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Viswanathan M, Rains C, Hart LC, Doran E, Sathe N, Hudson K, Ali R, Jonas DE, Chou R, Zolotor AJ. Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2024; 331:959-971. [PMID: 38502070 DOI: 10.1001/jama.2024.0276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Importance Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Caroline Rains
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Laura C Hart
- Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus
| | - Emma Doran
- Univerisity of North Carolina at Chapel Hill
| | - Nila Sathe
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Kesha Hudson
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Rania Ali
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- The Ohio State University College of Medicine, Columbus
| | - Roger Chou
- Oregon Health & Science University, Portland
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McPheeters M, O'Connor EA, Jonas DE. Pharmacotherapy for Alcohol Use Disorder-Reply. JAMA 2024; 331:800. [PMID: 38441584 DOI: 10.1001/jama.2023.28405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
| | | | - Daniel E Jonas
- Department of Internal Medicine, Ohio State University, Columbus
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Seiber EE, Garrity K, Moon KJ, Jankowski E, Nawaz S, Garner JA, Headings A, Jonas DE, Clark A, Bose-Brill S, Shrodes JC, Hoseus J, Baker C, McAlearney AS, Hefner JL, Joseph JJ, Vallangeon D, Walker DM. Sustainability of Social Needs Resolution Interventions: A Call to Consider Cost. Am J Prev Med 2024:S0749-3797(24)00022-9. [PMID: 38272244 DOI: 10.1016/j.amepre.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Eric E Seiber
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA; Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, OH, USA.
| | - Katharine Garrity
- Division of Medical Dietetics, School of Health and Rehabilitation Sciences, Ohio State University College of Medicine, Columbus, OH, USA
| | - Kyle J Moon
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
| | - Emma Jankowski
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA
| | - Saira Nawaz
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, OH, USA; Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, OH, USA
| | - Jennifer A Garner
- Division of Medical Dietetics, School of Health and Rehabilitation Sciences, Ohio State University College of Medicine, Columbus, OH, USA; John Glenn College of Public Affairs, Ohio State University, Columbus, OH, USA
| | - Amy Headings
- The Mid-Ohio Food Collective, Columbus, Ohio, USA
| | - Daniel E Jonas
- Division of General Internal Medicine, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, OH, USA
| | - Aaron Clark
- Department of Family and Community Medicine, Ohio State University College of Medicine, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer C Shrodes
- Division of General Internal Medicine, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, OH, USA
| | - Jenelle Hoseus
- Health Impact Ohio, Columbus, Ohio, United States of America
| | - Carrie Baker
- Health Impact Ohio, Columbus, Ohio, United States of America
| | - Ann Scheck McAlearney
- Department of Family and Community Medicine, Ohio State University College of Medicine, Columbus, OH, USA; Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer L Hefner
- Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, OH, USA
| | - Joshua J Joseph
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dana Vallangeon
- Ohio Association of Community Health Centers, Columbus, OH, USA
| | - Daniel M Walker
- Department of Family and Community Medicine, Ohio State University College of Medicine, Columbus, OH, USA; Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), Ohio State University College of Medicine, Columbus, OH, USA
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Malhotra S, Hyer JM, Dalmacy D, Hayes D, Tumin D, Kirkby SE, Jonas DE, Bose-Brill S, Li SS. Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population. J Cyst Fibros 2024:S1569-1993(23)01698-3. [PMID: 38220475 DOI: 10.1016/j.jcf.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/16/2023] [Accepted: 11/22/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.
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Affiliation(s)
- Sankalp Malhotra
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - J Madison Hyer
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States; Secondary Data Core, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Djhenne Dalmacy
- Center for Biostatistics, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States; Secondary Data Core, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Stephen E Kirkby
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Daniel E Jonas
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States
| | - Susan S Li
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 3691 Ridge Mill Drive, Hilliard, Columbus, OH 43026, United States; Department of Internal Medicine, University of South Carolina School of Medicine Greenville, 1809 Wade Hampton Blvd, Ste. 120, Greenville, SC 29609, United States.
