Archive
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.
What Do We Mean by “Behavioral Health Integrated with Primary Care”?
What Do We Mean by "Behavioral Health Integrated with Primary Care"?
Source: Agency for Healthcare Research and Quality
In this emerging field, like others, it is important to develop shared language that enables communication and collaboration across sites, disciplines, and time. The Academy’s Lexicon is a set of concepts and definitions developed by expert consensus for what we mean by behavioral health and primary care integration—a functional definition —what things look like in practice. This consensus Lexicon enables effective communication and concerted action among clinicians, care systems, health plans, payers, researchers, policymakers, business modelers, and patients working for effective, widespread implementation on a meaningful scale.
The original version of the Academy’s Lexicon was developed through an Agency for Health Research and Quality (AHRQ) small conference grant in 2009 to develop a National Research Agenda for Collaborative Care. Through the planning process for that meeting, it was clear that the experts used the same words to refer to different concepts or practices and struggled to communicate effectively. After the meeting’s pilot work to develop a shared understanding, participants agreed that the Lexicon was an important, even critical, advancement for the field but that it needed further refinement. To that end, AHRQ funded an R-13 grant that enabled C.J. Peek and the University of Minnesota to collaborate with the Academy’s National Integration Advisory Council (NIAC) to provide expert consensus and further refine the Lexicon. The current lexicon is the culmination of that effort.
The Lexicon starts with an executive summary that gives the reader an overview of what is to follow. The pages that follow expand and clarify the content. Appendices include a Glossary of common terms.
Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD)
Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) (PDF)
Source: Agency for Healthcare Research and Quality
Several psychological and pharmacological treatments have at least moderate SOE supporting their efficacy: exposure, CPT, CT, CBT-mixed therapies, EMDR, narrative exposure therapy, fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine.
Allergen-Specific Immunotherapy for the Treatment of Allergic Rhinoconjunctivitis and/or Asthma: Comparative Effectiveness Review
Source: Agency for Healthcare Research and Quality
Objectives.
Allergic rhinitis is highly prevalent in North America, affecting 20 to 40 percent of the population. Nearly 9 percent of Americans suffer from asthma, with more than half having evidence of atopy. This comparative effectiveness review describes the effectiveness and safety of subcutaneous immunotherapy and sublingual immunotherapy (off-label use of subcutaneousaqueous allergens for sublingual desensitization) compared with other therapies for treatment of allergic rhinoconjunctivitis and asthma.
Data sources.
We searched the MEDLINE® , Embase, LILACS, and CENTRAL databases from the beginning of each database through May 21, 2012.
Review methods.
Two reviewers independently selected randomized controlled trials according to established study inclusion criteria. Disagreements were resolved by consensus. Paired reviewers assessed the risk of bias of each study and extracted details about the population, intervention(s), and outcomes of interest. The results were summarized by immunotherapy type (sublingual or subcutaneous), allergen, and outcomes. Studies exclusively enrolling children were reviewed separately. The strength of the body of evidence was graded and summarized.
Results.
We included 74 references that investigated the efficacy and safety of subcutaneous immunotherapy, 60 studies that investigated the efficacy and safety of sublingual immunotherapy, and 8 studies that compared the two modes of delivery. All 142 studies were randomized controlled studies. The majority of studies were at medium risk of bias due to design choices. The strength of evidence is high that subcutaneous immunotherapy reduces asthma symptoms, rhinitis symptoms, conjunctivitis symptoms, asthma medication use, asthma plus rhinoconjunctivitis medication use, and rhinoconjunctivitis-specific quality of life. The strength of evidence is moderate that subcutaneous immunotherapy reduces rhinoconjunctivitis medication use, relative to usual care, which includes pharmacotherapy. Likewise, the strength of evidence is high that sublingual immunotherapy reduces asthma symptoms. The strength of evidence is moderate that sublingual immunotherapy reduces rhinitis/rhinoconjunctivitis symptoms, combined symptom scores, conjunctivitis symptoms, and medication useusage relative to usual care, and improves allergy-specific quality of life. In studies comparing subcutaneous with sublingual immunotherapy, strength of evidence supporting the superiority of subcutaneous immunotherapy for reducing allergic rhinitis and conjunctivitis symptoms, and the superiority of sublingual immunotherapy for reducing medication use, is low. We identified 13 pediatric studies of subcutaneous immunotherapy, 18 pediatric studies of sublingual immunotherapy, and 3 pediatric studies comparing subcutaneous and sublingual immunotherapy. The strength of evidence is moderate that subcutaneous immunotherapy reduces asthma symptoms and rhinitis symptoms in comparison to usual care. The strength of evidence is low that subcutaneous immunotherapy reduces conjunctivitis symptoms, medication scores, combined symptom-medication scores, or improves quality of life relative to usual care. The strength of evidence is high that sublingual immunotherapy reduces asthma symptoms, and moderate that it reduces rhinitis/rhinoconjunctivitis symptoms, combined asthma plus rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and decreases medication use. While local reactions were frequent with both treatment regimens, there were rare reports of anaphylaxis in the subcutaneous immunotherapy studies, and no anaphylaxis reported in the sublingual immunotherapy studies.
