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Child / Family Health Program Planning in Public Health: What's the Evidence?

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Child / Family Health Program Planning in Public Health: What's the Evidence?

  1. 1. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Child/Family Health Program Planning: Discussing Review- Level Evidence You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. What’s the evidence?  Winzenberg, T.M., Shaw, K., Fryer, J., & Jones, G. (2006). Calcium supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD005119.  Newton, M. S. & Ciliska, D. (2006). Internet-based innovations for the prevention of eating disorders: A systematic review. Eating Disorders, 14(5), 365-384.  Stinson, J., Wilson, R., Gill, N., Yamada, J., & Holt, J. (2009). A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology, 34, 495-510.  Shepperd, S., Doll, H., Gowers, S., James, A., Fazel, M., Fitzpatrick R., & Pollock, J. (2009). Alternatives to inpatient mental health care for children and young people. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD006410.
  3. 3. Housekeeping  Connection issues  Recommend you use a wired Internet connection rather than wireless, to help prevent connection challenges  Please contact the WebEx 24/7 help line: 1-866-229-3239
  4. 4. Side Panel in WebEx Housekeeping Feedback icon  How to post comments/questions Hand icon during the webinar Mic request  To write in CHAT or Q&A • Address questions to all Chat panelists • Raise hand using the ‘hand’ icon (indicated on the right) • Respond to general comments using the feedback icon Q&A  To talk: • If have a head set, you can ask to be passed the mic (mic request icon on right)
  5. 5. This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Child/Family Health Program Planning: Discussing Review- Level Evidence You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  6. 6. The Health Evidence Team Maureen Dobbins Kara DeCorby Daiva Tirilis Scientific Director Administrative Director Research Coordinator Tel: 905 525-9140 ext 22481 Tel: (905) 525-9140 ext. 20461 Tel: (905) 525-9140 ext. 20460 E-mail: dobbinsm@mcmaster.ca E-mail: kdecorby@health-evidence.ca E-mail: dtirilis@health-evidence.ca Lori Greco Heather Husson Robyn Traynor Lyndsey McRae Knowledge Broker Project Manager Research Coordinator Research Assistant
  7. 7. What is www.health-evidence.ca? Evidence inform Decision Making
  8. 8. Why use www.health-evidence.ca? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  9. 9. Meetings, Planning & Dissemination Project CIHR Funded MOP-238541
  10. 10. CIHR-Funded Reviews  Winzenberg, T.M., Shaw, K., Fryer, J., & Jones, G. (2006). Calcium supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD005119.  Newton, M. S. & Ciliska, D. (2006). Internet-based innovations for the prevention of eating disorders: A systematic review. Eating Disorders, 14(5), 365-384.  Stinson, J., Wilson, R., Gill, N., Yamada, J., & Holt, J. (2009). A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology, 34, 495-510.  Shepperd, S., Doll, H., Gowers, S., James, A., Fazel, M., Fitzpatrick R., & Pollock, J. (2009). Alternatives to inpatient mental health care for children and young people. Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD006410.
  11. 11. Evaluation Please check your email for the evaluation survey link after the webinar. It take 5 minutes to complete! If you’ve been watching with someone else and did not personally register for the webinar, please e- mail Jennifer McGugan at mcgugj@mcmaster.ca to be sent the survey.
  12. 12. Questions?
  13. 13. Summary Statement: Winzenberg(2006)
  14. 14. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  15. 15. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  16. 16. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  17. 17. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  18. 18. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  19. 19. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  20. 20. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between the increase in upper conclusions specific to peripubertal or non- limb bone mineral density and fracture risk was Caucasian populations, or those with a baseline not directly assessed in the studies. calcium intake <500 mg/day. NOTE: The results were taken from the sensitivity analyses, representing a more conservative estimate of effect.
