Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Discharge planning: from the acute sector for people over the age of 65

This paper reports the findings relating to discharge planning from a larger study (Hegney et al 2001) that aimed to investigate options to improve care co-ordination between the aged, community, acute and primary care sectors for the elderly residents of a large provincial town. The data, which were collected from a wide variety of aged care stakeholders in the region, are consistent with previous Australian studies. First, it appears that inappropriate discharge from acute hospitals occurs in Toowoomba because there is a perceived lack of information regarding the available community care options and a lack of suitable models to support people's care needs within their own homes. Second, inappropriate discharge practices from acute hospitals occur due to a lack of knowledge and communication on the part of health professionals employed in these settings with regard to the on- going health care needs of elderly people. Third, there is little discharge planning occurring that includes the general practitioner in post-discharge care. Finally, inappropriate discharge can also be attributed to the lack of sub-acute/step-down/rehabilitation options and long waiting lists for community home care services in the region.

Peripartum urinary incontinence : a study of midwive's knowledge and practices

Urinary incontinence impacts on women's quality of life and their wellbeing. The objectives of this study were to obtain knowledge and information on midwives’ assessment and management practices of urinary incontinence in childbearing women and to explore midwives’ knowledge of risk factors associated with developing urinary incontinence. A non-experimental descriptive research design was used, and participants were current members of the Victorian branch of the Australian College of Midwives. Data was obtained using a survey tool that contained both qualitative and quantitative questions. Key findings indicated that the majority of midwives do not assess women for urinary incontinence during the peripartum period and guidelines for bladder management in maternity services were lacking.

The academic acclimatisation difficulties of international students of the built environment

Teaching models common to Australasia can be antithetical to those of its Asian neighbours. Australasian andragogy is a bottom-up student-centred mode of knowledge transmission promoting extroverted learning styles, whilst in Asia andragogy is commonly a top-down teachercentred model promoting introspective learning. Yet these teaching styles are in opposition to the cultural-systems attributed to Asia and the West. Such socio-cultural differences are recognised in this research as contributing to the difficulties international Built Environment undergraduates experience when asked to learn in multi-disciplinary collaborative teams. This paper presents the initial stages of a study currently running as a reflexive research program aimed at resolving these learning difficulties. The primary aim of this program is to inform a new culturally inclusive andragogy for design teaching. The outcome of the research questions are addressed through a triangulated analysis including: the formative appraisal of student satisfaction through questionnaires; the summative evaluation of student achievement through the analysis of grades and the assessment of knowledge and skills gained through the measure of student design projects; and illuminative evaluation through focus group discussions and the observation of tutorials.

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.

A defection analysis of lapsed season ticket holders : a consumer and organizational study

This paper reports on a four-stage study that investigated the motivations and future intentions of recently lapsed members (season-ticket holders) of professional sports organizations, and the marketing responses of those organizations to the issue of customer retention. Survey responses from over 1,000 recently lapsed members across five large sporting clubs were collected. A further study on one club was then conducted to compare attitudes and demographics of lapsed members to those who renewed. The responses suggests that although these lapsed members report that they joined to financially support and feel more involved with the club, they let their membership lapse primarily due to an inability to attend games. Despite joining for intangible, altruistic reasons, it seems that if these members could not get to games, they believed that the membership was not worth maintaining. These members were satisfied with the membership; however, measures of overall level of satisfaction had only a weak positive relationship with the likelihood of members rejoining in the future. These sport organizations were greatly concerned by lapsed members but have only ad hoc relationship marketing strategies in place to either prevent members lapsing or renew lapsed members.

Do repatriate support practices influence repatriate experience, organisational commitment, turnover intentions and perceptions of career success?