Conclusions.
With some variation across outcomes, the overall body of evidence consistently provides moderate to high support for the effectiveness and safety of both subcutaneous and sublingual immunotherapy for the treatment of allergic rhinitis and asthma. The evidence to support the use of immunotherapy in children is somewhat weaker than the evidence supporting its use in adults. The superiority of one route of administration over the other is not known.
Strategies To Prevent Weight Gain Among Adults
Strategies To Prevent Weight Gain Among Adults (PDF)
Source: Agency for Healthcare Research and Quality
Objectives.
Adults tend to gain weight progressively through middle age. Although the average weight gain is 0.5 to 1 kg per year, this modest accumulation of weight can lead to obesity over time. We aimed to compare the effectiveness, safety, and impact on quality of life of strategies to prevent weight gain among adults. Self-management, dietary, physical activity, orlistat and combinations of these strategies were considered.
Data sources.
We searched MEDLINE ® , Embase ® , theCochrane Central Register of Controlled Trials, CINAHL® , and PsycINFO® through June 2012 for published articles that were potentially eligible for this review.
Review methods.
Two reviewers independently reviewed titles, abstracts, and articles, and included English-language articles that reported on maintenance of weight or prevention of weight gain among adults. Studies targeting a combination of weight loss with weight maintenance or weight loss exclusively were considered to be outside of the scope of this review. Trials of interventions and observational studies of approaches with at least 1 year of followup with a weight outcome were included. Data were abstracted on measures of weight, adherence, obesity-related outcomes, safety, and quality of life. The timepoints of interest for weight outcomes were: 1 year, 2 years, 5 years, and the last reported timepoint after 5 years. For the other outcomes, we abstracted data only from the last reported timepoint on or after 1 year. We selected a meaningful difference threshold in addition to a statistically significant threshold (p<0.05) for the outcomes. A meaningful between group difference was defined as 0.5 kg of weight, 0.2 units of BMI (based on a 0.5-kg change for an individual with a BMI of 27), or 1 cm of waist circumference per year of followup. We considered an intervention or approach effective if the difference between groups met the meaningful between group difference threshold and was statistically significant. We qualitatively synthesized the studies by population, intervention, and outcome.
Results.
We included 58 publications (describing 51 studies) involving 555,783 patients. Two interventions may be effective compared with no intervention at preventing weight gain with moderate strengths of evidence: workplace interventions having individual and environmental components and exercise performed at home by women with cancer. Potentially effective interventions with low strength of evidence include a clinic-based program to teach heart rate monitoring, a combination intervention for mothers of young children, small group sessions to educate college women, and physical activity among individuals at risk of cardiovascular disease and diabetes. Potentially effective approaches described in observational studies having low strength of evidence include eating meals prepared at home among college graduates and less television viewing among individuals with colorectal cancer. When reported, adherence to interventions tended to be below 80 percent. There were no adverse events among the few trials that reported on adverse events. Trial study quality tended to be poor due to knowledge of the intervention by the study personnel who measured the weight of the participants or lack of reporting on this item. This lack of blinding of the outcome assessor along with inclusion of studies that were not designed to prevent weight gain resulted in a low strength of evidence for the majority of comparisons.
Conclusions.
