Association Between Systolic Blood Pressure and Cardiovascular Inpatient Cost Moderated by Peer-Support Intervention Among Adult Patients With Type 2 Diabetes: A 2-Cohort Study.

OBJECTIVES: People with type 2 diabetes and increased systolic blood pressure (SBP) are at high risk of cardiovascular disease (CVD). In this study, we aimed to investigate the association between CVD-related hospital payments and SBP and tested whether this association is influenced by diabetes peer support. METHODS: Two cohorts comprising people with type 2 diabetes were included in the study. The first cohort comprised 4,704 patients with type 2 diabetes assessed between 2008 and 2009 from 18 general practices in Cambridgeshire and followed up to 2009-2011. The second cohort comprised 1,121 patients with type 2 diabetes from post-trial follow-up data, recruited between 2011 and 2012 and followed up to 2015. SBP was measured at baseline. Inpatient payments for CVD hospitalization within 2 years since baseline was the main outcome. The impact of 1:1, group or combined diabetes peer support and usual care were investigated in the second cohort. Adjusted mean CVD inpatient payments per person were estimated using a 2-part model after adjusting for baseline characteristics. RESULTS: A "hockey-stick" relationship between baseline SBP and estimated CVD inpatient payment was identified in both cohorts, with a threshold at 133 to 141 mmHg, suggesting increased payments for patients with SBP below and above the threshold. The combined peer-support intervention altered the aforementioned association, with no increased payment with SBP above the threshold, and payment slightly decreased with SBP beyond the threshold. CONCLUSIONS: SBP maintained between 133 and 141 mmHg is associated with the lowest CVD disease management costs for patients with type 2 diabetes. Combined peer-support intervention could significantly decrease CVD-related hospital payments.

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives.

OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

The Population Cost-Effectiveness of Weight Watchers with General Practitioner Referral Compared with Standard Care.

OBJECTIVE: This study aimed to assess population-level cost-effectiveness of the Weight Watchers (WW) program with doctor referral compared with standard care (SC) for Australian adults with overweight and obesity. METHODS: The target population was Australian adults ≥ 20 years old with BMI ≥ 27 kg/m2 , whose obesity status was subsequently modeled for 2015 to 2025. A microsimulation model (noncommunicable disease model [NCDMod]) was used to assess the incremental cost-effectiveness of WW compared with SC. A health system perspective was taken, and outcomes were measured by obesity cases averted in 2025, BMI units averted for 2015 to 2025, and quality-adjusted life years for 2015 to 2025. Univariate sensitivity testing was used to measure variations in the model parameters. RESULTS: The WW intervention resulted in 60,445 averted cases of obesity in 2025 (2,311 more cases than for SC), extra intervention costs of A$219 million, and cost savings within the health system of A$17,248 million (A$82 million more than for SC) for 2015 to 2025 compared with doing nothing. The modeled WW had an incremental cost-effectiveness ratio of A$35,195 in savings per case of obesity averted in 2025. WW remained dominant over SC for the different scenarios in the sensitivity analysis. CONCLUSIONS: The WW intervention represents good value for money. The WW intervention needs serious consideration in a national package of obesity health services.

Cost-utility analysis of meaning-centered group psychotherapy for cancer survivors.

BACKGROUND: Meaning-centered group psychotherapy for cancer survivors (MCGP-CS) improves meaning, psychological well-being, and mental adjustment to cancer and reduces psychological distress. This randomized controlled trial was conducted to investigate the cost-utility of MCGP-CS compared with supportive group psychotherapy (SGP) and care-as-usual (CAU). METHODS: In total, 170 patients were randomized to MCGP-CS, SGP, or CAU. Intervention costs, direct medical and nonmedical costs, productivity losses, and health-related quality of life were measured until 6 months follow-up, using the TIC-P, PRODISQ, data from the hospital information system, and the EQ-5D. The cost-utility was calculated by comparing mean cumulative costs and quality-adjusted life years (QALYs). RESULTS: Mean total costs ranged from €4492 (MCGP-CS) to €5304 (CAU). Mean QALYs ranged .507 (CAU) to .540 (MCGP-CS). MCGP-CS had a probability of 74% to be both less costly and more effective than CAU, and 49% compared with SGP. Sensitivity analyses showed these findings are robust. If society is willing to pay €0 for one gained QALY, MCGP-CS has a 78% probability of being cost-effective compared with CAU. This increases to 85% and 92% at willingness-to-pay thresholds of €10 000 and €30 000, which are commonly accepted thresholds. CONCLUSIONS: MCGP-CS is highly likely a cost-effective intervention, meaning that there is a positive balance between the costs and gains of MCGP-CS, in comparison with SGP and CAU.

