The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Levels and predictors of exercise referral scheme uptake and adherence: A systematic review

Background The effectiveness of exercise referral schemes (ERS) is influenced by uptake and adherence to the scheme. The identification of factors influencing low uptake and adherence could lead to the refinement of schemes to optimise investment. Objectives To quantify the levels of ERS uptake and adherence and to identify factors predictive of uptake and adherence. Methods A systematic review and meta-analysis was undertaken. MEDLINE, EMBASE, PsycINFO, Cochrane Library, ISI WOS, SPORTDiscus and ongoing trial registries were searched (to October 2009) and included study references were checked. Included studies were required to report at least one of the following: (1) a numerical measure of ERS uptake or adherence and (2) an estimate of the statistical association between participant demographic or psychosocial factors (eg, level of motivation, self-efficacy) or programme factors and uptake or adherence to ERS. Results Twenty studies met the inclusion criteria, six randomised controlled trials (RCTs) and 14 observational studies. The pooled level of uptake in ERS was 66% (95% CI 57% to 75%) across the observational studies and 81% (95% CI 68% to 94%) across the RCTs. The pooled level of ERS adherence was 49% (95% CI 40% to 59%) across the observational studies and 43% (95% CI 32% to 54%) across the RCTs. Few studies considered anything other than gender and age. Women were more likely to begin an ERS but were less likely to adhere to it than men. Older people were more likely to begin and adhere to an ERS. Limitations Substantial heterogeneity was evident across the ERS studies. Without standardised definitions, the heterogeneity may have been reflective of differences in methods of defining uptake and adherence across studies. Conclusions To enhance our understanding of the variation in uptake and adherence across ERS and how these variations might affect physical activity outcomes, future trials need to use quantitative and qualitative methods.

The cost-effectiveness of exercise referral schemes

Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting. Methods A decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition. Results Compared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS. Conclusions ERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

Republished research: Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis

Study question Can exercise referral schemes improve health outcomes in individuals with or without pre-existing conditions? Summary answer We found weak evidence of a short term increase in physical activity and reduction in levels of depression in sedentary individuals after participation in exercise referral schemes, compared with after usual care. What is known and what this paper adds Exercise referral schemes are commonly used in primary care to promote physical activity. Evidence indicating a health benefit of these schemes is limited, so their value in primary care remains to be ascertained.

Family mediation and women’s services: Towards effective referral

Central to Government’s strategy for separating families is the management and resolution of disputes away from courts and litigation processes wherever this is achievable. A key group of players in facilitating this vision are workers within the wide range of women’s services. This study surveyed workers at a number of Victorian women’s services that provide advice, support, and referral for women and explored their understanding of mediation processes and outcomes. The results indicate that, while generally supportive of mediation as a process that could assist their clients, workers were concerned about its appropriateness when family violence was an issue. Some of these concerns appeared to be based upon a good understanding of the limitations of mediation practices, but it is also apparent that some concerns were influenced by a misunderstanding and limited knowledge of contemporary mediation practice. It is recommended that family mediation services work proactively with women’s services in order to better inform each other of the possibilities and constraints in working with postseparation disputes.

Cholesterol-lowering management of stroke : inconsistencies of evidence and practice

Cholesterol-lowering treatment by statins is an important and costly issue; however, its role in stroke has not been well documented. The aim of the present study was to review literature and current practice regarding cholesterol-lowering treatment for stroke patients. A literature review was conducted on lipids in stroke and their management with both statins and diet, including the cost-effectiveness of medical nutrition therapy. Qualifying criteria and prescription procedures of the Pharmaceutical Benefits Scheme (PBS) were also reviewed. Data on lipid levels and statin prescriptions were analysed for 468 patients admitted to a stroke unit. The literature shows that management with both medication and diet can be effective, especially when combined; however, 60% of patients with an ischaemic event had fasting total cholesterol measures ≥4 mmol/L (n = 231), with only 52% prescribed statins on discharge (n = 120). Hypercholesterolaemia is an underdiagnosed and undertreated risk factor within the stroke population. It appears that the PBS has not kept pace with advances in the evidence in terms of statin use in the stroke population, and review is needed. The present review should address the qualifying criteria for the stroke population and recommendations on referral to dietitians for dietary advice. Cholesterol-lowering treatment for both stroke patients and the wider population is an area that needs awareness raising and review by the PBS, medical practitioners and dietitians. The role of dietary and pharmacological treatments needs to be clearly defined, including adjunct therapy, and the cost-effectiveness of medical nutrition therapy realised.

