Cost implications of specific and non-specific treatment for young persons at ultra high risk of developing a first episode of psychosis

Aim: Costs associated with mental health treatment for young persons at 'ultra' high risk (UHR) of developing a psychotic disorder have not previously been reported. This paper reports cost implications of providing psychological and pharmacological intervention for individuals at UHR for psychosis compared with minimal psychological treatment.

Method: Mental health service costs associated with a randomized controlled trial of two treatments (Specific Preventive Intervention: SPI and Needs-Based Intervention: NBI) for UHR young persons were estimated and compared at three time points: treatment phase, short-term follow up and medium-term follow up.

Results: Although the SPI group incurred significantly higher treatment costs than the NBI group over the treatment phase, they incurred significantly lower outpatient treatment costs over the longer term.

Conclusion: This study indicates that specific interventions designed to treat young persons who are identified as being at UHR of psychosis might be associated with some cost savings compared with non-specific interventions.

Client-reported reasons for non-engagement in drug and alcohol treatment

Introduction and Aims.To examine client-reported reasons for missed early appointments at a drug and alcohol treatment service and to compare characteristics of those who missed appointments with those who attended. Design and Methods. Clients who missed a first or second appointment between 1 May and 31 August 2007 at a public community-based outpatient treatment facility were invited to participate in a semistructured telephone interview.This consisted of an open-ended question asking the reason(s) for nonattendance, followed by a questionnaire of items for therapeutic alliance and service satisfaction, perceived impact of substance use and previous treatment experience, mostly rated on Likert scales. Database information on demographic and clinical variables was gathered for all clients who were accepted for treatment within the study time frame. Characteristics of those who missed a first or second appointment (n = 66) were compared with those who attended at least their first two appointments (n = 97). Results. Of clients who missed their appointments, 80.6% provided reasons for nonattendance, which included extraneous factors (50.0%), service shortcomings (29.7%), no further need for service (16.2%) and motivational ambivalence (4.1%). They generally had high ratings of therapeutic alliance and service satisfaction and identified their substance use as having a negative impact on their lives. Clients who missed appointments were more likely to be male, unmarried and have a history of polysubstance use. Discussion and Conclusions. Extraneous issues relating to the client may be a dominant obstacle in early treatment engagement. Efforts to overcome these issues may therefore improve early engagement.

Identifying depression and anxiety disorders in people presenting for substance use treatment

Objective: To identify the type and proportion of depressive and related mental health disorders in a group of individuals seeking outpatient treatment at an alcohol and other drug (AOD) service.
Design, setting and participants: A cross-sectional study using diagnostic interviews with 95 participants (56 men, 39 women) seeking treatment from an AOD service.
Main outcome measures: Mental health and substance disorders were measured using the Composite International Diagnostic Interview, Posttraumatic Stress Disorder Checklist, Beck Depression Inventory, and State–Trait Anxiety Inventory (Trait Version).
Results: This was a complex group with addiction, mental health and physical health conditions; 76% had a depressive disorder and 71% had an anxiety disorder. Most were diagnosed with at least two mental health disorders and 25% were diagnosed with four or more different disorders. Alcohol and cannabis use were the most commonly diagnosed AOD disorders. Further, those diagnosed with a drug use disorder reported significantly higher levels of depression compared with those with an alcohol-only disorder. Finally, 60% of the sample reported chronic health conditions, with over one third taking medication for a physical condition on a regular basis.
Conclusions: Primary care providers such as general practitioners are likely to be increasingly called on to assess, treat and/or coordinate care of patients with AOD disorders. We show that this group will likely present to their GP with more than one MJA 2011; 195: S60–S63 mental health disorder in addition to acute and chronic physical health conditions.

Clinical and economic burden of emergency department presentations for neutropenia following outpatient chemotherapy for cancer in Victoria, Australia

Objective. To examine the clinical characteristics and financial charges associated with treating adult cancer patients receiving chemotherapy in outpatient clinics who presented to the emergency department (ED) with neutropenia.
Design and Setting. A retrospective audit was conducted across two health services involving ED episodes and subsequent hospital admissions of patients who received chemotherapy through day oncology from January 1 to December 31, 2007 and presented to the ED with neutropenia. ED data were collected from the Victorian Emergency Minimum Dataset and charges were collected from Health Information Services. Descriptive and bivariate statistics were used to describe the patient and clinical characteristics and financial outcomes, and to explore associations between these factors.
Results. In total, 200 neutropenic episodes in 159 outpatients were seen in the ED over the survey period. The mean patient age was 56.6 years (standard deviation, 13.2 years) and 47.2% were male. Overall, 70.0% of ED episodes were triaged as Australasian Triage Scale 2 (emergency). The median ED wait time was 10 minutes and the median ED length of stay was 6.8 hours. The median charge for each ED episode was $764.08 Australian dollars. The total combined ED and inpatient charge per episode was in the range of $144.27-$174,732.68, with a median charge of $5,640.87.
Conclusions. This study provides important insights into the clinical and economic burden of neutropenia from both the ED and inpatient perspectives. Alternative treatment models, such as outpatient treatment, early discharge programs or prophylactic interventions to reduce the clinical and economic burden of neutropenia on our health system, must be explored.