Availability of breastfeeding peer support in the United Kingdom: A cross-sectional study.

Peer support is recommended by the World Health Organization for the initiation and continuation of breastfeeding, and this recommendation is included in United Kingdom (U.K.) guidance. There is a lack of information about how, when, and where breastfeeding peer support was provided in the U.K. We aimed to generate an overview of how peer support is delivered in the U.K. and to gain an understanding of challenges for implementation. We surveyed all U.K. infant feeding coordinators (n = 696) who were part of U.K.-based National Infant Feeding Networks, covering 177 National Health Service (NHS) organisations. We received 136 responses (individual response rate 19.5%), covering 102 U.K. NHS organisations (organisational response rate 58%). We also searched NHS organisation websites to obtain data on the presence of breastfeeding peer support. Breastfeeding peer support was available in 56% of areas. However, coverage within areas was variable. The provision of training and ongoing supervision, and peer-supporter roles, varied significantly between services. Around one third of respondents felt that breastfeeding peer-support services were not well integrated with NHS health services. Financial issues were commonly reported to have a negative impact on service provision. One quarter of respondents stated that breastfeeding peer support was not accessed by mothers from poorer social backgrounds. Overall, there was marked variation in the provision of peer-support services for breastfeeding in the U.K. A more robust evidence base is urgently needed to inform guidance on the structure and provision of breastfeeding peer-support services.

Randomized controlled trial and economic evaluation of nurse-led group support for young mothers during pregnancy and the first year postpartum versus usual care.

BACKGROUND: Child maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population. METHODS: A multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20-24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses. RESULTS: Between August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI - 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group - 0 · 68 (95% CI - 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%. CONCLUSIONS: The trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention. TRIAL REGISTRATION: ISRCTN78814904 . Registered on 17 May 2013.

[Online self-help for persons with suicidal intentions: budget impact analysis]. / Onlinehulp bij suïcidale gedachten: budgetimpactanalyse.

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Distribution and Neighborhood Correlates of Sober Living House Locations in Los Angeles.

Sober living houses (SLHs) are alcohol and drug-free living environments for individuals in recovery. The goal of this study was to map the distribution of SLHs in Los Angeles (LA) County, California (N = 260) and examine neighborhood correlates of SLH density. Locations of SLHs were geocoded and linked to tract-level Census data as well as to publicly available information on alcohol outlets and recovery resources. Neighborhoods with SLHs differed from neighborhoods without them on measures of socioeconomic disadvantage and accessibility of recovery resources. In multivariate, spatially lagged hurdle models stratified by monthly fees charged (less than $1400/month vs. $1400/month or greater), minority composition, and accessibility of treatment were associated with the presence of affordable SLHs. Accessibility of treatment was also associated with the number of affordable SLHs in those neighborhoods. Higher median housing value and accessibility of treatment were associated with whether a neighborhood had high-cost SLHs, and lower population density was associated with the number of high-cost SLHs in those neighborhoods. Neighborhood factors are associated with the availability of SLHs, and research is needed to better understand how these factors affect resident outcomes, as well as how SLHs may affect neighborhoods over time.

Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial.

OBJECTIVES: To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services. DESIGN: A randomized controlled trial. SETTING: Primary care and memory clinics in the Helsinki metropolitan area, Finland. PARTICIPANTS: PwD (N = 136) and their spouses (N = 136). INTERVENTION: Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support. MEASUREMENTS: The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months. RESULTS: At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR). CONCLUSIONS: The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12611001173987.

