Digital augmentation of aftercare for patients with anorexia nervosa : the TRIANGLE RCT and economic evaluation

Abstract

BACKGROUND: High-risk patients with complex anorexia nervosa are managed in inpatient/day patient care, but re-admission rates are high, and new treatments are needed. OBJECTIVE(S): To examine the effectiveness of a digital augmentation of aftercare (ECHOMANTRA). DESIGN: Transition Care In Anorexia Nervosa through Guidance Online from Peer and Carer Expertise was a multicentre, parallel-group, superiority randomised controlled trial. ECHOMANTRA augmented treatment as usual was compared with treatment as usual. Patient-carer dyads were randomised using minimisation on a 1 : 1 ratio into ECHOMANTRA + treatment as usual (ECHOMANTRA) or treatment as usual alone. SETTING: Specialised United Kingdom inpatient/day patient sites (n = 31) participated. PARTICIPANTS: Patient-carer dyads were randomised (n = 185 in ECHOMANTRA and n = 186 in treatment as usual). INTERVENTIONS: The digital ECHOMANTRA intervention included self-management tools (recovery tips videos) for patients and task-sharing materials for carers (skill-sharing video), supplemented with guided group chat sessions. All participants randomised to ECHOMANTRA + treatment as usual had access to the psychoeducational materials and joint patient/carer chat sessions were also offered. MAIN OUTCOME MEASURES: The primary outcome was patient distress at 12 months. Other outcomes included patient distress at 18 months, and eating disorder symptoms, social and work adjustment, and carer distress and skills at 12 and 18 months. RESULTS: There was no evidence of an intervention effect on the Depression Anxiety Stress Scale-21 outcome for patients (n = 370) at 12 months, estimated effect 0.48, 95% confidence interval -0.20 to 0.23, standardised estimate (0.02, p = 0.87). In the economic analysis, the intervention was dominated by treatment as usual from both a health system and wider societal perspective, as ECHOMANTRA cost more and resulted in fewer quality-adjusted life-years gained. However, the uptake of the interactive component of the intervention (i.e. the facilitated and moderated online groups) was limited, with only 20% of the dyad members attending the pre-set minimal adherence level (i.e. both the patient and carer attending at least four online forum group sessions). The feedback about the intervention was predominantly positive. For example, the group facilitators were rated highly. However, some feedback was that the intervention offered too little, too late, and that a more personalised intervention would be more helpful. LIMITATIONS: Participants were diverse (e.g. 20% were being treated under the Mental Health Act), and a large proportion had a range of comorbidities (depression, anxiety, obsessive-compulsive disorder and autistic spectrum disorders), all factors impacting prognosis. Although efforts were made to enhance inclusion, diversity in terms of gender, sexuality and race was limited, and technological barriers and/or lack of a carer may have led to exclusion. The high level of non-adherence to the group support (80% dyads) may have contributed to the non-significant findings. CONCLUSIONS: This guided self-management and task-sharing intervention was reviewed positively by some patients and supporters; however, there was no evidence that the intervention improved outcomes over usual aftercare. FUTURE WORK: Identifying mechanisms to increase engagement such as a more personalised approach to aftercare to address the diverse needs of this patient group are needed. Greater integration between intensive and step-down services with guidance from peer workers providing support may optimise care. TRIAL REGISTRATION: This trial is registered as ISRCTN14644379. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/68/09) and is published in full in Health Technology Assessment; Vol. 29, No. 31. See the NIHR Funding and Awards website for further award information. Transition Care In Anorexia Nervosa through Guidance Online from Peer and Carer Expertise aimed to examine whether offering a digital programme (ECHOMANTRA), containing information and online group support for patients with anorexia nervosa and their nominated supporters, could reduce patient distress and improve other outcomes in the 18-month period after leaving intensive treatment (inpatient or day care). The study also examined whether ECHOMANTRA is a good value for money to the National Health Service and the wider economy. Patients and a nominated supporter (371 pairs) were recruited and split into two groups at random: (1) usual treatment plus access to the ECHOMANTRA programme and (2) usual treatment alone. There were no differences between groups in the outcomes measured, which included patient distress, eating disorder symptoms, quality of life, social and work adjustment and carer distress and skills. ECHOMANTRA did not demonstrate good value for money. However, only 20% of participants allocated to ECHOMANTRA joined more than four online group sessions (the minimal recommended participation). Patients and their supporters reported inadequate planning and support following discharge from hospital. Patients reported low confidence in their ability to recover, and a need for more continuity in their care. Carers echoed the need for a supportive transition process. Several aspects of the ECHOMANTRA programme were welcomed, with the mixed patient/supporter online groups and online group facilitators experienced as particularly helpful. Participants were generally positive about the written and recovery tip videos. However, several suggested that more personalised content and access options were needed. ECHOMANTRA failed to show a benefit overall, which may reflect the limited uptake of the online groups and the broader access to carer support outside of the study. Together with participant feedback, these findings suggest that a more personalised programme, with more integration with clinical teams, may lead to increased engagement with the virtual elements of support offered by ECHOMANTRA. eng