Progress with the Progress with the literature reviews for the literature reviews for the CHOICE programmeCHOICE programme

Chris DickensChris Dickens

Aim of programmeAim of programme

Develop psychosocial strategies to reduce Develop psychosocial strategies to reduce the need for frequent unscheduled care in the need for frequent unscheduled care in patients with 4 common long term patients with 4 common long term conditions: conditions: – Asthma, Asthma, – Chronic Obstructive Pulmonary Disease, Chronic Obstructive Pulmonary Disease, – Coronary Heart Disease, Coronary Heart Disease, – DiabetesDiabetes

ObjectivesObjectives

To systematically synthesise current To systematically synthesise current evidence about evidence about – psychosocial drivers of unscheduled care and psychosocial drivers of unscheduled care and – psychosocial interventions to reduce the frequency psychosocial interventions to reduce the frequency

of unscheduled careof unscheduled care

Systematic reviewSystematic review

A very rigorous review of previous A very rigorous review of previous research evidence where the researcher:research evidence where the researcher:– expends considerable efforts to identify expends considerable efforts to identify

relevant literature through searching of relevant literature through searching of electronic databases and hand searching of electronic databases and hand searching of journalsjournals

– Uses explicit methods of searching so search Uses explicit methods of searching so search strategy is replicablestrategy is replicable

– Extracts the relevant information from each Extracts the relevant information from each paper in a systematic and reliable fashionpaper in a systematic and reliable fashion

– Builds-in checks of reliability throughout Builds-in checks of reliability throughout processprocess

Meta-analysisMeta-analysis

A method to statistical combine the A method to statistical combine the findings of different studies even if findings of different studies even if subjects studied and methods used in subjects studied and methods used in each study have variedeach study have varied

Systematic reviewsSystematic reviews

Will address 2 questionsWill address 2 questions What psychosocial factors are What psychosocial factors are

associated with use of unscheduled associated with use of unscheduled care in the 4 LTCs (SR1).care in the 4 LTCs (SR1).

What are the characteristics of What are the characteristics of psychosocial interventions that reduce psychosocial interventions that reduce the need for unscheduled care in the 4 the need for unscheduled care in the 4 LTCs (SR2).LTCs (SR2).

Electronic databases Electronic databases searchedsearched MEDLINE, MEDLINE, EMBASE, EMBASE, PSYCHINFO, PSYCHINFO, CINAHL, CINAHL, The British Nursing Index and The British Nursing Index and the Cochrane Library the Cochrane Library

Search strategySearch strategy

The search strategy included a block of The search strategy included a block of search terms relating to:search terms relating to:– health care utilisation and the use of unscheduled health care utilisation and the use of unscheduled

care, care, – the four long-term conditions, the four long-term conditions,

– methodological terms, e.g. prospective cohort methodological terms, e.g. prospective cohort

studies.studies.

Pico CriteriaPico CriteriaPopulation:Population: Adults (no upper age limit). Adults (no upper age limit). Must have one or more of the following long term Must have one or more of the following long term

conditions: conditions: Diabetes: type 1, type 2 or unspecifiedDiabetes: type 1, type 2 or unspecified Asthma: acute or chronicAsthma: acute or chronic COPD: COPD: chronic, acute exacerbationschronic, acute exacerbations CHD: could be acute coronary syndrome (any of MI, CHD: could be acute coronary syndrome (any of MI,

stable or unstable angina), CHD diagnosed from stable or unstable angina), CHD diagnosed from procedure or investigation, or patients recruited from procedure or investigation, or patients recruited from cardiac rehabilitation if 80% or more have diagnosis of cardiac rehabilitation if 80% or more have diagnosis of CHD. CHD.

Study type: Study type: Prospective cohort studyProspective cohort study

PICO criteria PICO criteria (continued)(continued)

Predictors:Predictors: Psychosocial measures, which could be one or more of:Psychosocial measures, which could be one or more of: Measures of psychological disorders: depression, anxiety, Measures of psychological disorders: depression, anxiety,

panic disorder, ‘panic fear’.panic disorder, ‘panic fear’. Measures must be standardised and validated.Measures must be standardised and validated.

Other measures of psychological aspects of health: Other measures of psychological aspects of health: somatisation, health anxiety, somatic amplification, illness somatisation, health anxiety, somatic amplification, illness perception, illness beliefs, self-reported health status, HRQOL perception, illness beliefs, self-reported health status, HRQOL measures where there is a specific mental health component, measures where there is a specific mental health component, health behaviours eg medication adherence.health behaviours eg medication adherence.

Social measures: social support, social network, social Social measures: social support, social network, social stresses.stresses.

Personality measures: locus of control, alexithymia, Personality measures: locus of control, alexithymia, neuroticism, attachment, coping, happiness.neuroticism, attachment, coping, happiness.