  21. 21. Interpreting the Evidence Calcium supplementation (19 RCTs, 2859 children) What’s the evidence? Implications for practice & policy • Calcium supplementation led to an increase • Calcium supplementation among healthy in upper limb bone mineral density children by public health is not supported at compared to placebo (SMD 0.14 mg/cm2, this time. 95% CI 0.04, 0.24) (13 studies); an effect • There is insufficient evidence to support equal to a ~1.7% greater increase in calcium supplementation of any supplemented groups, which at best would dose/duration among healthy children to reduce absolute fracture risk in children by increase long-term lumbar bone mineral 0.1-0.2% per annum based on average peak content, femoral neck bone mineral density, fracture incidence. However, results were total body bone mineral content, or upper not maintained after stopping limb bone mineral density. supplementation. • No impact observed on femoral neck or lumbar spine bone mineral density, or on total body bone mineral content.
  22. 22. Calcium Supplementation  Calcium supplementation led to an increase in upper limb bone mineral density compared to placebo (SMD +0.14 mg/cm2, 95%CI 0.04, 0.24)
  23. 23. Interpreting the Evidence Calcium supplementation (19 RCTs, 2859 children) What’s the evidence? Implications for practice & policy • Calcium supplementation led to an increase • Calcium supplementation among healthy in upper limb bone mineral density children by public health is not supported at compared to placebo (SMD 0.14 mg/cm2, this time. 95%CI 0.04, 0.24) (13 studies); an effect • There is insufficient evidence to support equal to a ~1.7% greater increase in calcium supplementation of any supplemented groups, which at best would dose/duration among healthy children to reduce absolute fracture risk in children by increase long-term lumbar bone mineral 0.1-0.2% per annum based on average peak content, femoral neck bone mineral density, fracture incidence. However, results were total body bone mineral content, or upper not maintained after supplementation was limb bone mineral density. stopped. • No impact observed on femoral neck or lumbar spine bone mineral density, or on total body bone mineral content.
  24. 24. Interpreting the Evidence Calcium supplementation (19 RCTs, 2859 children) What’s the evidence? Implications for practice & policy • Calcium supplementation led to an increase • Calcium supplementation among healthy in upper limb bone mineral density children by public health is not supported at compared to placebo (SMD 0.14 mg/cm2, this time. 95%CI 0.04, 0.24) (13 studies); an effect • There is insufficient evidence to support equal to a ~1.7% greater increase in calcium supplementation of any supplemented groups, which at best would dose/duration among healthy children to reduce absolute fracture risk in children by increase long-term lumbar bone mineral 0.1-0.2% per annum based on average peak content, femoral neck bone mineral density, fracture incidence. However, results were total body bone mineral content, or upper not maintained after supplementation was limb bone mineral density. stopped. • No impact observed on femoral neck or lumbar spine bone mineral density, or on total body bone mineral content.
  25. 25. Interpreting the Evidence Calcium supplementation (19 RCTs, 2859 children) What’s the evidence? Implications for practice & policy • Calcium supplementation led to an increase • Calcium supplementation among healthy in upper limb bone mineral density children by public health is not supported at compared to placebo (SMD 0.14 mg/cm2, this time. 95%CI 0.04, 0.24) (13 studies); an effect • There is insufficient evidence to support equal to a ~1.7% greater increase in calcium supplementation of any supplemented groups, which at best would dose/duration among healthy children to reduce absolute fracture risk in children by increase long-term lumbar bone mineral 0.1-0.2% per annum based on average peak content, femoral neck bone mineral density, fracture incidence. However, results were total body bone mineral content, or upper not maintained after supplementation was limb bone mineral density. stopped. • No impact observed on femoral neck or lumbar spine bone mineral density, or on total body bone mineral content.
  26. 26. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Calcium supplementation had: This review suggests there are no gains to be • a small, positive effect on bone mineral made from promoting calcium supplementation density for upper limb (short term but not among healthy children. long term) • no impact on bone mineral content for Public health decision makers should note that total body, femoral neck, or lumbar spine fracture rates were not assessed. However, it is unlikely that the small increase in bone mineral Baseline calcium intake, gender, physical activity, density of the upper limb will lead to a clinically duration of supplementation and type (e.g. milk significant decrease in fracture risk later in life. extract) did not impact findings. Evidence remains insufficient to make The association between upper limb bone conclusions specific to peripubertal or non- mineral density and fracture risk is unknown. Caucasian populations, or those with a baseline calcium intake <500 mg/day.
