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Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety |
Smolders M, Laurant M, Roberge P, van Balkom A, van Rijswijk E, Bower P, Grol R |
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CRD summary This review of knowledge transfer and change interventions for improved provision of guidance on primary and ambulatory anxiety care concluded that collaborative interventions were the most effective. Substantial clinical heterogeneity and poor-quality included studies mean that the broad conclusions should be considered tentative and their reliability is unclear. Specific features of effective collaborative care were not clearly specified. Authors' objectives To assess the effectiveness of different knowledge transfer and change interventions to improve primary and ambulatory anxiety care and provide guidance to professionals and policy makers in mental health care. Searching MEDLINE, PsycINFO, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to December 2006; search terms were reported. This review was an update of a review (see Other Publications of Related Interest) that searched up to January 2003; additional searching was undertaken from January 2003 to December 2006. Searches were restricted to English-language publications. References lists were scanned and authors were contacted in an attempt to identify eligible studies. Study selection Studies were eligible if they were randomised controlled trials (RCTs), controlled before-and-after studies or interrupted time series studies that assessed the effectiveness of a professional-directed, organisational, financial or regulatory intervention targeted at improved recognition or management of anxiety (as a primary diagnosis) in primary or ambulatory health care settings. Other outcomes of interest were costs and resource use. Studies were excluded if they assessed effectiveness of screening strategies, directly compared effectiveness of therapies or took place in other settings.
Included studies were of professional-directed interventions or provider-orientated and patient-orientated organisational interventions. Several studies that included an educational component were multifaceted. No studies of regulatory or financial interventions were found. Participant populations varied; two studies focused on target patients (children, elderly). Control groups for professional-directed intervention studies had no intervention. Control groups were mostly usual care for provider-orientated and patient-orientated organisational intervention studies. Some studies were exclusively restricted to anxiety disorders or symptoms and others had mental health problems that included anxiety and/or depressive disorders or symptoms. Anxiety was measured by either Hospital Anxiety and Depression Scale, State-Trait Anxiety Inventory, Beck Anxiety Inventory or Child Report Version of Spence Children's Anxiety Scale. Economic outcomes were measured in six studies. Most studies were undertaken at the interface of primary care and ambulatory mental health care services.
Two reviewers independently undertook study selection based on titles and abstracts. Differences were resolved by consensus. Assessment of study quality Methodological quality of studies was assessed according to Effective Practice of Care (EPOC) guidelines. Quality criteria assessed included power calculation, concealment of allocation, blinding of outcomes, comparability of groups at baseline, protection against contamination and appropriate choice of control site. Separate scores for each component for each study were provided in table format.
Pairs of reviewers independently undertook quality assessment. Differences were resolved by discussion or recourse to a third reviewer. Data extraction Data were extracted on outcomes of anxiety, cost and resource use. Where appropriate, it appeared that mean differences and standard deviations between intervention and control groups were extracted for anxiety outcomes.
Pairs of reviewers independently undertook quality assessment. Differences were resolved by discussion or recourse to a third reviewer. Methods of synthesis Data were mostly synthesized in a qualitative narrative analysis. Specific design features and results of each study were described under broad categories of type of intervention in text format and in tables. These included professional-directed (audit and feedback, education and educational outreach), provider-orientated organisation (collaborative care and doctor-nurse substitution) or patient oriented organisation (non-guided self help, guided self help and computerised care). Where appropriate data were available, the effects of interventions on anxiety were meta-analysed with a random-effects model. Summary standardised mean differences (SMD) with 95% confidence intervals (CI) were calculated from the meta-analysis. Heterogeneity was assessed with Χ2 and I2. Results of the review This update review identified 17 studies to add to the seven included in the first version of the review. The 24 included studies were identified in 34 publications. Sample sizes ranged from 30 to 2,022 patients and 16 to 286 providers. Seven studies of professional-directed (audit and feedback, education or educational outreach) interventions and 17 studies of provider-orientated (collaborative care or doctor-nurse substitution) and patient-orientated (non-guided self help, guided self help or computerised care) organisational interventions were identified. Several studies that included an educational component were multifaceted. No studies of regulatory or financial interventions were found.
