Inpatient Versus Outpatient Care, Partial Hospitalisation and Wait-List For People With Eating Disorders (Protocol)

Cochrane Database of Systematic Reviews
Inpatient versus outpatient care, partial hospitalisation and

wait-list for people with eating disorders (Protocol)
Hay PJ, Claudino AM, Smith CA, Touyz S, Lujic S, Madden S
Hay PJ, Claudino AM, Smith CA, Touyz S, Lujic S, Madden S.

Inpatient versus outpatient care, partial hospitalisation and wait-list for people with eating disorders.
Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD010827.
DOI: 10.1002/14651858.CD010827.
www.cochranelibrary.com
Inpatient versus outpatient care, partial hospitalisation and wait-list for people with eating disorders (Protocol)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Inpatient versus outpatient care, partial hospitalisation and wait-list for people with eating disorders (Protocol) i
[Intervention Protocol]
Inpatient versus outpatient care, partial hospitalisation and

wait-list for people with eating disorders
Phillipa J Hay1,2 , Angélica M Claudino3 , Caroline A Smith4 , Stephen Touyz5 , Sanja Lujic6 , Sloane Madden7
1 School of Medicine, University of Western Sydney, Penrith, Australia. 2 James Cook University, Townsville, Australia. 3 Section of Eating
Disorders, Institute of Psychiatry, King’s College London, London, UK. 4 Centre for Complementary Medicine Research, University
of Western Sydney, Sydney, Australia. 5 School of Psychology and Boden Institute School of Medicine, University of Sydney, Sydney,
Australia. 6 School of Medicine, University of Western Sydney, Sydney, Australia. 7 The Children’s Hospital at Westmead, University of
Sydney, Sydney, Australia
Contact address: Phillipa J Hay, School of Medicine, University of Western Sydney, Locked Bag 1797, Penrith, New South Wales,
2751, Australia. p.hay@uws.edu.au.
Editorial group: Cochrane Common Mental Disorders Group.

Publication status and date: New, published in Issue 12, 2013.
Citation: Hay PJ, Claudino AM, Smith CA, Touyz S, Lujic S, Madden S. Inpatient versus outpatient care, partial hospitalisation
and wait-list for people with eating disorders. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD010827. DOI:
10.1002/14651858.CD010827.
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
1. To assess the effects of treatment setting (inpatient, partial hospitalisation or outpatient) on reduction in symptoms and increase
in remission rates in people with:
i) anorexia nervosa and atypical anorexia nervosa; and
ii) bulimia nervosa and other eating disorders.
2. To assess the effects of continuing hospitalisation until the person is restored to a normal weight in people with anorexia nervosa.
1. anorexia nervosa and atypical anorexia nervosa; and
2. bulimia nervosa and other eating disorders.
BACKGROUND Eating disorders are a group of diagnoses defined by severe dis-