  27. 27. Questions?
  28. 28. Summary Statement: Newton(2006)
  29. 29. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  30. 30. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  31. 31. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  32. 32. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  33. 33. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  34. 34. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  35. 35. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  36. 36. Interpreting the Evidence Body Satisfaction, Attitudes, and Behaviours (5 trials, 356 participants) What’s the evidence? Implications for practice & policy • No impact on restraint, eating concern, shape • Based on currently available evidence, concern, weight concern, or eating disordered internet-based public health programs attitudes and behaviours, body satisfaction, or are not supported. eating attitudes.
  37. 37. Interpreting the Evidence Social Support (Internet-based discussion groups) (2 RCTs) What’s the evidence? Implications for practice & policy • Participants in the program reported a • As a strategy to improve perceived “moderate” amount of support, as well as self- social support among this population, and other-acceptance, from the on-line public health may consider discussion boards. implementing intervention-based discussion groups.
  38. 38. Interpreting the Evidence Knowledge (1 RCT; 1 quasi-experiment) What’s the evidence? Implications for practice & policy • Statistically significant improvements in • Public health should consider Internet- knowledge were observed when participants based eating disorder prevention were exposed to a multi-session intervention programs for improving knowledge focused on healthy lifestyle attitudes/ behaviours related to healthy lifestyles and that also allowed time for participants to reflect attitudes/behaviours. on new learning and experiment with newly- acquired skills.
  39. 39. Interpreting the Evidence Software Experience (qualitative findings based on 1 RCT and 1 quasi-experiment) What’s the evidence? Implications for practice & policy • Most (77.5%) reported high satisfaction with the • Public health should provide internet- program. Students reported feeling that: (1) they based prevention programs for eating could talk about their concerns in the on-line disorders considering it was viewed as discussion group and felt supported, (2) other being “useful, helpful, and fun”. group members understood their concerns, and • However, this type of program could (3) input they received from group members negatively impact participants. Public was trusted (1 RCT). health should consider the potential • Participants expressed high levels of impact posted Internet messages could anxiety/frustration related to participant posted have on anxiety levels and frustration Internet messages (1 RCT). from posted messages.
  40. 40. Interpreting the Evidence Software Experience (qualitative findings based on 1 RCT and 1 quasi-experiment) What’s the evidence? Implications for practice & policy • Most (77.5%) reported high satisfaction with the • Public health should provide internet- program. Students reported feeling that: (1) they based prevention programs for eating could talk about their concerns in the on-line disorders considering it was viewed as discussion group and felt supported, (2) other being “useful, helpful, and fun”. group members understood their concerns, and • However, this type of program could (3) input they received from group members negatively impact participants. Public was trusted (1 RCT). health should consider the potential • Participants expressed high levels of impact posted Internet messages could anxiety/frustration related to participant posted have on anxiety levels and frustration Internet messages (1 RCT). from posted messages.
  41. 41. Interpreting the Evidence Software Experience (qualitative findings based on 1 RCT and 1 quasi-experiment) What’s the evidence? Implications for practice & policy • Most (77.5%) reported high satisfaction with the • Public health should provide internet- program. Students reported feeling that: (1) they based prevention programs for eating could talk about their concerns in the on-line disorders considering it was viewed as discussion group and felt supported, (2) other being “useful, helpful, and fun”. group members understood their concerns, and • However, this type of program could (3) input they received from group members negatively impact participants. Public was trusted (1 RCT). health should consider the potential • Participants expressed high levels of impact posted Internet messages could anxiety/frustration related to participant posted have on anxiety levels and frustration Internet messages (1 RCT). from posted messages.
  42. 42. Interpreting the Evidence Software Experience (qualitative findings based on 1 RCT and 1 quasi-experiment) What’s the evidence? Implications for practice & policy • Most (77.5%) reported high satisfaction with the • Public health should provide internet- program. Students reported feeling that: (1) they based prevention programs for eating could talk about their concerns in the on-line disorders considering it was viewed as discussion group and felt supported, (2) other being “useful, helpful, and fun”. group members understood their concerns, and • However, this type of program could (3) input they received from group members negatively impact participants. Public was trusted (1 RCT). health should consider the potential • Participants expressed high levels of impact posted Internet messages could anxiety/frustration related to participant posted have on anxiety levels and frustration Internet messages (1 RCT). from posted messages.
