Exploratory economic analyses of two primary care mental health projects : implications for sustainability

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions.

Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists.

Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio.

The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

The diversity of critical care nursing education in Australian universities

A range of critical care nursing educational courses exist throughout Australia. These courses vary in level of award, integration of clinical and academic competence and desired educational outcomes; this variability potentially leads to confuson by stakeholders regarding educational and clinical outcomes. The study objective was to describe the range of critical care nursing courses in Australia. Following institutional ethics approval, all relevant higher education providers (n=18) were invited to complete a questionnaire about course structure, content and nomenclature. Information about desired professional and general graduate characteristics and clinical competency was also sought.

A total of 89% of providers (n=16) responded to the questionnaire. There was little consistency in course structure in regard to the proportion of each programme devoted to core, speciality or generic subjects. In general, graduate certificate courses concentrated on core aspects of critical care, graduate diploma courses provided similar amounts of critical care core and speciality content, while master's level courses concentrated on generic nursing issues. The majority of courses had employment requirements, although only a small proportion specified the minimum level of critical care unit required for clinical experience. The competency standards developed by the Australian College of Critical Care Nurses (ACCCN) were used by 83% of providers, albeit in an adapted form, to assess competency. However, only 60% of programmes used personnel with a combined clinical and educational role to assess such competence.

In conclusion, stakeholders should not assume consistency in educational and clinical outcomes from critical care nursing education programmes, despite similar nomenclature or level of programme. However, consistency in the framework for speciality nurse education has the potential to prove beneficial for all stakeholders.

Key stakeholders' expectations of educational outcomes from Australian critical care nursing courses: a Delphi study

Background
Educational preparation for critical care nursing in Australia varies considerably in terms of the level of qualification resulting in a lack of clarity for key stakeholders about student outcomes.

Objectives
The study aim was to identify and reach consensus regarding the desired learning outcomes from Australian post-registration critical care education programs as demonstrated through the graduate's knowledge, skills and attitudes.

Design
A Delphi technique was used to establish consensus between educators, managers, clinicians and students regarding learning outcomes expected of graduates with a Graduate Certificate, Graduate Diploma and Master level qualification in critical care nursing.

Participants
A total of 164 critical care nurses (66 clinicians, 48 educators, 32 managers and 18 students) participated and 99 questionnaires were returned in the first round (response rate 60%). Fifty-seven questionnaires were returned for Round 2 (response rate 58%).

Methods
Learning outcomes were obtained from the Australian College of Critical Care Nurses Competency Standards for Specialist Critical Care Nurses. Some statements included more than one characteristic, and these were split to create learning outcomes with one characteristic per item. A survey of Australian higher education providers of critical care education provided additional learning outcomes, for a total of 73 learning outcomes for the first Delphi round.

Results
Findings suggest that patient comfort, safety, professional responsibility and ethical conduct are deemed most important for all three levels of educational preparation. There was a lack of emphasis on clinical practice issues for all levels. Participants placed higher emphasis on learning outcomes related to complex decision-making, leadership, supervision, policy development and research for Graduate Diploma and Master level programs.

Conclusion
The findings have implications for curriculum development and the profession with regards to the level of educational preparation required of critical care nurses and suggest that further work is required before clear recommendations can be made for desired educational outcomes from critical care nursing programs in Australia.

Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity

OBJECTIVES: To reduce gain in body mass index (BMI) in overweight/mildly obese children in the primary care setting.
DESIGN: Randomized controlled trial (RCT) nested within a baseline cross-sectional BMI survey.
SETTING: Twenty nine general practices, Melbourne, Australia.
PARTICIPANTS: (1) BMI survey: 2112 children visiting their general practitioner (GP) April-December 2002; (2) RCT: individually randomized overweight/mildly obese (BMI z-score <3.0) children aged 5 years 0 months-9 years 11 months (82 intervention, 81 control).
INTERVENTION: Four standard GP consultations over 12 weeks, targeting change in nutrition, physical activity and sedentary behaviour, supported by purpose-designed family materials.
MAIN OUTCOME MEASURES: Primary: BMI at 9 and 15 months post-randomization. Secondary: Parent-reported child nutrition, physical activity and health status; child-reported health status, body satisfaction and appearance/self-worth.
RESULTS: Attrition was 10%. The adjusted mean difference (intervention-control) in BMI was -0.2 kg/m(2) (95% CI: -0.6 to 0.1; P=0.25) at 9 months and -0.0 kg/m(2) (95% CI: -0.5 to 0.5; P=1.00) at 15 months. There was a relative improvement in nutrition scores in the intervention arm at both 9 and 15 months. There was weak evidence of an increase in daily physical activity in the intervention arm. Health status and body image were similar in the trial arms.
CONCLUSIONS: This intervention did not result in a sustained BMI reduction, despite the improvement in parent-reported nutrition. Brief individualized solution-focused approaches may not be an effective approach to childhood overweight. Alternatively, this intervention may not have been intensive enough or the GP training may have been insufficient; however, increasing either would have significant cost and resource implications at a population level.

