Outcomes after stroke: Basic and instrumental activities of daily living, community reintegration and generic health status

This study describes the discharge destination, basic and instrumental activities of daily living (ADL), community reintegration and generic health status of people after stroke, and explored whether sociodemographic and clinical characteristics were associated with these outcomes. Participants were 51 people, with an initial stroke, admitted to an acute hospital and discharged to the community. Admission and discharge data were obtained by chart review. Follow-up status was determined by telephone interview using the Modified Barthel Index, the Assessment of Living Skills and Resources, the Reintegration to Normal Living Index, and the Short-Form Health Survey (SF-36). At follow up, 57% of participants were independent in basic ADL, 84% had a low risk of experiencing instrumental ADL difficulties, most had few concerns with community reintegration, and SF-36 physical functioning and vitality scores were lower than normative values. At follow up, poorer discharge basic ADL status was associated with poorer instrumental ADL and community reintegration status, and older participants had poorer instrumental ADL, community reintegration and physical functioning. Occupational therapists need to consider these outcomes when planning inpatient and post-discharge intervention for people after stroke.

Utilising survey data to inform public policy: Comparison of the cost-effectiveness of treatment of ten mental disorders

Background Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced. Aims To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each. Method Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared in terms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs). Results Summing across all disorders, current treatment averted 13% of the burden, at an average cost of AUS$30 000 per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of AUS$18 000 per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at AUS$16 000 per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable. Conclusions The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders. Declaration of interest None. Funding detailed in Acknowledgements.

The impact of peginterferon alfa-2a plus ribavirin combination therapy on health-related quality of life in chronic hepatitis C

Background/Aims: Peginterferon alfa-2a plus ribavirin improves sustained virological responses compared with interferon alfa-2b and ribavirin, or peginterferon alfa-2a alone in chronic hepatitis C. We examined the impact of these treatments on health related quality of life (HRQOL). Methods: Patients (n = 1121) were randomized to peginterferon alfa-2a weekly plus ribavirin or placebo, or interferon alfa-2b thrice weekly plus ribavirin. HRQOL was assessed with the SF-36 Health Survey and Fatigue Severity Scale (FSS). Results: Patients receiving peginterferon alfa-2a plus ribavirin reported better HRQOL than those receiving interferon alfa-2b plus ribavirin. These differences were statistically significant for three SF-36 domains and both FSS scores (p < = 0.05). Patients receiving peginterferon alfa-2a plus placebo had the least impairment; adding ribavirin significantly decreased five domains of the SF-36 and both FSS scores. Sustained virological response was associated with improvement at follow-up on all SF-36 and FSS scores. Conclusions: The effects of combination therapy on HRQOL and fatigue are less with peginterferon alfa-2a plus ribavirin than interferon alfa-2b plus ribavirin. Each medication in combination therapy with interferon and ribavirin, affects patients' quality of life differently. Understanding the relationship of specific therapeutic options to HRQOL may help physicians minimize the impact of therapy on HRQOL. (C) 2004 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Alcohol dependence: the impact of cognitive behaviour therapy with or without naltrexone on subjective health status

Objectives: To examine the health-related quality of life of alcohol-dependent patients across a 12-week cognitive behaviour treatment (CBT) program and identify whether the patient selection of the anticraving medication naltrexone further enhanced these outcomes. Method: One hundred and thirty-six consecutive alcohol-dependent subjects voluntarily participated and were offered naltrexone, of which 73 (54%) participants declined medication. A matched design was used. Of the 136 subjects, 86 (43 naltrexone and CBT; 43 CBT only) could be individually matched (blind to outcome measures) for gender, age, prior alcohol detoxification and dependence severity. Measures of health status and mental health wellbeing included the Rand Corporation Medical Outcomes Short Form 36 Health Survey (SF-36) and the General Health Questionnaire (GHQ-28). Results: Pre-treatment, all had SF-36 and GHQ-28 scores markedly below national norms. Post-treatment, significant improvement in seven of the eight SF-36 subscales and all of the GHQ-28 subscales occurred, approximating national normative levels. Patients in the CBT + naltrexone group were significantly more likely to have increased days abstinent (p = 0.002) and to complete the program abstinent (p = 0.051). The adjunctive use of naltrexone did not provide additional benefit as reflected in SF-36 and GHQ-28 scores, beyond CBT alone. Conclusions: Patients who completed the CBT-based treatment program reported significant improvements in self-reported health status (SF-36) and wellbeing (GHQ-28). The adjunctive use of naltrexone demonstrated no additional improvement in these measures.

