GP access for inclusion health groups: perspectives and recommendations.

BACKGROUND: General practice has seen the widespread adoption of remote consulting and triage systems. There is a lack of evidence exploring how inclusion health populations have been impacted by this transformation. AIM: This study aimed to explore the post-pandemic GP access for inclusion health populations, through the lens of those with lived experience, and identify practical recommendations for improving access for this population. DESIGN & SETTING: A mixed-methods study exploring the direct experience of people from inclusion health groups trying to access GP care in 13 practices in east London. METHOD: A mystery shopper exercise involving 39 in-person practice visits and 13 phone calls were undertaken. The findings were reflected on by a multidisciplinary stakeholder group, which identified recommendations for improvements. RESULTS: Only 31% of the mystery shopper visits (n = 8) resulted in registration and the offer of an appointment to see a GP for an urgent problem. None of the mystery shoppers was able to book an appointment over the phone but n = 10/13 felt that they would be able to register and make an appointment if they followed the receptionist's instructions. Most mystery shoppers felt respected, listened to, and understood the information provided to them. Just under half of the practices (46%, n = 6) received positive comments on how accessible and supportive their spaces felt. Practice- and system-level recommendations were identified by the stakeholder group. CONCLUSION: Ongoing GP access issues persist for inclusion health populations. We identified practice- and system-level recommendations for improving access for this vulnerable population.

Home versus outpatient hospital intravenous immunoglobulin infusion and health care resource utilization.

BACKGROUND: Home health care delivery is projected to increase. Intravenous immunoglobulin (IVIG) therapy has high potential to move from the outpatient hospital (OPH) setting to home delivery. OBJECTIVE: This study examined the relationship between home and OPH IVIG infusions and health care utilization. METHODS: We used a retrospective cohort study design and the Humana Research Database to identify patients with 1 or more medical or pharmacy claims for an IVIG infusion agent from January 1, 2017, to December 31, 2018. Eligible patients were enrolled in a Medicare Advantage Prescription Drug (MAPD) or commercial health plan, with at least 12 months of continuous enrollment before and after their first infusion (i.e., index date) received in the home or OPH setting. We measured the odds of experiencing an inpatient (IP) stay or emergency department (ED) visit, adjusted for baseline differences in age, sex, race, region, population density, low-income, and dual eligibility status, MAPD or commercial health plan, plan type, treatment-naïve status, home health use, RxRisk-V comorbidity burden score, and indications for IVIG use. RESULTS: A total of 208 and 1079 patients received IVIG infusions in the home and OPH setting, respectively. The odds for an IP stay (odds ratio [OR] 0.56 [95% CI 0.38-0.82]) and ED visit (OR 0.62 [95% CI 0.41-0.93]) were significantly lower in patients who received IVIG infusion in the home than patients receiving infusion in the OPH setting. CONCLUSIONS: Our findings suggest there may be value to increasing referrals for IVIG home infusion. Decreased health care utilization provides value to the system in cost savings and to patients and families owing to less disruption and improved clinical outcomes. Further study can help inform health policy designed to maximize the benefits of IVIG home infusion while minimizing potential risks.

Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND): protocol and baseline outcomes for a stepped-wedge cluster-randomised prevention trial.

INTRODUCTION: Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders. METHODS AND ANALYSIS: RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools. ETHICS AND DISSEMINATION: Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media. TRIAL REGISTRATION NUMBER: ACTRN12618001986268p.

Protocol for the Let's Grow randomised controlled trial: examining efficacy, cost-effectiveness and scalability of a m-Health intervention for movement behaviours in toddlers.

