Evidence report/technology assessment最新文献

Objective: To estimate the overall balance of harms and benefits from the potential use of oral contraceptives (OCs) for the primary prevention of ovarian cancer

Data sources: We searched PubMed®, Embase®, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov for English-language studies published from January 1990 to June 2012 that evaluated the potential benefits (reduction in ovarian, colorectal, and endometrial cancers) and harms (increase in breast and cervical cancer, and vascular complications) of OC use.

Review methods: Two investigators screened each abstract and full-text article for inclusion; the investigators abstracted data, and they performed quality ratings, applicability ratings, and evidence grading. Random-effects models were used to compute summary estimates of effects. A simulation model was used to estimate the effects of OC use on the overall balance of benefits and harms.

Results: We reviewed 55 studies relevant to ovarian cancer outcomes, 66 relevant to other cancers, and 50 relevant to vascular events. Ovarian cancer incidence was significantly reduced in OC users (OR [odds ratio], 0.73; 95% CI [confidence interval], 0.66 to 0.81), with greater reductions seen with longer duration of use. Breast cancer incidence was slightly but significantly increased in OC users (OR, 1.08; 95% CI, 1.00 to 1.17), with a significant reduction in risk as time since last use increased. The risk of cervical cancer was significantly increased in women with persistent human papillomavirus infection who used OCs, but heterogeneity prevented a formal meta-analysis. Incidences of both colorectal cancer (OR, 0.86; 95% CI, 0.79 to 0.95) and endometrial cancer (OR, 0.57; 95% CI, 0.43 to 0.76) were significantly reduced by OC use. The risk of vascular events was increased in current OC users compared with nonusers, although the increase in myocardial infarction was not statistically significant. The overall strength of evidence for ovarian cancer prevention was moderate to low, primarily because of the lack of randomized trials and inconsistent reporting of important characteristics of use, such as duration. The simulation model predicted that the combined increase in risk of breast and cervical cancers and vascular events was likely to be equivalent to or greater than the decreased risk in ovarian cancer, although the harm/benefit ratio was much more favorable when protection against endometrial and colorectal cancers was added, resulting in net gains in life expectancy of approximately 1 month.

Conclusions: There is insufficient evidence to recommend for or against the use of OCs solely for the primary prevention of ovarian cancer. Although the net effects of the current patterns of OC use likely result in increased life expectancy when other noncontraceptive benefits are included, the harm/benefit ratio for ovarian cancer

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.

Objectives: To update the Agency for Healthcare Research and Quality (AHRQ) Evidence Report Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6-Prevention of Healthcare-Associated Infections on quality improvement (QI) strategies to increase adherence to preventive interventions and/or reduce infection rates for central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), surgical site infections (SSI), and catheter-associated urinary tract infections (CAUTI).

Data sources: MEDLINE®, CINAHL®, and Embase® were searched from January 2006 to January 2012 for English-language studies with sample size ≥100 patients, a defined baseline period, and reported statistical analysis for adherence and/or infection rates. Articles from the previous report were screened and those meeting selection criteria were included.

Review methods: We sought studies that evaluated the following QI strategies to improve adherence to evidence-based preventive interventions and/or reduce healthcare-associated infection (HAI) rates: audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems. Data were abstracted by a single reviewer and fact-checked by a second. Outcomes were adherence to preventive interventions, infection rates, adverse outcomes, and cost savings. Study quality was assessed using relative rankings based on study design, adequacy of statistical analysis, length of followup, reporting and analysis of baseline and postintervention adherence and infection rates, and implementation of the intervention independent of other QI efforts. Combinations of QI strategies were assessed, not individual strategies. Strength of evidence was judged according to the AHRQ Methods Guide.

Results: Sixty-one articles yielded 71 analyses at the infection level, including 9 articles (10 analyses) from the 2007 report, which evaluated the use of one or more QI strategies to improve adherence or infection rates and also controlled for confounding or secular trend. Twenty-six analyses were performed on CLABSI, 19 on VAP, 15 on SSI, and 11 on CAUTI. There were 34 analyses on adherence, of which 31 (91%) showed significant improvement. There were 63 analyses of infection rates, of which 42 (67%) showed significant improvement.

Conclusions: There is moderate strength of evidence across all four infections that both adherence and infection rates improve when either audit and feedback plus provider reminder systems or audit and feedback alone is added to the base strategies of organizational change and provider education. There is low strength of evidence that adherence and infection rates improve when provider reminder systems alone are added to the base strategies. There was insufficient evidence for reduction

Objective: To examine how health care outcomes for general medical care have been assessed for people with disabilities within the rubrics of care coordination and quality improvement.

Data sources: MEDLINE®, PsychINFO, ERIC, and CIRRIE through March 27, 2012; hand searches of references from relevant literature and journals. A search of high-quality gray literature sources was also conducted.