Too young to drink but old enough to drive under the influence : a study of underage offenders as seen in substance abuse treatment in Texas

Driving under the influence (DUI) is a major road safety problem. Historically, alcohol has been assumed to play a larger role in crashes and DUI education programs have reflected this assumption, although recent evidence suggests that younger drivers are becoming more likely to drive drugged than to drive drunk. This is a study of 7096 Texas clients under age 21 who were admitted to state-funded treatment programs between 1997 and 2007 with a past-year DUI arrest, DUI probation, or DUI referral. Data were obtained from the State’s administrative dataset. Multivariate logistic regressions models were used to understand the differences between those minors entering treatment as a DUI as compared to a non-DUI as well as the risks for completing treatment and for being abstinent in the month prior to follow-up. A major finding was that over time, the primary problem for underage DUI drivers changed from alcohol to marijuana. Being abstinent in the month prior to discharge, having a primary problem with alcohol rather than another drug, and having more family involved were the strongest predictors of treatment completion. Living in a household where the client was exposed to alcohol abuse or drug use, having been in residential treatment, and having more drug and alcohol and family problems were the strongest predictors of not being abstinent at follow-up. As a result, there is a need to direct more attention towards meeting the needs of the young DUI population through programs that address drug as well as alcohol consumption problems.

CPR training in households of patients with chest pain

The objectives of this study are to (1) quantify prior cardiopulmonary resuscitation (CPR) training in households of patients presenting to the Emergency Department (ED) with or without chest pain or ischaemic heart disease (IHD); (2) evaluate the willingness of household members to undertake CPR training; and (3) identify potential barriers to the learning and provision of bystander CPR. A cross-sectional study was conducted by surveying patients presenting to the ED of a metropolitan teaching hospital over a 6-month period. Two in five households of patients presenting with chest pain or IHD had prior training in CPR. This was no higher than for households of patients presenting without chest pain or IHD. Just under two in three households of patients presenting with chest pain or IHD were willing to participate in future CPR classes. Potential barriers to learning CPR included lack of information on CPR classes, perceived lack of intellectual and/or physical capability to learn CPR and concern about causing anxiety in the person at risk of cardiac arrest. Potential barriers to CPR provision included an unknown cardiac arrest victim and fear of infection. The ED provides an opportunity for increasing family and community capacity for bystander intervention through referral to appropriate training.

Decolonising the concept of knowledge

Controlling the definition of what was essentially a subjugated culture, the colonisers reserve the power to distinguish authentic aspects of the living traditions of the colonised. If the colonised argue political demands by reference to their culture, the colonisers are quick to adjudicate what is genuine in such claims. (Fannon, 1967) Since colonial invasions, Australia’s Indigenous people have weathered rapid change. While the origins of Australia’s Indigenous peoples continues to be an archaeological interest for many, how Indigenous cultures have survived, transformed and retained a sense of ‘difference’ is fundamental to understanding the diversity of Aboriginal and Torres Strait Islander cultures within this continent as both contemporaneous and historical. It is important that teachers, students and researchers within Indigenous studies remind themselves that much of the literature on Aboriginal and Torres Strait Islanders can be ideologically traced back to the emergence of ‘knowledge’ about native peoples in the context of European imperialism and expansion from the fifteenth century. Care must therefore be taken in not conveying ‘scientific’ rational knowledge as perhaps the hidden agenda or notion of assumptions of European ‘superiority’ and non-European inferiority. The recognition by the High Court of Australia (1992) abandoned the legal myth of terra nullius which based the dispossession of Indigenous land on the basis of it being considered an empty land. It could also be argued that this decision recognised that distinct customs and traditions continue to exist within the social and cultural ‘knowledge’ of Indigenous peoples of Australia. General issues and concerns relating to research design, methodology and articulation within QUT are not just confined to this university and the research project presented as a case study but are important in dealing with how Aboriginal and Torres Strait Islander students and academics participate or are employed within the university. We feel that the design and methodology of research that either covertly or overtly focuses on Indigenous Australians can no longer presume that all research will naturally follow protocols that are culturally appropriate as this appropriateness is usually defined by the institution. By no means do we feel that research should be debilitated as a result of raising these issues, but that collaborative approaches within the ‘process’ of research will address Aboriginal and Torres Strait Islander people and communities as much as the intended outcomes of research itself.