Economic Evaluation of a Primary Care Trial to Reduce Weight Gain in Overweight/Obese Children: The LEAP Trial

Background:- A common policy response to the childhood obesity epidemic is to recommend that primary care physicians screen for and offer counseling to the overweight/obese. As the literature suggests, this approach may be ineffective; it is important to document the opportunity costs incurred by brief primary care obesity interventions that ultimately may not alter body mass index (BMI) trajectory.

Methods:- Live, Eat and Play (LEAP) was a randomized controlled trial of a brief secondary prevention intervention delivered by family physicians in 2002-2003 that targeted overweight/ mildly obese children aged 5 to 9 years. Primary care utilization was prospectively audited via medical records, and parents reported family resource use by written questionnaire. Outcome measures were BMI (primary) and parent-reported physical activity and dietary habits (secondary) in intervention compared with control children.

Results:- The cost of LEAP per intervention family was AU $4094 greater than for control families, mainly due to increased family resources devoted to child physical activity. Total health sector costs were AU $873 per intervention family and AU $64 per control, a difference of AU $809 {P < .001). At 15 months, intervention children did not differ significantly in adjusted BMI or daily physical activity scores compared with the control group, but dietary habits had improved.

Conclusions:- This brief intervention resulted in higher costs to families and the health care sector, which could have been devoted to other uses that do create benefits to health and/or family well-being. This has implications for countries such as the United States, the United Kingdom, and Australia, whose current guidelines recommend routine surveillance and counseling for high child BMI in the primary care sector.

Outcomes and costs of primary care surveillance and intervention for overweight or obese children : the LEAP 2 randomised controlled trial

Objective To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children.

Design Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment.

Setting 45 family practices (66 general practitioners) in Melbourne, Australia.

Participants 3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score 3.0) were excluded.

Intervention Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials.

Main outcomes measures Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI.

Results Of 781 eligible children, 258 (33%) entered the trial; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention – control) at 6 and 12 months were, for BMI, –0.12 (95% CI –0.40 to 0.15, P=0.4) and –0.11 (–0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (–4 to 52, P=0.09) and 11 (–26 to 49, P=0.6); and, for nutrition score, 0.2 (–0.03 to 0.4, P=0.1) and 0.1 (–0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm.

Conclusions Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia.

Factors affecting the offer of pulmonary rehabilitation to patients with chronic obstructive pulmonary disease by primary care professionals : a qualitative study

Aim: To explore health professionals’ experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting.

Background: Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving
the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals’ experiences when referring patients. Reports suggest that a health care professional’s attitude towards a treatment affects the willingness of patients to accept advice.

Methods: Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.

Findings: Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.

Addressing evidence treatment gaps for cardiovascular disease through primary care collaboration

Aims & Rationale/Objectives
The aim is to establish the frequency of counselling by general practitioners (GPs) and community pharmacists (CPs) for patients with uncontrolled CVD risk factors. This will identify conditions for which CPs might collaborate with GPs in addressing evidence-treatment gaps.

Methods
A population survey undertaken in the Wimmera region of Victoria in 2006. 1425 adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 723 participants were recruited.

Principal Findings
Data on GP and CP visits were available for 694 participants. Overall, participants visited GPs 4.6 times and CPs 6.0 times/annum. However, one third of participants never consulted a pharmacist in 12 months compared to just 11.5% for GPs. Among obese patients (BMI ?? 30), the average number of visits/annum was 4.5 to GPs and 6.8 to CPs. The equivalent numbers were 5.6 and 8.6 respectively for those with systolic BP ?? 140 mmHg; 3.7 and 5.5 for total cholesterol > 5.0 mmol/L; and, 6.7 and 14.6 for patients with random blood glucose concentrations ?? 7.0 mmol/L.

Implications
People with suboptimal status for most common CVD risk factor are counselled frequently by CPs. A coordinated approach with GPs to the delivery of cardiovascular health promotion could provide valuable reinforcement of key messages and offers greater opportunity to identify at-risk individuals. Acknowledgements: KM is a pharmacist-academic at Greater Green Triangle UDRH, a position funded by the Department of Health and Ageing through the Rural and Remote Pharmacy Workforce Development Program