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Archive for the ‘Agency for Healthcare Research and Quality’ Category

Trends in Pediatric and Adult Hospital Stays for Asthma, 2000-2010

March 17, 2014 Comments off

Trends in Pediatric and Adult Hospital Stays for Asthma, 2000-2010
Source: Agency for Healthcare Research and Quality

Asthma is a chronic disease characterized by inflammation of the airways. It restricts the passage of air into the lungs and leads to episodes of wheezing, coughing, chest tightness, and shortness of breath. Severe asthmatic episodes can close off airways completely and, in some cases, may be life-threatening.1

In 2010, approximately 7.0 million children aged 0—17 years and 18.7 million adults aged 18 years and older had a diagnosis of asthma. The prevalence of asthma in the United States has increased from 7.3 percent of the population in 2001 to 8.4 percent in 2010.2

Asthma is largely controllable with proper primary care, and the need for hospitalization can usually be prevented. However, differences in rates of hospitalization for asthma suggest that there is significant room for improvement in caring for the condition.

This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on trends in pediatric and adult inpatient hospital stays for asthma at U.S. community hospitals from 2000 through 2010. In addition, we present patient characteristics of pediatric and adult hospital stays for asthma in 2010. Differences that are noted in the text exhibit at least a 10 percent difference between estimates and are statistically significant at 0.05 or better.

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Trends in Antidepressant Utilization and Expenditures in the U.S. Civilian Noninstitutionalized Population by Age, 2000 and 2010

March 5, 2014 Comments off

Trends in Antidepressant Utilization and Expenditures in the U.S. Civilian Noninstitutionalized Population by Age, 2000 and 2010
Source: Agency for Healthcare Research and Quality

Highlights

  • From 2000 to 2010, the number of people in the U.S. civilian noninstitutionalized population purchasing at least one outpatient prescription antidepressant increased for those ages 18-44, 45-64, and 65 and older. For those persons under age 18, there was no significant increase or decrease.
  • Comparing 2000 and 2010, the total number of outpatient prescription antidepressants purchased increased for those ages 18-44, 45-64, and 65 and older.
  • Comparing 2000 with 2010, for persons ages 18-44, 45-64, and 65 and older in the U.S. civilian noninstitutionalized population, the inflation adjusted total expense for antidepressants increased.
  • From 2000 to 2010, for people ages 45-64 the total number of people purchasing one or more prescribed antidepressant increased by 91.3 percent, the total number of antidepressants purchased increased by 107.4 percent, and total expense for antidepressants increased by 103.3 percent.
  • From 2000 to 2010, for persons age 65 and older, inflation adjusted total expense on antidepressants increased 125.6 percent and the number of antidepressants purchased increased 122.0 percent.

Guide to Patient and Family Engagement in Hospital Quality and Safety

January 13, 2014 Comments off

Guide to Patient and Family Engagement in Hospital Quality and Safety
Source: Agency for Healthcare Research and Quality

Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.

Guide to Patient and Family Engagement in Hospital Quality and Safety

December 18, 2013 Comments off

Guide to Patient and Family Engagement in Hospital Quality and Safety
Source: Agency for Healthcare Research and Quality

The Guide to Patient and Family Engagement in Hospital Quality and Safety focuses on four primary strategies for promoting patient/family engagement in hospital safety and quality of care:

  • Encourage patients and family members to participate as advisors.
  • Promote better communication among patients, family members, and health care professionals from the point of admission.
  • Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.
  • Engage patients and families in discharge planning throughout the hospital stay.

Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement

November 29, 2013 Comments off

Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement
Source: Agency for Healthcare Research and Quality

This toolkit provides information and resources to help physicians’ offices, clinics, and other ambulatory care facilities assess and improve the testing process in their offices.

Most Frequent Procedures Performed in U.S. Hospitals, 2011

October 23, 2013 Comments off

Most Frequent Procedures Performed in U.S. Hospitals, 2011
Source: Agency for Healthcare Research and Quality (Healthcare Cost and Utilization Project)

When hospitalized, patients may undergo procedures for surgery, treatments (e.g., blood transfusions), or for diagnostic purposes (e.g., biopsy). The principal procedure is the procedure performed for definitive treatment. Hospitalizations usually involve multiple procedures, which together constitute the all-listed procedures performed during a hospital stay. Data on inpatient hospital procedures can help hospital administrators, health practitioners, researchers, and others understand how hospital care, including care related to diagnosis and treatment, is currently provided and what changes or consistencies in care delivery have occurred over time.

