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Mild hypertension in people at low risk

September 22, 2014 Comments off

Mild hypertension in people at low risk
Source: British Medical Journal

Summary box

  • Clinical context—Up to 40% of adults worldwide have hypertension, complications of which may account for up to 9.4 million deaths annually from cardiovascular disease
  • Diagnostic change—Recommendations for drug treatment have decreased from diastolic pressure of >115 mm Hg to ≥140/90 mm Hg. A new category, prehypertension (120/80-139/89 mm Hg), has also been introduced
  • Rationale for change—Patients with even mildly raised blood pressure may have increased cardiovascular risk
  • Leap of faith—Lowering threshold blood pressures will lead to increased diagnosis and treatment, which will decrease mortality
  • Impact on prevalence—22% of adults worldwide have mild hypertension (systolic pressure 140-159 mm Hg) and 13.5% have a systolic pressure ≥160 mm Hg
  • Evidence of overdiagnosis—Use of a uniform threshold (140 mm Hg) to mark hypertension risk ignores evidence that risk varies by individual and includes many people who will not benefit from drug treatment
  • Harms from overdiagnosis—Studies suggest over half of people with mild hypertension are treated with drugs even though this approach has not been proved to decrease mortality or morbidity. Overemphasis on drug treatment risks adverse effects, such as increased risk of falls, and misses opportunities to modify individual lifestyle choices and tackle lifestyle factors at a public health level
  • Limitations of evidence — Lack of randomised trials that use hard outcomes and compare drugs with lifestyle interventions and placebo in patients with mild hypertension
  • Conclusion—Lowering definitions of hypertension has led to identification and drug treatment of larger populations of patients despite lack of evidence that drugs reduce morbidity or mortality
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World Alzheimer Report 2014: Dementia and Risk Reduction

September 19, 2014 Comments off

World Alzheimer Report 2014: Dementia and Risk Reduction
Source: Alzheimer’s Disease International

The World Alzheimer Report 2014, Dementia and Risk Reduction: An analysis of protective and modifiable factors critically examines the evidence for the existence of modifiable risk factors for dementia.

It focuses on sets of potential modifiable risk factors in four key domains: developmental, psychological and psychosocial, lifestyle and cardiovascular conditions. The report makes recommendations to drive public health campaigns and disease prevention strategies.

Vitamin D and Calcium: A Systematic Review of Health Outcomes (Update)

September 18, 2014 Comments off

Vitamin D and Calcium: A Systematic Review of Health Outcomes (Update)
Source: Agency for Healthcare Research and Quality

In 2009, the Tufts Evidence-based Practice Center (EPC) conducted a systematic review of the scientific literature on vitamin D and calcium intakes as related to status indicators and health outcomes. The purpose of this report was to guide the nutrition recommendations of the Institute of Medicine (IOM) Dietary Reference Intakes (DRIs).

In September 2007, the IOM held a conference to examine the lessons learned from developing DRIs, and future challenges and best practices for developing DRIs. The conference concluded that systematic reviews would enhance the transparency and rigor of DRI committee deliberations. With this framework in mind, the Agency for Healthcare Research and Quality (AHRQ) EPC program invited the Tufts EPC to perform the systematic review of vitamin D and calcium.

In May and September 2007, two conferences were held on the effect of vitamin D on health. Subsequently, a working group of scientists from the United States and Canadian Governments convened to determine whether enough new research had been published since the 1997 vitamin D DRI to justify an update. Upon reviewing the conference proceedings and results from a recent systematic review, the group concluded that sufficient new data beyond bone health had been published. Areas of possible relevance included new data on bone health for several of the life stage groups, reports on potential adverse effects, dose-response relations between intakes and circulating 25-hydroxyvitamin D (25(OH)D) concentrations and between 25(OH)D concentrations, and several health outcomes. Throughout the remainder of this summary and in the report, new text is presented in boldface type.

The Health Risks of Bathing in Recreational Waters: A Rapid Evidence Assessment of Water Quality and Gastrointestinal Illness

September 18, 2014 Comments off

The Health Risks of Bathing in Recreational Waters: A Rapid Evidence Assessment of Water Quality and Gastrointestinal Illness
Source: RAND Corporation

The European Bathing Directive (2006/7/EC) stipulates water quality standards for recreational bathing waters based on specified limits of faecal indicator organisms (FIOs). Presence of FIOs above the limits is considered to be indicative of poor water quality and to present a risk to bathers’ health. The European Bathing Directive (2006) is to be reviewed in 2020. We conducted a rapid evidence assessment on recreational bathing waters and gastrointestinal illness (GI) to identify the extent of the literature published since the previous review period in 2003 and to determine whether there is any new evidence which may indicate that a revision to the Directive would be justified.