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McPheeters M, O’Connor EA, Riley S, Kennedy SM, Voisin C, Kuznacic K, Coffey CP, Edlund MD, Bobashev G, Jonas DE. Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis. JAMA 2023; 330:1653-1665. [PMID: 37934220 PMCID: PMC10630900 DOI: 10.1001/jama.2023.19761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 09/12/2023] [Indexed: 11/08/2023]
Abstract
Importance Alcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality. Objective To compare efficacy and comparative efficacy of therapies for alcohol use disorder. Data Sources PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023. Study Selection For efficacy outcomes, randomized clinical trials of at least 12 weeks' duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included. Data Extraction and Synthesis Two reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit. Main Outcomes and Measures The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms. Results Data from 118 clinical trials and 20 976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, -4.99 days; 95% CI, -9.49 to -0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo. Conclusions and Relevance In conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.
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Affiliation(s)
- Melissa McPheeters
- RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | | | - Sean Riley
- RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Sara M. Kennedy
- RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Christiane Voisin
- RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- Department of Internal Medicine, The Ohio State University, Columbus
| | | | - Cory P. Coffey
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Mark D. Edlund
- RTI International, Research Triangle Park, North Carolina
| | | | - Daniel E. Jonas
- RTI International–University of North Carolina at Chapel Hill Evidence-Based Practice Center, Chapel Hill
- Department of Internal Medicine, The Ohio State University, Columbus
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6
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Jonas DE, Riley SR, Lee LC, Coffey CP, Wang SH, Asher GN, Berry AM, Williams N, Balio C, Voisin CE, Kahwati LC. Screening for Latent Tuberculosis Infection in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 329:1495-1509. [PMID: 37129650 DOI: 10.1001/jama.2023.3954] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Importance Latent tuberculosis infection (LTBI) can progress to active tuberculosis disease, causing morbidity and mortality. Objective To review the evidence on benefits and harms of screening for and treatment of LTBI in adults to inform the US Preventive Services Task Force (USPSTF). Data Sources PubMed/MEDLINE, Cochrane Library, and trial registries through December 3, 2021; references; experts; literature surveillance through January 20, 2023. Study Selection English-language studies of LTBI screening, LTBI treatment, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of LTBI screening and treatment for public health surveillance or disease management were excluded. Data Extraction and Synthesis Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when a sufficient number of similar studies were available. Main Outcomes and Measures Screening test accuracy; development of active tuberculosis disease, transmission, quality of life, mortality, and harms. Results A total of 113 publications were included (112 studies; N = 69 009). No studies directly evaluated the benefits and harms of screening. Pooled estimates for sensitivity of the TST were 0.80 (95% CI, 0.74-0.87) at the 5-mm induration threshold, 0.81 (95% CI, 0.76-0.87) at the 10-mm threshold, and 0.60 (95% CI, 0.46-0.74) at the 15-mm threshold. Pooled estimates for sensitivity of IGRA tests ranged from 0.81 (95% CI, 0.79-0.84) to 0.90 (95% CI, 0.87-0.92). Pooled estimates for specificity of screening tests ranged from 0.95 to 0.99. For treatment of LTBI, a large (n = 27 830), good-quality randomized clinical trial found a relative risk (RR) for progression to active tuberculosis at 5 years of 0.35 (95% CI, 0.24-0.52) for 24 weeks of isoniazid compared with placebo (number needed to treat, 112) and an increase in hepatotoxicity (RR, 4.59 [95% CI, 2.03-10.39]; number needed to harm, 279). A previously published meta-analysis reported that multiple regimens were efficacious compared with placebo or no treatment. Meta-analysis found greater risk for hepatotoxicity with isoniazid than with rifampin (pooled RR, 4.22 [95% CI, 2.21-8.06]; n = 7339). Conclusions and Relevance No studies directly evaluated the benefits and harms of screening for LTBI compared with no screening. TST and IGRAs were moderately sensitive and highly specific. Treatment of LTBI with recommended regimens reduced the risk of progression to active tuberculosis. Isoniazid was associated with higher rates of hepatotoxicity than placebo or rifampin.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Sean R Riley
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Lindsey C Lee
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Cory P Coffey
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Shu-Hua Wang
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
- Global One Health Initiative, The Ohio State University, Columbus
| | - Gary N Asher
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Anne M Berry
- Department of Family Medicine, University of North Carolina at Chapel Hill
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina
| | - Niketa Williams
- Department of Family Medicine, University of North Carolina at Chapel Hill
- North Carolina Department of Health and Human Services, Division of Public Health, Raleigh
| | - Casey Balio
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- Center for Rural Health Research, East Tennessee State University, Johnson City
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park
- RTI International, Research Triangle Park, North Carolina
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Walker DM, Garner JA, Hefner JL, Headings A, Jonas DE, Clark A, Bose-Brill S, Nawaz S, Seiber E, McAlearney AS, Brock G, Zhao S, Reopell L, Coovert N, Shrodes JC, Spees C, Sieck CJ, Di Tosto G, DePuccio M, Williams A, Hoseus J, Baker C, Brown MM, Joseph JJ. Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study. Contemp Clin Trials 2023; 130:107212. [PMID: 37121390 DOI: 10.1016/j.cct.2023.107212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN 2 × 2 factorial design. INTERVENTIONS Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS gov: NCT05472441.