The present Statistical Brief presents 2011 data on the most common all-listed procedures performed during hospital stays in the United States, overall and by patient age. Changes between 1997 and 2011 in the number of stays and in the rate of hospitalizations with these procedures are also presented. All differences between estimates noted in the text are statistically significant at the .001 level or better.

Differentials in the Concentration in the Level of Health Expenditures across Population Subgroups in the U.S., 2010

October 8, 2013 Comments off

Differentials in the Concentration in the Level of Health Expenditures across Population Subgroups in the U.S., 2010
Source: Agency for Healthcare Research and Quality

Highlights

+ In 2010, the top 1 percent ranked by their health care expenses accounted for 21.4 percent of total health care expenditures with an annual mean expenditure of $87,570. Overall, the top 50 percent of the population ranked by their expenditures accounted for 97.2 percent of overall health care expenditures while the lower 50 percent accounted for only 2.8 percent of the total.

+ Children under the age of 18 were characterized by substantially greater concentrated levels of health care spending relative to their older counterparts. Alternatively, the elderly had the highest mean levels of health care expenditures relative to younger population subgroups at the top quantiles of the expenditure distribution.

+ The top 5 percent of the uninsured population under age 65 ranked by their health care expenses accounted for 67.3 percent of the health care expenditures incurred by this subpopulation with an annual mean of $17,453. Conditioned on insurance coverage status, the uninsured had the most concentrated levels of health care expenditures and the lowest annual mean expenses.

+ The top 5 percent of individuals with four or more chronic conditions accounted for 29.7 percent of health care expenditures for this subpopulation with an annual mean of $81,790. Based on chronic condition status, persons with four or more chronic conditions had the lowest concentrated levels of health care expenditures and the highest annual mean expenses at the top quantiles of the expenditure distribution.

Treatment for Restless Legs Syndrome

September 30, 2013 Comments off

Treatment for Restless Legs Syndrome
Source: Agency for Healthcare Research and Quality

In response to a request from the public, a review was undertaken to evaluate the evidence regarding the potential benefits and adverse effects associated with various treatments for restless legs syndrome (RLS). This review did not cover other sleep disorders such as periodic limb movement disorder. The systematic review included 53 reports of randomized clinical trials and observational studies published through June 2012. The online version of this summary and the full report can be accessed on the right side of this page. This summary is provided to inform discussions with patients of options and to assist in decisionmaking along with consideration of a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions–An Update to the 2009 Report

September 26, 2013 Comments off

Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions–An Update to the 2009 Report
Source: Agency for Healthcare Research and Quality

Among women in the United States, breast cancer is the second most common malignancy (after skin cancer), and the second most common cause of cancer death (after lung cancer).1 Approximately 1 in 8 U.S. women will develop breast cancer during their lifetime, and an estimated 2.7 million women had a current or past diagnosis of breast cancer as of 2009.2 The American Cancer Society estimates that 232,340 new cases of invasive breast cancer and 64,640 new cases of noninvasive breast cancer will be diagnosed in 2013, and 39,620 women will die of breast cancer.3

During the earliest stages of breast cancer, there are usually no symptoms. The process of breast cancer diagnosis is initiated by detection of an abnormality through self-examination, physical examination by a clinician, or screening mammography. Data from the Behavioral Risk Factor Surveillance System show that, in 2010, 75.4 percent of U.S. women aged ≥40 years and 79.7% of women aged 50 to 74 years reported having a mammogram within the past 2 years.4 If initial assessment suggests that the abnormality may be breast cancer, the woman may be referred for a biopsy, which is a sampling of cells or tissue from the suspicious lesion. Among women screened annually for 10 years, approximately 50 percent will need additional imaging tests, and a large proportion will have biopsies.5,6 More than a million women have breast biopsies each year in the United States. There are currently three techniques for obtaining samples from suspicious breast lesions: fine-needle aspiration, biopsy with a hollow core needle, or open surgical excision of tissue. Fine-needle aspiration, which retrieves a sample of cells, is generally considered less sensitive than both core-needle and open biopsy methods.7 Core-needle biopsy, which retrieves a sample of tissue, and open surgical procedures are, therefore, the most frequently used procedures.