INTRODUCTION: Despite being an important period for the development of movement behaviours (physical activity, sedentary behaviour and sleep), few interventions commencing prior to preschool have been trialled. The primary aim of this trial is to assess the 12-month efficacy of the Let's Grow mHealth intervention, designed to improve the composition of movement behaviours in children from 2 years of age. Let's Grow is novel in considering composition of movement behaviours as the primary outcome, using non-linear dynamical approaches for intervention delivery, and incorporating planning for real-world implementation and scale-up from its inception. METHODS AND ANALYSIS: A randomised controlled trial will test the effects of the 12-month parental support mHealth intervention, Let's Grow, compared with a control group that will receive usual care plus electronic newsletters on unrelated topics for cohort retention. Let's Grow will be delivered via a purpose-designed mobile web application with linked SMS notifications. Intervention content includes general and movement-behaviour specific parenting advice and incorporates established behaviour change techniques. Intervention adherence will be monitored by app usage data. Data will be collected from participants using 24-hour monitoring of movement behaviours and parent report at baseline (T0), mid-intervention (T1; 6 months post baseline), at intervention conclusion (T2; 12 months post baseline) and 1-year post intervention (T3; 2 years post baseline). The trial aims to recruit 1100 families from across Australia during 2021. In addition to assessment of efficacy, an economic evaluation and prospective scalability evaluation will be conducted. ETHICS AND DISSEMINATION: The study was approved by the Deakin University Human Ethics Committee (2020-077). Study findings will be disseminated through publication in peer-reviewed journals, presentation at scientific and professional conferences, and via social and traditional media. TRIAL REGISTRATION NUMBER: ACTRN12620001280998; U1111-1252-0599.

Treatment utilization patterns of newly initiated oral anticancer agents in a national sample of Medicare beneficiaries.

BACKGROUND: Few studies have examined oral anticancer treatment utilization patterns among Medicare beneficiaries. OBJECTIVE: To assess treatment utilization patterns of newly initiated oral anticancer agents across national samples of Medicare beneficiaries for 5 cancer types: chronic myeloid leukemia (CML), multiple myeloma (MM), metastatic prostate cancer (mPC), metastatic renal cell carcinoma (mRCC), and metastatic breast cancer (mBC). METHODS: This retrospective claims analysis used 100% Medicare Chronic Condition Data Warehouse (CCW) Parts A, B, and D files from 2011 to 2014 (for CML, MM, mPC, and mRCC patients) and a 5% random fee-for-service sample from 2011 to 2013 (for mBC patients). Outcomes of interest were the number of 30-day supply prescriptions, adherence, and discontinuation of newly initiated (ie, index) oral anticancer agents indicated for each of the cancers. Adherence was calculated with both the "traditional" proportion of days covered (PDC) approach, measured over a fixed 1-year period or until hospice/death, and a "modified" PDC approach, measured over the time between the first and last fill of the index oral anticancer agent. Patients with PDC of at least 0.80 were deemed as being adherent. Discontinuation was defined as the presence of a continuous 90-day gap in the availability of days supply of the index oral anticancer agent. RESULTS: Our study included 1,650, 7,461, 6,998, 2,553, and 79 patients for CML, MM, mPC, mRCC, and mBC, respectively. Patients with mRCC had the highest proportion of patients with only 1 fill of their index anticancer agent (28%) followed by mBC (17%), MM (17%), mPC (12%), and CML (12%). Patients with CML had the highest mean (SD) number of 30-day supply equivalent prescriptions (8.3 [4.6]), followed by patients with mPC (6.5 [4.2]), MM (5.7 [4.1]), mBC (4.7 [3.2]), and mRCC (4.5 [3.9]). Using the modified PDC measured between the first and last fills, approximately three-quarters of patients with CML (74%), mRCC (71%), and mBC (70%) were adherent to the index oral anticancer agent. Adherence was highest for patients with mPC (87%) and lowest for patients with MM (58%). The percentage of patients defined as adherent to the index oral anticancer agent decreased for all cancers when using the traditional PDC measure over a fixed 1-year period: CML (54%), MM (35%), mPC (48%), mRCC (37%), and mBC (22%). Rates of discontinuation for patients in our sample were 32% (CML), 38% (mPC), 42% (mRCC), 48% (MM), and 58% (mBC). CONCLUSIONS: Between 13% and 42% of Medicare patients were nonadherent between the first and last fill of their newly initiated oral anticancer therapies across a range of cancers. This study provides a valuable benchmark for stakeholders seeking to measure and improve adherence to oral anticancer agents in Medicare patients. DISCLOSURES: This study was supported by Humana, Inc. (Louisville, KY). The sponsor played a role in the development of the study protocol, interpretation of results, and revisions of the manuscript. The sponsor was not involved in data analysis. Brown is employed by Humana, Inc., and Ward was employed by Humana, Inc., from research inception through initial drafts. Doshi has served as an advisory board member or consultant for Allergan, Ironwood Pharmaceuticals, Janssen, Kite Pharma, Merck, Otsuka, Regeneron, Sarepta, Sage Therapeutics, Sanofi, and Vertex and has received research funding from AbbVie, Biogen, Humana, Janssen, Novartis, PhRMA, Regeneron, Sanofi, and Valeant. Her spouse holds stock in Merck and Pfizer. All other authors have no financial conflicts of interest to report.