The literature provides some, although limited, evidence about interventions and approaches that may prevent weight gain. Although there is not strong evidence to promote a particular weight gain prevention strategy, there is no evidence that not adopting a strategy to prevent weight gain is preferable.
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices
Source: Agency for Healthcare Research and Quality
Objectives. To review important patient safety practices for evidence of effectiveness, implementation, and adoption.
Data sources. Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.
Review methods. The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains:
• How important is the problem?
• What is the patient safety practice?
• Why should this practice work?
• What are the beneficial effects of the practice?
• What are the harms of the practice?
• How has the practice been implemented, and in what contexts?
• Are there any data about costs?
• Are there data about the effect of context on effectiveness?
We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were “strongly encouraged” for adoption, and those practices that were “encouraged” for adoption.
Results. From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least “moderate,” and 25 practices had at least “moderate” evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be “strongly encouraged” for adoption, and an additional 12 practices were classified as those that should be “encouraged” for adoption.
Conclusions. The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.
Developing a Protocol for Observational Comparative Effectiveness Research: A User’s Guide
Developing a Protocol for Observational Comparative Effectiveness Research: A User’s Guide
Source: Agency for Healthcare Research and Quality
Researchers from the Effective Health Care Program’s DEcIDE Network authored this 11-chapter guide that aims to serve as a resource for researchers when developing observational comparative effectiveness research (CER) studies. The user’s guide identifies best practices for designing observational CER studies and standardizes the review of study protocols with checklists in each chapter. Topics in this user’s guide include developing study objectives and questions, study design, data sources, and analysis.
The educator resources, 12 presentations in PowerPoint format, are aligned with each chapter to expand training in these best practices.
Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence
Source: Agency for Healthcare Research and Quality
Objectives.
To assess the effectiveness of interventions that target traumatic stress symptoms and syndromes among children exposed to trauma other than maltreatment or family violence (Key Question 1 [KQ 1]), or children exposed to trauma other than maltreatment or family violence who already have symptoms (KQ 2); to identify subgroup characteristics that moderate the effect of an intervention on outcomes (KQ 3); and to assess harms associated with interventions (KQ 4).
Data sources.
MEDLINE ® , The Cochrane Library, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, and Web of Science. Additional studies were identified from reference lists and technical experts.
Review methods.
Two trained reviewers independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We did not quantitatively analyze our data because of statistical heterogeneity, insufficient numbers of similar studies, or variation in outcome reporting; thus, we synthesized the data qualitatively. KQ 1, KQ 2, and KQ 4 present outcomes categorized by intervention type. KQ 3 presents outcomes of interventions categorized by child characteristics.
Results.
We found a total of 21 trials and 1 cohort study (reported in 25 articles) of either medium or low risk of bias from our review of 6,647 unduplicated abstracts. We did not find studies that attempted to replicate findings of effective interventions; rather, studies tested unique interventions. No pharmacotherapy intervention demonstrated effectiveness. Studies demonstrating improvement in outcomes generally compared results of interventions with waitlist controls. With a single exception, studies comparing interventions with active controls did not show benefit. Some psychotherapy interventions targeting children exposed to trauma appear promising based on the magnitude and precision of effects found. These interventions were school-based treatments with elements of cognitive behavioral therapy (CBT). We found less compelling evidence regarding potentially promising interventions targeting already existing symptoms, each of which also had elements of CBT.
Authors typically evaluated short-term outcomes. The body of evidence provides no insight into how interventions targeting children exposed to trauma, some of whom already have symptoms, might influence healthy long-term development. We found little evidence on how effectiveness might vary by child characteristics and no evidence on how effectiveness might vary by treatment characteristics or setting. We also found almost no evidence on harms associated with psychological treatments. Only pharmacological interventions attempted to assess harms in this vulnerable population.
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care
Source: Agency for Healthcare Research and Quality
Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. A fall may result in fractures, lacerations, or internal bleeding, leading to increased health care utilization. Research shows that close to one-third of falls can be prevented. Fall prevention involves managing a patient’s underlying fall risk factors and optimizing the hospital’s physical design and environment. This toolkit focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program.