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Affiliation(s)
- Daniel M Walker
- The Ohio State University College of Medicine, Columbus, OH, United States of America.
| | - Jennifer A Garner
- The School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, United States of America; The John Glenn College of Public Affairs, The Ohio State University, Columbus, OH, United States of America
| | - Jennifer L Hefner
- The Ohio State University College of Public Health, Columbus, OH, United States of America
| | - Amy Headings
- The Mid-Ohio Food Collective, Columbus, OH, United States of America
| | - Daniel E Jonas
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Aaron Clark
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Seuli Bose-Brill
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Saira Nawaz
- The Ohio State University College of Public Health, Columbus, OH, United States of America
| | - Eric Seiber
- The Ohio State University College of Public Health, Columbus, OH, United States of America
| | - Ann Scheck McAlearney
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Guy Brock
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Songzhu Zhao
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Luiza Reopell
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Nicolette Coovert
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Jennifer C Shrodes
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Colleen Spees
- The Ohio State University College of Medicine, Columbus, OH, United States of America; The School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Cynthia J Sieck
- Dayton Children's Hospital Center for Health Equity, Dayton, OH, United States of America
| | - Gennaro Di Tosto
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Matthew DePuccio
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Amaris Williams
- The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Jenelle Hoseus
- Health Impact Ohio, Columbus, OH, United States of America
| | - Carrie Baker
- Health Impact Ohio, Columbus, OH, United States of America
| | | | - Joshua J Joseph
- The Ohio State University College of Medicine, Columbus, OH, United States of America
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Asher GN, Feltner C, Harrison WN, Schwimmer E, Rains C, Jonas DE. Serologic Screening for Genital Herpes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 329:510-512. [PMID: 36786798 PMCID: PMC9929693 DOI: 10.1001/jama.2022.20356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/11/2022] [Indexed: 02/15/2023]
Abstract
This systematic review to support the 2023 US Preventive Services Task Force Recommendation Statement on serologic screening for genital herpes summarizes published evidence on the benefits and harms of screening and interventions for genital herpes in asymptomatic sexually active adolescents, adults, and pregnant persons with no clinical history of genital herpes.
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Affiliation(s)
- Gary N. Asher
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Wade N. Harrison
- Department of Pediatrics, University of North Carolina at Chapel Hill
| | - Emmanuel Schwimmer
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Caroline Rains
- RTI International, Research Triangle Park, North Carolina
| | - Daniel E. Jonas
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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Feltner C, Wallace IF, Aymes S, Cook Middleton J, Hicks KL, Schwimmer M, Baker C, Balio CP, Moore D, Voisin CE, Jonas DE. Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1951-1971. [PMID: 36378203 DOI: 10.1001/jama.2022.18357] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
IMPORTANCE Obstructive sleep apnea (OSA) is associated with adverse health outcomes. OBJECTIVE To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force. DATA SOURCES PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022. STUDY SELECTION English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials. MAIN OUTCOMES AND MEASURES Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms. RESULTS Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg). CONCLUSIONS AND RELEVANCE The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shannon Aymes
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Kelli L Hicks
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Manny Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey P Balio
- Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City
| | - Daniel Moore
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
