General Practice and Primary Care - Research Publications
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ItemEconomic evaluation of a Decision Support Tool to guide intensity of mental health care in general practice: the Link-me pragmatic randomised controlled trial(BMC, 2022-09-16)BACKGROUND: This paper reports on the cost-effectiveness evaluation of Link-me - a digitally supported, systematic approach to triaging care for depression and anxiety in primary care that uses a patient-completed Decision Support Tool (DST). METHODS: The economic evaluation was conducted alongside a parallel, stratified individually randomised controlled trial (RCT) comparing prognosis-matched care to usual care at six- and 12-month follow-up. Twenty-three general practices in three Australian Primary Health Networks recruited 1,671 adults (aged 18 - 75 years), predicted by the DST to have minimal/mild or severe depressive or anxiety symptoms in three months. The minimal/mild prognostic group was referred to low intensity services. Participants screened in the severe prognostic group were offered high intensity care navigation, a model of care coordination. The outcome measures included in this evaluation were health sector costs (including development and delivery of the DST, care navigation and other healthcare services used) and societal costs (health sector costs plus lost productivity), psychological distress [Kessler Psychological Distress Scale (K10)] and quality adjusted life years (QALYs) derived from the EuroQol 5-dimension quality of life questionnaire with Australian general population preference weights applied. Costs were valued in 2018-19 Australian dollars (A$). RESULTS: Across all participants, the health sector incremental cost-effectiveness ratio (ICER) of Link-me per point decrease in K10 at six months was estimated at $1,082 (95% CI $391 to $6,204) increasing to $2,371 (95% CI $191 to Dominated) at 12 months. From a societal perspective, the ICER was estimated at $1,257/K10 point decrease (95% CI Dominant to Dominated) at six months, decreasing to $1,217 (95% CI Dominant to Dominated) at 12 months. No significant differences in QALYs were detected between trial arms and the intervention was dominated (less effective, more costly) based on the cost/QALY ICER. CONCLUSIONS: The Link-me approach to stepped mental health care would not be considered cost-effective utilising a cost/QALY outcome metric commonly adopted by health technology assessment agencies. Rather, Link-me showed a trend toward cost-effectiveness by providing improvement in mental health symptoms, measured by the K10, at an additional cost. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ANZCTRN 12617001333303.
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ItemNo Preview AvailableClinical efficacy of a Decision Support Tool (Link-me) to guide intensity of mental health care in primary practice: a pragmatic stratified randomised controlled trial(ELSEVIER SCI LTD, 2021-03)BACKGROUND: The volume and heterogeneity of mental health problems that primary care patients present with is a substantial challenge for health systems, and both undertreatment and overtreatment are common. We developed Link-me, a patient-completed Decision Support Tool, to predict severity of depression or anxiety, identify priorities, and recommend interventions. In this study, we aimed to examine if Link-me reduces psychological distress among individuals predicted to have minimal/mild or severe symptoms of anxiety or depression. METHODS: In this pragmatic stratified randomised controlled trial, adults aged 18-75 years reporting depressive or anxiety symptoms or use of mental health medication were recruited from 23 general practices in Australia. Participants completed the Decision Support Tool and were classified into three prognostic groups (minimal/mild, moderate, severe), and those in the minimal/mild and severe groups were eligible for inclusion. Participants were individually and randomly assigned (1:1) by a computer-generated allocation sequence to receive either prognosis-matched care (intervention group) or usual care plus attention control (control group). Participants were not blinded but intervention providers were only notified of those allocated to the intervention group. Outcome assessment was blinded. The primary outcome was the difference in the change in scores between the intervention and control group, and within prognostic groups, on the 10-item Kessler Psychological Distress Scale at 6 months post randomisation. The trial was registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12617001333303. OUTCOMES: Between Nov 21, 2017, and Oct 31, 2018, 24 616 patients were invited to complete the eligibility screening survey. 1671 of these patients were included and randomly assigned to either the intervention group (n=834) or the control group (n=837). Prognosis-matched care was associated with greater reductions in psychological distress than usual care plus attention control at 6 months (p=0·03), with a standardised mean difference (SMD) of -0·09 (95% CI -0·17 to -0·01). This reduction was also seen in the severe prognostic group (p=0·003), with a SMD of -0·26 (-0·43 to -0·09), but not in the minimal/mild group (p=0·73), with a SMD of 0·04 (-0·17 to 0·24). In the complier average causal effect analysis in the severe prognostic group, differences were larger among those who received some or all aspects of the intervention (SMD range -0·58 to -1·15). No serious adverse effects were recorded. INTERPRETATION: Prognosis-based matching of interventions reduces psychological distress in patients with anxiety or depressive symptoms, particularly in those with severe symptoms, and is associated with better outcomes when patients access the recommended treatment. Optimisation of the Link-me approach and implementation into routine practice could help reduce the burden of disease associated with common mental health conditions such as anxiety and depression. FUNDING: Australian Government Department of Health.
