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.     

'I saw the panic rise in her eyes,and evidence-based medicine went out of the door.' An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease

Background. Coronary heart disease (CHD) is the leading cause of death in the UK, yet only 50% of CHD patients receive appropriate secondary prevention. Objectives. To explore GP attitudes to evidence about CHD, and to identify factors influencing the implementation of secondary prevention in GP consultations. METHODS: Semi-structured interviews and focus groups exploring consultations with patients previously diagnosed as having CHD. RESULTS: Use of evidence is influenced by credibility. Lack of time was the greatest barrier to accessing evidence and to implementing secondary prevention. Patients were more likely to receive secondary prevention in a dedicated clinic. Patient characteristics including physical and mental co-morbidity mitigate against secondary prevention. GPs experienced difficulty balancing implementation of evidence with the demands of the doctor-patient relationship. CONCLUSIONS: The doctor-patient relationship may act as a barrier to the delivery of secondary prevention in primary care. It may be time to re-evaluate models of these relationships and reconsider the strategies for implementing evidence.     

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.     

A consultation leaflet to improve an older patient''s involvement in general practice care: a randomized trial

OBJECTIVE: To evaluate the effects of a programme to enhance the involvement of older patients in their consultations in general practice. DESIGN: Cluster randomized trial, in which data was collected from different cohorts. SETTING AND PARTICIPANTS: Twenty-five general practices in the south-east part of the Netherlands and their patients aged 70 years and over. INTERVENTION: Patients in the intervention group received a leaflet to help them prepare for the consultation. General practitioners (GPs) received an outreach visit to optimize older patients' involvement when visiting their GP. Patients in the control group received usual care. MAIN OUTCOME MEASURES: Questionnaires measuring involvement (COMRADE), enablement (Patient Enablement Index) and satisfaction with their care (EUROPEP). RESULTS: Pre-intervention 315 patients and post-intervention 263 patients were included. Subjects were satisfied with their involvement and the GP's behaviour during the consultation. No differences in effect as a result of the leaflet on involvement, enablement or satisfaction were found between the intervention and the control group. Of 318 patients who received the leaflet and visited their GP in the intervention period, 47 patients used the leaflet. These users were more accustomed to prepare themselves for consultations. Users reported more psychological problems than non-users. CONCLUSIONS: No relevant effects of the implementation programme on involvement, enablement or satisfaction were found. Other strategies are needed to enhance involvement of older patients in their care. Alternatively, older patients may perceive themselves sufficiently involved.     

Home Health Care With Telemonitoring Improves Health Status for Older Adults With Heart Failure

Home telemonitoring can augment home health care services during a patient's transition from hospital to home. Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations. This randomized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring. Patients were followed up to 180 days post-discharge from home health care services. Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care. Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care. Therefore, for older adults with heart failure, telemonitoring may be an important adjunct to home health care services to improve health status.     

Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong

Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs' inability to diagnose properly, and patients' wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients' wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors' inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.     

Consultation between family physicians and specialists about the hospital admission of patients]

Consultation between GPs and specialists about patients' in-hospital treatment is to be expected from the claim of Dutch GPs that they are responsible for continuous care for the patients on their lists. Data were gathered in the Dutch National Survey of General Practice: registration concerning all patients hospitalized during a three-month period (n = 7815) by 161 GPs. GPs consult specialists most frequently about the decision to admit patients (15% of all admissions). Consultation during patient's stay in hospital (5%) and about the discharge decision and possible aftercare (4%) is less usual. Consultation results from practical circumstances, such as the GP's initiative in the admission and a contact between patient and GP about the admission. The results leave GPs to answer the question whether the little actual consultation about the patient's stay in hospital, discharge and aftercare accords with their task to provide continuous care.     

Saying 'goodbye' to single-handed practices; what do patients and staff lose or gain?

BACKGROUND: The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices. OBJECTIVE: The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. METHODS: Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included 'single-handed/group practice', 'rural/ urban' 'part-time/full-time' and 'male/female'. RESULTS: Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education. DISCUSSION AND CONCLUSION: The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.     