turbances in eating behaviour. They include anorexia nervosa, bu-
limia nervosa, binge eating disorder and other specified or unspec-
ified eating disorder (APA 2013; WHO 1992). Anorexia nervosa
Description of the condition is an eating disorder with features of weight loss or failure to gain
Inpatient versus outpatient care, partial hospitalisation and wait-list for people with eating disorders (Protocol) 1
weight. This leads to a weight that is less than 85% of that ex- ders seldom require an admission unless there are medical compli-
pected for height and age, an intense fear of gaining weight, a dis- cations, for example, hypokalaemia (reduced levels of potassium
torted body image and loss of at least three consecutive menstrual in the blood) or high suicide intent (NICE 2004; RANZCP 2004;
cycles. Bulimia nervosa, by definition, is a disorder of normal or APA 2006). Inpatient programmes are usually multidisciplinary
above normal weight characterised by binge eating and extreme (where treatment providers include psychologists or psychiatrists
weight control methods to compensate for the binge eating. Re- (or both), dieticians, nurses and other allied healthcare special-
current binge eating is defined as eating unusually large amounts ists) and involve a programme of nutritional counselling and su-
of food over which there is a sense of loss of control. The com- pervised meals, combined with individual and group psychother-
pensatory extreme weight-control behaviours may take the form apy and medical care (La Puma 2009). Partial hospitalisation is
of self induced vomiting with or without laxative or diuretic use similar to inpatient programmes with regards to multidisciplinary
(purging), or fasting with or without intense exercise (the non- care, intensity of therapy, the capacity for regular supervision of
purging form of bulimia nervosa). In addition to disordered eating meals and the direct provision of meals (Thornton 2009). How-
behaviours, people with bulimia nervosa also have specific eating ever, there is no overnight stay with partial hospitalisation. In con-
disorder psychopathology whereby their self view or self evaluation trast, outpatient care does not provide regular meal supervision. In
is unduly influenced by concerns about their weight, shape, body outpatient care, therapy is also usually less frequent (e.g. occurring
image or a combination of these. Other eating disorders may share one or two times a week) and care is less likely to include therapists
the body image, shape and weight concerns of those people with of multiple disciplines. Indeed, in an outpatient programme, care
anorexia nervosa or bulimia nervosa, or share the disordered eating may be delivered by a single therapist of one discipline (e.g. a psy-
or weight control behaviours, or share a combination of these. Peo- chologist). We present an overview of the different components
ple with binge eating disorder have regular binge eating behaviour of care across treatment settings in Table 1.
but do not have regular extreme weight control behaviours. Other There is no one psychotherapeutic approach that is applied con-
specified eating disorders include atypical anorexia nervosa (where sistently in outpatient care worldwide, although cognitive be-
the person’s weight is in or above the normal range); bulimia ner- havioural therapy has the best evidence base for bulimia nervosa
vosa or binge eating disorder of low frequency or limited duration (NICE 2004; Hay 2009). In adolescents and children, a family-
or low frequency and limited duration; purging disorder and night based approach is regarded as the first line in treatment (NICE
eating syndrome. Finally, unspecified feeding or eating disorder is 2004). It is superior to ’treatment as usual’ but there is insuffi-
a heterogeneous category where patients do not meet criteria for cient evidence for any single form of family therapy (Fisher 2010).
an eating disorder but have a clinical eating or feeding disorder Derivations of the Maudsley model (as described in Le Grange
syndrome. It most usually comprises people with disordered eating 2005 and in Rhodes 2009) have gained ascendancy worldwide.
behaviours with or without body image disturbance characteristic Medical care comprises physician and nursing management of
of the better-defined disorders. This review will not address feed- physical aspects of eating disorders. This includes re-feeding but
ing disorders such as ’avoidant restrictive food intake disorder’, also management of osteopenia and other effects from starvation.
which are categorised with eating disorders in the new Diagnostic A comprehensive account of medical management is provided in
and Statistical Manual of Mental Disorders, Fifth Edition (DSM- the text by Birmingham and Treasure (Birmingham 2010). Med-
5) diagnostic scheme (APA 2013; WHO 1992). ications for physical or psychological co-morbidities are seldom
Eating disorders are common (Hoek 2003; Hudson 2007), and in- used as a stand-alone treatment but will often be used in either
creasing (Lucas 1991; Hay 2008). One national US survey found inpatient or outpatient settings. Evaluations of the relative efficacy
that lifetime prevalence estimates of DSM-IV anorexia nervosa, of medications in eating disorders are also found in Flament 2012
bulimia nervosa and binge eating disorder were 0.9%, 1.5% and and Hay 2012. These reviews reported that the evidence of effi-
3.5%, respectively among women, and 0.3%, 0.5% and 2.0%, re- cacy of drug treatments is mostly weak or moderate with gener-
spectively among men (Hudson 2007). In Australia between 1995 ally low recovery rates. However, there was support for the use of
and 2005, there was a two-fold increase in the point prevalence of antidepressants, particularly high-dose fluoxetine in bulimia ner-
eating disorder behaviours in the general community (Hay 2008). vosa, and anticonvulsants (topiramate) for binge-eating disorder.
Attrition rates were usually higher than for psychotherapies and
combined treatments in bulimia nervosa and binge eating disor-
Description of the intervention der had better outcomes than either approach alone. Low-dose
antipsychotic medication was considered to be possibly clinically
Treatments for eating disorders have been developed for outpa-
useful as adjunct treatment of anxiety in anorexia nervosa but more
tient, inpatient and partial hospitalisation (the latter is also known
trials were needed.
as day hospital care). Clinical practice guidelines vary on rec-
Further details of psychological approaches in treatment may
ommendations, but there is some consensus that inpatient care
be found in complementary Cochrane reviews of family ther-
is most often needed for people with anorexia nervosa (NICE
apy (Fisher 2010), and individual outpatient psychotherapies for
2004; RANZCP 2004). Bulimia nervosa and other eating disor-
anorexia nervosa (Hay 2003), and other eating disorders (Hay patient acceptability, and less risk of further psychological harm
2009). There are also three Cochrane reviews of antidepressant to a patient’s already fragile self esteem. It may also be associated
medication use, one in bulimia nervosa (Bacaltchuk 2003), one in with less stigma, and the maintenance of usual social and work
anorexia nervosa (Claudino 2006), and one of combination med- (including educational) activities.
ication and psychotherapies in bulimia nervosa (Hay 2001). Partial hospitalisation has the advantages of increased intensity
However, while there is a growing evidence base for treatments of care (and supported or supervised meals) found in inpatient
(albeit still sparse in anorexia nervosa (Lock 2009)), many peo- services. It also has an argued increased preservation of personal
ple with eating disorders do not access treatment. In particular, autonomy and life activities that are associated with outpatient
up to half of people with anorexia nervosa may never present for care. However, it has higher fiscal cost than outpatient care.
treatment (Keski-Rahkonen 2007), and attrition in anorexia ner-
vosa treatment trials can be unacceptably high with reasons for
dropout difficult to identify (Halmi 2005). Stigma and perceived Why it is important to do this review
fear of hospitalisation may well contribute to underutilisation of
Eating disorders have high social, medical and fiscal costs (Crow
services. Where trials have compared inpatient versus outpatient
2003). For example, in Australia they are the 12th leading cause of
care, preference for the outpatient care (Freeman 1992) and higher
mental health hospitalisation expenses (Mathers 1999). It is agreed
attrition in the inpatient care have been found (Gowers 2007). In