Overall, 21 papers (from 16 studies), including two RCTs, met the inclusion criteria; 12 were conducted in marine waters and four were conducted in freshwater. Considerable heterogeneity existed between study protocols and the majority had significant methodological limitations, including self-selection and misclassification biases. Moreover, there was limited variation in water quality among studies, providing a limited evidence base on which to assess the classification standards.

Overall, there appears to be a consistent significant relationship between faecal indicator organisms and GI in freshwater, but not marine water studies. Given the apparent lack of relationship between GI and water quality, it is unclear whether the boundaries of the Bathing Waters Directive are supported by studies published in the post-2003 period. We suggest that more epidemiological evidence is needed to disprove or confirm the original work that was used to derive these boundaries for marine waters.

The Cost of Inaction for Young Children Globally: Workshop Summary (2014)

September 18, 2014 Comments off

The Cost of Inaction for Young Children Globally: Workshop Summary (2014)
Source: Institute of Medicine (IOM); National Research Council

The Cost of Inaction for Young Children Globally is the summary of a workshop hosted by the Institute of Medicine Forum on Investing in Young Children Globally in April 2014 to focus on investments in young children and the cost of inaction. Participants explored existing, new, and innovative science and research from around the world to translate this evidence into sound and strategic investments in policies and practices that will make a difference in the lives of children and their caregivers. This report discusses intersections across health, education, nutrition, living conditions, and social protection and how investments of economic, natural, social, and other resources can sustain or promote early childhood development and well-being.

Transforming Cancer Care and the Role of Payment Reform

September 17, 2014 Comments off

Transforming Cancer Care and the Role of Payment Reform
Source: Brookings Institution

According to the National Cancer Institute there are more than 13 million people living with cancer in the United States; it is the second leading cause of death in the U.S. It is expected that 41% of Americans will be diagnosed with cancer at some point during their lives. More than 1.6 million new cases of cancer will be diagnosed in 2014; a nearly 22% increase over the last decade.

Cancer care is also expensive. In 2010 it accounted for $125 billion in health care spending and is expected to cost at least $158 billion by 2020, due to population increase. In 2011 Medicare alone spent nearly $35 billion in fee-for-service (FFS) payments for cancer care, representing almost 9% of all Medicare FFS payments overall.

Broadly speaking, problems in complex clinical care fall into two categories: deficits in knowledge (for example, lack of any effective treatment for certain brain tumors) and deficits in execution (for example, failure to treat breast cancer with a standard-of-care protocol). Delivery reform seeks to find opportunity in the latter problem type. Considering cancer care through this lens, there are many opportunities to improve outcomes and potentially lower costs, including better coordination of care, eliminating duplication of services and reducing fragmentation of care. In addition, almost two-thirds of oncology revenue derives from drug sales, and pricing for drugs (calculated by the average sale price plus 6% profit for providers) may incentivize the use of the most expensive drugs rather than equally effective, lower-cost alternatives.

Promising approaches are being developed to deliver high quality care, improve the patient experience, and reduce costs for this condition and other chronic diseases. Care redesign strategies such as adopting team-based models, offering extended practice hours, providing triage to keep patients out of the emergency room, and implementing care pathways help providers address avoidable costs and maximize the value of care. Many of these strategies are not currently reimbursed in the FFS, volume-based payment system.

Consequently, much policy attention is focusing on payment reform. On the heels of the Affordable Care Act (ACA), and numerous quality and payment focused initiatives in the private sector, health care organizations need to enhance the competitiveness and efficiency of their system in the marketplace. Alternative payment models (APMs) such as Accountable Care Organizations (ACOs), bundled payments, and patient-centered oncology medical homes (PCOMH) are just a few of the initiatives supported by public and private payers to align care redesign and payment reform and encourage continuous improvement. This paper provides a comprehensive overview of the complex care associated with oncology and the alternate payment models which help support optimal care and encourage continuous improvement.

Medical Aspects of Transgender Military Service

September 16, 2014 Comments off

Medical Aspects of Transgender Military Service
Source: Armed Forces & Society

At least eighteen countries allow transgender personnel to serve openly, but the United States is not among them. In this article, we assess whether US military policies that ban transgender service members are based on medically sound rationales. To do so, we analyze Defense Department regulations and consider a wide range of medical data. Our conclusion is that there is no compelling medical reason for the ban on service by transgender personnel, that the ban is an unnecessary barrier to health care access for transgender personnel, and that medical care for transgender individuals should be managed using the same standards that apply to all others. Removal of the military’s ban on transgender service would improve health outcomes, enable commanders to better care for their troops, and reflect the military’s commitment to providing outstanding medical care for all military personnel.

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