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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.
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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.

Integrating Primary Care Practices and Community-based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices

July 1, 2014 Comments off

Integrating Primary Care Practices and Community-based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices
Source: Agency for Healthcare Research and Quality

Managing and treating obesity is particularly challenging for primary care practices. Although evidence suggests the potential for improving eating and physical activity behaviors by effectively linking primary care practices and community resources, establishing such linkages may be especially challenging in rural areas, where limited availability of and access to services may compound standard barriers.

In 2010 the Oregon Rural Practice-based Research Network (ORPRN) received funding from the Agency for Health Care Research and Quality for research into “Integrated Primary Care Practices and Community-based Programs to Manage Obesity.” Over a 2-year period we worked with eight primary care practices and community-based health coalitions in four rural Oregon communities to:

  1. Evaluate local clinic and community factors necessary to develop sustainable linkages between primary care and community resources for obesity management.
  2. Design, implement, and evaluate a participatory process using practice facilitation and community-health development principles to achieve these linkages.

We used the findings from this 2-year process to develop this toolkit to help other primary care clinics that want to improve linkages with community-based resources for obesity management. This process highlights strategies to build on the ties that often already exist in rural areas. Although our process is tailored to rural settings, we anticipate that many of the strategies will be beneficial for urban practices and communities to consider. This toolkit offers key steps in our process, providing tools and recommended steps that we encourage you to adapt to fit your local setting.

Complicating Conditions Associated With Childbirth, by Delivery Method and Payer, 2011

June 24, 2014 Comments off

Complicating Conditions Associated With Childbirth, by Delivery Method and Payer, 2011
Source: Agency for Healthcare Research and Quality

Childbirth is the most prevalent reason for hospitalization in the United States. Of the 4.1 million hospital stays in 2009 involving childbirth, 91.3 percent of vaginal and 99.9 percent of cesarean section deliveries had at least one complicating condition. These conditions range in severity and may include those that are preexisting, such as mental health disorders; those that create risk factors, such as multiple gestation; and those that may lead to complications of care, such as an abnormality of fetal heart rate or rhythm.

In the United States, childbirth accounts for about 10 percent of all maternal hospital stays and $12.4 billion in hospitalization costs for live births; it represents, in the aggregate, one of the most costly conditions for inpatient hospital care. The average cost of a vaginal birth in 2008 was $2,900 without complications and $3,800 with complications. The average cost of a cesarean section was $4,700 without complications and $6,500 with complications.

A recent report from the Centers for Disease Control and Prevention analyzed and compared 2010 payment source data from U.S. birth certificates and the National Hospital Discharge Survey. Results showed that the most common payment source for deliveries was private insurance. However, in the past decade, privately insured deliveries have declined by 16 percent, while Medicaid-covered deliveries have increased by 40 percent.6 Type of insurance may influence the prevalence of interventions (e.g., induction of labor, cesarean section) associated with a complicating condition and mode of delivery.

This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) on the source of payment for pregnancy and childbirth hospitalizations with complicating conditions versus without complicating conditions by mode of delivery in 2011. We examine stays for vaginal and cesarean section deliveries and compare rates of complicating conditions by expected payer type (Medicaid versus private insurance). All data are reported from the maternal perspective (i.e., reflecting the experience of the mother, not the newborn) among women who had a hospital delivery in 2011.

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital

June 23, 2014 Comments off

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital
Source: Agency for Healthcare Research and Quality

Summary
In 2009, the Massachusetts Department of Public Health became the first State to ban ambulance diversions—a practice in which a crowded emergency department temporarily stops accepting patients who are transported by ambulance, instead sending them to other nearby emergency departments. To make implementation of the ban as smooth as possible, the Department of Public Health gave hospitals 6 months advance notice, provided general guidance on how hospitals could improve overall patient flow (thereby reducing crowding), and offered administrators frequent opportunities to ask questions and seek guidance on implementation. Despite fears that the ban would lead to increased emergency department crowding and ambulance delays, the steps hospitals took to improve patient flow in the wake of the ban prevented such problems. At nine Boston-area hospitals, emergency department length of stay for patients subsequently admitted to the hospital fell, as did ambulance turnaround time (i.e., how long the ambulance spends at the hospital before returning to service). Emergency department leaders strongly support the ban, believing it has improved patient care, strengthened relationships among health care staff, and increased patient satisfaction.

