Therapist-assisted, internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists

Background: Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes.
Objective: The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists.
Methods: Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up).
Results: Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F₁,₈₂ = 9.13, P = .00) and environmental (F₁,₈₂ = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (χ²₁ = 4.40, P = .02, N = 96).
Conclusions: This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

Environmental determinants of healthy eating : in need of theory and evidence

In order to promote healthful nutrition, insight is needed into the determinants of nutrition behaviours. Behavioural determinant research and behavioural nutrition interventions have focused mostly on individual-level motivational factors. It has been argued that the individual's socio-cultural and physical environments may be the main determinants of nutrition behaviours. However, the theoretical basis and empirical evidence for environmental determinants of nutrition behaviours are not strong. The present paper is a narrative review informed by a series of systematic reviews and recent original studies on associations between environmental factors and nutrition behaviours to provide an overview and discussion of the evidence for environmental correlates and predictors of nutrition behaviour. Although the number of studies on potential environmental determinants of nutrition behaviours has increased steeply over the last decades, they include only a few well-designed studies with validated measures and guided by sound theoretical frameworks. The preliminary evidence from the available systematic reviews indicates that socio-cultural environmental factors defining what is socially acceptable, desirable and appropriate to eat may be more important for healthful eating than physical environments that define the availability and accessibility of foods. It is concluded that there is a lack of well-designed studies on environmental determinants of healthful eating behaviours. Preliminary evidence indicates that social environmental factors may be more important than physical environmental factors for healthful eating. Better-designed studies are needed to further build evidence-based theory on environmental determinants to guide the development of interventions to promote healthful eating.

Developing a web-based information resource for palliative care : an action-research inspired approach

Background : General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website.

Method : The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197) scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166).

Results : Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers).

Conclusion : Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to volunteer networks forms an integral part of such an approach.

Men's health literacy : advancing evidence and priorities

Men's health literacy and its bearing on health-related attitudes and behaviour are curiously absent from discussions on health literacy and men's health. This is perhaps understandable given the lack of a theoretical understanding and empirical evidence. In this article, we review and comment on the published literature addressing health literacy and men's health literacy. We define 'health literacy', note a silent discourse on gender in the international debate on health literacy and identify gaps addressing men's health literacy. We also raise issues for research priorities and the practical development and implementation of evidence-based policies and programs aimed at improving men's health.

Evidence for healthy cities : reflections on practice, method and theory

The European Healthy Cities project can be characterized as a social movement that employs an extremely wide range of political, social and behavioural interventions for the development and sustenance of urban population health. At all of these levels, the movement is inspired by ideological, theoretical and evidence-based perspectives. The result of this stance is a dynamic, complex and diverse landscape of initiatives, plans, programmes and actions. In quantitative terms (the number of WHO designated cities and associated cities and communities through national networks), ‘Healthy Cities’ can be regarded as an extraordinary accomplishment and a credit for both WHO and cities in the movement. In qualitative terms, however, critics of the movement have maintained that little evidence on its success and effectiveness has been generated. This critique finds its foundations in the mere perceptions of evidence, the politics of science and urban governance, and perspectives on the preferred or professed utilities of evidence-based health notions. The article reviews the nature of evidence and its interface with politics and governance. Applying a conceptual framework combining insights from knowledge utilization theory, theoretical perspectives on (health) policy development, theory-based evaluations and planned intervention approaches, it demonstrates that, although the evidence is overwhelming, there are barriers to the implementation of such evidence that should be further addressed by ‘Healthy Cities’.

An observational study of health professionals’ use of evidence to inform the development of clinical management tools

Aim. This observational study sought to investigate the process of evidence use by health professionals during development of evidence-based clinical management tools.

Background. Studies conducted to explore the process of research use are scarce and knowledge of this process is essential for our understanding of the influences on research use in practice.

Design. A qualitative, non-participant, observational design.

Methods. Behaviour and actions of two separate multidisciplinary teams were observed and audio-recorded during a combined total of seven meetings for the development of clinical management tools. Semi-structured, one-to-one interviews were conducted approximately half-way through the development process and following completion of the clinical management tools.

Results. Three major themes emerged from this research. First, the process of clinical management tool development and evidence use. Nurses assumed responsibility for coordination of development which focused on describing current practice. Second, the forms of evidence employed during the development process included the use of experiential knowledge, opinions and knowledge of the context, in addition to research evidence. However, reference to research evidence was limited and its incorporation into the instrument was infrequently observed. Third, the use of research evidence emerged with respect to how such evidence was employed.

Conclusion. This study focused on real-life discussion and decision-making that occurred between health professionals when developing evidence-based clinical management tools. Health professionals may have a tendency to rely on their professional experience and current practice in preference to seeking and applying relevant research evidence.

Relevance to clinical practice. Nurses have an important role to play in the development of multidisciplinary evidence-based clinical management tools, but to actively participate in this process they need to be familiar with the relevant research evidence and have the skills and confidence to integrate the evidence into practice.

The treatment of opiate dependency

The portfolio examines use of opiate antagonist medication (naltrexone hydrochloride) as a safe and effective treatment for opiate dependence. The program incorporates evidence-based assessment, treatment planning and after-care counselling. Detoxification using naltrexone is highly effective. Use of naltrexone predicts long-term abstinence and better health and social outcomes. Naltrexone implants improve compliance and outcomes.