Review methods: We included all forms of disability except severe and persistent mental illness for all age groups in outpatient and community settings. We focused on outcomes, patient experience, and care coordination process measures. We looked for generic outcome measures rather than disability-condition-specific measures. We also looked for examples of outcomes used in the context of disability as a complicating condition for a set of basic service needs relevant to the general population, and secondary conditions common to disability populations. Two independent reviewers screened all articles; disagreements were resolved through consensus. Included articles were abstracted to evidence tables and quality-checked by a second reviewer. Data synthesis was qualitative.

Results: A total of 15,513 articles were screened; 15 articles were included for general outcome measures and 44 studies for care coordination. A large number of outcome measures have been critically assessed and mapped to the International Classification of Functioning, Disability and Health. We found no eligible studies of basic medical needs or secondary conditions that examined mixed populations of disabled and nondisabled participants for disability as a complicating condition. Care coordination literature for people with disabilities is relatively new and focuses on initial implementation of interventions rather than assessing the quality of the implementation.

Conclusions: We found very few direct examples of work conducted from the perspective of disability as a complicating condition. The sparse literature indicates the early stages of research development. Capturing the disability perspective will require collaboration and coordination of measurement efforts across medical interventions, rehabilitation, and social support provision.

Objective: To systematically review the evidence on the effectiveness of health care and palliative care interventions to improve outcomes for patients with advanced and serious illness.

Data sources: We searched MEDLINE®, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through 2011. We identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts.

Review methods: We developed questions in collaboration with technical experts. We excluded retrospective and uncontrolled studies. Two investigators independently screened search results and abstracted data from eligible studies. We adapted previous frameworks to categorize included studies (e.g., by improvement target, setting). Because many studies did not report effect sizes and almost all studies were small (lt 200 studies), in order to be able to quantitatively describe the literature, we calculated the percentage of studies with a significant improvement in outcomes with the intervention compared to control group for each category. We also checked that all other studies did not report significant results in the opposite direction and checked that there were not differences between larger and smaller studies.

Results: We included 90 studies described in 96 articles. Of the 23 studies targeting continuity, coordination, and transitions, 33 percent of studies that evaluated quality of life as an outcome, 67 percent that evaluated patient satisfaction, and 31 percent that evaluated health care utilization (admissions and length of stay) found a statistically significant improvement with the intervention. Of the 21 studies targeting pain, almost all focused on patient education and self-management; 48 percent of them found a statistically significant improvement with the intervention. Findings for larger (>100) and smaller (le 100) studies were similar. For distress, only 29 percent of the seven included studies found a statistically significant impact. Of the 20 studies in communication and decisionmaking, only 22 percent of studies addressing patient or family satisfaction found a statistically significant improvement for this outcome, compared to 73 percent for the outcome of health care utilization. We found only two studies within hospice programs, both of which found a statistically significant improvement in at least one outcome; nine studies were in nursing homes, 78 percent of which demonstrated a significant improvement with the intervention. In terms of types of quality improvement, for the target of continuity, studies including patient-centered quality improvement types, such as education and self-management, had the strongest evidence of effectiveness on patient- and family-centered domains such as satisfaction and quality of life. Studies of provider-focused interventions (e.g., education, reminders) were more likely to have an impact

Background: There is uncertainty as to the optimal approach for screening and diagnosis of gestational diabetes mellitus (GDM). Based on systematic reviews published in 2003 and 2008, the U.S. Preventive Services Task Force concluded that there was insufficient evidence upon which to make a recommendation regarding routine screening of all pregnant women.

Objectives: (1) Identify properties of screening tests for GDM, (2) evaluate benefits and harms of screening for GDM, (3) assess the effects of different screening and diagnostic thresholds on outcomes for mothers and their offspring, and (4) determine the benefits and harms of treatment for a diagnosis of GDM.

Data sources: We searched 15 electronic databases from 1995 to May 2012, including MEDLINE and Cochrane Central Register of Controlled Trials (which contains the Cochrane Pregnancy and Childbirth Group registry); gray literature; Web sites of relevant organizations; trial registries; and reference lists.

Methods: Two reviewers independently conducted study selection and quality assessment. One reviewer extracted data, and a second reviewer verified the data. We included published randomized and nonrandomized controlled trials and prospective and retrospective cohort studies that compared any screening or diagnostic test with any other screening or diagnostic test; any screening with no screening; women who met various thresholds for GDM with those who did not meet various criteria, where women in both groups did not receive treatment; any treatment for GDM with no treatment. We conducted a descriptive analysis for all studies and meta-analyses when appropriate. Key outcomes included preeclampsia, maternal weight gain, birth injury, shoulder dystocia, neonatal hypoglycemia, macrosomia, and long-term metabolic outcomes for the child and mother.