Do socioeconomic gradients in women's health widen over time and with age

A population-based study was conducted to investigate changes over time in women's well-being and health service use by socio-cconomic status and whether these varied by age. Data from 12,328 mid-age women (aged 45-50 years in 1996) and 10,430 older women (aged 70-75 years) from the Australian Longitudinal Study on Women's Health were analysed. The main outcome measures were changes in the eight dimensions of the Short Form General Health Survey (SF-36) adjusted for baseline scores, lifestyle and behavioural factors; health care utilisation at Survey 2; and rate of deaths (older cohort only). Cross-sectional analyses showed clear socioeconomic differentials in well-being for both cohorts. Differential changes in health across tertiles of socioeconomic status (SES) were more evident in the mid-age cohort than in the older cohort. For the mid-aged women in the low SES tertile, declines in physical functioning (adjusted mean change of -2.4, standard error (SE) 1.1) and general health perceptions (-1.5, SE 1.1) were larger than the high SES group (physical functioning -0.8 SE 1.1, general health perceptions -0.8 SE 1.2). In the older cohort, changes in SF-36 scores over time were similar for all SES groups but women in the high SES group had lower death rates than women in the low SES group (relative risk: 0.79, 95% confidence interval 0.64-0.98). Findings suggest that SES differentials in physical health seem to widen during women's mid-adult years but narrow in older age. Nevertheless, SES remains an important predictor of health, health service use and mortality in older Australian women. (C) 2003 Elsevier Ltd. All rights reserved.

Burden of care and general health in families of patients with schizophrenia

Background De-institutionalization of psychiatric patients has led to a greater emphasis on family management in the community, and family members are often overwhelmed by the demands that caring for a patient with schizophrenia involves. Most studies of family burden in schizophrenia have taken place in developed countries. The current study examined family burden and its correlates in a regional area of a medium income country in South America. Method Sixty-five relatives of patients with schizophrenia who were attending a public mental health out-patient service in the province of Arica, Chile, were assessed on Spanish versions of the Zarit Caregiver Burden Scale and SF-36 Health Survey (SF-36). Results Average levels of burden were very high, particularly for mothers, carers with less education, carers of younger patients and carers of patients with more hospitalisations in the previous 3 years. Kinship and number of recent hospitalisations retained unique predictive variance in a multiple regression. Burden was the strongest predictor of SF-36 subscales, and the prediction from burden remained significant after entry of other potential predictors. Conclusions In common with families in developed countries, family members of schizophrenia patients in regional Chile reported high levels of burden and related functional and health impact. The study highlighted the support needs of carers in contexts with high rates of poverty and limited health and community resources.

Implications of non-response of older women to a short form of the Center for Epidemiologic Studies Depression Scale

The Center for Epidemiologic Studies Depression Scale (CES-D) is frequently used in epidemiological surveys to screen for depression, especially among older adults. This article addresses the problem of non-completion of a short form of the CES-D (CESD-10) in a mailed survey of 73- to 78-year-old women enrolled in the Australian Longitudinal Study on Women's Health. Completers of the CESD-10 had more education, found it easier to manage on available income and reported better physical and mental health. The Medical Outcomes Study Short Form Health Survey (SF-36) scores for non-completers were intermediate between those for women classified as depressed and not depressed using the CESD-10. Indicators of depression had an inverted U-shaped relationship with the number of missing CESD- 10 items and were most frequent for women with two to seven items missing. Future research should pay particular attention to the level of missing data in depression scales and report its potential impact on estimates of depression.

Estimating physical activity level: The role of domestic activities

Appropriate measures of physical activity are essential for determining the population prevalence of physical activity, for tracking trends over time, and for guiding intervention efforts. Physical activity measurement is characterised by the synthesis of information on the type, frequency, intensity, and duration of activity over a specified period. To date, emphasis in physical activity assessment has been on the measurement of leisure time physical activities. However, some domestic and transport related activities entail energy expenditures equivalent to moderate intensity of 3.0–6.0 METS1 considered to be of sufficient intensity to achieve a health benefit are yet to be included in routine population level physical activity surveillance. This leads to population estimates based only on measures of leisure time physical activities.

Test-retest reliability of four physical activity measures used in population surveys

Accurate monitoring of prevalence and trends in population levels of physical activity (PA) is a fundamental public health need. Test-retest reliability (repeatability) was assessed in population samples for four self-report PA measures: the Active Australia survey (AA, N=356), the short International Physical Activity Questionnaire (IPAQ, N=104), the physical activity items in the Behavioral Risk Factor Surveillance System (BRFSS, N=127) and in the Australian National Health Survey (NHS, N=122). Percent agreement and Kappa statistics were used to assess reliability of classification of activity status as 'active', 'insufficiently active' or 'sedentary'. Intraclass correlations (ICCs) were used to assess agreement on minutes of activity reported for each item of each survey and for total minutes. Percent agreement scores for activity status were very good on all four instruments, ranging from 60% for the NHS to 79% for the IPAQ. Corresponding Kappa statistics ranged from 0.40 (NHS) to 0.52 (AA). For individual items, ICCs were highest for walking (0.45 to 0.78) and vigorous activity (0.22 to 0.64) and lowest for the moderate questions (0.16 to 0.44). All four measures provide acceptable levels of test-retest reliability for assessing both activity status and sedentariness, and moderate reliability for assessing total minutes of activity.