Real-World Incidence and Management of Immune-Related Adverse Events from Immune Checkpoint Inhibitors: Retrospective Claims-Based Analysis.

PURPOSE: We assessed real-world spectrum and patterns of irAEs for patients treated with anti-PD(L)1 ICIs. METHODS: irAEs were defined using medical and pharmacy claims for patients enrolled in a Medicare Advantage Prescription Drug plan who initiated treatment with anti-PD(L)-1 and received ≥ 1 dose of therapy between 1 September 2014 and 28 February 2018. RESULTS: Treatment was discontinued for 46.6% of patients, and withheld and subsequently restarted for 10.3%. While toxicity profiles did not differ by age, RiskRx-V co-morbidity index was higher in patients with irAEs. CONCLUSION: These data underscore the needs for tailored irAE diagnostic and management pathways.

Use and impact of social prescribing: a mixed-methods feasibility study protocol.

INTRODUCTION: Social prescribing aims to address social determinants of health, which account for 80%-90% of health outcomes, but the evidence base behind it is limited due to a lack of data linkingsocial prescribing activity and outcomes. METHODS AND ANALYSIS: The objective of the quantitative component of this feasibility studyisto identify the characteristics of individuals who receive social prescriptions and describe the use and estimate the impact of social prescribing; the latter will be done on a homeless subgroup. We will use the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network, whose general practicescover a population of over 4 000 000 patients. Social prescribing data will be extracted onall recorded patients for 5 years up to 31 January 2020. The objective for the qualitative component of the study isto explore approaches to understand the contextual factors that will have influenced our quantitative findings to identify mechanisms to encourage adoption of social prescribing in primary care while improving data quality. Itwill comprise up to three 90-120 minute advisory group meetings for six to eight participants. Participants will be recruited based on their experience of delivering primary care within Oxfordshire and Surrey. The advisory group outputs will be analysed using framework analysis and will be used to create a survey instrument consisting of statements that surveyees, who will consist of primary care practitioners within the RCGP RSC, can agree or disagree with. ETHICS AND DISSEMINATION: All RCGP RSC data are pseudonymised at the point of data extraction. No personally identifiable data are required for this investigation. This protocol follows the Good Reporting of a Mixed Methods Study checklist. The study results will be published in a peer-reviewed journal and the dataset will be available to other researchers.

Protocol for economic evaluation alongside the SHINE (Supporting Healthy Image, Nutrition and Exercise) cluster randomised controlled trial.