The clinical utility of a suite of continence assessment tools for use in residential aged care facilities

According to the Institute of Medicine of the National Academies, 80% of direct care in nursing homes in the USA is provided by workforce that has least formal education about patient care (1). This situation is echoed in Australian residential aged care facilities where the day-to-day management is largely provided by unregulated workers (i.e. nursing assistants, personal carers and nursing aides) and is overseen by registered nurses. Some facilities additionally have access to expert advice from continence nurse advisors. In order to assist the residential aged care workforce to provide continence care that is evidence-based, a team of researchers developed and trialled a suite of continence assessment tools that were mainly targeted to unregulated workers. This paper presents information on the development of the tools (Stage 1) and on their evaluation (Stage 2).

Evaluation of a community pharmacy-based intervention for improving patient adherence to antihypertensives: a randomised controlled trial

Background
The majority of patients using antihypertensive medications fail to achieve their recommended target blood pressure. Poor daily adherence with medication regimens and a lack of persistence with medication use are two of the major reasons for failure to reach target blood pressure. There is no single intervention to improve adherence with antihypertensives that is consistently effective. Community pharmacists are in an ideal position to promote adherence to chronic medications. This study aims to test a specific intervention package that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications - Hypertension Adherence Program in Pharmacy (HAPPY).

Methods/Design
The HAPPY trial is a multi-centre prospective randomised controlled trial. Fifty-six pharmacies have been recruited from three Australian states. To identify potential patients, a software application (MedeMine CVD) extracted data from a community pharmacy dispensing software system (FRED Dispense®). The pharmacies have been randomised to either 'Pharmacist Care Group' (PCG) or 'Usual Care Group' (UCG). To check for 'Hawthorne effect' in the UCG, a third group of patients 'Hidden Control Group' (HCG) will be identified in the UCG pharmacies, which will be made known to the pharmacists at the end of six months. Each study group requires 182 patients. Data will be collected at baseline, three and six months in the PCG and at baseline and six months in the UCG. Changes in patient adherence and persistence at the end of six months will be measured using the self-reported Morisky score, the Tool for Adherence Behaviour Screening and medication refill data.

Discussion
To our knowledge, this is the first research testing a comprehensive package of evidence-based interventions that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications. The unique features of the HAPPY trial include the use of MedeMine CVD to identify patients who could potentially benefit from the service, control for the 'Hawthorne effect' in the UCG and the offer of the intervention package at the end of six months to patients in the UCG, a strategy that is expected to improve retention.

Trial Registration
Australian New Zealand Clinical Trial Registry ACTRN12609000705280

An empirical investigation of hybrid corporate governance systems in large firms : evidence from India

The heightened pace of corporate governance reforms has focussed attention on countryspecific governance models. In relation to India, scholars have observed that a hybrid of the outsider Anglo-Saxon system and the insider Continental system is likely. This paper reports
the results of a study that investigated the corporate governance system of five large firms in 2008. It presents evidence based on publicly available documents and twelve key executive interviews. The paper initially presents a literature review and establishes six propositions
based on the distinguishing features of the two major systems, and then presents the methodology, findings and discussion. The governance characteristics of the Indian firms are classified in terms of the two systems with a view to assessing the extent and nature of hybridization. The findings endorse the hybrid corporate governance system in India.
However, the scope of this study was limited to large listed companies and business groups. Future research should use a larger and more diverse sample including private and unaffiliated firms for outcomes that can be generalized.

Body image among Chinese-Australian and European-Australian men

Little is known about the body image concerns of non-European men living in Australia. In this research, Chinese-Australians demonstrated an "holistic" body image that included body shape, height, clothing and hairstyling concerns. Contrastingly, European-Australians separated muscularity concerns from general appearance considerations. Chinese-Australians utilised both Asian and Western internalisation/appearance comparison targets. The portfolio aims to critically evaluate the clinical utility of Evidence Based Practice (EBP). Four case studies analyse the practical advantages and disadvantages of EBP.

Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease

Background: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD.
Methods: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO2), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h.
Results: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P = 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P = 0.001). SpO2 > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO2 < 90% were not given oxygen (61.8%; 30%; 45.5%).
Conclusions: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence-based supporting
oxygen use and better understanding of clinicians’ oxygen decision-making in patients with COPD.

The uptake of an early warning system in an Australian emergency department : a pilot study

Objectives: To evaluate the uptake of an emergency department early warning system (ED EWS) for recognition of, and response to, clinical deterioration.

Design, setting and participants: A descriptive exploratory study conducted in an urban district hospital in Melbourne, Australia. Systematic sampling was used to identify every 10th patient for whom the ED EWS was activated from May 2009 to May 2011.

Main outcome measures: Patient characteristics, ED system data and ED EWS activation characteristics.

Results: ED EWS activation occurred in 1.5% of ED patients; 204 patients were included in this pilot study. The median age was 65.1 years (interquartile range [IQR], 47.8-77.5 years), 89.2% of patients were classified as triage category 2 or 3, and 82.4% of patients were seen by medical staff before ED EWS activation. Hypotension (27.7%) and tachycardia (23.7%) were the most common reasons for ED EWS activation. Median duration of clinical instability was 39 minutes (IQR, 5- 129 minutes). Nurses made 93.1% of ED EWS activations. Median time between documenting physiological abnormalities and ED EWS activation was 5 minutes (IQR, 0- 20). Most patients (57.8%) required hospital admission: 4.4% of patients required intensive care unit admission.

Conclusions: The ED EWS resulted in at least two formal reports of clinical deterioration in ED patients per day, indicating reasonable uptake by clinicians. A greater understanding of clinical deterioration in ED patients is warranted to inform an evidence-based approach to recognition of, and response to, clinical deterioration in ED patients.