Samples obtained by any of these methods are evaluated by pathologists and classified into histological categories with the primary goal of determining whether the lesion is benign or malignant. Because a core-needle biopsy often samples only part of the breast abnormality, there is the risk that a lesion will be classified as benign or as high risk (e.g., atypical ductal hyperplasia [ADH]) or noninvasive (e.g., ductal carcinoma in situ [DCIS]) when invasive cancer is in fact present in unsampled areas. In contrast, open surgical biopsy often samples most or the entire lesion, and it is thought that there is a much smaller risk of misdiagnosis. However, while open surgical biopsy methods are considered to be the most accurate, they also appear to carry a higher risk of complications, such as bleeding or infection, when compared with core-needle biopsy.8 Therefore, if core-needle biopsy is also highly accurate, women and their clinicians may prefer some type of core-needle biopsy to open surgical biopsy.

Core-needle biopsy may be carried out using a range of techniques. If the breast lesion to be biopsied is not palpable, an imaging method (i.e., stereotactic mammography, ultrasound, or magnetic resonance imaging [MRI]) may be used to locate the lesion. The biopsy may be carried out with needles of varying diameters, and one or more samples of tissue may be taken. Sometimes a vacuum device is used to assist in removing the tissue sample through the needle. It is thought that these and other variations in how a core-needle biopsy is performed may affect the accuracy and rate of complications of the biopsy. However, the impact aspects of biopsy technique have on test performance and safety are not clear.

In 2009, the ECRI Evidence-based Practice Center (EPC) conducted a comparative effectiveness review for core-needle versus open surgical biopsy on behalf of the Agency for Health Care Research and Quality (AHRQ).9,10 The review assessed the diagnostic test performance and harms of multiple core-needle biopsy techniques and tools, when compared with open surgical biopsy, and also evaluated differences between open biopsy and core-needle biopsy with regard to patient preference, costs, availability, and other factors. The conclusions were that core-needle biopsies were almost as accurate as open surgical biopsies, had a lower risk of severe complications, and were associated with fewer subsequent surgical procedures.10 The need for an update of the 2009 review was assessed in 2010 by the RAND EPC.11 Several high-impact general medical and specialty journals were searched, a panel of experts in the field was consulted, and an overall assessment of the need to update the review was produced. The conclusion of the updated Surveillance Report was that additional studies and changes in practice render some conclusions of the original report possibly out of date. Specifically, the Surveillance Report noted the following:

New studies are available that could be included in the updated report regarding the following topics:

  • The underestimation rate of stereotactically-guided vacuum-assisted core-needle biopsy for DCIS
  • The test performance of MRI-guided core-needle biopsy
  • The test performance of freehand automated-device core-needle technology
  • New studies on the test performance of core-needle biopsy may include additional information allowing the exploration of the heterogeneity for test performance or harm outcomes.

On the basis of the Surveillance Report findings, an updated review of the published literature was considered necessary to synthesize all evidence on currently available methods for core-needle and open surgical breast biopsy.

Treatments for Seasonal Allergic Rhinitis

August 19, 2013 Comments off

Treatments for Seasonal Allergic Rhinitis
Source: Agency for Healthcare Research and Quality

Objectives:
This review compared the effectiveness and common adverse events of medication classes used to treat seasonal allergic rhinitis (SAR) in adolescents and adults, in pregnant women, and in children. We sought to compare the following classes of drugs: oral and nasal antihistamines and decongestants; intranasal corticosteroids, mast cell stabilizers (cromolyn), and anticholinergics (ipratropium); oral leukotriene receptor antagonists (montelukast); and nasal saline.

Data sources:
We identified English-language studies using a peer-reviewed search strategy. The following databases were
searched on July 18, 2012, with no date restrictions: MEDLINE® (PubMed® and Ovid), Embase® (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and DARE (Database of Abstracts of Reviews of Effects).