The focus of this paper is the development of a model for the effective management of repatriation in multinational enterprises (MNEs). It reviews the literature associated with the relationships between repatriate support practices in relation to repatriation experiences, organisational commitment, turnover intentions, and perceptions of career success. A model has been developed where it is hypothesized that the perception of the provision of important and higher quality practices will result in positive repatriation experiences A positive experience will be positively related to organisational commitment, and perceptions of career success, and negatively related to turnover intentions. These relationships are based on the concepts of social support, uncertainty reduction theory, and psychological contract theory.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce.
Types of services offered by units varied considerably; paid overtime hours were low (<2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Effect of sodium bicarbonate on muscle metabolism during intense endurance cycling

Introduction: Sodium bicarbonate (NaHCO₃) ingestion has been shown to increase both muscle glycogenolysis and glycolysis during brief submaximal exercise. These changes may be detrimental to performance during more prolonged, exhaustive exercise. This study examined the effect of NaHCO₃ ingestion on muscle metabolism and performance during intense endurance exercise of ~60 min in seven endurance-trained men. Methods: Subjects ingested 0.3 g·kg^-1 body mass of either NaHCO₃ or CaCO₃ (CON) 2 h before performing 30 min of cycling exercise at 77 ± 1% [latin capital V with dot above]O_2peak followed by completion of 469 ± 21 kJ as quickly as possible (~30 min, ~80% [latin capital V with dot above]O_2peak). Results: Immediately before, and throughout exercise, arterialized-venous plasma HCO₃- concentrations were higher (P < 0.05) whereas plasma and muscle H⁺ concentrations were lower (P < 0.05) in NaHCO₃ compared with CON. Blood lactate concentrations were higher (P < 0.05) during exercise in NaHCO₃, but there was no difference between trials in muscle glycogen utilization or muscle lactate content during exercise. Reductions in PCr and ATP and increases in muscle Cr during exercise were also unaffected by NaHCO₃ ingestion. Accordingly, exercise performance time was not different between treatments. Conclusion: NaHCO₃ ingestion resulted in a small muscle alkalosis but had no effect on muscle metabolism or intense endurance exercise performance in well-trained men.

Population-Based Randomized Controlled Trial of a Stage-Targeted Physical Activity Intervention

BACKGROUND: Intervention trials with self-selected participants have shown that mailed stage-targeted print materials can increase participation in physical activity in the short term. We examined the effects of a mailed stage-targeted print intervention designed to promote physical activity, in a random sample of adults living in a regional city.

METHOD: Participants (n = 462, 40-60 years of age) were randomly allocated to an intervention (n = 227) or control group (n = 235). Measures included validated 2-week physical activity recall and stage of motivational readiness for physical activity. The intervention consisted of a single mailing of a letter and full-color stage-targeted booklets (specific to precontemplation, contemplation, preparation, and action/maintenance) 1 week postbaseline. Follow-up interviews were conducted at 2 and 6 months postbaseline.

RESULTS: After 2 months, participants in the intervention group were significantly more likely to meet the current American College of Sports Medicine/Centers for Disease Control and Prevention recommendation for sufficient physical activity than those in the control group (adjusted odds ratio [OR] = 2.40; 95% confidence interval [CI] = 1.44-3.99). After 6 months, intervention participants who reported receiving and reading the intervention materials were significantly more likely to be meeting the sufficient physical activity criterion compared with the control group (adjusted OR = 2.03; 95% CI = 1.16-3.56).

CONCLUSIONS: The stage-targeted print intervention was effective in promoting short-term increases in physical activity and was most effective for participants who recognized and used the materials. This low-cost, generalizable intervention has demonstrated potential as a practical population-based physical activity promotion strategy. Further research is required before widespread dissemination would be justified, as additional strategies may be required to ensure sustained change.

Effects of creatine loading and prolonged creatine supplementation of body composition, fuel selection, sprint and endurance performance in humans