Staff perspectives of a cardiology short stay unit

Objective To evaluate staff perceptions about working environment, efficiency and the clinical safety of a cardiovascular intervention short stay unit (SSU) during the first year of operation. Design Postal questionnaire. Setting Cardiac catheterisation laboratory (CCL), coronary care unit (CCU), general cardiology ward (GCW) and the short stay unit (SSU) of a tertiary referral hospital situated in the mid coastal region of NSW. Subjects Cardiologists (including visiting medical officers [VMO]), cardiology fellows, cardiology advanced trainees and nurses. Results Responses on the working environment of the SSU and the discharge process were statistically significant. A substantial proportion of both nurses and doctors had concerns about patient safety, even though no adverse events were formally recorded in the database. Conclusions Though the participants of the survey agree on the efficiency of the SSU in providing beds to the hospital, they disagree on aspects that are important in the functioning of the SSU, including the working environment, patient selection and clinical safety. The results highlight potential issues that could be improved or addressed and are relevant to the rollout of SSUs across NSW.

Student success : the identification and support of first year university students at risk of attrition

The engagement behaviour of 1,524 student-enrolments (“students”) in five first year units was monitored and 608 (39.9%) were classified as “at risk” using the criterion of not submitting or failing their first assignment. Of these, 327 (53.8%) were successfully contacted (i.e., spoken to by phone) and provided with advice and/or referral to learning and personal support services while the remaining 281 (46.2%) could not be contacted. Nine hundred and sixteen students (60.1%) were classified as “not at risk.” Overall, the at risk group who were contacted achieved significantly higher end-of-semester final grades than, and persisted (completed the unit) at more than twice the rate of, the at risk group who were not contacted. There were variations among the units which were explained by the timing of the first assignment, specific teaching-learning processes and the structure of the curriculum. Implications for curriculum design and supporting first year students within a personal, social and academic framework are discussed.

Should mental health issues be addressed in primary care, and can it be done? Views of rural general practitioners in Queensland

Objective: The aim of this paper was to examine self-efficacy and perceived appropriateness among rural general practitioners (GPs) in regards to screening and intervention for physical, lifestyle and mental health issues. ----- Method: Fifty GPs from 25 practices in eight rural Queensland towns completed a written survey designed for the study. ----- Results: General practitioners rated opportunistic screening or assessment for smoking and for detection of relapse of mental disorders as the most appropriate, with even cardiovascular and diabetes risk falling behind these. Self-efficacy was highest for medical disorders for smoking assessment. It was significantly lower for alcohol, mental health issues, and addressing risks of physical disorder in people with mental disorders. ----- Conclusions: High appropriateness ratings suggest that current strategies to boost self-efficacy of GPs in addressing mental health issues are timely.

Views of general practitioners and benzodiazepine users on benzodiazepines : a qualitative analysis

Effectively assisting benzodiazepine users to cease use requires a greater understanding of general practitioners’ (GPs)and benzodiazepine users’ views on using and ceasing benzodiazepines. This paper reports the findings from a qualitative study that examined the views of 28 GPs and 23 benzodiazepine users (BUs) in Cairns, Australia. A semistructured interview was conducted with all participants and the information gained was analysed using the Consensual Qualitative Research Approach, which allowed comparisons to be made between the views of the two groups of interviewees. There was commonality between GPs and BUs on reasons for commencing benzodiazepines, the role of dependence in continued use, and the importance of lifestyle change in its cessation. However, several differences emerged regarding commencement of use and processes of cessation. In particular, users felt there was greater need for GPs to routinely advise patients about non-pharmacological management of their problems and potential adverse consequences of long-term use before commencing benzodiazepines. Cessation could be discussed with all patients who use benzodiazepines for longer than 3 months, strategies offered to assist in management of withdrawal and anxiety, and referral to other health service providers for additional support. Lifestyle change could receive greater focus at all stages of treatment.

Introduction of a short writing task to measure and develop academic literacy in first year health undergraduates

This paper describes an initiative in the Faculty of Health at the Queensland University of Technology, Australia, where a short writing task was introduced to first year undergraduates in four courses including Public Health, Nursing, Social Work and Human Services, and Human Movement Studies. Over 1,000 students were involved in the trial. The task was assessed using an adaptation of the MASUS Procedure (Measuring the Academic Skills of University Students) (Webb & Bonanno, 1994). Feedback to the students including MASUS scores then enabled students to be directed to developmental workshops targeting their academic literacy needs. Students who achieved below the benchmark score were required to attend academic writing workshops in order to obtain the same summative 10% that was obtained by those who had achieved above the benchmark score. The trial was very informative, in terms of determining task appropriateness and timing, student feedback, student use of support, and student perceptions of the task and follow-up workshops. What we learned from the trial will be presented with a view to further refinement of this initiative.