Review methods:
We consulted a Technical Expert Panel to identify the treatment comparisons most relevant to patients and providers. Subpopulations of interest were individuals with asthma or eye symptoms. Outcomes of interest were patient-reported symptom scores, quality of life, and adverse events. Inclusion was limited to studies that reported an outcome of interest and directly compared drugs of interest that were approved by the U.S. Food and Drug Administration (FDA). Two independent reviewers performed study selection and data abstraction. Disagreements were resolved by consensus or a third reviewer.

Results:
We identified 59 trials that addressed 13 of 22 treatment comparisons of interest for adolescents and adults, 0 of 17 comparisons of interest for pregnant women, and 1 of 21 comparisons of interest for children. Across all comparisons, 20 of 39 drugs FDA approved for the treatment of SAR were studied. For adolescents and adults with SAR, evidence was sufficient to form the following conclusions. For the treatment of nasal symptoms, montelukast (oral leukotriene receptor antagonist) and intranasal corticosteroid were similarly effective (high strength of evidence [SOE]). For the treatment of nasal symptoms and eye symptoms, intranasal corticosteroid, nasal antihistamine, and combination intranasal corticosteroid plus nasal antihistamine were similarly effective (high SOE), and montelukast and oral selective antihistamine were similarly effective (moderate SOE). For improved quality of life, montelukast and oral selective antihistamine were similarly effective (moderate SOE), and combination oral selective antihistamine plus intranasal corticosteroid was superior to oral selective antihistamine alone (low SOE). To avoid insomnia, oral selective antihistamine was superior to oral decongestant and to combination oral selective antihistamine plus oral decongestant (moderate SOE). In patients codiagnosed with SAR and asthma, montelukast was superior to oral selective antihistamine for reduced asthma rescue medication use (moderate SOE). In sensitivity analyses using a lower threshold for minimum clinical effectiveness, combination oral selective antihistamine plus oral decongestant was superior to oral selective antihistamine alone for the treatment of nasal symptoms in adolescents and adults with SAR (moderate SOE). In this population, we did not find evidence that any single treatment was both more effective and had lower risk of harms. Evidence for both effectiveness and harms was insufficient regarding the comparison between oral selective and oral nonselective antihistamine in children. All effectiveness and harms outcomes were limited by short trial durations.

Conclusions:
Several effectiveness comparisons demonstrated similarity of treatments for selected outcomes. For most harms comparisons, the evidence was insufficient. Conclusions were limited by (1) lack of comparative evidence for all drugs within each class and (2) lack of evidence on the magnitude of symptom change that constitutes a minimal clinically important difference.

Surgical Management of Inguinal Hernia

July 30, 2013 Comments off

Surgical Management of Inguinal Hernia
Source: Agency for Healthcare Research and Quality

Surgical repair of inguinal hernias is the most commonly performed general surgical procedure in the United States. Such a large volume of procedures suggests that even modest improvements in patient outcomes would substantially improve population health. The primary goals of surgery include preventing strangulation, repairing the hernia, minimizing the chance of recurrence, returning the patient to normal activities quickly, improving quality of life, and minimizing postsurgical discomfort and the adverse effects of surgery. Recurrence occurs in approximately 1 to 5 percent of cases of inguinal hernia.

Surgical procedures for inguinal hernia repair generally fall into three categories: open repair without a mesh implant (i.e., sutured), open repair with a mesh, and laparoscopic repair with a mesh. The near-universal adoption of mesh means that the most relevant questions about hernia repair involve various mesh procedures. However, mesh is not recommended for repair of pediatric inguinal hernia for several reasons including concerns about inflammatory reactions, damage to the vas deferens and/or testes, infertility, and growth-related complications. The findings from the research review presented here may inform clinical decisions by patients and surgeons, treatment recommendations by professional societies, purchasing decisions by hospitals, and coverage decisions by third-party payers.

Treatment Options When Your SSRI Antidepressant Is Not Working Well

July 29, 2013 Comments off

Treatment Options When Your SSRI Antidepressant Is Not Working Well
Source: Agency for Healthcare Research and Quality

This summary will tell you about options to treat your depression if your SSRI did not work or did not work well enough. There are many options that work to treat depression. But there is not enough research to know for sure which option might be best after an SSRI did not work or did not work well enough. This summary can help you talk with your doctor about which treatment to try next.