National Health Care Expenses in the U.S. Civilian Noninstitutionalized Population, 2010
National Health Care Expenses in the U.S. Civilian Noninstitutionalized Population, 2010 (PDF)
Source: Agency for Healthcare Research and Quality
This Statistical Brief presents estimates of health care expenses by type of service and distributions by payment sources for the U.S. civilian noninstitutionalized population in 2010. Health care expenses, as reported in this Brief, represent payments to hospitals, physicians, and other health care providers based on utilization information collected in the Medical Expenditure Panel Survey (MEPS) Household Component and payment data collected in both the MEPS Household and Medical Provider Components. Expense estimates include amounts paid by individuals, private insurance, Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), and other payment sources. All differences between estimates discussed in the text are statistically significant at the 0.05 level.
Evaluation and Treatment of Cryptorchidism
Evaluation and Treatment of Cryptorchidism (PDF)
Source: Agency for Healthcare Research and Quality
Objectives
We assessed the effectiveness of imaging for identifying and correctly locating testicles, the use of hormonal stimulation for treatment planning and hormones for achieving testicular descent, and choices among surgical treatments, including surgical approach (open vs. laparoscopic).
Data sources
We searched MEDLINE® via PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase, as well as reference lists of included studies.
Review methods
We included studies published in English from January 1980 to February 2012. We included studies of prepubescent males with cryptorchidism. For treatment planning studies, we included all designs except case reports. Imaging studies needed to have confirmatory surgical data. For treatment studies, we required an appropriate comparison arm. We excluded studies of disorders of sexual development or ambiguous genitalia. Two reviewers independently assessed the quality (risk of bias) for each study and the overall strength of the evidence, with discrepancies adjudicated by a third reviewer.
Results
We identified 60 unique studies meeting our review criteria; eight were of good, eight were of fair, and 44 were of poor quality. The accuracy of imaging to identify the presence or absence of testicles was 21 to 76 percent for ultrasonography (US), 42 to 92 percent for magnetic resonance imaging (MRI), 60 percent for computed tomography (CT) scan, and 100 percent for magnetic resonance angiography (MRA) and magnetic resonance venography (MRV). Both US and MRI failed to identify most cases of atrophied testicles. Two studies for a total of 44 boys accurately predicted anorchia using hormonal stimulation testing. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by more than 10 percent. Surgical treatment for cryptorchidism is associated with success rates of testicular descent that range from 33 percent to 100 percent, depending on type of surgery. Weighted averages of success were 78.7 percent for one-stage Fowler-Stephens, 86 percent for two-stage Fowler-Stephens, and 96.4 percent for primary orchiopexy.
Conclusions
The body of the reviewed literature on cryptorchidism comprise primarily fair- and poor-quality studies, which limits our ability to draw definitive conclusions. No specific imaging technique is able to completely identify anorchia or position of the undescended testicles and thus eliminate the need for further surgical evaluation. Accuracy of imaging is related to location of the testicles, with less invasive methods demonstrating poor accuracy for abdominally located testicles and those that are atrophied. Hormonal stimulation testing may predict anorchia, but evidence is insufficient, with only two studies of fewer than 50 participants. Hormonal treatment is marginally effective relative to placebo, but it is successful in some children and has minimal side effects, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for Fowler-Stephens procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.
Interventions for Adolescents and Young Adults With Autism Spectrum Disorders
Interventions for Adolescents and Young Adults With Autism Spectrum Disorders (PDF)
Source: Agency for Healthcare Research and Quality
Few studies have been conducted to assess treatment approaches for adolescents and young adults with ASD, and as such there is very little evidence available for specific treatment approaches in this population; this is especially the case for evidence-based approaches to support the transition of youth with autism to adulthood. Of the small number of studies available, most were of poor quality, which may reflect the relative recency of the field. Five studies, primarily of medical interventions, had fair quality. Behavioral, educational, and adaptive/life skills studies were typically small and short term and suggested some potential improvements in social skills and functional behavior. Small studies suggested that vocational programs may increase employment success for some individuals. Few data are available to support the use of medical or allied health interventions in the adolescent and young adult population. The medical studies that have been conducted focused on the use of medications to address specific challenging behaviors, including irritability and aggression, for which effectiveness in this age group is largely unknown and inferred from studies including mostly younger children.
