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

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

8. Search strategy The search strategy included a block of search terms relating to: 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). Adults (no upper age limit). Must have one or more of the following long term conditions: Must have one or more of the following long term conditions: Diabetes: type 1, type 2 or unspecified Diabetes: type 1, type 2 or unspecified Asthma: acute or chronic Asthma: acute or chronic COPD: chronic, acute exacerbations 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. 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: Psychosocial measures, which could be one or more of: Measures of psychological disorders: depression, anxiety, panic disorder, ‘panic fear’. Measures of psychological disorders: depression, anxiety, panic disorder, ‘panic fear’. Measures must be standardised and validated. 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. 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. Social measures: social support, social network, social stresses. Personality measures: locus of control, alexithymia, neuroticism, attachment, coping, happiness. Personality measures: locus of control, alexithymia, neuroticism, attachment, coping, happiness. Alcohol misuse / substance misuse 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 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 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 SR1 After sifting of abstracts N = 187 SR1 After sifting of titles N = 514 Search strategy identified 9083 papers for SR1 & SR2

13. Psychosocial factors Psychosocial factors identified 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 Out-of-hour or urgent GP visits A/E visits A/E visits Urgent hospitalisations 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 Load and analyse data for self-efficacy /coping and attitudes towards asthma Update searches and load additional data Update searches and load additional data

21. Systematic Review 1 Psychosocial predictors of healthcare utilisation by people with asthma, COPD, diabetes and CHD SR1 After sifting of full papers N= 2 SR1 After sifting of abstracts N = 15 SR1 & SR2 After sifting of titles N = 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

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

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

24. Conclusion Psychosocial predictors of use of unscheduled care include: 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. Self-efficacy /coping and attitudes to asthma still to be assessed.