Results: The search identified 14,398 citations and included 97 studies (6 randomized controlled trials, 63 prospective cohort studies, and 28 retrospective cohort studies). Prevalence of GDM varied across studies and diagnostic criteria: American Diabetes Association (75 g) 2 to 19 percent; Carpenter and Coustan 3.6 to 38 percent; National Diabetes Data Group 1.4 to 50 percent; and World Health Organization 2 to 24.5 percent. Lack of a gold standard for the diagnosis of GDM and little evidence about the accuracy of screening strategies for GDM remain problematic. The 50 g oral glucose challenge test with a glucose threshold of 130 mg/dL versus 140 mg/dL improves sensitivity and reduces specificity. Both thresholds have high negative predictive values (NPV) but variable positive predictive values (PPVs) across a range of prevalence. There was limited evidence for the screening of GDM diagnosed less than 24 weeks' gestation (three studies). One study compared the International Association of Diabetes in Pregnancy Study Groups' (IADPSG) diagn

Objectives: To assess the effectiveness of patient, provider, and systems interventions (Key Question [KQ] 1) or policy interventions (KQ 2) in improving medication adherence for an array of chronic health conditions. For interventions that are effective in improving adherence, we then assessed their effectiveness in improving health, health care utilization, and adverse events.

Data sources: MEDLINE®, the Cochrane Library. Additional studies were identified from reference lists and technical experts.

Review methods: Two people independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We synthesized the evidence for effectiveness separately for each clinical condition, and within each condition, by type of intervention. We also evaluated the prevalence of intervention components across clinical conditions and the effectiveness of interventions for a range of vulnerable populations. Two reviewers graded the strength of evidence using established criteria.

Results: We found a total of 62 eligible studies (58 trials and 4 observational studies) from our review of 3,979 abstracts. These studies included patients with diabetes, hyperlipidemia, hypertension, heart failure, myocardial infarction, asthma, depression, glaucoma, multiple sclerosis, musculoskeletal diseases, and multiple chronic conditions. Fifty-seven trials of patient, provider, or systems interventions (KQ 1) evaluated 20 different types of interventions; 4 observational studies and one trial of policy interventions (KQ 2) evaluated the effect of reduced out-of-pocket expenses or improved prescription drug coverage. We found the most consistent evidence of improvement in medication adherence for interventions to reduce out-of-pocket expenses or improve prescription drug coverage, case management, and educational interventions across clinical conditions. Within clinical conditions, we found the strongest support for self-management of medications for short-term improvement in adherence for asthma patients; collaborative care or case management programs for short-term improvement of adherence and to improve symptoms for patients taking depression medications; and pharmacist-led approaches for hypertensive patients to improve systolic blood pressure.

Conclusions: Diverse interventions offer promising approaches to improving medication adherence for chronic conditions, particularly for the short term. Evidence on whether these approaches have broad applicability for clinical conditions and populations is limited, as is evidence regarding long-term medication adherence or health outcomes.

Objective: This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care.

Data sources: We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO.

Review methods: All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision.

Results: Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men.

Conclusions: The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventio

Background: "Bundled payment" is a method in which payments to health care providers are related to the predetermined expected costs of a grouping, or "bundle," of related health care services. The intent of bundled payment systems is to decrease health care spending while improving or maintaining the quality of care.

Purpose: To systematically review studies of the effects of bundled payment on health care spending and quality, and to examine key design and contextual features of bundled payment programs and their association with program effectiveness.

Data sources: Electronic literature search of PubMed® and the Cochrane Library for studies published between 1985 and 2011.

Study selection: Title and abstract review followed by full-text review to identify studies that assessed the effect of bundled payment on health care spending and/or quality.

Data extraction: Two authors independently abstracted data on study design, intervention design, context, comparisons, and findings. Reviewers rated the strength of individual studies as well as the strength and applicability of the body of evidence overall. Differences between reviewers were reconciled by consensus. Studies were categorized by bundled payment program and narratively summarized.

Data synthesis: We reviewed 58 studies, excluding studies of the Medicare Inpatient Prospective Payment System, for which we reviewed 4 review articles. Most studies (57 of 58) were observational or descriptive; 1 study employed randomization of providers, and none employed random assignment of patients to treatment and control groups. The included studies examined 20 different bundled payment interventions, 16 of which focused on single institutional providers. The introduction of bundled payment was associated with: (1) reductions in health care spending and utilization, and (2) inconsistent and generally small effects on quality measures. These findings were consistent across different bundled payment programs and settings, but the strength of the body of evidence was rated as low, due mainly to concerns about bias and residual confounding. Insufficient evidence was available to identify the influence of key design factors and most contextual factors on bundled payment effects.

Limitations: Most of the bundled payment interventions studied in reviewed articles (16/20) were limited to payments to single institutional providers (e.g., hospitals, skilled nursing facilities) and so have limited generalizability to newer programs including multiple provider types and/or multiple providers. Exclusion criteria and the search strategy we used may have omitted some relevant studies from the results. The review is limited by the quality of the underlying studies. The interventions studied were often incompletely described in the reviewed articles.

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