Treatment Strategies for Women With Coronary Artery Disease
Treatment Strategies for Women With Coronary Artery Disease (PDF)
Source: Agency for Healthcare Research and Quality
Objectives. Although coronary artery disease (CAD) is the leading cause of death for women in the United States, treatment studies to date have primarily enrolled men and may not reflect the benefits and risks that women experience. Our systematic review of the medical literature assessed the comparative effectiveness of major treatment options for CAD specifically in women. The comparisons were (1) percutaneous coronary intervention (PCI) versus fibrinolysis/supportive pharmacologic therapy in ST elevation myocardial infarction (STEMI), (2) early invasive versus initial conservative management in non-ST elevation myocardial infarction (NSTEMI) or unstable angina, and (3) PCI versus coronary artery bypass surgery (CABG) versus optimal medical therapy in stable or unstable angina. The endpoints assessed were clinical outcomes, modifiers of effectiveness by demographic and clinical factors, and safety outcomes.
…
From a limited number of studies reporting results for women separately from the total study population, our findings confirm current practice and evidence for care in one of the three areas evaluated. For women with STEMI, we found that an invasive approach with immediate PCI is superior to fibrinolysis for reducing cardiovascular events, which is similar to findings in previous meta-analyses combining results for both women and men. For women with NSTEMI or unstable angina, evidence suggested that an early invasive approach reduces cardiovascular events; however, it was not statistically significant. Previous meta-analyses of studies comparing early invasive with initial conservative strategies on a combined population of men and women showed a significant benefit of early invasive therapy. We also found that the few trials reporting sex-specific data on revascularization compared with optimal medical therapy for stable angina showed a greater benefit with revascularization for women, while the men in the study fared equally well with either treatment. In contrast, previous meta-analyses that combined results for men and women found similar outcomes for either treatment.
Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting
Objectives: For adults with concomitant depression and chronic medical conditions seen in the primary care setting, to assess the effectiveness of practice-based interventions for improving mental health or medical outcomes.Data Sources: We searched MEDLINE ® , Embase, the Cochrane Library, CINAHL ® , and PsycINFO ® from inception to December 2011. We identified additional studies from reference lists and technical experts.Review Methods: Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews. We conducted quantitative analyses for outcomes when feasible and reported all results by medical condition when possible. Two reviewers graded the strength of evidence (SOE) using established criteria.Results: We included 24 published articles reporting data from 12 studies (9 randomized controlled trials and 3 preplanned subgroup analyses from a tenth trial). Sample sizes ranged from 55 to 1,001, and study duration ranged from 6 to 60 months. Eleven studies were conducted in the United States (1 in Puerto Rico) and 1 in Scotland. All studies characterized their respective intervention as a form of collaborative care compared with usual or enhanced usual care, and generally involved a care manager with physician supervision; we found no studies describing other types of practice-based interventions. Settings of care for included studies, although rarely characterized, included both open and closed systems. All studies specified depression as the targeted mental health condition. Medical conditions included arthritis, cancer, diabetes, heart disease, HIV, and one or more conditions. Our meta-analyses found that intervention recipients achieved greater improvement than controls in depression symptoms, response, remission, and depression-free days (moderate SOE); satisfaction with care (moderate SOE); and mental and physical quality of life (moderate SOE). Few data were available on outcomes for chronic medical conditions, except for diabetes; only one trial used a medical outcome as the primary outcome. Diabetic patients receiving collaborative care exhibited no difference in diabetes control as compared with control groups (change in HbA1c: weighted mean difference 0.13, 95% CI, -0.22 to 0.48 at 6 months; 0.24, 95% CI, -0.14 to 0.62 at 12 months; low SOE).Conclusions: Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with multiple different medical conditions. Few data were available on medical outcomes, except for HbA1c in diabetes, which showed no difference between treatment and usual care. Future studies should be designed to target a broader range of medical conditions, or clusters of conditions, and should compare variations of practice-based interventions in head-to-head trials.
Medicines for Treating Depression: A Review of the Research for Adults
Medicines for Treating Depression: A Review of the Research for Adults
Source: Agency for Healthcare Research and Quality
Antidepressants are only one kind of medicine used to treat depression. They are the most common medicine used for this condition. Your doctor may prescribe other types of medicines to treat depression. This summary will review only the research on antidepressants. It does not review research on non-medicine therapies. The research studies also did not look at patients with bipolar disorder, substance abuse, bulimia nervosa, or schizophrenia.