Evidence Rating
Moderate: The evidence consists of pre- and post-implementation comparisons of length of stay for patients in the emergency department and ambulance turnaround times, along with post-implementation feedback from emergency department leaders about their impressions of the impact of the ban.

Developing Organizations
Massachusetts Department of Public Health

Use By Other Organizations
In King County, WA, 18 emergency departments voluntarily agreed to halt diversions in 2011.

Date First Implemented
2009

A Robust Health Data Infrastructure

May 12, 2014 Comments off

A Robust Health Data Infrastructure (PDF)
Source: Agency for Healthcare Research and Quality

The two overarching goals of moving to the electronic exchange of health information are improved health care and lower health care costs. Whether either, or both, of these goals can be achieved remains to be seen, and the challenges are immense. Health care is one of the largest segments of the US economy, approaching 20% of GDP. Despite the obvious technological aspects of modern medicine, it is one of the last major segments of the economy to become widely accepting of digital information technology, for a variety of practical and cultural reasons. That said, the adoption of electronic records in medicine has been embraced, particularly by health care administrators in the private sector and by the leaders of agencies of the federal and state governments with responsibility for health care. Although the transition to electronic records now seems a foregone conclusion, it is beset by many challenges, and the form and speed of that transition is uncertain. Furthermore, there are questions about whether that transition will actually improve the quality of life, in either a medical or economic sense.

Transitioning Newborns from NICU to Home: A Resource Toolkit

April 29, 2014 Comments off

Transitioning Newborns from NICU to Home: A Resource Toolkit
Source: Agency for Healthcare Research and Quality

This toolkit includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.

Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting.

This manual is designed to be adapted for any institution that cares for fragile newborn infants.

Children’s Dental Care: Advice and Visits, Ages 2-17, 2011

April 28, 2014 Comments off

Children’s Dental Care: Advice and Visits, Ages 2-17, 2011
Source: Agency for Healthcare Research and Quality

In 2011, 52.1 percent of children between the ages of 2 and 17 were offered advice from a doctor or other health provider about the need for routine dental checkups. In terms of actually receiving dental care, 50.5 percent of the children had at least one visit to the dentist during 2011.

Attitudes toward Health Insurance and Their Persistence over Time, Adults, 2001–2011

April 21, 2014 Comments off

Attitudes toward Health Insurance and Their Persistence over Time, Adults, 2001–2011
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,” in contrast to only 9.0 percent of adults in the prior decade (2001). In addition, 24.3 percent of adults agreed with the statement “Health insurance is not worth the money it costs” in 2011 relative to 21.8 percent of adults in 2001.

An examination of the persistence in attitudes over a two-year interval also revealed substantial shifts in preferences within individuals over time. For years 2010 and 2011, 12.6 percent of the same individuals indicated “health insurance is not worth the money it costs” in both years, in contrast to 9.8 percent for the 2001–2002 period. In addition, 5.2 percent of the same individuals indicated “I’m healthy enough that I really don’t need health insurance” in 2010 and 2011 in contrast to 3.2 percent for 2001–2002.

In both 2001 and 2011, uninsured adults ages 18–64 were substantially more likely to indicate they were healthy and did not need health insurance, relative to their insured counterparts. They were also more likely to indicate that health insurance was not worth its cost, relative to those with coverage.

The Five Most Costly Children’s Conditions, 2011: Estimates for U.S. Civilian Noninstitutionalized Children, Ages 0-17

April 17, 2014 Comments off

The Five Most Costly Children’s Conditions, 2011: Estimates for U.S. Civilian Noninstitutionalized Children, Ages 0-17
Source: Agency for Healthcare Research and Quality

This Statistical Brief presents data from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) regarding medical expenditures associated with the top five most costly conditions for children in 2011. These top five conditions–mental disorders; asthma/chronic obstructive pulmonary disease (COPD); trauma-related disorders; acute bronchitis and upper respiratory infections (URI); and otitis media (ear infections)–were determined by totaling and ranking the expenses for all medical care delivered in 2011.

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.

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.

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