Screening for Methicillin-Resistant Staphylococcus Aureus (MRSA)

July 8, 2013 Comments off

Screening for Methicillin-Resistant Staphylococcus Aureus
Source: Agency for Healthcare Research and Quality

A new AHRQ research review finds that there is not enough evidence in the available literature to compare the effectiveness of screening strategies for methicillin-resistant Staphylococcus aureus (MRSA) in select patient populations.

The review found that there is low strength of evidence that screening all hospitalized patients (universal screening) for MRSA bacteria decreases hospital-acquired MRSA infections compared with no screening. However, there is not enough evidence to draw conclusions on the effectiveness of universal MRSA screening strategies on other outcomes, including the risk of death and other potential harms.

After the completion of this EHC report, an AHRQ-funded project on different approaches to reduce MRSA infection was published in the May 30 online issue of the New England Journal of Medicine. In that study, researchers achieved a 44 percent reduction in all-cause bloodstream infections and significantly reduced the presence of MRSA when they decolonized every patient who entered the ICU, regardless of MRSA status. Ultimately, the research review underscores the need for additional well-designed studies that take into account factors that may complicate results.

Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness

June 20, 2013 Comments off

Interventions To Improve Cardiovascular Risk Factors in People With Serious Mental Illness

Source: Agency for Healthcare Research and Quality

Objectives:

Individuals with serious mental illness (SMI) have excess mortality from cardiovascular disease (CVD) and high rates of CVD risk factors such as diabetes, obesity, and hyperlipidemia. We conducted a systematic review to evaluate interventions to improve CVD risk factors in adults with SMI.

Data Sources:

We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for English-language trials published since 1980 that evaluated patient-focused behavioral interventions, peer or family support interventions, pharmacological treatments, and multicondition lifestyle interventions, or their combination, that targeted weight control, glucose levels, lipid levels, or CVD risk profile among adults with SMI at elevated risk of CVD.

Review Methods:

Two investigators screened each abstract and full-text article for inclusion, abstracted data, and performed quality ratings, efficacy–effectiveness ratings, and evidence grading. Qualitative and quantitative methods, using random-effects models, were used to summarize results.

Results:

Of 35 eligible studies, most enrolled patients with schizophrenia who were prescribed antipsychotics. Most studies were designed to control weight (n=28); one study specifically addressed diabetes management, none targeted hyperlipidemia, and three were multicondition interventions. Most studies were efficacy trials comparing behavioral interventions with control; none evaluated peer and family support. There were few direct comparisons of active interventions; effects on overall CVD risk, physical functioning, or cardiovascular events were reported rarely.

Compared with controls, behavioral interventions (mean difference [MD] −3.13 kg; 95% CI, −4.21 to −2.05), metformin (MD −4.13 kg; CI, −6.58 to −1.68), the anticonvulsive medications topiramate and zonisamide (MD −5.11kg; CI, −9.48 to −0.74), and adjunctive or antipsychotic switching to aripiprazole improved weight control. However, aripiprazole switching may be associated with higher rates of treatment failure. Nizatidine did not improve any outcome. The evidence was insufficient for all other interventions and effects on glucose and lipid control.

Conclusions:

Few studies have evaluated interventions to address one or more CVD risk factors in patients with SMI. Comparative effectiveness studies are needed to test multimodal strategies, agents known to be effective in non-SMI populations, and antipsychotic-management strategies.

Migraine in Children: Preventive Pharmacologic Treatments

June 19, 2013 Comments off

Migraine in Children: Preventive Pharmacologic Treatments (PDF)

Source: Agency for Healthcare Research and Quality

Limited low-strength evidence suggests that propranolol was more effective than placebo for preventing episodic migraine in children, with no bothersome adverse effects that could lead to treatment discontinuation. Long-term preventive benefits are unknown both for drugs and nonpharmacologic interventions. No studies examined quality of life or provided evidence for individualized treatment decisions. Future randomized trials of drugs with favorable benefits-to-harms ratio in adults are needed to identify effective and safe treatments to prevent episodic and chronic migraine in children.