that the more intensive care of a hospital admission is mandatory
addition, there is concern from professional bodies as, for exam-
where there is high medical or psychiatric risk (APA 2006; NICE
ple, expressed in position statements by the Australian and New
2004; RANZCP 2004). However, its advantage where patients
Zealand Academy for Eating Disorders that inpatient care may
may be ’safely’ cared for as an outpatient is unproven. Outpatient
be being underutilised, undervalued, or both, leading to a reduc-
care is also preferred by most people and has perceived advantages.
tion in services (www.anzaed.org.au/uploads/7/3/9/2/7392147/
These include being more collaborative in approach, with reduced
positionstatementinpatient.pdf). While many jurisdictions are not
associated stigma, maintenance of work/education and social re-
now providing inpatient services, lack of evidence hampers the
lationships, and fiscal savings. An admission necessarily will lead
ability to argue for these.
to loss of usual social contacts and interruption to work or ed-
ucation. Cost savings associated with avoiding hospitalisation or
reducing hospital stay, or both, to that needed for medical sta-
How the intervention might work bilisation alone could be very large. For example, one UK study
There is consensus that therapy in eating disorders includes di- found that outpatient care costs approximately 10% the cost of
etetic, medical, nursing and psychological care. In anorexia ner- inpatient care (Katzman 2000).
vosa, multidisciplinary care is expected (NICE 2004). This is in However, there are few studies into the role of treatment settings
order to be able to provide the level of expertise in medical or in mental health and these are largely confined to anorexia ner-
physical care, individual or group psychotherapy, and re-feeding vosa. Previous systematic reviews have found results from studies
that is needed. Medical or physical care may be administered by of anorexia nervosa to be contradictory (Lock 2009; Meads 1999;
a paediatrician, general practitioner or adult physician; individual Meads 2001). While some studies have found higher discharge
and group therapy from a psychologist, psychiatrist or other ther- weights to be associated with better long-term weight outcomes
apist; and re-feeding from a dietician (Steinhausen 2002; Zipfel (Barren 1995; Gross 2000; Zipfel 2000), a more recent trial linked
2000). hospital admissions with poor weight outcomes (Gowers 2000).
Inpatient and partial hospitalisation have the benefit of being able One very early trial also reported similar weight outcomes from in
to provide care for extended periods (6 to 24 hours a day). Notably, and out patient management (Crisp 1991). In addition, although
meals can be directly supervised and staff can respond quickly to hospitalisation is effective in the short-term, one 20-year retro-
psychiatric or physical emergencies (such as re-feeding syndrome) spective study found it was not predictive of long-term recovery
(Treasure 2005; La Puma 2009). However, outpatient care is ar- (Zipfel 2000).
gued to be both more effective and efficient in terms of therapy The aim of this review is to investigate whether or not there is
time and cost. Fairburn has described a comprehensive outpatient demonstrable benefit to inpatient compared with outpatient or
approach in his treatment manual for underweight, normal or day patient care in eating disorders, beyond that which is essen-
overweight patients with eating disorders (Fairburn 2008). Such tial for treating acute medical and psychiatric emergencies. This
treatment is usually conducted where inpatient care for medical review will extend the work of previous systematic reviews in
or psychiatric crises (e.g. hypokalaemia due to vomiting or active anorexia nervosa (Meads 1999; Meads 2001; Lock 2009, and fur-
suicidal ideation) is available. Admissions are for brief periods suf- ther strengthen the portfolio of Cochrane reviews in anorexia ner-
ficient for stabilisation prior to resumption of outpatient care. vosa and other eating disorders (Hay 2001; Hay 2003; Bacaltchuk
It is thought that outpatient care preserves the patient’s sense of au- 2003; Pratt 2002; Perkins 2006; Claudino 2006; Hay 2009; Fisher
tonomy and is perceived as collaborative. Thus, there is increased 2010).
OBJECTIVES 1. Inpatient care for weight restoration in anorexia nervosa,
provided by a specialist eating disorder service and health
1. To assess the effects of treatment setting (inpatient, partial professionals.
hospitalisation or outpatient) on reduction in symptoms and 2. Inpatient care for bulimia nervosa and other eating
increase in remission rates in people with: disorders, provided by a specialist eating disorder service and
health professionals.
i) anorexia nervosa and atypical anorexia nervosa; and
ii) bulimia nervosa and other eating disorders.
Comparators
2. To assess the effects of continuing hospitalisation until the
1. Individual or group or family-based outpatient care
person is restored to a normal weight in people with anorexia
(maximum two contacts per week) provided by specialist eating
nervosa.
disorder health professionals.
2. Individual or group outpatient care (maximum two
contacts per week) that is provided by non-eating disorder
METHODS specialist health professionals.
3. Inpatient care from a specialist or a non-specialist eating
disorder service for medical stabilisation that is time limited
Criteria for considering studies for this review (maximum three weeks) and discharge before full weight
restoration with planned outpatient follow-up.
4. Wait-list (no active treatment for the eating disorder) group.
5. Partial hospital or day patient care (more than two contacts
Types of studies
per week and more than three hours per day and includes
Parallel design randomised controlled trials. We will include cross- clinician-supervised meals).
over and cluster randomised trials. As 1, 2 and 3 all include active outpatient psychotherapies, we will
enter data to allow for analyses of these as a grouped comparator.
Types of participants
Adults, adolescents and children with a diagnosis of acute anorexia
Types of outcome measures
nervosa, bulimia nervosa, binge eating disorder, or specified or
unspecified eating disorder according to DSM-5 (APA 2013), or Studies that meet the above inclusion criteria will be included
International Classification of Disease (ICD)-10 criteria (WHO regardless of whether they report on the following outcomes.
1992), or other internationally accepted diagnostic criteria such as
the DSM-IV (APA 2000). We will analyse trials of weight restora-
tion in anorexia nervosa separately to those of other eating dis- Primary outcomes
orders. We will stratify trials of other eating disorders by diagno-
sis (bulimia nervosa, binge eating disorder, other eating disorder)
in analyses. We will extract and record data according to DSM-
5 criteria. For example, trials of DSM-IV (APA 2000) anorexia 1. Clinical improvement
nervosa and anorexia nervosa eating disorder not otherwise speci- a. For anorexia nervosa: weight (body mass index (BMI), kg/m2 )
fied (EDNOS) type, where all are underweight, will now be trials used as a proxy for physical health, corrected for age in adolescent
of DSM-5 anorexia nervosa and trials of DSM-IV bulimia ner- and child samples, at end of treatment where groups are not sig-
vosa and EDNOS, where the binge eating frequency meets DSM- nificantly different in mean BMI at start of treatment. (Note: in
5 criteria for bulimia nervosa, will be treated as trials of bulimia the meta-view graph where standardised mean difference (SMD)
nervosa. is greater than zero, the active treatment is favoured. This differs
We will not exclude because of co-morbidities. from the convention of SMD less than zero favouring treatment.)
b. For bulimia nervosa, binge eating disorder, specified bulimia ner-
vosa and binge eating disorder of low frequency, limited duration, or
Types of interventions both: binge eating (as defined in DSM-IV (APA 2013)) frequency.
c. For specified atypical anorexia nervosa, purging disorder or unspec-
ified eating disorder: global eating disorder symptom score as mea-
Experimental interventions sured by the Eating Disorder Examination interview (Fairburn
1993) or questionnaire (Fairburn 1994).
2. Acceptability 8. Remission or recovery (as defined in 1a, 1b or 2 above)
To be measured by proportion of drop-outs. For this outcome, we sustained over one-year follow-up.
will stratify the graph by type of eating disorder. Note: where outcomes are combined across eating disorders (i.e.
2, 3, 4, 5 and 6), we will stratify graphs by type of eating disorder.
Secondary outcomes
Timing of outcome assessment