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Clark SD, Reuland DS, Brenner AT, Jonas DE. Effect of Incidental Findings Information on Lung Cancer Screening Intent: a Randomized Controlled Trial. J Gen Intern Med 2022; 37:3676-3683. [PMID: 35113322 PMCID: PMC9585131 DOI: 10.1007/s11606-022-07409-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services requires decision aid use for lung cancer screening (LCS) shared decision-making. However, it does not require information about incidental findings, a potential harm of screening. OBJECTIVE To assess the effect of incidental findings information in an LCS decision aid on screening intent as well as knowledge and valuing of screening benefits and harms. DESIGN Randomized controlled trial conducted online between July 16, 2020, and August 22, 2020. PARTICIPANTS Adults 55-80 years, eligible for LCS. INTERVENTION LCS video decision aid including information on incidental findings or a control video decision aid. MAIN MEASURES Intent to undergo LCS; knowledge regarding the benefit and harms of LCS using six knowledge questions; and valuing of six benefits and harms using rating (1-5 scale, 5 most important) and ranking (ranked 1-6) exercises. KEY RESULTS Of 427 eligible individuals approached, 348 (83.1%) completed the study (173 intervention, 175 control). Mean age was 64.5 years, 48.6% were male, 73.0% white, 76.3% with less than a college degree, and 64.1% with income < $50,000. There was no difference between the intervention and controls in percentage intending to pursue screening (70/173, 40.5% vs 73/175, 41.7%, diff 1.2%, 95% CI - 9.1 to 11.5%, p = 0.81). Intervention participants had a higher percentage of correct answers for the incidental findings knowledge than controls (164/173, 94.8% vs 129/175, 73.7%, 95% CI - 28.4 to - 13.8%, p < 0.01). Incidental findings had the fifth highest mean importance rating (4.0 ± 1.1) and the third highest mean ranking (3.6 ± 1.5). There was no difference in mean rating or ranking of incidental findings between intervention and control groups (rating 4.0 vs 3.9, diff 0.1, 95% CI - 0.2, 0.3, p = 0.51; ranking 3.6 vs 3.6, diff 0.02, 95% CI - 0.3, 0.3, p = 0.89). CONCLUSIONS Incidental findings information in a LCS decision aid did not affect LCS intent, but it resulted in more informed individuals regarding these findings. In formulating screening preferences, incidental findings were less important than other benefits and harms. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04432753.
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Affiliation(s)
- Stephen D Clark
- Division of General Internal Medicine, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall St., Sanger Hall 1-010, Box, Richmond, VA, 980102, USA.
| | - Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison T Brenner
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel E Jonas
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
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11
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D'Amico RP, Schnell PM, Foraker R, Olayiwola JN, Jonas DE, Brill SB. Evolution of primary care telehealth disparities during COVID-19: a retrospective cohort study (Preprint). J Med Internet Res 2022; 25:e43965. [PMID: 37146176 DOI: 10.2196/43965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Telehealth has become widely utilized as a novel way to provide outpatient care during the coronavirus disease (COVID-19) pandemic, but data about telehealth use in primary care remains limited. Studies in other specialties raise concerns that telehealth may be widening existing healthcare disparities, requiring further scrutiny of trends in telehealth utilization. OBJECTIVE Our study aims to further characterize sociodemographic differences in primary care utilization via telehealth compared to in-person office visits before and during the COVID-19 pandemic, and determine if these disparities changed throughout 2020. METHODS We conducted a retrospective cohort study in a large U.S. academic center with 46 primary care practices from April-December 2019 and April-December 2020. Data were subdivided into calendar quarters and compared to determine evolving disparities throughout the year. We queried and compared billed outpatient encounters in General Internal Medicine and Family Medicine via binary logic mixed effects regression model and estimated odds ratios with 95% confidence intervals (OR, 95% CI). We used sex, race, and ethnicity of the patient attending each encounter as fixed effects. We analyzed socioeconomic status of patients in the institution's primary county based on the zip code the patient was residing in. RESULTS A total of 81,822 encounters in the pre-COVID-19 timeframe and 47,994 encounters in the intra-COVID-19 timeframe were analyzed; in the intra-COVID-19 timeframe, a total of 5,322 (11.1%) were telehealth encounters. Patients living in zip codes with high supplemental nutritional assistance usage were less likely to utilize primary care in the intra-COVID-19 timeframe (OR 0.94, 95% CI 0.90-0.98, P= .006). Encounters with the following patients were less likely to be via telehealth compared to in-person office visits- patients who self-identified as Asian (OR 0.74, 95% CI 0.63-0.86) and Nepali (OR 0.37, 95% CI 0.19-0.72), patients insured by Medicare (OR 0.77, 95% CI 0.68-0.88), and patients living in zip codes with high supplemental nutritional assistance usage (OR 0.84, 95% CI 0.71-0.99). Many of these disparities persisted throughout the year. While there was no statistically significant difference in telehealth utilization for patients insured by Medicaid throughout the whole year, sub analysis of quarter 4 found encounters with patients insured by Medicaid were less likely to be via telehealth (OR 0.73, 95% CI 0.55-0.97, P=.03). CONCLUSIONS Telehealth was not utilized equally by all patients within primary care throughout the first year of the COVID-19 pandemic, specifically by patients who self-identified as Asian and Nepali, were insured by Medicare, and lived in zip codes with low socioeconomic status. As the COVID-19 pandemic and telehealth infrastructure change, it is critical we continue to reassess the utilization of telehealth. Institutions should continue to monitor disparities in telehealth access, and advocate for policy changes that may improve equity. CLINICALTRIAL