INTRODUCTION: Limited evidence exists on the cost-effectiveness of interventions to prevent obesity and promote healthy body image in adolescents. The SHINE (Supporting Healthy Image, Nutrition and Exercise) study is a cluster randomised control trial (cRCT) aiming to deliver universal education about healthy nutrition and physical activity to adolescents, as well as targeted advice to young people with body image concerns who are at risk of developing disordered eating behaviours. This paper describes the methods for the economic evaluation of the SHINE cRCT, to determine whether the intervention is cost-effective as an obesity prevention measure. METHODS AND ANALYSIS: A public payer perspective will be adopted, with intervention costs collected prospectively. Within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will quantify the incremental costs and health gains of the intervention as compared with usual practice (ie, teacher-delivered curriculum). CEA will present results as cost per body mass index unit saved. CUA will present results as cost per quality-adjusted life year gained. A modelled CUA will extend the target population, time horizon and decision context to provide valuable information to policymakers on the potential for incremental cost offsets attributable to disease prevention arising from intervention. Intervention costs and effects will be extrapolated to the population of Australian adolescents in Grade 7 of secondary school (approximate age 13 years) and modelled over the cohort's lifetime. Modelled CUA results will be presented as health-adjusted life years saved and healthcare cost-savings of diseases averted. Incremental cost-effectiveness ratios will be calculated as the difference in costs between the intervention and comparator divided by the difference in benefit. Semi-structured interviews with key intervention stakeholders will explore the potential impact of scalability on cost-effectiveness. These data will be thematically analysed to inform sensitivity analysis of the base case economic evaluation, such that cost-effectiveness evidence is reflective of the potential for scalability. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Deakin University Human Research Ethics Committee (#2017-269) and the Victorian Department of Education and Training (#2018_003630). Study findings will be disseminated through peer-reviewed academic papers and participating schools will receive annual reports over the 3 years of data collection. TRIAL REGISTRATION NUMBER: ACTRN 12618000330246; Pre-results.

A Systematic Review and Meta-Analysis of Prostate Cancer Utility Values of Patients and Partners Between 2007 and 2016.

Background. There is widespread agreement that both the length and quality of life matter when assessing new technologies and/or models of care in the treatment for cancer patients. Quality of life for partners/carers also matters, particularly for prostate cancer. Purpose. This systematic review aims to provide up-to-date utility values along the prostate cancer care continuum (i.e., from prescreening through to palliative care) for use where future trial-based or modelled economic evaluations cannot collect primary data from men and/or partners. Data Sources. A protocol was developed and registered on the international register of systematic reviews-PROSPERO. Databases searched included EBSCO Information Services (CINAHL, EconLit, Global Health, HEED, MEDLINE Complete, PsycINFO), Cochrane Database of Systematic Reviews, Web of Science, and Embase. Study Selection. Study selection terms included health-related quality of life, prostate cancer, and partners or carers. Data Extraction. The authors identified articles published between 2007 and 2016 that provided health state utility values, with statistical uncertainty, for men with or at risk of prostate cancer and/or their partner/carers. Data Synthesis and Results. Study quality and generalizability of utilities was evaluated and meta-analysis conducted against prespecified criteria. From 906 original articles, 29 recent primary studies met the inclusion/exclusion criteria. We tabulate all the utility values with uncertainty, along with considerable methodological detail and patient population characteristics. Limitations. Utility values pertaining to carers/partners were limited to one study. Conclusions. Studies varied in design, measurement instruments utilized, quality, and generalizability. There is sufficient qualitative and quantitative detail for the reported utility values to be readily incorporated into economic evaluations. More research is needed with carers/partners and with newly developing prostate cancer-specific quality of life tools.

Patterns and costs of health-care utilisation in Australian children: The first 5 years.

AIM: To describe patterns of health-care utilisation and costs of a cohort of Australian children in the first 5 years of life and to investigate demographic factors associated with high health-care utilisation. METHODS: This was a secondary data analysis of prospectively linked health-care utilisation data, including primary and secondary health-care consults, hospitalisations and emergency. The subjects were 350 children from a disadvantaged area of Sydney. Outcomes were the frequency and cost of all health-care consults from birth to 5 years of age. Multivariable logistic regression examined the odds of being a high health-care user in relation to child and family characteristics. RESULTS: Children had more health-care consults and higher annual health-care costs in the first 2 years of life (mean 12 health-care visits per year, mean cost Australian dollars (AUD) 1400 per child) than in the next 3 years (8 visits per year, AUD 900 per child). Primary care consults formed 86% of all health-care encounters but only contributed to 30% of the total costs. Factors positively associated with frequent use of health care in the first 2 years of life included being male, mother not married/de facto and annual household income of less than AUD 40000. Frequent users mostly accessed primary care services. There was no association between demographic factors and frequent use of health care in years 3-5 of life. CONCLUSIONS: Children from low-income or single-parent families may require additional support services during the first 2 years of life. Maintaining or increasing access to free or very low-cost primary health-care services for disadvantaged families will promote equity in health.

