five evaluation indicators (clinical symptoms, quality of life, functionality, rehabilitation progress, and rehabilitation satisfaction). By measuring these endpoints, the studies included mainly reported on instruments that had been used throughout different indication groups ("generic tools"). In addition to children and adolescents with mental-health disorders, the parents were usually also included in the evaluations. Thus, the self-assessments of the children and adolescents (e.g., regarding the development of behavioral problems and strengths) were complemented by external assessments. Most evaluation studies included several subsequent time-points of measurement ("longitudinal studies"). The indicators may play a central role in future evaluation projects, since their range of topics provides comprehensive insights into rehabilitation results. However, with regard to the measurement methods, the psychometric quality criteria require proper reviews and consideration.

Antenatal interventions to reduce preterm birth: an overview of Cochrane Systematic Reviews.

BACKGROUND: Several factors are associated with an increased risk of preterm birth (PTB); therefore, various interventions might have the potential to influence it. Due to the large number of interventions that address PTB, the objective of this overview is to summarise evidence from Cochrane reviews regarding the effects and safety of these different interventions. METHODS: We conducted a systematic literature search in the Cochrane Database of Systematic Reviews. Included reviews should be based on randomised controlled trials comparing antenatal non-pharmacological and pharmacological interventions that directly or indirectly address PTB with placebo/no treatment or routine care in pregnant women at less than 37 completed weeks of gestation without signs of threatened preterm labour. We considered PTB at less than 37 completed weeks of gestation as the primary outcome. RESULTS: We included 56 Cochrane systematic reviews. Three interventions increased PTB risk significantly. Twelve interventions led to a statistically significant lower incidence of PTBs. However, this reduction was mostly observed in defined at-risk subgroups of pregnant women. The remaining antenatal interventions failed to prove a significant effect on PTB < 37 weeks, but some of them at least showed a positive effect in secondary outcomes (e.g., reduction in early PTBs). As an unintended result of this review, we identified 28 additional Cochrane reviews which intended to report on PTB < 37 weeks, but were not able to find any RCTs reporting appropriate data. CONCLUSIONS: The possible effects of a diverse range of interventions on PTB have been evaluated in Cochrane systematic reviews. Few interventions have been demonstrated to be effective and a small number have been found to be harmful. For around half of the interventions evaluated, the Cochrane review concluded that there was insufficient evidence to provide sound recommendations for clinical practice. No RCT evidence is available for a number of potentially relevant interventions.

Recommendations from international clinical guidelines for routine antenatal infection screening: does evidence matter?

AIM: Maternal infections in pregnancy may cause severe child morbidity. In this article, we aim to summarise recommendations from international evidence-based clinical guidelines for infection screening in pregnancy. METHODS: We conducted a systematic search for evidence-based guidelines in two databases (Guidelines International Network and National Guideline Clearinghouse) and a hand search on websites of international institutions and societies that develop evidence-based guidelines. We considered guidelines published from the 1 of January 2007 onwards and developed in Western, industrialised countries. The guidelines in our analysis had to be based on a systematic literature search in at least two databases and needed to provide recommendations explicitly linked to the evidence. We included five general antenatal clinical practice guidelines from Australia, UK and the United States and 20 disease-specific guidelines published by Canadian, German, UK and US guideline development groups. RESULTS: The comparison of evidence-based guidelines from nine different guideline development groups for 17 antenatal infection screenings showed variations in directions (pro-screening or contra-screening) as well as in grades of recommendations. Uniformly, all-pro-universal or all-contra-universal screening recommendations were identified for 10 of 17 diseases. Contradictions were primarily observed for group B streptococcus, chlamydia trachomatis, genital herpes and gonorrhoea infection screening. Whereas certainty of recommendations was high for all-pro-screening recommendations, it decreased in all-contra-screening recommendations and even displayed conflicting results for contradictory recommendations. CONCLUSION: The variety of grades of recommendations hamper across-guideline comparison. Nevertheless, the article highlights agreed screening areas based on the best available evidence as well as areas of still existing uncertainty. Local health policy decisions on whether to include or refrain from including screening measures in preventive care programmes can be facilitated by the comparison of recommendations from international evidence-based guidelines. Beyond the availability of evidence each country's health policy makers will have to make a judgement on the value of the test for a population-wide screening.

Artificial total disc replacement versus fusion for the cervical spine: a systematic review.

Cervical total disc replacement (CTDR) has been increasingly used as an alternative to fusion surgery in patients with pain or neurological symptoms in the cervical spine who do not respond to non-surgical treatment. A systematic literature review has been conducted to evaluate whether CTDR is more efficacious and safer than fusion or non-surgical treatment. Published evidence up to date is summarised qualitatively according to the GRADE methodology. After 2 years of follow-up, studies demonstrated statistically significant non-inferiority of CTDR versus fusion with respect to the composite outcome 'overall success'. Single patient relevant endpoints such as pain, disability or quality of life improved in both groups with no superiority of CTDR. Both technologies showed similar complication rates. No evidence is available for the comparison between CTDR and non-surgical treatment. In the long run improvement of health outcomes seems to be similar in CTDR and fusion, however, the study quality is often severely limited. After both interventions, many patients still face problems. A difficulty per se is the correct diagnosis and indication for surgical interventions in the cervical spine. CTDR is no better than fusion in alleviating symptoms related to disc degeneration in the cervical spine. In the context of limited resources, a net cost comparison may be sensible. So far, CTDR is not recommended for routine use. As many trials are ongoing, re-evaluation at a later date will be required. Future research needs to address the relative effectiveness between CTDR and conservative treatment.

Stem torsion in total hip replacement.

BACKGROUND AND PURPOSE: The clinical results of THR may be improved by correct femoral torsion. We evaluated the stem position by postoperative CT examination in 60 patients. METHODS: 60 patients requiring total hip arthroplasty were prospectively enrolled in this study. Minimally invasive THR was performed (anterior approach) in a lateral decubitus position and each patient underwent a postoperative CT examination. The position of the stem was evaluated by an independent external institution. RESULTS: Stem torsion ranged from ­ 19° retrotorsion to 33° antetorsion. Normal antetorsion (i.e 10­15° according to Tönnis) was present in 5 of 60 patients, so the prevalence of abnormal stem antetorsion was 92% (95% CI: 82­97). We found a stem antetorsion outside the range of 0­25° in 21 of 60 hips. Women had a higher mean stem antetorsion (8.0° (SD 11)) than men (1.5° (SD 10)). INTERPRETATION: Postoperative stem antetorsion shows a high variability and is gender-related. We suggest precise assessment of stem antetorsion intraoperatively by means of computer navigation, preparing the femur first. In abnormal stem antetorsion, the cup position can be adjusted using a combined anteversion concept; alternatively, modular femoral components or stems with retroverted or anteverted necks ("retrostem") could be used.