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Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma

September 29, 2014 Comments off

Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma (PDF)
Source: Agency for Healthcare Research and Quality

Objectives
Our objectives were to synthesize the available information on the diagnostic accuracy and clinical utility of commonly used imaging tests for the diagnosis and staging of pancreatic adenocarcinoma , as well as screening for pancreatic adenocarcinoma in high risk individuals .

Data sources
We searched Embase , MEDLINE, PubMed, and The Cochrane Library from 1980 through November 1, 2013 , for English – la nguage, full – length articles on the role of m ultidetector computed tomography ( MD CT), endoscopic ultrasound with fine – needle aspiration (EUS – FNA), magnetic resonance imaging (MRI), and positron emission tomography – computed tomography ( PET/CT ) in screening, diagnosis, and staging pancreatic adenocarcinoma. The searches identified 9, 776 citations; after screening against the inclusion criteria, we included 15 systematic reviews and 108 primary studies.

Methods
We extracted data from the included studies and constructed evidence tables. Comparative o utcomes of interest included diagnostic accuracy (sensitivity and specificity) , staging accuracy, screening accuracy, clinical management, quality of life, survival, and harms of imaging tests. For studies of a single imaging test, the key outcomes were accuracy and procedural harms. Where possible, we pooled the data using bivariate binomial regression models for comparative accuracy. For each pair of tests and each assessed aspect (e.g., determination of metastase s), we determined whether the evidence was sufficient to permit a conclusion of a difference, a conclusion of similar accuracy , or neither (i.e., insufficient ). We rated the risk of bias of individual studies using an internal validity instrument and grade d the overall strength of evidence of conclusions using Evidence – based Practic e Center methods . For dat a on single – test accuracy, procedural harms, patient tolerance, and screening accuracy, we tabulated the important information and summarized the evidenc e qualitatively.

Results
We included 15 systematic reviews and 108 primary studies. Regarding comparative accuracy, the evidence was sufficient to conclude that MDCT and EUS – FNA have similar accuracy in assess ing resectability in patients whose disease is unstaged , and that EUS – FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor) . Further, we concluded that MDCT and MRI are similarly accurate with respect to both diagnos ing and asses s ing vessel involvement. For PET/CT , evidence was generally inconclusive, but we f ound low – strength evidence to conclude that PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity) . No ne of the included studies reported comparative data on clinical management, survival, quality, or the impact on comparative accuracy of patient characteristics , tumor characteristics , or operator experience. Many studies have reported procedural harms, but har ms are generally rare and are different for different imaging modalities. In the screening of people at high risk of developing pancreatic adenocarcinoma , a vailable studies do not correlate the results of a given imagin g test to subsequent diagnoses.

Conclusions.
Current evidence permits some tentative conclusions about the comparative assessment of imaging tests for diagnosing and staging pancreatic adenocarcinoma, but many gaps remain. The conclusions we did draw are as follows: MDCT and EUS – FNA have similar accuracy in assessing resectability in patients whose disease is unstaged ; EUS – FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor) ; MDCT and MRI are similarly accurate with respect to both diagnos ing and assess ing vessel involvement ; and PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity). The prominent gaps include minimal information on MDCT angiography , impr ecis e data on other imaging techniques, a lack of comparative data on patient – oriented outco mes and factors that could influence comparative accuracy, and test – specific data on screening accuracy.

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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.

Attitudes toward Health Insurance and Their Persistence over Time, Adults, 2010-2011

August 13, 2014 Comments off

Attitudes toward Health Insurance and Their Persistence over Time, Adults, 2010-2011
Source: Agency for Healthcare Research and Quality

Highlights

  • In 2011, 12.1 percent of adults agreed with the statement “I’m healthy enough that I really don’t need health insurance,” and 24.3 percent of adults agreed with the statement “Health insurance is not worth the money it costs.”
  • There were no differences in the overall national estimates when comparing the 2011 attitudes towards the cost of health insurance with those observed in 2010; however, substantial shifts in preferences were noted for the same individuals over this time period.
  • Adults ages 18-64 who were uninsured for all of 2011 were nearly twice as likely as their privately insured counterparts, and two and one-half times as likely as those with public coverage to indicate they were healthy and did not need health insurance. These uninsured adults were also more likely to agree that health insurance was not worth its cost, relative to those with coverage.
  • Adults with consistent attitudes toward health insurance in both 2010 and 2011 had coverage and utilization behaviors in accordance with their expressed preferences. Those who consistently said they were healthy and did not need coverage were more than three times as likely not to have any medical expenditures in both years, relative to those who consistently disagreed with that classification.
  • In both years, adults under age 65 who consistently indicated that health insurance was not worth the cost were nearly three times as likely to be uninsured relative to those who consistently disagreed.