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Affiliation(s)
- Rachel P D'Amico
- Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Ave, Columbus, US
| | - Patrick M Schnell
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, US
| | - Randi Foraker
- Division of General Medical Sciences, Washington University in St. Louis School of Medicine, St Louis, US
| | | | - Daniel E Jonas
- Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Ave, Columbus, US
| | - Seuli Bose Brill
- Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Ave, Columbus, US
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12
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Jonas DE, Vander Schaaf EB, Riley S, Allison BA, Middleton JC, Baker C, Ali R, Voisin CE, LeBlanc ES. Screening for Prediabetes and Type 2 Diabetes in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:968-979. [PMID: 36098720 DOI: 10.1001/jama.2022.7957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Of youths diagnosed with type 2 diabetes, many develop microvascular complications by young adulthood. OBJECTIVE To review the evidence on benefits and harms of screening children and adolescents for prediabetes and type 2 diabetes to inform the US Preventive Services Task Force (USPSTF). DATA SOURCES PubMed/MEDLINE, Cochrane Library, and trial registries through May 3, 2021; references; experts; literature surveillance through July 22, 2022. STUDY SELECTION English-language controlled studies evaluating screening or interventions for prediabetes or type 2 diabetes that was screen detected or recently diagnosed. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular morbidity, diabetes-related morbidity, development of diabetes, quality of life, and harms. RESULTS This review included 8 publications (856 participants; mean age, 14 years [range, 10-17 years]). Of those, 6 were from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study. No eligible studies directly evaluated the benefits or harms of screening. One randomized clinical trial (RCT) (TODAY; n = 699 adolescents with obesity; mean age, 14 years) comparing metformin, metformin plus rosiglitazone, and metformin plus lifestyle intervention reported that 2 youths with recently diagnosed diabetes developed kidney impairment (0 vs 1 vs 1, respectively; P > .99) and 11 developed diabetic ketoacidosis (5 vs 3 vs 3, respectively; P = .70). One RCT of 75 adolescents (mean age, 13 years) with obesity with prediabetes compared an intensive lifestyle intervention with standard care and reported that no participants in either group developed diabetes, although follow-up was only 6 months. Regarding harms of interventions, 2 RCTs assessing different comparisons enrolled youths with recently diagnosed diabetes. Major hypoglycemic events were reported by less than 1% of participants. Minor hypoglycemic events were more common among youths treated with metformin plus rosiglitazone than among those treated with metformin or metformin plus lifestyle intervention in TODAY (8.2% vs 4.3% vs 3.4%, P = .05). In 1 study, gastrointestinal adverse events were more commonly reported by those taking metformin than by those taking placebo (abdominal pain: 25% vs 12%; nausea/vomiting: 17% vs 10%; P not reported). CONCLUSIONS AND RELEVANCE No eligible studies directly evaluated the benefits or harms of screening for prediabetes and type 2 diabetes in children and adolescents. For youths with prediabetes or recently diagnosed (not screen-detected) diabetes, the only eligible trials reported few health outcomes and found no difference between groups, although evidence was limited by substantial imprecision and a duration of follow-up likely insufficient to assess health outcomes.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Emily B Vander Schaaf
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
| | - Sean Riley
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Bianca A Allison
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Rania Ali
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Erin S LeBlanc
- Kaiser Permanente Center for Health Research, Portland, Oregon
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13
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Davis SA, Howard K, Ellis AR, Jonas DE, Carey TS, Morrissey JP, Thomas KC. Feasibility of a best-worst scaling exercise to set priorities for autism research. Health Expect 2022; 25:1643-1651. [PMID: 35678017 PMCID: PMC9327819 DOI: 10.1111/hex.13508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 04/06/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background The preferences of autism stakeholders regarding the top priorities for future autism research are largely unknown. Objective This study had two objectives: First, to examine what autism stakeholders think new research investments should be and the attributes of investment that they consider important, and second, to explore the feasibility, acceptability and outcomes of two prioritization exercises among autism stakeholders