Outcome assessments will be done at end of treatment and one-
3. Clinical response year follow-up.
a. For anorexia nervosa:
• weight restoration to within the normal weight range for
participant sample (e.g. BMI, 19 to 25 for female young adults, Search methods for identification of studies
or greater than 85% of that expected for age/height), or;
• recovery according to an agreed published definition (Kordy
2002) (e.g. the Morgan 1975 narrow scale of a good outcome, Electronic searches
namely normal body weight (greater than 85% of mean for age,
gender and height) with normal menstruation or an intermediate
outcome, namely normal body weight (greater than 85% of 1. CCDAN’s Specialized Register (CCDANCTR)
mean for age, gender and height) with no menstruation, or;
The Cochrane Depression, Anxiety and Neurosis Group (CC-
• the Morgan 1988 broader scale ratings (covering nutritional
DAN) maintains two clinical trials registers at their editorial base
status, menstruation, mental state, psychosexual adjustment and in Bristol, UK, a references register and a studies based register.
socioeconomic status) of intermediate or better outcome. (In the The CCDANCTR-References Register contains over 31,500 re-
meta-view graphs, this is depicted as those in a category less than
ports of randomised controlled trials in depression, anxiety and
two so that RR greater than 1 favours the active treatment.)
neurosis. Approximately 65% of these references have been tagged
b. For bulimia nervosa, binge eating disorder, specified bulimia ner- to individual, coded trials. The coded trials are held in the CC-
vosa and binge eating disorder of low frequency, limited duration, or DANCTR-Studies Register and records are linked between the
both: binge eating abstinence two registers through the use of unique Study ID tags. Coding of
trials is based on the EU-Psi coding manual. Please contact the
CCDAN Trials Search Coordinator for further details. Reports
4. Recovery of trials for inclusion in the Group’s registers are collated from
Global eating disorder symptom score as measured on the Eat- routine (weekly), generic searches of MEDLINE (1950-), EM-
ing Disorder Examination interview (Fairburn 1993), or question- BASE (1974-) and PsycINFO (1967-); quarterly searches of the
naire within one standard deviation above the community mean Cochrane Central Register of Controlled Trials (CENTRAL) and
(Fairburn 1994). review specific searches of additional databases. Reports of trials
will also be sourced from international trials registers c/o the World
Health Organization’s trials portal (ICTRP), drug companies, the
5. Quality of life score handsearching of key journals, conference proceedings and other
Measured by any validated questionnaire (e.g. the Short-Form-12) (non-Cochrane) systematic reviews and meta-analyses. Details of
(Ware 1996) or eating disorder specific (e.g. the Engel quality of CCDAN’s generic search strategies can be found on the Group’s
life instrument) (Engel 2005). website.
• The CCDANCTR-Studies Register will be searched on
condition alone (“anorexia nervosa” or bulimia or “eating
6. Depression symptom severity disorder*”) and records will be screened to identify relevant
Measured by any validated questionnaire (e.g. the Beck Depression studies.
Inventory) (Beck 1996). • The CCDANCTR-References Register will be searched for
additional untagged/uncoded records using a more sensitive set
of free-text terms (focusing on the treatment setting): (anorexi*
7. Cost-effectiveness or bulimi* or “eating disorder*” or EDNOS) and (setting or
Measured by the calculation of incremental cost-effectiveness ra- inpatient* or in-patient* or outpatient* or out-patient* or
tios (ICER) - the additional costs of one intervention compared hospital* or admission* or confinement or clinic or clinics or
with another divided by the additional effects of one intervention “clinical management” or “clinical support” or specialist or
compared with another. “specialized treatment” or “specialised treatment” or supervi* or
“day care” or “day centre*” or “day center*” or “day unit*” or Main planned comparisons:
“day treatment*” or “community mental health” or “mental 1. Inpatient care for weight restoration in anorexia nervosa
health service*” or residential or referral or referred or “patient provided by a specialist eating disorder service and health
care” or (weight and restor*) or feed* or re-feed* or refeed*) professionals; and
2. Inpatient care in bulimia nervosa and other eating disorders
2. International Trial Registers
by a specialist eating disorder service and health professionals.
The WHO International Clinical Trials Registry Platform (
ICTRP) and ClinicalTrials.gov will be searched on condition alone
(“anorexia nervosa” or bulimia or “eating disorder*”).
Versus:
Records will be screened to identify relevant unpublished and/or
ongoing studies. 1. Individual or group or family-based outpatient care
(maximum two contacts per week) provided by specialist eating
disorder health professionals; or
Searching other resources 2. Individual or group outpatient care (maximum two
contacts per week) provided by non-eating disorder specialist
We will inspect the reference lists of all papers and reviews (identi-
health professionals; or
fied from a separate systematic review search) for further relevant
3. Inpatient care from a specialist or a non-specialist eating
studies.
disorder service for medical stabilisation that is time limited
We will conduct a citation search (on the Web of Science) to
(maximum three weeks) and discharge before full weight
identify additional reports citing any of the included studies.
restoration with planned outpatient follow-up;
We will send personal letters to lead researchers and trialists in the
4. Wait-list (no active treatment for the eating disorder) group;
field of eating disorders.
5. Partial hospital or day patient care (more than two contacts
per week and more than three hours per day and includes
clinician supervised meals).
Data collection and analysis As 1, 2 and 3 above all include active outpatient psychotherapies
data will be entered to allow for analyses of these as a grouped
comparator.
Selection of studies
We will evaluate all studies according to the inclusion criteria listed Assessment of risk of bias in included studies
above. One review author (PH) will inspect abstracts and three For each included study, two review authors (PH, AC) will inde-
review authors (PH, AC and CS) will independently select stud- pendently complete The Cochrane Collaboration’s tool for assess-
ies based on abstracts and reading full-text articles. If the abstract ing risk of bias (Higgins 2011, Section 8.5.1) with any disagree-
indicates that it was a trial of treatment setting for eating disor- ments to be resolved through consultation with a third review au-
ders, three review authors (PH, AC and CS) will review the full thor (CS).
article to determine, first, if the trial was randomised and second, We will allocate each domain one of three possible categories for
if it was a trial of treatment setting for eating disorders meeting each of the included studies: ’low risk of bias’, ’high risk of bias’
our inclusion criteria. Consensus between authors will be reached and ’unclear risk of bias’.
through discussion. We will also document the following trial features.
We will translate non-English texts. 1. Adequate method of sequence generation:
i) appropriate method of randomisation used;
ii) method of randomisation not described;
Data extraction and management iii) randomised method described but not randomised
Authorship will not be concealed at the point of data collection. (e.g. every alternate participant given the control treatment).
Two review authors (PH, AC) will extract data independently to 2. Adequacy of allocation sequence concealment (’allocation
include documentation of the country or specific cultural aspects concealment’):
(or both) of the treatment setting. A third review author (CS) i) indicates adequate concealment;
will adjudicate where there are discrepancies. We will extract data ii) indicates uncertainty about whether allocation was
on features of each trial, quality appraisal, interventions and out- adequately concealed;
comes found according to a pre-designed data extraction form (see iii) indicates the allocation was definitely not adequately
Appendix 1). We will enter agreed data into a spreadsheet pro- concealed.
gram, and into the Review Manager 5 software program (RevMan 3. Blinding of participants and personnel:
2012).
i) blinding of both outcome assessor and participant Cross-over trials
(double-blind); If we find cross-over trials, we will follow the procedure according