Development of the Treatment Inventory of Costs in Psychiatric Patients: TIC-P Mini and Midi.

BACKGROUND: Medical costs of (psychiatric) illness can be validly measured with patient report questionnaires. These questionnaires comprise many detailed items resulting in lengthy administrations. OBJECTIVES: We set out to find the minimal number of items needed to retrieve 80% and 90% of the costs as measured by the Treatment Inventory of Costs in Patients with psychiatric disorders (TIC-P). METHODS: The TIC-P is a validated patient-reported outcome measure concerning the utilization of medical care and productivity losses. The present study focused on direct medical costs. We applied data of 7756 TIC-P administrations from three studies in patients with mental health care issues. Items that contribute least to the total cost were eliminated, providing that 80% and 90% of the total cost was retained. RESULTS: Average medical costs per patient were €658 over the last 4 weeks. The distribution of cost was highly skewed, and 5 of the 14 items of the TIC-P accounted for less than 10% of the total costs. The 80% Mini version of the TIC-P required five items: ambulatory services, private practice, day care, general hospital, and psychiatric clinic. The TIC-P Midi 90% inventory required eight items. Both had variance between the three samples in the optimal choice of the items. CONCLUSIONS: The number of items of the TIC-P can be reduced considerably while maintaining 80% and 90% of the medical costs estimated by the complete TIC-P. The reduced length makes the questionnaire more suitable for routine outcome monitoring.

Effect of combining a health program with a microfinance-based self-help group on health behaviors and outcomes.

OBJECTIVES: Women's participation in microfinance-based self-help groups (SHGs) and the resultant social capital may provide a basis to address the gap in health attainment for poor women and their children. We investigated the effect of combining a health program designed to improve health behaviours and outcomes with a microfinance-based SHG program. DESIGN: A mixed method study was conducted among 34 villages selected from three blocks or district subdivisions of India; one in Gujarat, two in Karnataka. METHODS: A set of 17 villages representing new health program areas were pair-matched with 17 comparison villages. Two rounds of surveys were conducted with a total of 472 respondents, followed by 17 key informant interviews and 17 focus group discussions. RESULTS: Compared to a matched comparison group, women in SHGs that received the health program had higher odds of delivering their babies in an institution (OR: 5.08, 95% CI 1.21-21.35), feeding colostrum to their newborn (OR: 2.83, 95% CI 1.02-5.57), and having a toilet at home (OR: 1.53, 95% CI 0.76-3.09). However, while the change was in the expected direction, there was no statistically significant reduction in diarrhoea among children in the intervention community (OR: 0.86, 95% CI 0.42-1.76), and the hypothesis that the health program would result in decreased out-pocket expenditures on treatment was not supported. CONCLUSION: Our study found evidence that health programs implemented with microfinance-based SHGs is associated with improved health behaviours. With broad population coverage of SHGs and the social capital produced by their activities, microfinance-based SHGs may provide an avenue for addressing the health needs of poor women.

Self-help for weight loss in overweight and obese adults: systematic review and meta-analysis.

We conducted a systematic review and meta-analysis investigating the components and effectiveness of self-help weight-loss interventions and their applicability to less-advantaged populations. We searched (November 2013) for randomized controlled trials comparing self-help interventions with each other or with minimal controls in overweight and obese adults, with 6 months or longer follow-up. We calculated mean difference between intervention and control for 6- and 12-month weight change. Twenty-three studies met the inclusion criteria (9632 participants; 39 intervention arms). Intervention participants lost significantly more weight than controls at 6 months (mean difference -1.85 kg; 95% confidence interval [CI]=-2.86, -0.83; 7 studies). No significant effect was detected at 12 months but results were sensitive to the inclusion of 1 study at high risk of bias. Interactive programs appeared more effective than standard ones at 6 months (mean difference -0.94 kg; 95% CI=-1.50, -0.38). Evidence is insufficient to reach conclusions on effectiveness in socioeconomically disadvantaged people, but suggests self-help interventions may be less effective in this group.