Evaluating the outcomes of adolescent day programs in an Australian child and adolescent mental health service

Adolescent day programs (ADPs) are an increasingly used approach to treating adolescents with mental health issues. However, there is a dearth of studies empirically examining the outcomes of adolescent day programs. This study retrospectively examined the mental health functioning of 84 adolescents, pre- and post-treatment, who in addition to their ongoing outpatient treatment had participated in an ADP during a five-year period. Their functioning was compared to matched adolescents who participated only in outpatient treatment during the same time period. Statistical and clinical examinations revealed the reported outcomes following ADP treatment were at least comparable, and sometimes significantly better, when compared to the reported outcomes following outpatient treatment excluding ADP involvement. This study, while having some methodological shortcomings, provides some evidence for the efficacy of ADPs.

The patient experience of a peripherally inserted central catheter (PICC): A qualitative descriptive study.

UNLABELLED: Abstract Aim: To investigate the patient experience of Peripherally Inserted Central Catheter (PICC) insertion, the significance of arm choice and the impact of the device on activities of daily living. BACKGROUND: Arm choice for PICC insertion is often determined by PICC nurses with little input from consumers. There are few studies that have investigated the patient experience of living with a PICC and none that have examined the impact of arm choice from the consumer's perspective. METHOD: Participants were recruited in a hospital whilst they waited for PICC insertion. A purposeful sampling approach was used to select participants based on diagnosis types. Semi-structured telephone interviews were conducted November 2012-August 2013. Transcripts of the interviews were analysed using thematic analysis. FINDINGS: Ten participants were interviewed. Four themes were identified: (i) apprehension/adaptation/acceptance, (ii) impact of treatment, (iii) asking questions (trusting doctors) and (iv) freedom. Although initially apprehensive, participants adapted to the PICC and came to accept that the device allowed convenient access for treatment. This allowed them the freedom to receive treatment at home. The use of the dominant or non-dominant arm for PICC insertion had marginal impact on activities of daily living for participants. Auxiliary factors such as the infusion pump had a significant impact for those who received outpatient treatment. For those participants who did not understand the procedure, many did not seek clarification and trusted medical and nursing staff to make decisions for them. CONCLUSION: Nurses should involve consumers in clinical decision-making and provide individualised information and support that facilitates adaptation for patients living with a PICC.

Outpatient cardiac rehabilitation attendance in England

Abstract
PURPOSE:
Cardiac rehabilitation is an effective but underprovided treatment for patients recovering from acute cardiac events. The geographical spread of provision has not been investigated recently in any country. This study aimed to investigate the level of participation in cardiac rehabilitation programs of patients following myocardial infarction or revascularization (eligible patients) and the geographical equity of attendance.
METHODS:
Questionnaire data were collected from all cardiac rehabilitation centers in England for the year 2003/2004. The number of patients attending rehabilitation was compared with eligible patients across the 9 Government Office Regions of England as indicated by Hospital Episode Statistics.
RESULTS:
Nationally, 29% of eligible patients attended rehabilitation, while within various regions, the proportion of eligible patients participating in rehabilitation ranged between 14% (95% CI, 13.2-14.3) and 37% (95% CI, 36.6-37.6). Participation also differed significantly by primary cardiac event: myocardial infarction, 25%; percutaneous coronary intervention, 24%; and coronary artery bypass surgery, 66% (P < .001).
CONCLUSION:
The participation rate of eligible patients in cardiac rehabilitation was low in all regions. There were large differences between regions with widely varying incidence of attendance in different parts of the country.

Is point of care testing for anaemia (HB) and microalbumin feasible in people with type 2 diabetes attending diabetes outpatient clinics?

Introduction: Diabetes is the major cause of chronic kidney disease (CKD) in Australia. Anaemia of CKD occurs earlier than in non-diabetics and is often insidious and undetected.

Aim: A large, prospective, single-centre study was undertaken to determine the feasibility of point of care testing (POCT) haemoglobin (Hb) and microalbumin in people with type 2 diabetes (T2DM) attending routine outpatient clinic appointments (OPC).