  43. 43. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications This high quality review is based on a small Eating disorder prevention programs should number of weak quality studies. use/encourage internet-based programs and online discussion boards to improve healthy Interventions consisting of psychoeducational lifestyles, attitudes/ behaviours and knowledge. readings and reflections, Internet-based body These programs are not as effective for image journaling, and asynchronous Internet improving disordered eating and symptomology. discussion groups resulted in: • perceptions of increased support Public health should expect internet-based • improved knowledge eating disorder programs to generate high but had no impact on: satisfaction but should also be cautious given • body satisfaction programs can create discomfort as personal • eating disordered attitudes and behaviours information is disclosed and face-to-face contact is eliminated. Strategies to minimize Declining completion rates associated with: anxiety and frustration should be considered. • discomfort with the intervention • lack of face-to-face contact Given the low quality studies, available for this • concerns with privacy/confidentiality review, findings should be used cautiously.
  44. 44. Questions?
  45. 45. Summary Statement: Stinson (2009)
  46. 46. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  47. 47. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  48. 48. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  49. 49. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  50. 50. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  51. 51. Interpreting the Evidence Improving health outcomes in terms of symptom management or disease control (9 studies) What’s the evidence? Implications for practice & policy • Seven studies found improvements in • Public health programs should consider symptom management or disease control using internet-based self-management (e.g., symptom free days, use of medications, education interventions to improve days of school missed, and activity symptom free days, use of medications, days restrictions) among intervention groups of school missed, and activity restrictions. compared to controls.
  52. 52. Interpreting the Evidence Disease-related Knowledge (4 studies) What’s the evidence? Implications for practice & policy • Two of three studies on asthma found an • Public health programs should use internet- increase in knowledge among the based self-management education to intervention groups compared to controls, increase asthma knowledge among children, whereas another study found no • At this time public health programs should improvements. not use internet-based education to • No impact on improvements in an improve knowledge on encopresis. encopresis study
  53. 53. Interpreting the Evidence Quality of Life (6 studies) What’s the evidence? Implications for practice & policy • Only two of six studies found • Public health programs should not rely on improvements in quality of life among internet-based education programs for intervention groups compared to controls. children with asthma to improve quality of • Four studies did not report outcome data. life.
  54. 54. Interpreting the Evidence Health Care Resources (4 studies) What’s the evidence? Implications for practice & policy • Two studies on asthma participants found • Public health programs should use internet- decreases in emergency room visits and based programs for children with asthma to physician consultations; one study observed decrease emergency room visits and a decrease in emergency room visits only, physician consultations, although no impact and a fourth study reported no effect. on hospitalizations and overall service use should be expected.
  55. 55. Interpreting the Evidence Cost-effectiveness (4 studies) What’s the evidence? Implications for practice & policy • All four studies found the intervention was • Public health should incorporate internet- more cost-effective than traditional based education in program planning to education programs (e.g. labour costs, achieve cost-effectiveness. resource utilization, health insurance, and societal costs).
  56. 56. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Internet-based self-management interventions Public health should support Internet-based for youth with health conditions improved : self-management interventions for older • symptoms among participants children with low SES, and African American • disease-specific knowledge (asthma) youth to: • cost effectiveness • increase symptom-free days and medication mixed effects on use , and decrease school days missed and • health care utilization activity restrictions • quality of life • increase asthma knowledge • decrease ER visits and physician consults The interventions appeared to be • provide cost-effective educational programs • most effective among children with asthma to improve health and asthma knowledge • more effective in certain sub-populations (e.g. older children with lower SES and Internet-based self management interventions African Americans) are not supported to: • improve quality of life • decrease health care utilization (other than ER visits and physician consultation).
  57. 57. Questions?