Most research on creatine has focused on short-term creatine loading and its effect on high-intensity performance capacity. Some studies have investigated the effect of prolonged creatine use during strength training. However, studies on the effects of prolonged creatine supplementation are lacking. In the present study, we have assessed the effects of both creatine loading and prolonged supplementation on muscle creatine content, body composition, muscle and whole-body oxidative capacity, substrate utilization during submaximal exercise, and on repeated supramaximal sprint, as well as endurance-type time-trial performance on a cycle ergometer. Twenty subjects ingested creatine or a placebo during a 5-day loading period (20g·day^-1) after which supplementation was continued for up to 6 weeks (2g·day^-1). Creatine loading increased muscle free creatine, creatine phosphate (CrP) and total creatine content (P<0.05). The subsequent use of a 2g·day^-1 maintenance dose, as suggested by an American College of Sports Medicine Roundtable, resulted in a decline in both the elevated CrP and total creatine content and maintenance of the free creatine concentration. Both short- and long-term creatine supplementation improved performance during repeated supramaximal sprints on a cycle ergometer. However, whole-body and muscle oxidative capacity, substrate utilization and time-trial performance were not affected. The increase in body mass following creatine loading was maintained after 6 weeks of continued supplementation and accounted for by a corresponding increase in fat-free mass. This study provides definite evidence that prolonged creatine supplementation in humans does not increase muscle or whole-body oxidative capacity and, as such, does not influence substrate utilization or performance during endurance cycling exercise. In addition, our findings suggest that prolonged creatine ingestion induces an increase in fat-free mass.

Guidelines for the management of postmenopausal osteoporosis for GPs

BACKGROUND : Since the last series of guidelines on the management of osteoporosis from Osteoporosis Australia was published in Australian Family Physician (October 2002), there have been further advances in our understanding of the treatment involved in both the prevention of bone loss and the management of established osteoporosis.

OBJECTIVE : This article provides updated guidelines for the management of postmenopausal osteoporosis to assist general practitioners identify those women at risk, and reviews current treatment strategies.

DISCUSSION : Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonatesr raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone therapy has mixed risks and benefits that requires individual patient counselling.

Evidence-based clinical policy: case report of a reproducible process to encourage understanding and evaluation of evidence

We report within a case study a reproducible process to facilitate the explicit incorporation of evidence by a multidisciplinary group into clinical policy development. To support the decision-making of a multidisciplinary Intersectoral Advisory Group (IAG) convened by the Royal Australasian College of Physicians Health Policy Unit, a systematic review of randomized controlled trials about environmental tobacco smoke and smoking cessation interventions in paediatric settings was first undertaken. As reported in detail here, IAG members were then formally engaged in a transparent and replicable process to understand and interpret the synthesized evidence and to proffer their independent reactions regarding policy, practice and research. Our intention was to ensure that all IAG members were democratically engaged and made aware of the available evidence. As clinical policy must engage stakeholder representatives from diverse backgrounds, a process to equalize understanding of the evidence and 'democratize' judgment about its implications is needed. Future research must then examine the benefits of such explicit steps when guidelines, in turn, are implemented. We hypothesize that changes to future practice will be more likely if processes undertaken to develop guidelines are transparent to clinicians and other target groups.

Systematic review of randomised controlled trials of sildenafil (Viagra®) in the treatment of male erectile dysfunction.

Background: Sildenafil (Viagra®), a new oral drug for the treatment of erectile dysfunction, was licensed for use across Europe in 1998. Aim: To examine the effectiveness and safety of sildenafil as an oral treatment for erectile dysfunction. Design of study: Systematic review and meta-analysis.
Setting: All published or unpublished randomised controlled trials comparing sildenafil with a placebo or alternative therapies. Method: Published studies were sought by computerised searches of electronic databases using the keywords ‘sildenafil’ and ‘Viagra’. A hand search was also done of the British Medical Journal, Lancet, Journal of the American
Medical Association, New England Journal of Medicine, British Journal of General Practice, Drug, Inpharma and Scrip. An assessment of quality of all identified studies and data extraction was undertaken independently by two researchers. Results were combined in a meta-analysis where appropriate, using RevMan version 3. Results: Twenty-one trials were identified. All trials showed a statistically significant improvement in erectile or sexual function in patients using sildenafil compared with a placebo. A meta-analysis of 16 trials reporting a global efficacy response showed that men were 3.57 (95% CI = 2.93–4.43) times as likely to have improved erections on sildenafil compared with those on a placebo. The number needed to treat to have one man with improved erections was two. The drug has a relatively safe side-effect profile. Conclusions: Available research shows that sildenafil is an effective treatment for male erectile dysfunction. Many trial participants had some baseline erectile function and it is probable that in clinical practice, where the erectile function tends to be more impaired, the number needed to treat may be higher.