Chronic heart failure home-based management with a telecardiology system: a comparison between patients followed by general practitioners and by a cardiology department

A group of patients with chronic heart failure (CHF) were followed by general practitioners (GPs) with a telecardiology system, and a second group of patients were followed by a home-based telemonitoring (HBT) protocol with medical and nursing supervision. The 212 GP patients were older than the 226 HBT patients, mostly women, with CHF secondary to chronic hypertension, less self-sufficient and with a non-optimized therapy. The mean number of telephone calls was 2.6 per patient in the GP group and 16.6 per patient in the HBT group (P<0.001). These preliminary data suggest the applicability and the efficacy of both management models for CHF patients.     

A randomized trial of primary intensive care to reduce hospital admissions in patients with high utilization of inpatient services.

Randomized controlled trials of case management in primary care have been infrequent and contradictory. The aim of this study was to determine if a clinic-based ambulatory case management intervention, Primary Intensive Care (PIC), would reduce hospital utilization and total cost and/or improve health outcomes among primary care patients with a recent history of high use of inpatient services. Current patients with > or =2 hospital admissions per year in the 12-18 months prior to recruitment in an urban primary care clinic were enrolled in a randomized clinical trial. Patients were randomized to the PIC intervention or usual care. PIC patients underwent a comprehensive multidisciplinary assessment with the result being a team-generated plan. The PIC team nurse practitioner served as case manager for the 12 months of follow-up and provided services designed to implement the care plan for those in the experimental group. Health care use, function, and a medication adherence scale were measured at baseline and at 12 months. There were no significant differences when either comparing the number of admissions pre and post enrollment within groups or the followup results post intervention between groups. A similar result was noted for the number of emergency department visits. The number of clinic visits increased in the intervention group by 1.5 visits per year which was statistically significant when compared to the control group. Overall functional status, health outcomes, and the Mental Health Functional Status subscore did not change significantly in either group during the study. We were unable to detect a difference in hospital use or functional status, mental health function, or medication adherence among patients who require frequent hospital admissions using our intervention.     

A cost study of a general practitioner hospital in the Netherlands

Objective: To perform a cost study of the first general practitioner (GP) hospital in the Netherlands.

Methods: We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into ‘hospital’ or ‘home care’). For the ‘rehabilitation’ and ‘nursing home’ patients the alternative care mode was admission to a hospital.

Results: The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were ?2533 per admission compared with ?3792 for hospital stay. For the group of GP bed patients for whom ‘home care’ was the best alternative, the costs were ?2494 for GP hospital days compared with ?2814, the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were ?4744 compared with ?8041 in a hospital. For patients waiting for admission to a nursing home, these costs were ?13,143 and ?22,670, respectively.

Conclusion: The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.     

Coping strategies in the self-management of chronic heart failure

BACKGROUND: A patient's psychological adaptation to heart failure can influence its impact on his or her life. However, attempts to understand how patients cope mentally with severe emotional strain have led to inconsistent use of a plethora of concepts, making communication and clinical care difficult. OBJECTIVES: The aim of the present study was to develop a framework for conceptualizing how patients with chronic heart failure cope mentally with their illness, and then use the framework to suggest how GPs can facilitate patient self-care. METHODS: We systematically reduced and reassembled the narrative texts of personal, semi-structured interviews until their interpretation was complete. The interviews were conducted during late 1999 with 62 heart failure patients under GP care in 30 practices across central Auckland, New Zealand. RESULTS: Our framework describes four coping strategies: avoidance, disavowal, denial and acceptance. Disavowal provides a distinct coping strategy through which patients, who basically understand the threat to their life situations, seek hope through positively reconstructing this threat. Use of this strategy was highly salient regardless of patients' age, the length of time since their recorded diagnosis or the degree of self-reported limitation of recent physical function due to heart failure. Only over age 70 were avoidance and acceptance also highly salient among patients whose heart failure was diagnosed at least 3 years previously and had mildly limited their recent physical function. CONCLUSION: Many different heart failure patients use disavowal to palliate the emotional strain and find hope. Disavowal is not a problem to deal with but a process GPs can facilitate by implementing a range of suggested strategies through methods such as story telling.     

Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care

BACKGROUND: The long-term effects of disease management programmes for coronary heart disease on health status are unknown. In a randomized trial of nurse-led secondary prevention clinics, we found significantly improved health status at 1 year. Participants were followed-up again at 4 years to determine if improvements had been sustained. OBJECTIVE: Our aim was to evaluate the effects on health of nurse-led clinics for the secondary prevention of coronary heart disease in primary care. METHODS: A total of 1343 patients with coronary heart disease were randomized to nurse-led secondary prevention clinics or usual care, with follow-up at 1 and 4 years by review of medical case notes and national data sets, and postal questionnaires. The study involved a stratified, random sample of 19 general practices in north-east Scotland. Health status was measured by the SF-36 questionnaire, chest pain by the angina TyPE specification and anxiety and depression by the hospital anxiety and depression scale. RESULTS: At 1 year, there were significant improvements in five of eight SF-36 domains (all functioning scales, pain and general health) in patients randomized to clinics. Role limitations attributed to physical problems improved the most [adjusted difference 8.52, 95% confidence interval (CI) 4.16-12.9]. At 4 years, the intervention group scored higher than control in all domains, but differences were no longer significant. At 1 year, fewer patients in the intervention group reported worsening chest pain (odds ratio 0.59, 95% C1 0.37-0.94). At 4 years, there were no significant differences between the proportion of intervention or control group patients who reported chest pain in the last week or who reported worsening chest pain. No significant effects were observed on anxiety or depression at 1 or 4 years. CONCLUSION: We have demonstrated previously a significantly greater survival in attendees at nurse-led secondary prevention clinics. Despite this, improvements in health status achieved in the first year of the study were reduced at 4 years. The case for nurse-led clinics remains strong, but further research is required on ways to optimize current health status.     

Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease

OBJECTIVES: Obesity and dyslipidemia are risk factors for ischemic heart disease, and prevention and treatment in primary care can reduce these risks. The objective of this cost-effectiveness analysis was to compare the costs and effects (in terms of life years gained) of providing nutritional counseling by a general practitioner (GP) or a dietician. METHODS: A total of 60 GPs, who accepted to participate, were randomized either to give nutritional counseling or to refer patients to a dietician for counseling. The life years gained was estimated using a Cox regression model. Costs were estimated on the basis of registered use of time (dieticians) or agreed salaries (GPs). RESULTS: The effect of nutritional counseling comparing GPs and dieticians is greatest when counseling is performed by a GP--0.0919 years versus 0.0274 years. These effects appear to be moderate, but they are significant. It is also proven that the GP group was the most cost-effective-the cost of gaining 1 extra life year was estimated to be 8213 DKK compared with the dietician group, for which the incremental cost-effectiveness ratio was estimated to be 59,987 DKK. CONCLUSIONS: The effects were moderate, but other studies of other patient groups and interventions report effects within the same magnitude. The GP group was the most cost-effective, but it must be concluded that both counseling strategies were relatively cost-effective. Even though the cost of gaining an extra life year was estimated to be 59,987 DKK in the dietician group, this might be an acceptable price.     

Shared care in gastroenterology: GPs' views of open access to out-patient follow-up for patients with inflammatory bowel disease