  58. 58. Summary Statement: Shepperd (2009)
  59. 59. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  60. 60. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  61. 61. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  62. 62. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  63. 63. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  64. 64. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  65. 65. Home-based multi- systemic therapy (MST) Definition Therapists provide therapy to the child and the family together in their home. Families are required to participate, and MST services - according to protocol - are available 24/7. MST therapists will continue to work with clients who are hospitalized. Multi-systemic therapy (MST) follows a standard protocol and is a family- centred, ecologically orientated therapy targeting individual, family, peer and environmental aspects of psychopathology in the community, and includes the development of aftercare plans. Family therapy, behavioural therapy and cognitive behavioural therapy are used. Comprehensive crisis plans are developed jointly by the therapist and the child psychiatrist and focus on mobilizing the problem-solving skills within the family and community.
  66. 66. Interpreting the Evidence Home-based Multi-systemic Therapy (MST) (2 trials) What’s the evidence? Implications for practice & policy • In treating psychosis, at four months, fewer • Public health decision makers may teacher-reported symptoms (SMD -0.52 95% consider supporting/encouraging MST as CI -0.90 to -0.14); fewer days spent out-of- opposed to inpatient care for psychosis school (SMD -0.47, 95% CI -0.85 to -0.09); given positive impact on some outcomes and less self-reported alcohol use (SMD - may be realized. However, for many 0.49, 95% CI -0.87 to -0.11) were reported. additional outcomes, for both the child • A study of low quality reported reduced self- and family, positive improvements should reported minor delinquency (SMD -2.72, not be expected. 95%CI -3.71 to -1.72), Youth Risk Behaviour scores (SMD -0.90, 95% CI -1.64 to -0.16), and fewer days of hospitalization (0.53 days/month vs. 3.88 days/month) • No impact on symptom severity, caregiver- reported symptoms, marijuana use, arrests, caregiver satisfaction, self-reported total drug use, family adaptability, and cohesion.
  67. 67. Interpreting the Evidence Home-based Multi-systemic Therapy (MST) (2 trials) What’s the evidence? Implications for practice & policy • In treating psychosis, at four months, fewer • Public health decision makers may consider teacher-reported symptoms SMD -0.52 95% supporting/encouraging MST as opposed to CI -0.90 to -0.14); fewer days spent out-of- inpatient care for psychosis given positive school (SMD -0.47, 95% CI -0.85 to -0.09); impact on some outcomes may be realized. and less self-reported alcohol use (SMD - However, for many additional outcomes, for 0.49, 95% CI -0.87 to -0.11) were reported. both the child and family, positive • A study of low quality reported reduced improvements should not be expected. self-reported minor delinquency (SMD -2.72, 95%CI -3.71 to -1.72), Youth Risk Behaviour scores (SMD -0.90, 95% CI -1.64 to -0.16), and fewer days of hospitalization (0.53 days/month vs. 3.88 days/month) • No impact on symptom severity, caregiver- reported symptoms, marijuana use, arrests, caregiver satisfaction, self-reported total drug use, family adaptability, and cohesion.
  68. 68. Interpreting the Evidence Home-based Multi-systemic Therapy (MST) (2 trials) What’s the evidence? Implications for practice & policy • In treating psychosis, at four months, fewer • Public health decision makers may consider teacher-reported symptoms SMD -0.52 95% supporting/encouraging MST as opposed to CI -0.90 to -0.14); fewer days spent out-of- inpatient care for psychosis given positive school (SMD -0.47, 95% CI -0.85 to -0.09); impact on some outcomes may be realized. and less self-reported alcohol use (SMD - However, for many additional outcomes, for 0.49, 95% CI -0.87 to -0.11) were reported. both the child and family, positive • A study of low quality reported reduced improvements should not be expected. self-reported minor delinquency (SMD - 2.72, 95%CI -3.71 to -1.72), Youth Risk Behaviour scores (SMD -0.90, 95% CI -1.64 to -0.16), and fewer days of hospitalization (0.53 days/month vs. 3.88 days/month) • No impact on symptom severity, caregiver- reported symptoms, marijuana use, arrests, caregiver satisfaction, self-reported total drug use, family adaptability, and cohesion.