regarding their priorities for future research in autism. Design This was a prospective stakeholder‐engaged iterative study consisting of best–worst scaling (BWS) and direct prioritization exercise. Setting and Participants A national snowball sample of 219 stakeholders was included: adults with autism, caregivers, service providers and researchers. Main Outcome Measures The main outcomes measures were attributes that participants value in future research investments, and priority research investments for future research. Results Two hundred and nineteen participants completed the exercises, of whom 11% were adults with autism, 58% were parents/family members, 37% were service providers and 21% were researchers. Among stakeholders, the BWS exercises were easier to understand than the direct prioritization, less frequently skipped and yielded more consistent results. The proportion of children with autism affected by the research was the most important attribute for all types of stakeholders. The top three priorities among future research investments were (1) evidence on which child, family and intervention characteristics lead to the best/worst outcomes; (2) evidence on how changes in one area of a child's life are related to changes in other areas; and (3) evidence on dietary interventions. Priorities were similar for all stakeholder types. Conclusions The values and priorities examined here provide a road map for investigators and funders to pursue autism research that matters to stakeholders. Patient or Public Contribution Stakeholders completed a BWS and direct prioritization exercise to inform us about their priorities for future autism research.
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Affiliation(s)
- Scott A Davis
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Asheville, North Carolina, USA
| | - Kirsten Howard
- Faculty of Medicine and Health, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Alan R Ellis
- Department of Sociology, North Carolina State University, Raleigh, North Carolina, USA
| | - Daniel E Jonas
- Department of Internal Medicine, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Timothy S Carey
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina, USA
| | - Joseph P Morrissey
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathleen C Thomas
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Asheville, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina, USA
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Chou R, Bougatsos C, Jungbauer R, Grusing S, Blazina I, Selph S, Jonas DE, Tehrani S. Screening for Impaired Visual Acuity in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:2129-2140. [PMID: 35608842 DOI: 10.1001/jama.2022.6381] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance A 2016 review for the US Preventive Services Task Force (USPSTF) found that effective treatments are available for refractive errors, cataracts, and wet (advanced neovascular) or dry (atrophic) age-related macular degeneration (AMD), but there were no differences between visual screening vs no screening on visual acuity or other outcomes. Objective To update the 2016 review on screening for impaired visual acuity in older adults, to inform the USPSTF. Data Sources Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to February 2021); surveillance through January 21, 2022. Study Selection Randomized clinical trials and controlled observational studies on screening, vascular endothelial growth factor (VEGF) inhibitors (wet AMD), and antioxidant vitamins and minerals (dry AMD); studies on screening diagnostic accuracy. Data Extraction and Synthesis One investigator abstracted data and a second checked accuracy. Two investigators independently assessed study quality. Results Twenty-five studies (N = 33 586) were included (13 trials, 11 diagnostic accuracy studies, and 1 systematic review [19 trials]). Four trials (n = 4819) found no significant differences between screening vs no screening in visual acuity or other outcomes. Visual acuity tests (3 studies; n = 6493) and screening question (3 studies; n = 5203) were associated with suboptimal diagnostic accuracy. For wet AMD, 4 trials (n = 2086) found VEGF inhibitors significantly associated with greater likelihood of 15 or more letters visual acuity gain (risk ratio [RR], 2.92 [95% CI, 1.20-7.12]; I2 = 76%; absolute risk difference [ARD], 10%) and less than 15 letters visual acuity loss (RR, 1.46 [95% CI, 1.22-1.75]; I2 = 80%; ARD, 27%) vs sham treatment, with no increased risk of serious harms. For dry AMD, a systematic review (19 trials) found antioxidant multivitamins significantly associated with decreased risk of progression to late AMD (3 trials, n = 2445; odds ratio [OR], 0.72 [95% CI, 0.58-0.90]) and 3 lines or more visual acuity loss (1 trial, n = 1791; OR, 0.77 [95% CI, 0.62-0.96]) vs placebo. Zinc was significantly associated with increased risk of genitourinary events and beta carotene with increased risk of lung cancer in former smokers; other serious harms were infrequent. Conclusions and Relevance This review found that effective treatments are available for common causes of impaired visual acuity in older adults. However, direct evidence found no significant association between vision screening vs no screening in primary care and improved visual outcomes.