ii) blinding of outcome assessor only (single-blind); to the Cochrane Handbook for Systematic Reviews of Interventions
iii) blinding not done. (Higgins 2011 Section 16.4.4). If carry-over or period effects are
4. Incomplete outcome data (attrition bias): not thought to be a problem, then we will analyse continuous data
i) attrition less than 20%; from a two-period, two-intervention cross-over trial with a paired
ii) attrition 20% to 49%; t-test. This will evaluate the value of ’measurement on experimen-
iii) attrition 50% or greater. tal intervention (E)’ minus ’measurement on control intervention
5. Selective outcome reporting: (C)’ separately for each participant. We will include the effect esti-
i) complete outcomes reported analyses; mate in a meta-analysis using the generic inverse-variance method
ii) outcomes reported on subset (e.g. only those in Review Manager 5 (RevMan 2012).
participants who were treated according to protocol or other
selective outcome reporting, e.g. selective omission of outcomes
from reports). Studies with multiple treatment groups
6. Other sources of bias: the comparability of groups after
If we find multiple intervention groups, we will follow the pro-
randomisation with regards to the following putative
cedure recommended by the Cochrane Handbook for Systematic
demographic and illness severity confounding factors: age,
Reviews of Interventions (Higgins 2011 Section 16.5.4) and first
gender, body weight, severity of illness at study inception (using
determine which intervention groups are relevant to this system-
measures applied at outcome assessment):
atic review, and second determine which intervention groups are
i) Groups comparable at baseline on demographic and
relevant to a particular pair-wise comparison in the meta-analysis.
illness severity;
All intervention groups of a multi-intervention will be described
ii) Uncertain - comparability not assessed; and
in the ’Characteristics of included studies’ table. We will describe
iii) Groups not comparable at baseline.
interventions relevant to this review and thus those potentially
Although imbalance may occur by chance, it may also occur where
used in analyses in detail. If more than two intervention groups
there is inadequate randomisation (or exclusion of participants af-
are relevant, we will, if possible, combine groups to create a sin-
ter randomisation) or inadequate allocation concealment (Higgins
gle pair-wise comparison (e.g. if a trial has one inpatient condi-
2011 Section 8.14.1.2) and it is thus relevant in assessing bias for
tion and two outpatient conditions we will plan to combine the
group comparability to be assessed and reported.
two outpatient conditions if appropriate). If this cannot be done,
we will determine if it is possible to split the ’shared’ group into
two or more groups with smaller sample size, and include two
Measures of treatment effect or more (reasonably independent) comparisons. If this cannot be
We will conduct risk ratio (RR) analyses for dichotomous outcome performed, we will select one pair of interventions and exclude the
data and SMD analyses for continuous outcome data, together others.
with 95% confidence intervals (CI). We chose RRs, as they are
less likely to overestimate a treatment effect (Higgins 2011 Section
9.2.2.3). Dealing with missing data
We will contact study authors to request information not avail-
able in the published study, including information needed for data
Unit of analysis issues analyses, subgroup and sensitivity analyses, quality evaluation of
the trials, and to obtain the results of unpublished or partly pub-
lished trials. We will contact study authors on a maximum of two
occasions. We will ask study authors to respond on each occasion
Cluster-randomised trials within three months of the request. We will do calculations of
If we find cluster-randomised trials, we will proceed according unpublished data, such as the standard deviation, where there is
to the Cochrane Handbook for Systematic Reviews of Interventions sufficient information (published or unpublished) provided as per
(Higgins 2011 Section 16.3.3) (i.e. to extract a direct estimate of Chapter 7.7 of the Cochrane Handbook for Systematic Reviews of
the required effect measure from an analysis that properly accounts Interventions (Higgins 2011).
for the cluster design (according to statistical advice of author SL)). We will record when and what information was supplied by the
We will then meta-analyse the effect estimates and their standard study authors in the ’Risk of bias’ sections of the ’Characteristics
errors from correct analyses of cluster-randomised trials using the of included studies’ tables.
generic inverse-variance method in Review Manager 5 (RevMan Where there are missing statistics, we will seek this first from the
2012). study authors or, if possible, we will calculate it using methods
that enable this (e.g. if standard deviations are missing it may be We will attempt to minimise putative duplicate publication bias
possible to calculate these from the CI values, standard errors or t by checking with authors for suspected duplicate publication. We
values). As the number of trials will be few, we will take statistical will attempt to minimise location, language and citation bias by
advice on imputation and only attempt this if the majority of comprehensive and systematic searches that are as broad as possible
trials in the meta-analysis have completed statistics (Higgins 2011 and include non-English language trials.
Section 16.2.3.1).
The only data that will be imputed for categorical outcome vari-
ables are where outcomes on weight restoration or binge/purging
abstinence (or both) are not available. In these first instances, we Data synthesis
will assume that if there is no follow-up information the partici- We will favour the random-effects model when there are different
pant(s) concerned did not attain normal weight for age and height interventions and where it is unlikely that the same treatment
or did not achieve abstinence (or both). effect is being estimated. Thus, we will use the random-effects
In the case of continuous data, we will only include data on those model in all analyses.
whose results are known. We will consider the potential impact of
the missing data on the results in the interpretation of the results
of the review with reference to the amount of missing data, the
pooled estimate of the treatment effect and the variability of the Subgroup analysis and investigation of heterogeneity
outcomes, which will also be considered as a potential source of It is planned that we will combine data for all eating disorders in a
heterogeneity. We will perform a sensitivity analysis for continuous single meta-analysis of the same outcome for the same intervention
data using the method described in Higgins 2011 (Section 16.2.3), comparison. We will enter data such that the following subgroup
which is to assume a fixed difference between the actual mean for analyses can be conducted.
the missing data and the mean assumed by the analysis. 1. Diagnostic subgroups of DSM-5 (APA 2013), bulimia
nervosa, binge eating disorder and other specified or unspecified
eating disorders.
Assessment of heterogeneity 2. Children and adolescents (i.e. under 17 years of age).
We will assess heterogeneity using the Chi2 test (P value < 0.10) 3. Adults and older adolescents (i.e. 17 years of age or older).
and the observed value of the I2 statistic. The observed value of the 4. Family-based inpatient programmes and non-family-based
I2 statistic depends on (i) the magnitude and direction of effects inpatient programmes.
and (ii) the strength of evidence for heterogeneity (e.g. P value 5. Cognitive behavioural therapy versus other individual
from the Chi2 test, or a CI for the I2 statistic). However, interpre- psychotherapies used.
tation of the I2 statistic can be misleading, since the importance of We will address identified heterogeneity by first checking again
inconsistency depends on several factors. Higgins 2011 has pro- that the data are correct. If data are correct and if there is a large
vided a guide to interpretation with overlapping bands as follows: degree of inconsistency in results, we will consider conducting
• 0% to 40%: might not be important; a sensitivity analysis by sequentially removing trials by sample
• 30% to 60%: may represent moderate heterogeneity; size starting with the smallest until there are only three trials or
• 50% to 90%: may represent substantial heterogeneity; heterogeneity is reduced to a non-significant (P value ≥ 0.1) level,
• 75% to 100%: considerable heterogeneity. or both.
If the I2 statistic is moderate to high and the direction and mag-