  69. 69. Interpreting the Evidence Home-based Multi-systemic Therapy (MST) (2 trials) What’s the evidence? Implications for practice & policy • In treating psychosis, at four months, fewer • Public health decision makers may consider teacher-reported symptoms SMD -0.52 95% supporting/encouraging MST as opposed to CI -0.90 to -0.14); fewer days spent out-of- inpatient care for psychosis given positive school (SMD -0.47, 95% CI -0.85 to -0.09); impact on some outcomes may be realized. and less self-reported alcohol use (SMD - However, for many additional outcomes, for 0.49, 95% CI -0.87 to -0.11) were reported. both the child and family, positive • A study of low quality reported reduced improvements should not be expected. self-reported minor delinquency (SMD - 2.72, 95%CI -3.71 to -1.72), Youth Risk Behaviour scores (SMD -0.90, 95% CI -1.64 to -0.16), and fewer days of hospitalization (0.53 days/month vs. 3.88 days/month) • No impact on symptom severity, caregiver- reported symptoms, marijuana use, arrests, caregiver satisfaction, self-reported total drug use, family adaptability, and cohesion.
  70. 70. Specialist Outpatient Services Definition Provided by a range of health care professionals in clinics. Included a motivational interview, cognitive behavioural therapy (CBT), parental counselling, dietary therapy and multi-modal feedback on weight management and monitoring.
  71. 71. Interpreting the Evidence Specialist Outpatient Services (1 trial) What’s the evidence? Implications for practice & policy • No impact on the number of post-discharge • Public health decision makers should not nights spent at an inpatient facility, promote specialist outpatient services over outpatient appointments, or day patient inpatient treatment for youth with anorexia contacts for youth with anorexia nervosa nervosa, while acknowledging evidence is receiving cognitive behavioural therapy, limited to a single study. motivational interviewing, and parent counselling compared to inpatient care.
  72. 72. Intensive Home Treatment Definition Provides children with therapy in their home to solve problems with the way they interact with other people in the home and to improve their psychological symptoms. A problem-solving approach using a child and family centred approach is used, with importance placed on addressing difficulties with the psychosocial environment and alleviating individual psychiatric symptoms.
  73. 73. Interpreting the Evidence Intensive Home Treatment (2 trials) What’s the evidence? Implications for practice & policy • A greater proportion of children with • Public health decision makers should not emotional/behaviour disorders lived at promote intensive home treatment as an home up to 3 years post-intervention (72% alternative to inpatient treatment. vs. 50%) compared to inpatient care. • No impact on number of symptoms for children with behavioural/emotional disorders between groups at two-five years, or overall parent satisfaction compared to inpatient psychiatric admission.
  74. 74. Interpreting the Evidence Intensive Home Treatment (2 trials) What’s the evidence? Implications for practice & policy • A greater proportion of children with • Public health decision makers should not emotional/behaviour disorders lived at promote intensive home treatment as an home up to 3 years post-intervention (72% alternative to inpatient treatment. vs. 50%) compared to inpatient care. • No impact on number of symptoms for children with behavioural/emotional disorders between groups at two-five years, or overall parent satisfaction compared to inpatient psychiatric admission.
  75. 75. Interpreting the Evidence Intensive Home Treatment (2 trials) What’s the evidence? Implications for practice & policy • A greater proportion of children with • Public health decision makers should not emotional/behaviour disorders lived at promote intensive home treatment as an home up to 3 years post-intervention (72% alternative to inpatient treatment. vs. 50%) compared to inpatient care. • No impact on number of symptoms for children with behavioural/emotional disorders between groups at two-five years, or overall parent satisfaction compared to inpatient psychiatric admission.
  76. 76. Intensive Home-based Crisis Intervention Definition (Homebuilders model for crisis intervention) The focus is on the identification of family and individual psychosocial, cultural, community and welfare needs. Components include relationship building, reframing problems, anger management, communication, setting treatment goals and cognitive behavioural therapy. The aim is to prevent an out-of-home placement for children at high risk. Short-term out-of-home placement from three days is permitted for respite care purposes in some cases.