Is there an association between early weight status and utility-based health-related quality of life in young children?

PURPOSE: Few studies focus on the health-related quality of life (HRQoL) of preschool children with overweight or obesity. This is relevant for evaluation of obesity prevention trials using a quality-adjusted life year (QALY) framework. This study examined the association between weight status in the preschool years and HRQoL at age 5 years, using a preference-based instrument. METHODS: HRQoL [based on parent proxy version of the Health Utilities Index Mark 3 (HUI3)] and weight status were measured in children born in Australia between 2007 and 2009. Children's health status was scored across eight attributes of the HUI3-vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain, and these were used to calculate a multi-attribute utility score. Ordinary least squares (OLS), Tobit and two-part regressions were used to model the association between weight status and multi-attribute utility. RESULTS: Of the 368 children for whom weight status and HUI3 data were available, around 40% had overweight/obesity. After adjusting for child's sex, maternal education, marital status and household income, no significant association between weight status in the preschool years and multi-attribute utility scores at 5 years was found. CONCLUSIONS: Alternative approaches for capturing the effects of weight status in the preschool years on preference-based HRQoL outcomes should be tested. The application of the QALY framework to economic evaluations of obesity-related interventions in young children should also consider longitudinal effects over the life-course. Clinical Trial Registration The Healthy Beginnings Trial was registered with the Australian Clinical Trial Registry (ACTRNO12607000168459).

Feasibility of implementing a cellphone-based reminder/recall strategy to improve childhood routine immunization in a low-resource setting: a descriptive report.

BACKGROUND: Reminder/recall systems are effective ways to improve immunization rates, but their feasibility in primary health care (PHC) settings in Nigeria has not been adequately evaluated. In this study we describe the acceptability and adaptability of immunization reminder/recall system in an urban setting in southwest Nigeria. METHODS: This is a descriptive report of a cluster randomized controlled trial. Four local government areas (LGAs) were randomly assigned into a cellphone reminder/recall intervention group or a usual care control group. Within each LGA, PHC centers were purposively selected to participate in the study. In each PHC center, mothers and their infants aged 0-3 months were enrolled into the two groups during the infants' first immunization visit. Mothers (or other contact persons) in the intervention group received cellphone calls reminding them to take their child for scheduled immunizations. Follow-up of all the children lasted till the final scheduled immunization visit for each child. The intervention lasted for 13 months. RESULTS: A total of 595 mothers/infants pairs (295 in the intervention group and 300 in the control group) participated in the study. Almost all mothers (n = 590, 99.2%) had access to their own cellphone or had access to a cellphone belonging to a significant other. Ninety-eight percent (n = 584) of all mothers were willing to receive immunization reminder/recall phone calls. Eighty-seven percent (n = 2023) of all calls (n = 2324) for the reminder/recall intervention went through to the recipients and of these calls, 1948 (96.3%) were received. The mean cost of each call in US Dollars was about 5 cents. Immunization compliance rate (the receipt of required number of doses of routine vaccines at the appropriate age at recommended interval) was 79.2% among the children in intervention group and 46.4% in the control group (p < 0.001). CONCLUSION: Results demonstrate that cellphone reminder/recall interventions to improve routine childhood immunization are feasible in PHC settings in limited-resource settings with wide cellphone coverage, such as urban areas in Nigeria. Further research to test the potential for scale up in a variety of settings is recommended. TRIAL REGISTRATION: PACTR201702002043415 ; Date of registration: 17 February 2017. (Retrospectively registered).

