Progress with the literature reviews for the CHOICE programme

1. Progress with the literature reviews for the CHOICE programme Chris Dickens

2. Aim of programme • Develop psychosocial strategies to reduce the need for frequent unscheduled care in patients with 4 common long term conditions: • Asthma, • Chronic Obstructive Pulmonary Disease, • Coronary Heart Disease, • Diabetes

3. Objectives • To systematically synthesise current evidence about • psychosocial drivers of unscheduled care and • psychosocial interventions to reduce the frequency of unscheduled care

4. Systematic review • A very rigorous review of previous research evidence where the researcher: • expends considerable efforts to identify relevant literature through searching of electronic databases and hand searching of journals • Uses explicit methods of searching so search strategy is replicable • Extracts the relevant information from each paper in a systematic and reliable fashion • Builds-in checks of reliability throughout process

5. Meta-analysis • A method to statistical combine the findings of different studies even if subjects studied and methods used in each study have varied

6. Systematic reviews Will address 2 questions • What psychosocial factors are associated with use of unscheduled care in the 4 LTCs (SR1). • What are the characteristics of psychosocial interventions that reduce the need for unscheduled care in the 4 LTCs (SR2).

7. Electronic databases searched • MEDLINE, • EMBASE, • PSYCHINFO, • CINAHL, • The British Nursing Index and • the Cochrane Library

8. Search strategy • The search strategy included a block of search terms relating to: • health care utilisation and the use of unscheduled care, • the four long-term conditions, • methodological terms, e.g. prospective cohort studies.

9. Pico Criteria Population: • Adults (no upper age limit). • Must have one or more of the following long term conditions: • Diabetes: type 1, type 2 or unspecified • Asthma: acute or chronic • COPD: chronic, acute exacerbations • CHD: could be acute coronary syndrome (any of MI, stable or unstable angina), CHD diagnosed from procedure or investigation, or patients recruited from cardiac rehabilitation if 80% or more have diagnosis of CHD. Study type: Prospective cohort study

10. PICO criteria (continued) Predictors: • Psychosocial measures, which could be one or more of: • Measures of psychological disorders: depression, anxiety, panic disorder, ‘panic fear’. • Measures must be standardised and validated. • Other measures of psychological aspects of health: somatisation, health anxiety, somatic amplification, illness perception, illness beliefs, self-reported health status, HRQOL measures where there is a specific mental health component, health behaviours eg medication adherence. • Social measures: social support, social network, social stresses. • Personality measures: locus of control, alexithymia, neuroticism, attachment, coping, happiness. • Alcohol misuse / substance misuse

11. Pico criteria continued Outcomes: For inclusion studies must have at least one of: • Prospective measures of urgent health care utilization e.g. number of visits to GP, consultant, specialist nurse, A and E, walk in clinic, unscheduled GP visits. • Prospective measures of health care costs. No papers were found to have an urgent health costs measure analysed separately

12. Flow chart SR1 After sifting of full papers, reference checking N=25 Search strategy identified 9083 papers for SR1 & SR2 SR1 After sifting of titles N = 514 SR1 After sifting of abstracts N = 187

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

14. Types of unscheduled care • Out-of-hour or urgent GP visits • A/E visits • Urgent hospitalisations

15. Results of meta-analysis to date

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

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

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

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

20. Still to do • Load and analyse data for self-efficacy /coping and attitudes towards asthma • Update searches and load additional data

21. Systematic Review 1 Psychosocial predictors of healthcare utilisation by people with asthma, COPD, diabetes and CHD Re-run of the literature search 2008 -2009 Total duplicates N= 233/841 SR1 & SR2 After sifting of titles N = 147 SR1 After sifting of full papers N= 2 SR1 After sifting of abstracts N = 15 Total number of new papers identified from the re-run search N= 608

22. Systematic review 2 • SYSTEMATIC REVIEW 2 Characteristics of psychosocial interventions that reduce the need for unscheduled care in coronary heart disease, asthma, COPD and diabetes • Participants • Adults from the age of 18 • Both genders • No upper age limit • No limitations on the setting – ie could be recruited from primary care, secondary care, residential settings such as care homes • People with one or more of the 4 diseases, including stroke and hypertension • Intervention • A psychosocial intervention • Could be delivered on an individual or group basis, or using technology such as telephone or computer • Includes education, rehabilitation, psychological therapy, social intervention, organisational intervention • Outcomes • Measures of unscheduled health care utilisation or unscheduled health care costs. • Design • Randomised controlled trials.

23. Systematic Review 2 Psychosocial interventions for people with asthma, COPD, diabetes and CHD SR2 After sifting of abstracts N = 240 SR2 182/240 full papers found Search strategy identified 9083 papers for SR1 & SR2 SR2 After sifting of titles N = 622

24. Conclusion • Psychosocial predictors of use of unscheduled care include: • Depression ( 50%) • Anxiety ( 30%) • Self-rated health status ( 50%) • Not Panic fear • Self-efficacy /coping and attitudes to asthma still to be assessed.