The burden of major depression avoidable by longer-term treatment strategies

Background: Major depression is the largest single cause of nonfatal disease burden in Australia. Effective drug and psychological treatments exist, yet are underused. Objective: To quantify the burden of disease currently averted in people seeking care for major depression and the amount of disease burden that could be averted in these people under optimal episodic and maintenance treatment strategies. Design: Modeling impact of current and optimal treatment strategies based on secondary analysis of mental health survey data, studies of the natural history of major depression, and meta-analyses of effectiveness data. Monte Carlo simulation of uncertainty in the model. Setting: The cohort of Australian adults experiencing an episode of major depression in 2000 are modeled through "what if" scenarios of no treatment, current treatment, and optimal treatment strategies with cognitive behavioral therapy or antidepressant drug treatment. Main Outcome Measure: Disability-Adjusted Life Year. Results: Current episodic treatment averts 9% (95% uncertainty interval, 6%-12%) of the disease burden of major depression in Australian adults. Optimal episodic treatment with cognitive behavioral therapy could avert 28% (95% uncertainty interval, 19%-39%) of this disease burden, and with drugs 24% (95% uncertainty interval, 19%-30%) could be averted. During the 5 years after an episode of major depression, current episodic treatment patterns would avert 13% (95% uncertainty interval, 10%-17%) of Disability-Adjusted Life Years, whereas maintenance drug treatment could avert 50% (95% uncertainty interval, 40%-60%) and maintenance cognitive behavioral therapy could avert 52% (95% uncertainty interval, 42%-64%), even if adherence of around 60% is taken into account. Conclusions: Longer-term maintenance drug or psychological treatment strategies are required to make significant inroads into the large disease burden associated with major depression in the Australian population.

Comparability of skin screening histories obtained by telephone interviews and mailed questionnaires: A randomized crossover study

The comparability of information collected through telephone interviews and information collected through mailed questionnaires has not been well studied. As part of the first phase of a randomized controlled trial of population screening for melanoma in Queensland, Australia, the authors compared histories of skin examination reported in telephone interviews and self-administered mailed questionnaires. A total of 1,270 subjects each completed a telephone interview and a mailed questionnaire 1 month apart in 1999; 564 subjects received the interview first, and 706 received the mailed questionnaire first. Agreement between the two methods was 91.2% and 88.6% for whole-body skin examination by a physician in the last 12 months and the last 3 years, respectively, and 81.9% for whole-body skin self-examination in the last 12 months. Agreement was lower for any skin self-examination. Agreement between the two methods was similar regardless of whether the interview or the questionnaire was administered first. Missing data were less frequent for interviews (0.5%) than for mailed questionnaires (3.8%). Costs were estimated at A$9.55 (US$6.21) per completed interview and A$3.01 (US$1.96) per questionnaire. The similarity of results obtained using telephone interviews and mailed questionnaires, coupled with the substantially higher cost of telephone interviews, suggests that self-administered mailed questionnaires are an appropriate method of assessing this health behavior.

The experience of insomnia among older women

Study Objectives: To measure sleeping difficulty and sleep quality among older women, explore experience and attitudes towards sleep, and test for negative association between difficulty sleeping and health-related quality of life. Design: Four-year longitudinal study. Setting: Women were participants in the Australian Longitudinal Study on Women's Health. Participants: Women were sampled according to use of sleeping medication and classified into 4 groups: sleeping badly and using sleeping medications; not sleeping badly, but using sleeping medications; sleeping badly, not using sleeping medications; not sleeping badly, not using sleeping medications. Interventions: None. Measurements and Results: Sleeping difficulty and sleeping-medication use were measured at Survey 1, Survey 2 (3 years later), and Survey 3 (4 years later). Survey 3 included: Nottingham Health Profile Sleep Subscale, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Geriatric Depression Scale, Duke Social Support Index, Medical Outcomes Study Short-Form 36-item Health Survey, and a 21-item life events scale. Survey 3 was returned by 1011 women (84%). Sleeping problems were negatively associated with SF-36 subscale scores. Most associations remained significant after comorbid conditions, Geriatric Depression Scale, life events scores, and medication use were added to models. Most women with sleeping problems (72%) sought help from a doctor, and 54% used prescribed sleeping medications in the past month. Conclusions: Sleeping difficulty is a serious symptom for older women and is associated with poorer quality of life. Some of this effect can be explained by comorbidities, depression scores, life events, and use of sleeping medications.