Anxiety disorders are common, yet treatment options in general practice are often limited to medication or CBT. There is a lack of evidence for the effectiveness of exercise in the treatment of ...anxiety in patients who present to general practice and also about the intensity of exercise required to lead to improvement. The aim of this systematic review was to assess the use of exercise versus waiting list control groups in the treatment of anxiety and also to assess the benefit of high intensity exercise vs low intensity exercise. Long term follow up scores were also analysed. We included patients who met diagnostic criteria for anxiety disorders or had clinically raised anxiety levels on a validated rating scale and performed a subgroup analysis of the outcomes between the two groups. The intervention was any aerobic exercise programme carried out for at least two weeks, or exercise carried out at high intensity for at least two weeks. The comparison groups were either a waiting list control group or low intensity exercise.
Systematic review of randomised controlled trials. Three databases were searched; CENTRAL, Medline and Embase. Outcome assessment was based on validated anxiety rating scales. The quality of the studies was appraised according to the Cochrane Risk of Bias tool. Effect sizes were calculated using the standardised mean difference.
Fifteen studies were identified with a total of 675 patients. Nine trials had participants with diagnosed anxiety disorders and six trials had participants with raised anxiety on a validated rating scale. Aerobic exercise was effective in the treatment of raised anxiety compared to waiting list control groups (effect size - 0.41, 95% CI = - 0.70 to - 0.12). High intensity exercise programmes showed greater effects than low intensity programmes. There was no significant difference in outcomes between groups of patients with diagnosed anxiety disorders and patients who had raised anxiety on a rating scale. Conclusions were limited by the small number of studies and wide variation in the delivery of exercise interventions.
Exercise programmes are a viable treatment option for the treatment of anxiety. High intensity exercise regimens were found to be more effective than low intensity regimens. The results have implications for the use of exercise schemes in General Practice.
AbstractObjectiveTo systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.DesignSystematic review and meta-analysis.Data ...sourcesMedline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.Review methodsObservational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.ResultsOf the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).ConclusionsAround one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.
As the global burden of chronic disease rises, policy makers are showing a strong interest in adopting telehealth technologies for use in long term condition management, including COPD. However, ...there remain barriers to its implementation and sustained use. To date, there has been limited qualitative investigation into how users (both patients/carers and staff) perceive and experience the technology. We aimed to systematically review and synthesise the findings from qualitative studies that investigated user perspectives and experiences of telehealth in COPD management, in order to identify factors which may impact on uptake.
Systematic review and meta-synthesis of published qualitative studies of user (patients, their carers and clinicians) experience of telehealth technologies for the management of Chronic Obstructive Pulmonary Disease. ASSIA, CINAHL, Embase, Medline, PsychInfo and Web of Knowledge databases were searched up to October 2014. Reference lists of included studies and reference lists of key papers were also searched. Quality appraisal was guided by an adapted version of the CASP qualitative appraisal tool.
705 references (after duplicates removed) were identified and 10 papers, relating to 7 studies were included in the review. Most authors of included studies had identified both positive and negative experiences of telehealth use in the management of COPD. Through a line of argument synthesis we were able to derive new insights from the data to identify three overarching themes that have the ability to either impede or promote positive user experience of telehealth in COPD: the influence on moral dilemmas of help seeking-(enables dependency or self-care); transforming interactions (increases risk or reassurance) and reconfiguration of 'work' practices (causes burden or empowerment).
Findings from this meta-synthesis have implications for the future design and implementation of telehealth services. Future research needs to include potential users at an earlier stage of telehealth/service development.
Understanding why people take part in health research is critical to improve research efficiency and generalisability. The aim of this overview of systematic reviews was to identify psychosocial ...determinants of research participation and map them to psychological theory and empirical recruitment research, to identify effective strategies to increase research participation.
Qualitative and quantitative systematic reviews were systematically identified. No date or language limits were applied. Two reviewers independently selected reviews. Methodological quality was rated using AMSTAR, and poor-quality reviews (scoring 0-3) were excluded. Barriers and facilitators were coded to psychological theory (Theoretical Domains Framework) and empirical recruitment research (recruitment interventions that had been subjected to randomised controlled trial evaluation).
We included 26 systematic reviews (429 unique primary studies), covering a wide range of patient populations and health settings. We identified five groups of facilitators, of which three were dominant (potential for personal benefit, altruism, trust) and appear to be relevant across research setting and design. We identified nine groups of barriers, which were more dependent on the particular study (context, population, design). Two determinants (participant information, social influences) were found to be both barriers and facilitators. Barriers and facilitators could be coded to the Motivation and Opportunity components of the Theoretical Domains Framework; only one was coded to a Capability component. There was some overlap between psychosocial determinants and empirical recruitment research, but some barriers and facilitators had not been tested at all.
Identifying effective recruitment strategies could increase the efficiency and generalisability of primary research. We identified a number of barriers and facilitators that could be addressed by researchers. There is a need for more research to identify effective recruitment strategies that draw on the psychosocial facilitators and barriers identified in this overview.