Twenty-three studies were RCTs. One study had a controlled before-and-after design. Study quality was variable. Most studies had no significant differences between groups at baseline. Half or more of the studies lacked power calculations for sample size, adequate descriptions of concealment of allocation, blinding, protection against contamination and greater than 80% follow-up of participants.
Professional-directed interventions: Professional-directed interventions were effective only when combined with organisational approaches and when they were multifaceted.
Provider-orientated organisational interventions: Collaborative care between primary care professionals and mental health specialists was most effective in improved the management of anxiety. There was no evidence of an effect with doctor-nurse substitution.
Patient-orientated organisational interventions: Non-guided self help packages and self management tools were effective in three of four studies and led to a high level of satisfaction; no such effects were found with guided self help packages or computerised care.
Meta-analysis of eight studies (included doctor-nurse substitution, self help or computerised care) indicated that there was no effect of diverse organisational interventions compared to control conditions (mostly usual care or no intervention) on anxiety symptoms (SMD -0.08, 95% CI -0.31, 0.15, p=0.5). Moderate heterogeneity was reported between studies (I2=54.3%). Cost information Four of six studies that reported on economic outcomes indicated that interventions (two collaborative care, one doctor nurse substitution and one guided self help) had a high probability of being cost effective. Authors' conclusions The authors concluded that collaborative care (combinations of clinician and patient education, enhanced support from specialist psychiatric services and monitoring of drug concordance) appeared effective in improved primary and ambulatory care for anxiety and was likely to be cost effective. CRD commentary The review addressed a clear research question. Inclusion criteria were appropriate, although participants were eligible if they had either specific anxiety disorders and symptoms or mixed disorders that included anxiety or depression. Eligible interventions were diverse, but analysed separately in broad categories. Several relevant databases were searched and efforts made to find other studies by searching reference lists and asking experts. No explicit attempts were made to identify unpublished studies, so publication bias could not be ruled out. The restriction to English meant that language bias could not be ruled out. Methods for selection of studies, quality assessment and data extraction were appropriate. Quality of included studies was variable and there were significant methodological shortcomings in some studies. Synthesis of studies in a narrative format due to clinical heterogeneity was appropriate. Moderate heterogeneity in the meta-analysis of eight studies with available data that measured anxiety according to specific validated scales reflected the variable nature of the interventions included in the analysis. Due to substantial clinical heterogeneity and poor quality of the included studies, the authors' broad conclusions should be considered tentative. The reliability of the conclusions is unclear and specific features of effective collaborative care not clearly specified. Implications of the review for practice and research Practice: The authors stated that government and organisational policy makers needed to offer fair and reasonable reimbursement for case management services and for telephone or in-person supervision by mental health professionals serving primary care providers. They suggested that important aspects required included: supportive structures; service reorganisation; location of primary care physicians and mental health specialists; and provision of resources.
Research: The authors stated that research was required to clarify whether collaborative care could be translated and implemented in settings outside USA. Studies were needed to address longer-term effects and longer-term cost-effectiveness. Funding Geestkracht program of the Dutch Scientific Organisation (ZON-MW, grant number 10-000-1002) and matching funds from participating universities and mental health care organisations (VU University Medical Centre, GGZ Buitenamstel, GGZ Geestgronden, Leident University Medical Centre, GGZ Rivierduinen University Medical Centre Groningen, Lentis, GGZ Friesland, GGZ, Drenthe). Bibliographic details Smolders M, Laurant M, Roberge P, van Balkom A, van Rijswijk E, Bower P, Grol R. Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety. Canadian Journal of Psychiatry 2008; 53(5): 277-293 Other publications of related interest Heideman J, van Rijswijk E, van Lin N, de Loos S, Laurant M, Wensing M, van de Lisdonk E, Grol R. Interventions to improve management of anxiety disorders in general practice: a systematic review. Br J Gen Pract 2005; 55(520): 867-874. Indexing Status Subject indexing assigned by NLM MeSH Ambulatory Care; Anxiety Disorders /diagnosis /psychology /therapy; Health Knowledge, Attitudes, Practice; Health Policy; Humans; Mental Health Services /organization & Primary Health Care; Transfer (Psychology); administration AccessionNumber 12008105007 Date bibliographic record published 31/03/2009 Date abstract record published 04/08/2010 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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