  77. 77. Interpreting the Evidence Intensive Home-based Crisis Intervention (1 trial) What’s the evidence? Implications for practice & policy • Intensive home-based crisis intervention for • Public health decision makers should emotional/behavioural disorders found promote intensive home-based crisis small improvements in social competency intervention to improve social competency (SMD -0.34, 95%CI -0.67 to -0.01) in children with emotional/behavioural compared to case management. Case disorders. management led to improved self-concept • But should not promote intensive home- 6 months post-intervention. based crisis intervention over case • No impact at six months on child behaviour management if the aim is to improve self or family cohesion. concept, behaviour, and level of family cohesion.
  78. 78. Interpreting the Evidence Intensive Home-based Crisis Intervention (1 trial) What’s the evidence? Implications for practice & policy • Intensive home-based crisis intervention for • Public health decision makers should emotional/behavioural disorders found promote intensive home-based crisis small improvements in social competency intervention to improve social competency (SMD -0.34, 95%CI -0.67 to -0.01) in children with emotional/behavioural compared to case management. Case disorders. management led to improved self-concept • But should not promote intensive home- 6 months post-intervention. based crisis intervention over case • No impact at six months on child behaviour management if the aim is to improve self or family cohesion. concept, behaviour, and level of family cohesion.
  79. 79. Interpreting the Evidence Intensive Home-based Crisis Intervention (1 trial) What’s the evidence? Implications for practice & policy • Intensive home-based crisis intervention for • Public health decision makers should emotional/behavioural disorders found promote intensive home-based crisis small improvements in social competency intervention to improve social competency (SMD -0.34, 95%CI -0.67 to -0.01) in children with emotional/behavioural compared to case management. Case disorders. management led to improved self-concept • But should not promote intensive home- 6 months post-intervention. based crisis intervention over case • No impact at six months on child behaviour management if the aim is to improve self or family cohesion. concept, behaviour, and level of family cohesion.
  80. 80. Interpreting the Evidence Intensive Home-based Crisis Intervention (1 trial) What’s the evidence? Implications for practice & policy • Intensive home-based crisis intervention for • Public health decision makers should emotional/behavioural disorders found promote intensive home-based crisis small improvements in social competency intervention to improve social competency (SMD -0.34, 95%CI -0.67 to -0.01) in children with emotional/behavioural compared to case management. Case disorders. management led to improved self-concept • But should not promote intensive home- 6 months post-intervention. based crisis intervention over case • No impact at six months on child behaviour management if the aim is to improve self or family cohesion. concept, behaviour, and level of family cohesion.
  81. 81. Overall Considerations Considerations for Public Health Practice Conclusions from Health Evidence General Implications Children with non-specific emotional/ Based on this review, public health behavioural disorders programs should include and/or support: Home-based multi-systemic therapy reduces: • home-based multi-systemic • symptoms such as aggression and hyperactivity therapy for children with non-specific reported by teachers emotional/behavioural disorders • days spent out-of-school • self-reported alcohol use should not include/support: Intensive home treatment or intensive home-based • intensive home treatment for crisis intervention, does not improve: children with non-specific • symptom severity behavioural/emotional disorders • number of symptoms • specialist outpatient services for • family cohesion youth with anorexia nervosa Youth with anorexia nervosa Public health decision makers should be Specialist outpatient treatment does not improve: aware that the interventions presented • # post-discharge nights at inpatient facility were based on limited evidence and small • outpatient appointments sample sizes. • day patient contacts
  82. 82. Questions?
  83. 83. Discussion Forum Please continue to discuss this topic and other topics on our discussion forum. www.health-evidence.ca/forum/ Login with your health-evidence username and password or register if you aren’t a member yet. Join us for a LIVE on Monday, February 6 at 1:00 pm EST to have your questions answered in real time!
  84. 84. Evaluation Please check your email for the evaluation link. It take 5 minutes to complete! If you’ve been watching with someone else and did not personally register for the webinar, please e-mail Jennifer McGugan at mcgugj@mcmaster.ca to be sent the survey. Thank you for your participation!

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