Trends in Anticonvulsants Utilization and Expenditures for the U.S. Civilian Noninstitutionalized Population, 1999 and 2009
Rising health care costs in general and prescribed medicine costs in particular continue to be a concern for U.S. policymakers and consumers of care. Analyzing down total prescription drug costs into therapeutic classes and subclasses provides decision makers and the public with an understanding of the costs and extent to which specific therapeutic classes and subclasses of drugs are contributing to the upturn in total costs. This Statistical Brief provides trends for one therapeutic subclass of prescribed drugs—anticonvulsants.This Brief presents trends in utilization and expenditures for outpatient prescription anticonvulsants for the years 1999 and 2009. The estimates are for the U.S. civilian noninstitutionalized population and are derived from the 1999 and 2009 Household Component of the Medical Expenditure Panel Survey (MEPS-HC). For outpatient prescription anticonvulsants, the Brief compares, for 1999 and 2009, the number of persons obtaining at least one prescription, total expenditures, and total number of prescriptions, as well as average annual cost per person and average drug cost.Only prescriptions purchased or obtained in an outpatient setting are included in these estimates. Prescription medicines administered in an inpatient setting or in a clinic or physician’s office are excluded. Expenditure estimates are presented in real dollars; estimates for 1999 were inflated to 2009 dollars based on the GDP Price Index (http://www.meps.ahrq.gov/mepsweb/about_meps/ Price_Index.shtml). All differences discussed in the text are statistically significant at the 0.05 level.
Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse
Screening, Behavioral Counseling, and Referral in Primary Care to Reduce Alcohol Misuse
Source: Agency for Healthcare Research and Quality
Alcohol misuse, which includes the full spectrum from drinking above recommended limits (i.e., risky/hazardous drinking) to alcohol dependence, is associated with numerous health and social problems and more than 85,000 deaths per year in the United States and an estimated annual cost to society of more than $220 billion. Alcohol misuse is estimated to be the third leading cause of preventable mortality in the United States following tobacco use and being overweight. Alcohol misuse contributes to a variety of conditions, including hypertension, cirrhosis, gastritis and gastric ulcers, pancreatitis, breast cancer, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment, depression, insomnia, anxiety, and suicide. Excessive alcohol consumption is a major factor in injury and violence.
Though estimating the prevalence of alcohol misuse is challenging, it has been estimated that about 30 percent of the U.S. population is affected, with the majority of these individuals engaging in what is considered risky drinking. Older studies report a range of risky drinkers from 4 to 29 percent across primary care populations, with prevalence estimates of 0.3 to 10.0 percent for harmful drinkers and 2.0 to 9.0 percent for alcohol dependence. More recent data from the American Academy of Family Physicians National Research Network reveal that 21.3 percent of primary care patients reported risky/hazardous drinking (based on the three quantity and frequency questions from the Alcohol Use Disorders Identification Test [AUDIT-C]). Alcohol dependence has lifetime prevalence rates on the order of 17 percent for men and 8 percent for women;16 prevalence of current dependence (within the last 12 months and as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) is approximately 4 percent in the general adult population.17 Some studies have reported that one in five of those who screen positive for unhealthy alcohol use in primary care will have alcohol dependence (four in five will not). Rates of alcohol-use disorders among medical outpatients are similar to those seen in the general population and are generally higher in males and younger people of all races/ethnicities.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed epidemiologically based alcohol-use guidelines to limit risks for drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds. Maximum recommended consumption is three or fewer standard drinks per day (seven per week) for adult women and for anyone older than 65 years of age, and four or fewer standard drinks per day (14 per week) for adult men. A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits. These guidelines do not apply to certain people (such as adolescents, pregnant women, and people with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe.
Disparities Report Highlights Health Care Challenges For Racial and Ethnic Minorities
Disparities Report Highlights Health Care Challenges For Racial and Ethnic Minorities
Source: Agency for Healthcare Research and Quality (AHRQ)
The latest National Healthcare Disparities Report released today by the Agency for Healthcare Research and Quality (AHRQ) shows that access to health care was not improving for most racial and ethnic groups in the years 2002 through 2008 leading up to enactment of the Affordable Care Act.