Digital diabetes prevention programs (digital-DPPs) are being implemented as population-based approaches to type 2 diabetes mellitus prevention in several countries to address problems with the ...uptake of traditional face-to-face diabetes prevention programs. However, assessments of digital-DPPs have largely focused on clinical outcomes and usability among those who have taken them up, whereas crucial information on decision-making about uptake (eg, whether a user downloads and registers on an app) and engagement (eg, the extent of use of an app or its components over time) is limited. Greater understanding of factors that influence uptake and engagement decisions may support large-scale deployments of digital-DPPs in real-world settings.
This study aimed to explore the key influences on uptake and engagement decisions of individuals who were offered the National Health Service Healthier You: Digital Diabetes Prevention Programme (NHS-digital-DPP).
A qualitative interview study was conducted using semistructured interviews. Participants were adults, aged ≥18 years, diagnosed with nondiabetic hyperglycemia, and those who had been offered the NHS-digital-DPP. Recruitment was conducted via 4 providers of the NHS-digital-DPP and 3 primary care practices in England. Interviews were conducted remotely and were guided by a theoretically informed topic guide. Analysis of interviews was conducted using an inductive thematic analysis approach.
Interviews were conducted with 32 participants who had either accepted or declined the NHS-digital-DPP. In total, 7 overarching themes were identified as important factors in both decisions to take up and to engage with the NHS-digital-DPP. These were knowledge and understanding, referral process, self-efficacy, self-identity, motivation and support, advantages of digital service, and reflexive monitoring. Perceptions of accessibility and convenience of the NHS-digital-DPP were particularly important for uptake, and barriers in terms of the referral process and health care professionals' engagement were reported. Specific digital features including health coaches and monitoring tools were important for engagement.
This study adds to the literature on factors that influence the uptake of and engagement with digital-DPPs and suggests that digital-DPPs can overcome many barriers to the uptake of face-to-face diabetes prevention programs in supporting lifestyle changes aimed at diabetes prevention.
An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, ...and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis.
We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care.
This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future.
The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).
Obsessive–compulsive disorder (OCD) is a disabling mental health condition. Despite effective psychological treatments for OCD, a significant percentage of patients fail to experience lasting ...benefit. Factors underlying variable treatment response are poorly understood. Moderators of outcome can help understand “for whom” and “under what circumstances” an intervention works best and thus improve service effectiveness.
This paper synthesizes the evidence on predictors and moderators and assesses the quality of reporting of related analyses in psychological therapies for adults with OCD. Trials were identified through electronic searches (CENTRAL, MEDLINE, PsycINFO, EMBASE), key author, and reference list searches of relevant systematic reviews.
Fifty five percent (38/69) of relevant trials reported baseline factors associated with outcome; these encompassed clinical, demographic, interpersonal, OCD symptom-specific, psychological/psychosocial, and treatment-specific variables. Predictors were commonly assessed via a validated pre-randomization measure, though few trials adopted best practice by stating a priori hypotheses or conducting a test of interaction. Potential associations emerged between worse OCD treatment outcome and the following factors: hoarding pathology, increased anxiety and OCD symptom severity, certain OCD symptom subtypes, unemployment, and being single/not married. However, the applied utility of these analyses is currently limited by methodological weaknesses.
•Predictors of outcome are commonly reported.•Potential associations emerged between a small number of predictors and outcome.•The quality of assessing and reporting of predictors was relatively poor.•Methodological/reporting guidelines can guide assessment/reporting of predictors.
To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- ...and middle-income (LAMI) countries.
Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother-infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions.
Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was -0.38 (95% confidence interval: -0.56 to -0.21; I (2) = 79.9%). Where assessed, benefits to the child included improved mother-infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates.
In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.
Social prescribing to community assets, like social groups, is a current policy goal. As aging adults lead longer, healthier lives, the effects of participating in community assets raises questions ...about whether subjective quality of life (QoL) improves during participation and on what dimensions.
The study's goal was to examine the effectiveness of community assets at improving QoL among older people living in the community.
Examining longitudinal survey data which tracked health and wellbeing in older adults living in Salford, UK over 12 months, we first used regressions on community assets to compare the World Health Organization's QoL Assessment (WHOQOL-BREF) domains at baseline for those who already participated in community assets (54%) and with non-participants (46%). Second, we used propensity score matching to compare QoL in an ‘uptake’ group (no initial participation but who participated at 12 months), to those who never participated, and to a ‘cessation’ group who participated initially, but ceased within one year, to those who always participated.
Group comparisons confirmed that participants reported significantly higher QoL on all domains – environmental, psychological, physical, and social QoL – and on 16 predicted facets. After affirming group matching reliability, the strongest results were for the uptake group, with significant improvements in all domains, and in 18 facets. All QoL domains decreased in the cessation group, but overall, the effect was weaker. As predicted from the context, QoL relating to ‘opportunities for recreation and leisure’ showed the greatest effect. Furthermore, QoL increased with uptake, and decreased with cessation.
Policies to improve QoL in later life should be designed not just to promote community assets, but also maintain participation once initiated.
•Social prescribing to community assets such as social groups is now a policy goal.•Little is known about their effect on participants' quality of life (QoL).•Community asset participants reported higher QoL on all four domains.•Participation uptake strongly led to increased QoL.•Cessation was detrimental to QoL.
Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of ...collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication).
Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient -0.11, 95% CI -0.20 to -0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication.
Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.
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