Cost-effectiveness of a lifestyle modification program in long-term survivors of hemopoietic stem cell transplantation.

To evaluate the cost-effectiveness of a lifestyle modification program targeting long-term survivors of hematological malignancy treated with hemopoietic stem cell transplantation, a multistate life table Markov model was used to calculate health outcomes for both the intervention and no intervention. Cost per health-adjusted life year (HALY) saved was reported for four scenarios: all participants with/without standard weight regain, and participants who at baseline were overweight with/without standard weight regain. The program recruited 53 participants and was associated with reductions in body weight of 2.2 kg and BMI 0.8 units on intervention completion (12 months) at a cost of $1233/participant. These adipose reductions were sustained and remained significant at 24 months. The incremental cost-effectiveness ratios varied from $118 418 per HALY to dominant, depending on the weight regain assumption. The program may be cost-effective in transplant survivors, with the results most sensitive to the weight regain assumption and intervention cost.

Professional interventions for general practitioners on the management of musculoskeletal conditions.

BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care.  SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. AUTHORS' CONCLUSIONS: There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

Designing insurance to promote use of childhood obesity prevention services.

Childhood obesity is a recognized public health crisis. This paper reviews the lessons learned from a voluntary initiative to expand insurance coverage for childhood obesity prevention and treatment services in the United States. In-depth telephone interviews were conducted with key informants from 16 participating health plans and employers in 2010-11. Key informants reported difficulty ensuring that both providers and families were aware of the available services. Participating health plans and employers are beginning new tactics including removing enrollment requirements, piloting enhanced outreach to selected physician practices, and educating providers on effective care coordination and use of obesity-specific billing codes through professional organizations. The voluntary initiative successfully increased private health insurance coverage for obesity services, but the interviews described variability in implementation with both best practices and barriers identified. Increasing utilization of obesity-related health services in the long term will require both family- and provider-focused interventions in partnership with improved health insurance coverage.

The association between EIC receipt and employment in a sample of drug using and non-drug using TANF recipients.

This article examines the extent to which Temporary Assistance to Needy Families (TANF) recipients file income tax returns and take advantage of the Earned Income Credit (EIC), a program specifically designed to increase the economic self-sufficiency of lower income earners by supplementing earned and other income to make working more profitable. This study consisted primarily of Black and Hispanic women (n = 317), recruited for a longitudinal study designed to examine the effects of welfare reform on drug using and non-drug using welfare recipients. At the 2-year mark, 70% of the sample reported having ever filed an income tax return, of these 76% had received an EIC. Both hours worked and earnings were positively associated with EIC receipt. In this population, EIC appears to be a successful mechanism for improving economic self-sufficiency.

Social support, drug use, and employment among low-income women.

This study examined social support and its association with employment, income, and drug use in a sample of 534 low-income women. Functional support was defined as the perceived quality of one's interactions with others. Structural support was defined as the number of individuals within five particular types of networks: social, employment, drug, close, and emergency. Over the two-year study period, significant increases were observed in hours worked, income from work, income from other sources, and total income. There was also a significant decrease in welfare income. Results suggest that the perceived quality of support received is an important factor in achieving positive employment outcomes.

Personal adjustment and substance abuse problems in a longitudinal study of TANF recipients and the potential need for treatment.

OBJECTIVE: This study assessed the need over time for treatment of personal adjustment and substance abuse problems among chronic drug using and other recipients of Temporary Assistance for Needy Families (TANF). METHODS: Participants were administered the personal adjustment problems and substance abuse problems scales contained in the Multidimensional Addictions and Personality Profile (MAPP) at intake, one-year, and two-year interviews. RESULTS: Most participants who were not chronic users had total scale scores that would indicate no recommended referral or a referral to outpatient treatment. Approximately one-third of chronic users had scores that would indicate referral to inpatient treatment. Many chronic users had comorbid conditions but reported receiving no psychological or substance abuse treatment. CONCLUSIONS: Many TANF recipients may be experiencing coexisting personal and substance abuse related problems that are going untreated.