Method: Clinic nurses measured Hb and microalbumin using the HemoCue Haemoglobin Capillary Analyser and the HemoCue Urine Albumin Analyser (Medipac Scientific), respectively when they tested blood glucose, weight and blood pressure. The nurses were trained to use the analysers before the study commenced. Standard demographic data, duration of diabetes, treatment mode, and presence of complications, comorbidities, and HbA1c were ascertained from patients’ medical records.

Results: Five hundred and fifty-four (80%) patients were screened. The nurses were able to perform the tests competently but testing, especially microalbumin, was time-consuming. Patients’ mean age was 62 years (11 SD): 230 females, mean blood glucose (BG) 10 (3.9 SD) mmol/L, mean haemoglobin 127.2 (16.3 SD) g/L; mean microalbumin 47.8 (58.7 SD) mg/L: 324 were males, mean BG 10.2 (3.9 SD) mmol/L, mean Hb 138.6 (18.8 SD) gm/L, and mean microalbumin 67.9 (73.9 SD) mg/L. 27% of males and 22% of females were anaemic. Of those with anaemia, 27% of females and 29% of males had microalbuminuria.

Conclusions: POCT is feasible in routine outpatient clinics but is time-consuming. One in four T2DM attending OPC were anaemic. POCT Hb testing in OPC is feasible and could identify T2DM who need full haematological assessment.

Outpatient versus inpatient IV antibiotic management for pediatric oncology patients with low risk febrile neutropenia: a randomised trial

Febrile neutropenia (FN) is a frequent, serious complication of intensive pediatric chemotherapy regimens. The aim of this trial was to compare quality of life (QOL) between inpatient and outpatient intravenous antibiotic management of children and adolescents with low risk febrile neutropenia (LRFN).

Efficacy of nefazodone in the treatment of neuroleptic induced extrapyramidal side effects: a double-blind randomised parallel group placebo-controlled trial.

Many atypical antipsychotics show antagonism at both serotonergic and dopaminergic neurones and show fewer extrapyramidal side effects (EPS). Nefazodone blocks postsynaptic 5HT2A receptors and weakly inhibits serotonin reuptake. This study aimed to elucidate the role of nefazodone in the treatment of antipsychotic-induced EPS. The trial was a double-blind, randomised, placebo-controlled trial of patients requiring antipsychotic treatment with haloperidol 10mg daily; from which a subgroup of patients who developed EPS were selected for the study. Patients were randomised to add-on therapy with either placebo (n=24) or nefazodone (n=25) 100mg bd. EPS were measured on days 0, 3 and 7 using the Simpson Angus, Barnes akathisia, abnormal involuntary movement and Chouinard scales. Nefazodone significantly reduced EPS as measured by both the Simpson Angus scale and CGI (p=0.007 and 0.0247, respectively). Akathisia and tardive dyskinesia did not differ between the two groups (p=0.601; p=0.507, respectively). These results suggest the role of 5HT2 antagonism in the mechanism of action of atypical antipsychotics with respect to lowering rates of drug-induced EPS. In addition, a therapeutic role for nefazodone is suggested in the treatment of antipsychotic-induced EPS.

Multicenter randomized controlled trial of a home walking intervention after outpatient cardiac rehabilitation on health-related quality of life in women

BACKGROUND: Poor health-related quality of life (HRQL) has been shown to be predictive of adverse outcomes in cardiac patients. As women with coronary heart disease have been shown to have lower HRQL than men with coronary heart disease, women are at greater risk of a poor clinical outcome. This study tested the effect of a 12-week home walking intervention after completion of outpatient cardiac rehabilitation (OCR) on HRQL and maintenance of physical activity among women. DESIGN: Multicenter two-group randomized trial. METHODS: After completion of OCR, participants were randomly allocated to the intervention or usual care groups. The outcomes were HRQL (assessed using the MacNew Heart Disease HRQL instrument) and self-reported physical activity (assessed using the Stages of Change model of exercise behavior) at 3, 6, and 12 months after OCR. RESULTS: Seventy-two women were randomized to the intervention and 81 to usual care. Attrition was greater in the treatment group (13 vs. 1%). HRQL scores increased relative to the base level in both arms and were significantly higher in the intervention group at 6 months, but not at 3 or 12 months. Maintenance of physical activity declined over time in both groups, however, this decline was significantly reduced among women in the intervention group. CONCLUSION: HRQL improved in both groups, but seemed to increase earlier among women in the intervention group. As maintenance of physical activity was higher among women in the intervention group, this minimal intervention could be used to facilitate women's progression from supervised to independent exercise.