OBJECTIVE: The aim of this study was to ascertain GPs' views about open access to out-patient follow-up for patients with inflammatory bowel disease (IBD). METHODS: Semi-structured interviews and a postal survey were carried out in general practices in West Glamorgan UK, each with at least one IBD patient taking part in a randomized trial of open access versus routine follow-up, which has been reported elsewhere. A total of 112 GPs from 53 general practices who referred the 180 study patients to specialist gastroenterological care in Neath or Swansea were included in the study. Main outcome measures were GPs' experience of the trial; preferences between methods of out-patient follow-up; and their views about enhancing open access follow-up. RESULTS: Sixty-nine GPs from 40 practices took part in the practice-specific data collection and 91 returned 156 patient-specific questionnaires. They expressed a strong preference for open access follow-up, for both specific patients (108/156 patients) and IBD patients in general (47/69 GPs). Preference for extending open access follow-up to other chronic conditions was not so strong (21/69 GPs). A substantial number of GPs considered their experience of the trial limited (30/69), and few GPs were aware of the shared care guideline distributed before the trial started (8/69). Few GPs encountered any problems in the management of the study patients (9/69) and <50% of the GPs used a Cumulative Encounter Form (29/69) developed for the study. Most GPs were supportive of giving patients written guidelines (56/69) and establishing a gastroenterological (GI) nurse practitioner (45/69). CONCLUSIONS: Open access follow-up of patients with IBD is supported by GPs. The approach would probably be improved by the distribution of written information to patients, the establishment of a GI nurse practitioner and an integrated approach between the nurse, hospital specialist, GP and patient.     

Medically unexplained symptoms--GPs' attitudes towards their cause and management

BACKGROUND: Medically unexplained physical symptoms present one of the most common problems in modern medical practice but often prove difficult to manage. The central position of the GP in the care of patients with medically unexplained symptoms has been emphasized repeatedly, but little is known about the attitudes of GPs to this role. Understanding how GPs view these patients may inform the development of effective strategies for management. OBJECTIVE: Our aim was to survey the attitudes of UK GPs towards medically unexplained symptoms (MUS) and somatization. METHODS: A random sample of 400 GPs in the South Thames (West) region were surveyed using a postal questionnaire. Respondents' attitudes toward the cause and management of MUS were recorded. RESULTS: A total of 284 completed questionnaires were returned (22 returned incomplete), giving an adjusted response rate of 75%. Although it was broadly felt that patients with MUS are difficult to manage, most GPs felt that patients with MUS should be managed in primary care. Providing reassurance, counselling and acting as a 'gatekeeper' to prevent inappropriate investigations were considered important roles for GP management. A majority felt that patients with MUS have personality problems or psychiatric illness. Fewer than half of the respondents felt that there are effective treatments available for somatization. CONCLUSION: GPs consider the management of patients with MUS to be an important part of their workload, but there is a perception that effective management strategies are lacking. Psychiatrists need to offer greater support and training for GPs in this area of health care.     

Improvement of primary health care of patients with poorly regulated diabetes mellitus type 2 using shared decision-making - the DEBATE trial

ABSTRACT: BACKGROUND: Since 2004, a national Disease Management Program (DMP) has been implemented in Germany, which includes educational measures aimed at patients with type-2 diabetes (T2D). However, about 15-20% of T2D patients remain in poor metabolic control. Qualitative research shows that one reason for this might be an increasing frustration of general practitioners (GPs) with the management of their poorly regulated T2D patients over time. We aim at approaching this problem by improving the GP-patient-communication and fostering shared decision-making. METHODS: An educative intervention will be tested within a multi-centred cluster-randomized controlled trial (RCT) in Germany. We include 20 GPs in three regions. Each of the 60 GPs will recruit about 13 patients meeting the inclusion criteria (total of 780 patients). GPs allocated to the intervention group will receive a peer-visit from a specifically trained GP-colleague who will motivate them to apply patient-centred communication techniques including patient-centred decision aids. GPs allocated to the control group will not take part in any intervention program, but will provide care as usual to their patients. The primary inclusion criterion for patients at the time of the recruitment is an HbA1c-level of over 8.0. Primary outcome is the change of HbA1c at 6, 12, 18, and 24 months compared to HbA1c at baseline. Secondary outcomes include patient's participation in the process of shared decision-making and quality of life. DISCUSSION: If this intervention proves to be effective it may be integrated into the existing Disease Management Program for T2D in Germany.     