The data contained in the National Healthcare Disparities Report and the companion National Healthcare Quality Report predate the Affordable Care Act; however, some provisions in the new health care law are aimed at improving health care quality and addressing health care disparities. The HHS Action Plan to Reduce Health Disparities, announced in April 2011, outlines goals and actions HHS will take to reduce health disparities among racial and ethnic minorities, building on important efforts made possible by the Affordable Care Act and other ongoing private-sector and state-led initiatives.
"The health care law’s groundbreaking policies will reduce health disparities identified in the report and help achieve health equity," said Carolyn M. Clancy, M.D. director of AHRQ. "We are releasing the report during National Minority Health Month to raise awareness about the steps being taken to help ensure every American receives safe and appropriate health care to help them achieve their best possible health."
The congressionally mandated disparities and quality reports, which AHRQ has produced annually since 2003, are based on over 40 different national sources that collect data regularly. Today’s reports, which include about 250 health care measures, show the persistent challenges in access to care faced by most racial and ethnic groups. Fifty percent of the measures that tracked disparities in health care access showed no improvement between the years 2002 and 2008, while 40 percent of those measures were getting worse.
Specifically, for 2002 through 2008, Latinos, American Indians and Alaska Natives experienced worse access to care than Whites on more than 60 percent of the access measures, while African Americans experienced worse access on slightly more than 30 percent of the access measures. Asian Americans experienced worse access to care than non-Latino Whites on only 17 percent of the access measures.
Treatment for Glaucoma: Comparative Effectiveness
Treatment for Glaucoma: Comparative Effectiveness (PDF)
Source: Agency for Healthcare Research and Quality
Objectives. Glaucoma is a leading cause of visual impairment and blindness worldwide. Treatment focuses on the reduction of intraocular pressure (IOP), which secondarily prevents worsening of visual field loss; in this way, available treatments may prevent visual impairment and blindness. The objective of this Comparative Effectiveness Review is to summarize the evidence regarding the safety and effectiveness of medical, laser, and other surgical treatments for open-angle glaucoma in adults.
Data Sources. We searched MEDLINE®, Embase, LILACS, and CENTRAL through October 6, 2011 to identify clinical trials. We searched MEDLINE and CENTRAL (from 2009 to March 2, 2011) and screened an existing database to identify relevant systematic reviews.
Review Methods. Two reviewers independently assessed citations for eligibility. One reviewer assessed the risk of bias and extracted descriptions of the study. A second reviewer verified the data. Two reviewers also screened the results for systematic reviews. Details about the eligible systematic reviews were abstracted, including elements related to the methodological rigor.
Results. We identified 23 systematic reviews. Twelve reviews addressed medical treatments, 9 addressed surgical treatment, and 1 compared medical versus surgical treatments. One review addressed different surgical treatments as well as medical versus surgical treatments. We identified 73 RCTs and 13 observational studies addressing adverse effects. We identified no studies that evaluated treatments with regard to their impact on visual impairment. We also found insufficient evidence comparing treatment versus no treatment on patient-reported outcomes. No studies addressed the possible link between intermediate outcomes (IOP, optic nerve structure, or visual field) and visual impairment or patient-reported outcomes. There is moderate evidence that medical and surgical treatments can lower IOP and reduce the risk of progression by both visual field and optic nerve criteria. Among medical treatments, the prostaglandin agents are superior to other classes with regard to lowering IOP. While laser trabeculoplasty decreases IOP, the technology used does not make a difference in pressure lowering. With regard to incisional surgeries, trabeculectomy provides more pressure lowering than the class of nonpenetrating procedures. As expected, incisional surgeries produce more significant side effects than do medical treatments.
Conclusions. We did not find evidence addressing direct or indirect links between glaucoma treatment and visual impairment or patient-reported outcomes. This should be an area of focus in future trials of adequate size and duration to detect differences between treatment groups. However, we did find that a number of medical and surgical treatments clearly lower IOP and can prevent visual field loss and optic nerve damage. While we found direct comparisons between some treatments, there are significant gaps in our knowledge of comparative effectiveness.
Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report
Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report
Source: Agency for Healthcare Research and Quality
This topic is an update to the original topic, “Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis.” Please click on the the title to view the original research review and associated products.
+ Full Document (PDF)
