Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective.

OBJECTIVE: Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch. METHOD: In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap. RESULTS: Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. CONCLUSIONS: Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

Assessing the validity and responsiveness of a generic preference quality of life measure in the context of posttraumatic stress disorder.

PURPOSE: There is limited research exploring the usefulness of generic preference-based quality of life (GPQoL) measures used to facilitate economic evaluation in the context of posttraumatic stress disorder (PTSD). The aim of the current study was to explore the validity and responsiveness of a common GPQoL measure (Assessment of Quality of Life 8 Dimension [AQoL-8D]) in relation to a PTSD condition-specific outcome measure (Posttraumatic Stress Disorder Checklist for the DSM-5 [PCL-5]). METHOD: This aim was investigated in a sample of individuals (N = 147) who received trauma-focused cognitive-behavioural therapies for posttraumatic stress disorder. Convergent validity was investigated using spearman's correlations, and the level of agreement was investigated using Bland-Altman plots. Responsiveness was investigated by exploring the standardised response means (SRM) from pre-post-treatment across the two measures, which allow the comparison of the magnitude of change between the measures over time. RESULTS: Correlations between the AQoL-8D (dimensions, utility and summary total scores) and the PCL-5 total score ranged from small to large and agreement between the measures was considered moderate to good. While SRMs were large for the AQoL-8D and PCL-5 total scores, the SRM for the PCL-5 was nearly double that of the AQoL-8D. CONCLUSION: Our findings demonstrate that the AQoL-8D has good construct validity but present preliminary evidence that economic evaluations using only GPQoL measures may not fully capture the effectiveness of PTSD treatments.

Evaluating evidence-based interventions in low socio-economic-status populations.

OBJECTIVE: Socio-economic-status (SES) has rarely been reported or investigated in eating disorders (EDs) research. This Research Forum considers, from various perspectives, how SES may impact on evaluating evidence-based treatments for EDs. METHOD: We first reviewed previous literature that informs how SES impacts prevalence of EDs, help-seeking, and treatment outcome. We then present findings from a case series effectiveness study of an early intervention program in low SES areas for EDs and discuss implications about the impact of SES on the effectiveness of evidence-based interventions. Finally, we examine barriers to conducting rigorous evaluations in this population and discuss directions for future treatment outcome research. RESULTS: Evidence suggests a higher level of disordered eating but less help seeking in lower SES groups. In our case series, 96 participants started treatment and completed a mean of 13.85 sessions, 84 (87.5%) completed a mean of 6.40 sessional measures on ED cognitions and behaviors, but only 31% completed more extensive pre-treatment and post-treatment measures. The completer effect size decrease for the global Eating Disorder Examination-Questionnaire score was 2.05 (95% CI: 1.43, 2.68) commensurate with other effectiveness studies in mixed SES groups. The high rates of missing data related to more extensive assessment present a barrier to evaluating evidence-based treatments in this population. DISCUSSION: Evidence from the present study revealed individuals from low SES can achieve similar treatment outcomes to other populations when receiving evidence-based ED treatment. Future studies should investigate a range of approaches to maximizing data collection, including use of shorter sessional measures.

Ascertaining an efficient eligibility cut-off for extended Medicare items for eating disorders.

OBJECTIVE: Currently eligibility for expanded Medicare items for eating disorders (excluding anorexia nervosa) require a score ⩾ 3 on the 22-item Eating Disorder Examination-Questionnaire (EDE-Q). We compared these EDE-Q "cases" with continuous scores on a validated 7-item version of the EDE-Q (EDE-Q7) to identify an EDE-Q7 cut-off commensurate to 3 on the EDE-Q. METHODS: We utilised EDE-Q scores of female university students (N = 337) at risk of developing an eating disorder. We used a receiver operating characteristic (ROC) curve to assess the relationship between the true-positive rate (sensitivity) and the false-positive rate (1-specificity) of cases ⩾ 3. RESULTS: The area under the curve showed outstanding discrimination of 0.94 (95% CI: .92-.97). We examined two specific cut-off points on the EDE-Q7, which included 100% and 87% of true cases, respectively. CONCLUSION: Given the EDE-Q cut-off for Medicare is used in conjunction with other criteria, we suggest using the more permissive EDE-Q7 cut-off (⩾2.5) to replace use of the EDE-Q cut-off (⩾3) in eligibility assessments.

The cost-effectiveness of cognitive behavioral therapy for bulimia nervosa in the Australian context.

OBJECTIVE: This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context. METHOD: An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18-65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results. RESULTS: Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted. CONCLUSION: This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery.

Development of a new statewide eating disorder service: The role of evidence in a real world setting.

OBJECTIVE: There are three aims of this report. First, to describe how research evidence informed a service development rationale for a new statewide eating disorder service (SEDS) for people aged 15 years and older. Second, to examine the profile of people accessing SEDS in the first 2 years of its operation with respect to the three broad dimensions: illness stage, illness severity, and previous history of treatment. Finally, to examine which patient characteristics resulted in the recommendation of ongoing treatment contact with SEDS. METHOD: Over a 2-year period (July 2014 to July 2016) 292 people were referred to the service, 171 (59%) who consented to have their data used in research. RESULTS: Half of the referrals related to anorexia nervosa (AN; 51.2%), with the remainder split between bulimia nervosa (25.3%) and other specified feeding and eating disorders (23.5%); 65.9% had previously received treatment for an eating disorder. The initial information about the service was typically provided by the general practitioner/primary care physician. Compared with any other eating disorder diagnosis, people with AN were three times more likely to be recommended to retain treatment contact with SEDS. DISCUSSION: Service development informed by research evidence, clinical expertise, and consideration of patients' characteristics, values, and circumstances, allows for a flexible but accountable development strategy.

Factors influencing attendance at cardiac rehabilitation among coronary heart disease patients.

OBJECTIVE: The current study examined predictors of, and reasons for, non-attendance at cardiac rehabilitation (CR) among coronary heart disease patients. METHODS: Measures of demographics, surgical procedures, cardiac risk factors, cardiac damage, and psychological variables (depression, trauma, anxiety and alexithymia) were obtained at baseline in 85 coronary heart disease patients, of whom 34 (40%) attended CR. Patients not attending CR reported reasons for their non-attendance. RESULTS: Men who had a sedentary lifestyle or were obese were significantly more likely to attend CR. Women were significantly more likely to attend CR if they had a partner. Patients reported numerous personal reasons for their non-attendance, some of which reflect a dislike of a group format. CONCLUSION: The results suggest the presence of obstacles to attendance and completion of CR that may differ for men and women. Innovative approaches are needed to encourage participation, including the development and evaluation of alternative formats of CR.