nitude of treatment effects suggests important heterogeneity, we
will investigate the putative source of the heterogeneity (see below) Sensitivity analysis
(Higgins 2011).
We will perform sensitivity analyses whereby the following types
of trials will be excluded.
1. Trials with attrition rates of greater than 50%.
Assessment of reporting biases 2. Trials where care is not multidisciplinary across all
We will investigate systematic differences between reported and intervention groups.
unreported findings by inspection of funnel plots (in meta-analy- 3. Non-blinded trials.
ses of 10 or more trials) and statistical tests for funnel plot asym- Where there is a large amount of missing continuous data then we
metry of primary continuous outcome variable(s). However, it is will perform a sensitivity analysis using the method described in
acknowledged that an asymmetrical funnel plot is not necessarily Higgins 2011 (Section 16.2.3), which is to assume a fixed differ-
indicative of publication bias and that publication bias does not ence between the actual mean for the missing data and the mean
necessarily cause asymmetry. assumed by the analysis.
Summary of findings tables ACKNOWLEDGEMENTS
CRG Funding Acknowledgement
Summary of findings tables will be developed to summarise the The National Institute for Health Research (NIHR) is the largest
key findings of the review, for all relevant populations. For the single funder of the Cochrane Depression, Anxiety and Neurosis
given comparisons, we will select up to seven of the most impor- Group.
tant outcomes (both desirable and non-desirable) and present the
Disclaimer
findings for these relating to standardised effect size estimates (and
95% CIs) to illustrate comparative risk, the number of studies and The views and opinions expressed herein are those of the authors
participants, and the quality of evidence based on standards of the and do not necessarily reflect those of the NIHR, National Health
GRADE working group (see Balshem 2011). Service or the Department of Health.
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∗
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ADDITIONAL TABLES
Table 1. Comparative components of treatments across different settings
Inpatient Partial or day hospital Outpatient
Anorexia nervosa Multidisciplinary medi- Multidisciplinary medi- Multidisciplinary medi-