Multidisciplinary Rehabilitation Programs for Moderate to Severe Traumatic Brain Injury in Adults: Future Research Needs

June 14, 2013 Comments off

Multidisciplinary Rehabilitation Programs for Moderate to Severe Traumatic Brain Injury in Adults: Future Research Needs

Source: Agency for Healthcare Research and Quality

This Future Research Needs (FRN) project is a followup to the recently completed Comparative Effectiveness Review (CER) “Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults.” The CER was motivated by uncertainty around the effectiveness and comparative effectiveness of rehabilitation programs for adult patients with sustained impairments from moderate to severe traumatic brain injury (TBI). This FRN project aims to identify and prioritize specific gaps in the current literature about the effectiveness and comparative effectiveness of multidisciplinary rehabilitation programs for which additional research would aid decisionmakers. We used a deliberative process to identify evidence gaps, translate gaps into researchable questions, and solicit stakeholder opinion on the importance of research questions. This report proposes specific research needs along with research design considerations that could advance research in this field.

Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 3 4.9 kg/m²

June 10, 2013 Comments off

Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m² (PDF)

Source: Agency for Healthcare Research and Quality

We found only 24 studies reporting bariatric surgery results in this specific target population. Two were trials comparing different procedures, three were trials of surgical versus nonsurgical interventions, and the rest were observational studies. Both weight and blood glucose improved significantly for surgery patients in the trials. In the observational studies, surgery patients showed much greater weight loss at 1 year than reported in systematic reviews and randomized controlled trials (RCTs) on diet, exercise, medication, and other behavioral interventions. While both behavioral interventions and medications lowered HbA1c (glycosylated hemoglobin) levels significantly, the decreases reported in surgery patients were much greater. Improvements in blood glucose measures were reported as early as one month postsurgery. Improvements in hypertension, low-density lipoprotein (LDL) cholesterol, and triglycerides were also reported in some studies. Short-term rates of adverse events associated with bariatric surgery were relatively low. One death, a case of sepsis at 20 months in an LAGB patient, was reported. Short-term complications were minor and tended not to require major intervention. Due to the dearth of long-term studies of bariatric surgery in this particular target population, few data exist about long-term adverse effects, and we found no evidence regarding major clinical endpoints such as all-cause mortality, cardiovascular mortality and morbidity, and peripheral arterial disease.

Efficacy and Safety of Screening for Postpartum Depression

May 30, 2013 Comments off

Efficacy and Safety of Screening for Postpartum Depression

Source: Agency for Healthcare Research and Quality

The potential effectiveness of screening for postpartum depression appears to be related to the availability of systems to ensure adequate followup of women with positive results. The ideal characteristics of a screening test for postpartum depression, including sensitivity, specificity, timing, and frequency, have not been defined. Because the balance of benefits and harms, at both the individual level and health system level, is highly dependent on these characteristics, broad consensus on these characteristics is needed.

Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force

May 28, 2013 Comments off

Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force

Source: Agency for Healthcare Research and Quality

Background:

In the United States, the annual burden of suicide is substantial, accounting for almost 37,000 deaths and an estimated 1.4 million years of potential life lost in recent years.

Purpose:

To systematically review evidence for the accuracy of suicide risk screening instruments, the efficacy and safety of screening for suicide risk, and the efficacy and safety of treatments to prevent suicide.

Methods:

We searched MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Cumulative Index for Nursing Allied Health to identify literature that was published between January 2002 and July 17, 2012. We also examined the references from the previous review and additional relevant reviews, searched Web sites of government agencies, professional organizations, and other organizations for grey literature, and monitored health news Web sites and journal tables of contents to identify potentially eligible trials. Two investigators independently reviewed identified abstracts and full-text articles against a set of a priori inclusion and quality criteria. One investigator abstracted data into an evidence table and a second investigator checked these data. We conducted random effects meta-analyses to estimate the effect size of suicide prevention interventions on suicide attempts, suicidal ideation, depression, and global functioning. We grouped trials into 11 intervention types among three categories (psychotherapy, medication, and enhanced usual care).