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ItemNo Preview AvailableLink-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care(ELSEVIER SCIENCE INC, 2019-03)Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.
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ItemNo Preview AvailableThe Health Service Use of Frequent Users of Telephone Helplines in a Cohort of General Practice Attendees with Depressive Symptoms(SPRINGER, 2016-09)We examined the relationship between frequent use of telephone helplines and health service use over time in a cohort of 789 general practice attendees with depressive symptoms. Telephone helpline use (no use, non-frequent use, frequent use) was measured at 3, 6, 9 and 12 months and analysed using ordered logistic regression. Sixteen participants (2 %) reported frequent use of telephone helplines. Reporting frequent use was associated with visiting multiple general practitioners, using emergency services and visiting mental health specialists in the previous 3 months. Despite this pattern of service use, there was evidence that these services were not meeting the needs of frequent users of telephone helplines, as they were also more likely to report dissatisfaction with their access to health services compared to non-frequent and non-users of telephone helplines. Our findings suggest that a model of care which addresses the complex needs of frequent users of telephone helplines is needed.
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ItemThe experiences of frequent users of crisis helplines: A qualitative interview study(ELSEVIER IRELAND LTD, 2016-11)OBJECTIVE: To understand why some users call crisis helplines frequently. METHODS: Nineteen semi-structured telephone interviews were conducted with callers to Lifeline Australia who reported calling 20 times or more in the past month and provided informed consent. Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was used to generate common themes. Approval was granted by The University of Melbourne Human Research Ethics Committee. RESULTS: Three overarching themes emerged from the data and included reasons for calling, service response and calling behaviours. Respondents called seeking someone to talk to, help with their mental health issues and assistance with negative life events. When they called, they found short-term benefits in the unrestricted support offered by the helpline. Over time they called about similar issues and described reactive, support-seeking and dependent calling behaviours. CONCLUSION: Frequent users of crisis helplines call about ongoing issues. They have developed distinctive calling behaviours which appear to occur through an interaction between their reasons for calling and the response they receive from the helpline. PRACTICE IMPLICATIONS: The ongoing nature of the issues prompting frequent users to call suggests that a service model that includes a continuity of care component may be more efficient in meeting their needs.
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ItemCharacteristics of People Who Use Telephone Counseling: Findings from Secondary Analysis of a Population-Based Study(Springer Verlag, 2014-09-19)The characteristics of people who use telephone counseling are not well understood. This secondary analysis used data from a nationally representative community survey of 8,841 Australian adults to compare callers and non-callers to telephone counseling services. Callers have a poorer clinical profile, including a higher risk of suicide, than people who do not use telephone counseling. They also use a variety of other mental health services. Repeat calls are associated with anxiety disorders, receipt of mental health care from general practitioners, and social disadvantage. All callers have a potential need for telephone counseling and further population studies that distinguish between telephone services intended to provide crisis (one-off) and ongoing counseling are warranted.
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ItemSystematic review of research into frequent callers to crisis helplines(SAGE PUBLICATIONS LTD, 2014-03)We conducted a systematic review of research into callers making multiple calls to crisis helplines. Two databases were searched, identifying 561 articles from 1960 until 2012, of which 63 were relevant. Twenty-one articles from 19 separate studies presented empirical data about callers making multiple calls to crisis helplines. Of the 19 studies, three were intervention studies, five were surveys of callers and 11 were call record audits. Most studies were conducted in the USA and defined frequent callers as people making two or more calls. Frequent callers were more likely to be male and unmarried compared to other callers. There were no reported differences between frequent callers and other callers with regard to age, mental health conditions or suicidality. Three studies tested interventions designed to better manage frequent callers. These studies, even though small, reported reductions in the number of calls made by frequent callers. Suggested techniques for responding to frequent callers included: limiting the number and duration of calls allowed, assigning a specific counsellor, implementing face to face contact, the service initiating contact with the caller instead of waiting for callers to contact the service, providing short term anxiety and depression treatment programmes by telephone, and creating a specific management plan for each frequent caller. Future work requires robust study design methods using larger sample sizes and validated measurements.