State Differences in the Cost of Job-Related Health Insurance, 2013

August 5, 2014 Comments off

State Differences in the Cost of Job-Related Health Insurance, 2013
Source: Agency for Healthcare Research and Quality

This Statistical Brief presents state variations from the national average of the cost of job-related health insurance and how these costs are shared by employers and their employees. The Brief specifically examines the average premiums and employee contributions for private-sector establishments in the 10 most populous states in 2013, using the most recent data available from the Insurance Component of the Medical Expenditure Panel Survey (MEPS-IC).

Out-of-Pocket Health Care Expenses by Age and Insurance Coverage, 2011

July 29, 2014 Comments off

Out-of-Pocket Health Care Expenses by Age and Insurance Coverage, 2011
Source: Agency for Healthcare Research and Quality

Highlights

  • In 2011, an average of $703 was paid out of pocket for health care among people with some health care expenses. However, the median out-of-pocket amount was notably lower ($237).
  • Nearly one-fifth of people with some health care expenses had out-of-pocket expenses greater than $1,000 while 8.2 percent had out-of-pocket expenses greater than $2,000.
  • Average out-of-pocket expenses increased with age, ranging from $283 for children under 18 to $1,215 for people age 65 and older.
  • On average, the uninsured paid nearly two-thirds of their health care expenses out of pocket while people under age 65 covered by public insurance and people age 65 and older covered by Medicare and other public insurance paid a substantially lower percentage (only 9–11 percent).

Selection and Costs for Employer-Sponsored Health Insurance in the Private Sector, 2013 versus 2012

July 18, 2014 Comments off

Selection and Costs for Employer-Sponsored Health Insurance in the Private Sector, 2013 versus 2012
Source: Agency for Healthcare Research and Quality (Medical Expenditure Panel Survey)

Highlights

  • In 2013, 51.3 percent of private-sector employees enrolled in employer-sponsored health insurance chose single coverage, rather than employee-plus-one or family coverage. This percentage did not differ from that for 2012.
  • Average annual total premiums across all three coverage types were up in 2013 compared to 2012. Single premiums rose 3.5 percent, employee-plus-one premiums rose 3.5 percent, and family premiums rose 3.6 percent.
  • The average annual dollar amount that employees contributed toward the premium also rose for all three types of coverage in 2013 versus 2012.

Overview of Emergency Department Visits in the United States, 2011

July 4, 2014 Comments off

Overview of Emergency Department Visits in the United States, 2011
Source: Agency for Healthcare Research and Quality

Emergency departments (EDs) provide a significant source of medical care in the United States, with over 131 million total ED visits occurring in 2011. Over the past decade, the increase in ED utilization has outpaced growth of the general population, despite a national decline in the total number of ED facilities. In 2009, approximately half of all hospital inpatient admissions originated in the ED. In particular, EDs were the primary portal of entry for hospital admission for uninsured and publicly insured patients (privately insured patients were more likely to be directly admitted to the hospital from a doctor’s office or clinic).

ED utilization reflects the greater health needs of the surrounding community and may provide the only readily available care for individuals who cannot obtain care elsewhere. Many ED visits are “resource sensitive” and potentially preventable, meaning that access to high-quality, community-based health care can prevent the need for a portion of ED visits.

This HCUP Statistical Brief presents data on ED visits in the United States in 2011. Patient and hospital characteristics for two types of ED visits are provided: ED visits with admission to the same hospital and ED visits resulting in discharge, which includes patients who were stabilized in the ED and then discharged home, transferred to another hospital, or any other disposition. The most frequent conditions treated by patient age group also are presented for both types of ED visits. All differences between estimates noted in the text are statistically significant at the .0005 level or better.

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