Testing the proclaimed affordances of online support groups in a nationally representative sample of adults seeking mental health assistance.

In this study, explanations for why people turn to the Internet for social support are tested using a nationally representative sample of adults who sought mental health support through a traditional treatment outlet, an in-person support group, or an online support group. Results indicate that the more adults report having social stigma concerns, the more likely they are to seek support online instead of help from an in-person support group or traditional treatment. Likewise, as the reported number of logistical barriers to mental health treatment increases, a corresponding increase occurs in the odds of adults seeking online support instead of traditional treatment. These findings as well as estimates of demographic variation in the use of online support are discussed.

[Ambulatory alcohol withdrawal]. / Der ambulante qualifizierte Alkoholentzug.

Alcohol addiction is a common problem in daily life as well as in medicine. Apart from inpatient therapy programs, ambulatory withdrawal is a relatively new option, which may be done safely, efficient and cost-effective close to the domicile an without stigmatisation of the patient.

Feasibility and pilot study of the effects of microfinance on mortality and nutrition in children under five amongst the very poor in India: study protocol for a cluster randomized controlled trial.

BACKGROUND: The United Nations Millennium Development Goals include targets for the health of children under five years old. Poor health is linked to poverty and microfinance initiatives are economic interventions that may improve health by breaking the cycle of poverty. However, there is a lack of reliable evidence to support this. In addition, microfinance schemes may have adverse effects on health, for example due to increased indebtedness. Rojiroti UK and the Centre for Promoting Sustainable Livelihood run an innovative microfinance scheme that provides microcredit via women's self-help groups (SHGs). This pilot study, conducted in rural Bihar (India), will establish whether it is feasible to collect anthropometric and mortality data on children under five years old and to conduct a limited cluster randomized trial of the Rojiroti intervention. METHODS/DESIGN: We have designed a cluster randomized trial in which participating tolas (small communities within villages) will be randomized to either receive early (SHGs and microfinance at baseline) or late intervention (SHGs and microfinance after 18 months). Using predesigned questionnaires, demographic, and mortality data for the last year and information about participating mothers and their children will be collected and the weight, height, and mid upper arm circumference (MUAC) of children will be measured at baseline and at 18 months. The late intervention group will establish SHGs and microfinance support at this point and data collection will be repeated at 36 months.The primary outcome measure will be the mean weight for height z-score of children under five years old in the early and late intervention tolas at 18 months. Secondary outcome measures will be the mortality rate, mean weight for age, height for age, prevalence of underweight, stunting, and wasting among children under five years of age. DISCUSSION: Despite economic progress, marked inequalities in child health persist in India and Bihar is one of the worst affected states. There is a need to evaluate programs that may alleviate poverty and improve health. This study will help to inform the design of a definitive trial to determine if the Rojiroti scheme can improve the nutrition and survival of children under five years of age in deprived rural communities. TRIAL REGISTRATION: Clinicaltrials.gov (study ID: NCT01845545). Registered on 24 April 2013.

An oasis in the hospital: the perceived benefits of a cancer support center in a hospital setting offering complementary therapies.

AIMS: The aim of this study was to explore and describe the experiences of persons attending a cancer support center, providing emotional support to cancer patients through self-selected complementary therapies offered free of charge through qualified volunteer therapists. A grounded theory methodology was used. Sources of data were 16 semistructured interviews with persons attending the center. Interviews were digitally recorded and transcribed verbatim. Analysis was conducted using the constant comparative method. FINDINGS: The overarching theme that emerged in this study was the benefits attributed to attendance at the cancer support center. The center was described as an "oasis" in the hospital, and three aspects relating to this were identified: (a) facilitating comfort, (b) increasing personal control, and (c) helping make sense of the cancer experience. CONCLUSION: A drop-in center offering complementary therapies appeared to enable coping with the diagnosis and treatment of cancer by facilitating comfort and increasing perceptions of personal control. The center also helped some participants to make sense of their experience with cancer. This research has provided a unique insight into the ongoing emotional needs of cancer patients, and directions for further development and research into the provision of holistic care for patients within a hospital setting.