Results:

We included 86 articles representing 56 unique studies. Very limited data showed no clear positive or negative immediate (1 to 14 days) effects of suicide risk screening. Limited data suggest that there are screening instruments with acceptable performance characteristics for adults and possibly older adults; however, positive predictive value was below 40 percent in all cases where sensitivity was 80 percent or higher. No effects of treatment were seen on suicide deaths, though reporting was sparse and trials were underpowered for this rare outcome. Psychotherapy reduced the risk of suicide attempts by 32 percent compared with usual care in adults, but did not show a benefit in adolescents, and four of 11 adolescent trials reporting on suicide attempts showed statistically nonsignificant increases in the risk of suicide attempt by 22 percent or more. Depression was improved in both adults (standardized mean difference [SMD], −0.37 [95% CI, −0.55 to −0.19]) and adolescents (SMD, −0.36 [95% CI, −0.63 to −0.08]), but there was little or no consistent effect on suicidal ideation. Other outcomes were sparsely reported. The single trial of lithium in adults was limited by high attrition. Practice-based interventions in primary care settings targeting older adults showed some benefits; however, a variety of other approaches to enhance usual care showed no consistent benefit.

Conclusions:

Suicide screening is of high national importance. It is very difficult, however, to predict who will die from suicide, and there are many inherent difficulties in establishing the effectiveness of treatment to reduce suicide and suicide attempts. Limited evidence suggests that primary care-feasible screening instruments may be able to identify adults at increased risk of suicide, and psychotherapy targeting suicide prevention can be an effective treatment in adults. Evidence was more limited in older adults and adolescents; additional research is urgently needed.

Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma

May 15, 2013 Comments off

Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma

Source: Agency for Healthcare Research and Quality

OBJECTIVES:

To assess efficacy, comparative effectiveness, and harms of psychological, pharmacological, and emerging interventions to prevent posttraumatic stress disorder (PTSD) in adults.

DATA SOURCES:

PubMed®, the Cochrane Library, CINAHL, Embase, PILOTS, International Pharmaceutical Abstracts, PsycINFO®, Web of Science, reference lists of published literature (from January 1, 1980, to July 30, 2012). In addition, we searched various sources for grey literature.

REVIEW METHODS:

Two investigators independently selected, extracted data from, and rated risk of bias of relevant studies. If data were sufficient, we conducted quantitative analyses using random-effects models to estimate pooled effects. We graded strength of evidence (SOE) based on established guidance.

RESULTS:

We included 19 trials with a range of populations exposed to a variety of psychological traumas. Participants suffered from symptoms of PTSD but did not meet diagnostic criteria for PTSD. For most interventions studied, we did not find reliable evidence to support efficacy for the prevention of PTSD or for the reduction of PTSD-related symptom severity. Evidence was sufficient to justify conclusions about three treatments. First, debriefing does not reduce either the incidence or the severity of PTSD or related psychological symptoms in civilian victims of crime, assault, or accident trauma (low SOE). Second, our meta-analyses of three trials showed that, in subjects with acute stress disorder, brief trauma-focused cognitive behavioral therapy (CBT) was more effective than supportive counseling (SC) in reducing the severity of PTSD (moderate SOE). Pooled results did not reach statistical significance for incidence of PTSD, depression symptom severity (both low SOE), and anxiety symptom severity (moderate SOE), but numerically favored CBT over SC. Finally, collaborative care for a traumatic injury requiring hospitalization produces a greater decrease in PTSD symptom severity at 6, 9, and 12 months after injury than does usual care (low SOE). The efficacy of psychological interventions to prevent PTSD did not differ between men and women (low SOE). Evidence was insufficient to determine whether previous depression or a history of child abuse or baseline PTSD symptoms influence the effectiveness of interventions. Evidence was insufficient to determine the effect of timing, intensity, or dosing on the effectiveness or risk of harms of interventions or to justify conclusions about the comparative risk of harms. For emerging interventions such as yoga, dietary supplements, and complementary or alternative interventions, no studies met our eligibility criteria. Evidence was insufficient to determine whether any treatment approaches were more effective for victims of particular trauma types.

CONCLUSIONS:

Evidence supporting the effectiveness of most interventions used to prevent PTSD is lacking. If available in a given setting, brief trauma-focused CBT might be the preferable choice for reducing PTSD symptom severity in persons with acute stress disorder and collaborative care might be preferred for trauma patients requiring surgical hospitalization; by contrast, debriefing appears to be an ineffective intervention to reduce symptoms and prevent PTSD.

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