Screening for common mental disorders: who will benefit? Results from a randomised clinical trial

BACKGROUND: Outcomes of studies on mental health screening in primary care are conflicting. A feasible and effective case-finding approach could benefit both GPs and their patients. OBJECTIVES: (1) to examine the effect of using a composite screening questionnaire (SQ) on GPs' recognition and provision of care, and (2) to outline useful strategies for case-finding. METHODS: 38 GPs in Aarhus County, Denmark, volunteered to participate in this trial. 1785 consecutive patients aged 18-65 years consulting with new health problems were included. Patients were screened before consultation using an SQ including scales for somatisation, anxiety, depression and alcohol abuse. Patients were randomised into one of two groups: 900 questionnaires were disclosed to and scored by GPs, 885 were blinded. Number of diagnoses, subjects of conversation, and actions taken were analysed. Additional analyses aimed to identify GP and patient factors that could predict improved outcomes. RESULTS: Overall, disclosure of SQ results increased GPs' recognition of mental disorders by 3.8% [95% confidence interval (CI) -0.5% to 8.0%], and 6.6% (95% CI 1.2% to 12.0%) for patients screened positive. There was a marked variation in GPs' detection rates, and for GPs with moderate or low recognition rates increases were significant (P = 0.001). Conversation on psychological topics increased by 3.2% (95% CI -0.7% to 7.1%), and by 7.0% (95% CI 1.8% to 12.3%) for patients screened positive. Rates of planned follow-up consultations increased by 3.9% (95% CI 0.6% to 7.3%) and by 4.9% (95% CI 0.7% to 9.1%) for patients screened positive. GPs' self-reported benefit from screening was related to better outcomes. A range of patient and GP factors suggesting added value from using SQs were identified. CONCLUSION: GPs' recognition and provision of mental health care can be influenced by the use of composite SQs. Perceived benefit from screening may serve as a useful predictor of better patient management. Pragmatic case-finding approaches need further evaluation.     

Using preventive home monitoring to reduce hospital admission rates and reduce costs: a case study of telehealth among chronic obstructive pulmonary disease patients

We studied whether preventive home monitoring of patients with chronic obstructive pulmonary disease (COPD) could reduce the frequency of hospital admissions and lower the cost of hospitalization. Patients were recruited from a health centre, general practitioner (GP) or the pulmonary hospital ward. They were randomized to usual care or tele-rehabilitation with a telehealth monitoring device installed in their home for four months. A total of 111 patients were suitable for inclusion and consented to be randomized: 60 patients were allocated to intervention and three were lost to follow-up. In the control group 51 patients were allocated to usual care and three patients were lost to follow-up. In the tele-rehabilitation group, the mean hospital admission rate was 0.49 per patient per 10 months compared to the control group rate of 1.17; this difference was significant (P = 0.041). The mean cost of admissions was €3461 per patient in the intervention group and €4576 in the control group; this difference was not significant. The Kaplan-Meier estimates for time to hospital admission were longer for the intervention group than the controls, but the difference was not significant. Future work requires large-scale studies of prolonged home monitoring with more extended follow-up.     

An alternative trial design to overcome validity and recruitment problems in primary care research

BACKGROUND: Although the randomized controlled trial is widely accepted as the best design to investigate new interventions, conducting a trial in primary care may present researchers with many methodological problems. OBJECTIVE: Our aim was to present an alternative trial design to overcome internal validity and recruitment problems. METHODS: In a randomized controlled trial, fatigued employees absent from work were selected among the population of an occupational health service in the South of The Netherlands. Patients randomly assigned to the experimental condition received cognitive behavioural therapy by a research GP near their home address, whereas patients in the control group received no intervention. We describe our considerations for building an alternative design. Research GPs and patients were recruited separately for the study. The pre-randomization design was applied. RESULTS: Nine research GPs performed all the interventions. Seventy-six experimental patients and 75 control patients were selected for study participation. Of these, only six patients in the experimental group and seven patients in the control group withdrew from the study at some point during follow-up. CONCLUSION: Results suggest that recruitment and randomization procedures in the alternative design served their purpose well. The alternative design proposed here might have several advantages compared with conventional trial procedures. However, our design is not widely applicable and there are ethical aspects involved that should be considered. Researchers should address their creativity when trying to minimize the problems they may encounter in designing a study.