Conceptions of school based youth health nursing : a phenomenographic study

The School Based Youth Health Nurse Program was established in 1999 by the Queensland Government to fund school nurse positions in Queensland state high schools. Schools were required to apply for a School Based Youth Health Nurse during a five-phase recruitment process, managed by the health districts, and rolled out over four years. The only mandatory selection criterion for the position of School Based Youth Health Nurse was registration as a General Nurse and most School Based Youth Health Nurses are allocated to two state high schools. Currently, there are approximately 115 Full Time Equivalent School Based Youth Health Nurse positions across all Queensland state high schools. The literature review revealed an abundance of information about school nursing. Most of the literature came from the United Kingdom and the United States, who have a different model of school nursing to school based youth health nursing. However, there is literature to suggest school nursing is gradually moving from a disease-focused approach to a social view of health. The noticeable number of articles about, for example, drug and alcohol, mental health, and contemporary sexual health issues, is evidence of this change. Additionally, there is a significant the volume of literature about partnerships and collaboration, much of which is about health education, team teaching and how school nurses and schools do health business together. The surfacing of this literature is a good indication that school nursing is aligning with the broader national health priority areas. More particularly, the literature exposed a small but relevant and current body of research, predominantly from Queensland, about school based youth health nursing. However, there remain significant gaps in the knowledge about school based youth health nursing. In particular, there is a deficit about how School Based Youth Heath Nurses understand the experience of school based youth health nursing. This research aimed to reveal the meaning of the experience of school based youth health nursing. The research question was How do School Based Youth Health Nurses’ understand the experience of school based youth health nursing? This enquiry was instigated because the researcher, who had a positive experience of school based youth health nursing, considered it important to validate other School Based Youth Health Nurses’ experiences. Consequently, a comprehensive use of qualitative research was considered the most appropriate manner to explore this research question. Within this qualitative paradigm, the research framework consists of the epistemology of social constructionism, the theoretical perspective of interpretivism and the approach of phenomenography. After ethical approval was gained, purposeful and snowball sampling was used to recruit a sample of 16 participants. In-depth interviews, which were voluntary, confidential and anonymous, were mostly conducted in public venues and lasted from 40-75 minutes. The researcher also kept a researchers journal as another form of data collection. Data analysis was guided by Dahlgren and Fallsbergs’ (1991, p. 152) seven phases of data analysis which includes familiarization, condensation, comparison, grouping, articulating, labelling and contrasting. The most important finding in this research is the outcome space, which represents the entirety of the experience of school based youth health nursing. The outcome space consists of two components: inside the school environment and outside the school environment. Metaphorically and considered as whole-in-themselves, these two components are not discreet but intertwined with each other. The outcome space consists of eight categories. Each category of description is comprised of several sub-categories of description but as a whole, is a conception of school based youth health nursing. The eight conceptions of school based youth health nursing are: 1. The conception of school based youth health nursing as out there all by yourself. 2. The conception of school based youth health nursing as no real backup. 3. The conception of school based youth health nursing as confronted by many barriers. 4. The conception of school based youth health nursing as hectic and full-on. 5. The conception of school based youth health nursing as working together. 6. The conception of school based youth health nursing as belonging to school. 7. The conception of school based youth health nursing as treated the same as others. 8. The conception of school based youth health nursing as the reason it’s all worthwhile. These eight conceptions of school based youth health nursing are logically related and form a staged hierarchical relationship because they are not equally dependent on each other. The conceptions of school based youth health nursing are grouped according to negative, negative and positive and positive conceptions of school based youth health nursing. The conceptions of school based youth health nursing build on each other, from the bottom upwards, to reach the authorized, or the most desired, conception of school based youth health nursing. This research adds to the knowledge about school nursing in general but especially about school based youth health nursing specifically. Furthermore, this research has operational and strategic implications, highlighted in the negative conceptions of school based youth health nursing, for the School Based Youth Health Nurse Program. The researcher suggests the School Based Youth Health Nurse Program, as a priority, address the operational issues The researcher recommends a range of actions to tackle issues and problems associated with accommodation and information, consultations and referral pathways, confidentiality, health promotion and education, professional development, line management and School Based Youth Health Nurse Program support and school management and community. Strategically, the researcher proposes a variety of actions to address strategic issues, such as the School Based Youth Health Nurse Program vision, model and policy and practice framework, recruitment and retention rates and evaluation. Additionally, the researcher believes the findings of this research have the capacity to spawn a myriad of future research projects. The researcher has identified the most important areas for future research as confidentiality, information, qualifications and health outcomes.