cal, nursing, dietetic (re- cal, nursing, dietetic (re- cal, nursing, dietetic (re-
feeding) and psychologi- feeding) and psychologi- feeding) and psycholog-
cal care1 cal care ical care or psychologi-
cal care incorporating re-
feeding and other ele-
ments delivered variably
Table 1. Comparative components of treatments across different settings (Continued)
Bulimia nervosa Multidisciplinary medi- Multidisciplinary medi- May be multidisciplinary

cal, nursing, dietetic and cal, nursing, dietetic and but is most usually in-
psychological care psychological care dividual psychotherapy
with limited medical care
of complications from
purging
Binge eating disorder Multidisciplinary medi- Multidisciplinary medi- May be multidisciplinary

cal, nursing, dietetic and cal, nursing, dietetic and but is most usually in-
psychological care psychological care dividual psychotherapy
with dietetic care for
those with obesity
Other eating disorders Multidisciplinary medi- Multidisciplinary medi- Multidisciplinary medi-

cal, nursing, dietetic and cal, nursing, dietetic and cal, nursing, dietetic and
psychological care psychological care psychological care or psy-
chological care and other
elements delivered vari-
ably
1 Psychological care refers to individual, group and family psychotherapy. This may be delivered by psychologists, psychiatrists or people
from other disciplines such as social work who have specific training in psychological therapies.
APPENDICES
Appendix 1. Data extraction form

INPATIENT TREATMENT FOR EATING DISORDERS
Trial ID
Date Form completed

Other comments Extractors initials
Title: Author(s): Year (Issue) Volume Pages Country Language
Inclusion criteria Men Women AN BN BED EDNOS
Diagnosis DSM IV Diagnosis ICD10 Diagnosis other (specify).
Describe Inpatient program/care - Type of programme and psychotherapies applied including intensity and numbers of sessions and if
pharmacotherapy was included and if so what medications.
Describe comparison program/care
1.
2.
3.
4.
Interventions multidisciplinary YES/NO
Inpatient non-family-based programme YES/NO
Outpatient non-family-based programme YES/NO
Inpatient family-based programme YES/NO
Outpatient family-based programme YES/NO
Partial hospitalisation family based YES/NO
Partial hospitalisation not family based YES/NO
Interventions evidence based YES/NO
Interventions incorporating re-feeding YES/NO
Interventions not incorporating re-feeding
Selection bias
1. How was the allocation sequence generated? Specify method & circle below:
Adequate Inadequate
Computer generated sequence Case number
Random number tables Date of birth
Lot drawing Date of admission
Coin tossing Alternation
Shuffling cards Other (specify)
Throwing dice
OR NOT STATED
Was the allocation sequence adequately generated?

Yes (low risk of bias)
No (high risk of bias)
Unclear (uncertain risk of bias)
Were participants cluster randomised?

Yes
No
Unclear
2. Was there adequate concealment of allocation sequence? Specify method & circle:
Adequate (low risk of bias)
Central and/or computerised randomisation
Coded boxes
Envelopes: Sealed / Opaque Sequentially numbered
Inadequate (high risk of bias)

Open allocation sequence
Procedures based on inadequate generation
Unclear (uncertain risk of bias)
3 Outcome of randomisation.
A. Groups comparable at baseline on demographic features and illness severity
B. Uncertain -comparability not assessed
C. Groups not comparable at baseline
Performance bias
Measure used to attempt or ensure blinding of trial participants and key personnel from knowledge of which intervention a participant
had received.
Was effectiveness of blinding assessed? YES/NO Specify method.
Patient
Adequate
Inadequate
Feasible
Unfeasible
Unclear
NA
Therapist
Adequate
Inadequate
Feasible
Unfeasible
Unclear
NA
Outcome assessor
Adequate
Inadequate
Feasible
Unfeasible
Unclear
NA
Incomplete data outcome
Were reasons for attrition/exclusions reported? YES/NO
Flow diagram N
Potentially eligible
Excluded before randomisation
Number randomised in each group Control Experiment
Post randomised exclusions in
each group
No. analysed
No. analysed at 12 months follow-up
Circle
1. Low risk - attrition < 20 % Some risk - attrition 20% to 49% High risk ≥ 50%
2. Intention to treat analyses Completers only analyses
Follow-up points
Three months YES/NO
12 months YES/NO
Six months YES/NO
> 12 months (specify) YES/NO
OUTCOME RESULTS
Inpatient Control group

group
Primary outcome mea- Event n Event n

sure or mean (SD) or mean (SD)
1 BMI
2 Binge eating frequency
3 Global ED symptom
score
4 Weight restoration
5 Morgan recovered
6 No ED behaviour
7 Binge eating abstinence

1 month
Secondary outcomes
1 Quality of life generic
2 Quality of life ED spe-

cific
3 Depression
4 Psychological symptoms
general
5 Patient satisfaction
6 Adaptive function
(Continued)
7 Morgan broad
8 Non-completers (any
reason)
9 Non-completers
(adverse event)
SUBGROUP ANALYSIS 1.
Diagnostic subgroups of eating disorders, anorexia nervosa, bulimia nervosa, and subtypes of EDNOS
ANonly Inpatient Control
Primary outcome measure Event n Event n

or mean (SD) or mean (SD)
1 BMI
3 Global ED symptom score
5 Morgan recovered
6 No ED behaviour
Secondary outcomes
2 Quality of life ED specific
3 Depression
4 Psychological symptoms gen-

eral
6 Adaptive function
7 Morgan broad
(Continued)
8 Non-completers (any reason)
9 Non-completers (adverse
event)
BN only Inpatient Control