Alcohol misuse / substance misuseAlcohol misuse / substance misuse

Pico criteria continuedPico criteria continued

Outcomes: Outcomes: For inclusion studies must have For inclusion studies must have at least one of:at least one of:

Prospective measures of urgent health Prospective measures of urgent health care utilization e.g. number of visits to GP, care utilization e.g. number of visits to GP, consultant, specialist nurse, A and E, walk consultant, specialist nurse, A and E, walk in clinic, unscheduled GP visits. in clinic, unscheduled GP visits.

Prospective measures of health care costs. Prospective measures of health care costs. No papers were found to have an urgent No papers were found to have an urgent health costs measure analysed separatelyhealth costs measure analysed separately

Flow chartFlow chart

SR1 After sifting of full papers, reference

checkingN=25

SR1After sifting of abstracts

N = 187

SR1After sifting of

titlesN = 514

Search strategy

identified 9083 papers for SR1 & SR2

Psychosocial factorsPsychosocial factors

Psychosocial factors identifiedPsychosocial factors identified– Depression (10 studies)Depression (10 studies)– Anxiety (4 studies)Anxiety (4 studies)– Panic / panic fear (3 studies)Panic / panic fear (3 studies)– Self-rated health status (9 studies)Self-rated health status (9 studies)– Self efficacy / coping (2 studies)Self efficacy / coping (2 studies)– Attitudes to asthma (2 studies)Attitudes to asthma (2 studies)– Perceptions of social support (1 study)Perceptions of social support (1 study)– Neuroticism (1 study)Neuroticism (1 study)– Hostility (1 study)Hostility (1 study)

Types of unscheduled Types of unscheduled carecare Out-of-hour or urgent GP visitsOut-of-hour or urgent GP visits A/E visitsA/E visits Urgent hospitalisationsUrgent hospitalisations

Results of meta-analysis to dateResults of meta-analysis to date

N=10, OR = 1.5, p<0.0005, Q = no sig

n-=4, OR = 1.3, p=0.03, Q = not sig

N=3, OR = 1.4, p=0.57, Q, p=0.09

N=9, OR = 1.5, p= 0.01, Q, p<0.0005

Still to doStill to do

Load and analyse data for self-Load and analyse data for self-efficacy /coping and attitudes efficacy /coping and attitudes towards asthmatowards asthma

Update searches and load Update searches and load additional dataadditional data

Systematic Review 1 Psychosocial predictors of Systematic Review 1 Psychosocial predictors of healthcare utilisation by people with asthma, healthcare utilisation by people with asthma, COPD, diabetes and CHDCOPD, diabetes and CHD

SR1 After sifting of full

papers N= 2

SR1After sifting of abstracts

N = 15

SR1 & SR2After sifting of

titlesN = 147

Re-run of the literature search 2008 -2009

Total duplicates N= 233/841

Total number of new papers

identified from the re-run search

N= 608

Systematic review 2Systematic review 2

SYSTEMATIC REVIEW 2 SYSTEMATIC REVIEW 2 Characteristics of psychosocial interventions that reduce Characteristics of psychosocial interventions that reduce the need for unscheduled care in coronary heart disease, asthma, COPD and the need for unscheduled care in coronary heart disease, asthma, COPD and diabetesdiabetes

ParticipantsParticipants Adults from the age of 18Adults from the age of 18 Both gendersBoth genders No upper age limitNo upper age limit No limitations on the setting – ie could be recruited from primary care, secondary care, No limitations on the setting – ie could be recruited from primary care, secondary care,

residential settings such as care homesresidential settings such as care homes People with one or more of the 4 diseases, including stroke and hypertensionPeople with one or more of the 4 diseases, including stroke and hypertension

InterventionIntervention A psychosocial interventionA psychosocial intervention Could be delivered on an individual or group basis, or using technology such as telephone or Could be delivered on an individual or group basis, or using technology such as telephone or

computercomputer Includes education, rehabilitation, psychological therapy, social intervention, organisational Includes education, rehabilitation, psychological therapy, social intervention, organisational

interventionintervention

OutcomesOutcomes Measures of unscheduled health care utilisation or unscheduled health care costs. Measures of unscheduled health care utilisation or unscheduled health care costs.

DesignDesign Randomised controlled trials.Randomised controlled trials.

SR2After sifting of

abstractsN = 240

SR2182/240

full papers found

Systematic Review 2 Psychosocial interventions Systematic Review 2 Psychosocial interventions for people with asthma, COPD, diabetes and CHDfor people with asthma, COPD, diabetes and CHD

SR2After sifting of titles N = 622

Search strategy identified 9083

papers for SR1 & SR2

ConclusionConclusion Psychosocial predictors of use of Psychosocial predictors of use of

unscheduled care include:unscheduled care include:– Depression ( 50%)Depression ( 50%)– Anxiety ( 30%)Anxiety ( 30%)– Self-rated health status ( 50%)Self-rated health status ( 50%)– Not Panic fearNot Panic fear

Self-efficacy /coping and attitudes Self-efficacy /coping and attitudes to asthma still to be assessed.to asthma still to be assessed.