3 Global ED symptom
score
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
reason)
9 Non-completers
(adverse event)
(Continued)
BED only Inpatient Control

3 Global ED symptom
score
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
reason)
9 Non-completers
(adverse event)
EDNOS Inpatient Control

1 BMI
3 Global ED symptom
score
5 Morgan recovered
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
7 Morgan broad
reason)
9 Non-completers
(adverse event)
SUBGROUP ANALYSIS 2. Children and adolescents
Children and adolescents Inpatient Control
Primary outcome mea- Event/mean (SD) n Event /mean (SD) n

sure
1 BMI
3 Global ED symptom
score
5 Morgan recovered
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
7 Morgan broad
reason)
9 Non-completers
(adverse event)
Adults Inpatient Control
1 BMI
(Continued)
3 Global ED symptom
score
5 Morgan recovered
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
7 Morgan broad
reason)
9 Non-completers
(adverse event)
SUBGROUP ANALYSIS 3. Family based vs. non family based
family-based programme Inpatient Control
Primary outcome mea- Event/mean (SD) n Event /mean (SD) n

sure
1 BMI
3 Global ED symptom
score
5 Morgan recovered
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
7 Morgan broad
reason)
9 Non-completers
(adverse event)
Non-family-based programme Inpatient Control
1 BMI
(Continued)
3 Global ED symptom
score
5 Morgan recovered
6 No ED behaviour

1 month
Secondary outcomes

cific
3 Depression
general
6 Adaptive function
7 Morgan broad
reason)
9 Non-completers
(adverse event)
CONTRIBUTIONS OF AUTHORS
PH is lead author and responsible for all stages of the review.
AC and CM are experienced Cochrane review authors and will assist at all stages including data checking and quality appraisal ratings.
SM is a content expert and will assist in trial selection and appraisal, data interpretation and preparation of final manuscript.
Sl is a biostatistician who will contribute to statistical analyses and data interpretation.
DECLARATIONS OF INTEREST
PH: receives sessional fees and lecture fees from the Australian Medical Council, Therapeutic Guidelines publication, and New South
Wales Institute of Psychiatry and royalties from Hogrefe and Huber, McGraw Hill Education and Blackwell Scientific Publications, and
she has received research grants from the National Health and Medical Research Council (NHMRC) (2010 to 2013) and Australian
Research Council (ARC) (2010 to 2011). She is Deputy Chair of the National Eating Disorders Collaboration in Australia (2012 to
2013).
ST has received royalties from McGraw Hill and Hogrefe and Huber, as well as research support from the NHMRC.
AC, CM, SM, SI: none known.
SOURCES OF SUPPORT
Internal sources
• None, Not specified.
External sources
• None, Not specified.

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Cochrane Database of Systematic Reviews

Inpatient versus outpatient care, partial hospitalisation and

Hay PJ, Claudino AM, Smith CA, Touyz S, Lujic S, Madden S

Hay PJ, Claudino AM, Smith CA, Touyz S, Lujic S, Madden S.

Inpatient versus outpatient care, partial hospitalisation and

Editorial group: Cochrane Common Mental Disorders Group.

i) anorexia nervosa and atypical anorexia nervosa; and

ii) bulimia nervosa and other eating disorders.

1. anorexia nervosa and atypical anorexia nervosa; and

2. bulimia nervosa and other eating disorders.

BACKGROUND Eating disorders are a group of diagnoses defined by severe dis-

If the I2 statistic is moderate to high and the direction and mag-

Additional references Claudino 2006

Balshem 2011 Fairburn 1993

Birmingham 2010 Fisher 2010

Inpatient Partial or day hospital Outpatient

Anorexia nervosa Multidisciplinary medi- Multidisciplinary medi- Multidisciplinary medi-

Bulimia nervosa Multidisciplinary medi- Multidisciplinary medi- May be multidisciplinary

Binge eating disorder Multidisciplinary medi- Multidisciplinary medi- May be multidisciplinary

Other eating disorders Multidisciplinary medi- Multidisciplinary medi- Multidisciplinary medi-

Appendix 1. Data extraction form

Date Form completed

Was the allocation sequence adequately generated?

Were participants cluster randomised?

Inadequate (high risk of bias)

Unclear (uncertain risk of bias)

Inpatient Control group

Primary outcome mea- Event n Event n

2 Binge eating frequency

7 Binge eating abstinence

1 Quality of life generic

2 Quality of life ED spe-

ANonly Inpatient Control

Primary outcome measure Event n Event n

3 Global ED symptom score

1 Quality of life generic

2 Quality of life ED specific

4 Psychological symptoms gen-

8 Non-completers (any reason)

BN only Inpatient Control

Primary outcome mea- Event n Event n

2 Binge eating frequency

7 Binge eating abstinence

1 Quality of life generic

2 Quality of life ED spe-

BED only Inpatient Control

Primary outcome mea- Event n Event n

2 Binge eating frequency

7 Binge eating abstinence

1 Quality of life generic

2 Quality of life ED spe-

Primary outcome mea- Event n Event n

2 Binge eating frequency

7 Binge eating abstinence

1 Quality of life generic

2 Quality of life ED spe-

SUBGROUP ANALYSIS 2. Children and adolescents

Primary outcome mea- Event/mean (SD) n Event /mean (SD) n