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Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Ian Blazina
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Shelley Selph
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University; Portland
| | - Daniel E Jonas
- Department of Internal Medicine, The Ohio State University, Columbus
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
| | - Shandiz Tehrani
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University; Portland
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Chou R, Selph S, Blazina I, Bougatsos C, Jungbauer R, Fu R, Grusing S, Jonas DE, Tehrani S. Screening for Glaucoma in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:1998-2012. [PMID: 35608575 DOI: 10.1001/jama.2022.6290] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Two 2013 systematic reviews to inform the US Preventive Services Task Force (USPSTF) found insufficient evidence to assess benefits and harms of screening for primary open-angle glaucoma (OAG) in adults. OBJECTIVE To update the 2013 reviews on screening for glaucoma, to inform the USPSTF. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to February 2021); surveillance through January 21, 2022. STUDY SELECTION Randomized clinical trials (RCTs) of screening, referral, and treatment; and studies of screening test diagnostic accuracy. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data and a second checked accuracy. Two investigators independently assessed study quality. RESULTS Eighty-three studies (N = 75 887) were included (30 trials and 53 diagnostic accuracy studies). One RCT (n = 616) found screening of frail elderly persons associated with no difference in vision outcomes vs no screening but with significantly greater falls risk (relative risk [RR], 1.31 [95% CI, 1.13-1.50]). No study evaluated referral to an eye health professional. For glaucoma diagnosis, spectral domain optical coherence tomography (providing high-resolution cross-sectional imaging; 15 studies, n = 4242) was associated with sensitivity of 0.79 (95% CI, 0.75-0.83) and specificity of 0.92 (95% CI, 0.87-0.96) and the Humphrey Visual Field Analyzer (for perimetry, or measurement of visual fields; 6 studies, n = 11 244) with sensitivity of 0.87 (95% CI, 0.69-0.95) and specificity 0.82 (95% CI, 0.66-0.92); tonometry (for measurement of intraocular pressure; 13 studies, n = 32 892) had low sensitivity (0.48 [95% CI, 0.31-0.66]). Medical therapy for ocular hypertension and untreated glaucoma was significantly associated with decreased intraocular pressure and decreased likelihood of glaucoma progression (7 trials, n = 3771; RR, 0.68 [95% CI, 0.49-0.96]; absolute risk difference -4.2%) vs placebo, but 1 trial (n = 461) found no differences in visual acuity, quality of life, or function. Selective laser trabeculoplasty and medical therapy had similar outcomes (4 trials, n = 957). CONCLUSIONS AND RELEVANCE This review found limited direct evidence on glaucoma screening, showing no association with benefits. Screening tests can identify persons with glaucoma and treatment was associated with a lower risk of glaucoma progression, but evidence of improvement in visual outcomes, quality of life, and function remains lacking.
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Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Shelley Selph
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Ian Blazina
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Daniel E Jonas
- Department of Internal Medicine, The Ohio State University; Columbus
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
| | - Shandiz Tehrani
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland
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Balio CP, Riley SR, Grammer D, Weathington C, Barclay C, Jonas DE. Barriers to recruiting primary care practices for implementation research during COVID-19: A qualitative study of practice coaches from the Stop Unhealthy (STUN) Alcohol Use Now trial. Implementation Research and Practice 2022; 3:26334895221094297. [PMID: 37091109 PMCID: PMC9924268 DOI: 10.1177/26334895221094297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The COVID-19 pandemic has brought widespread change to health care practice and research. With heightened stress in the general population, increased unhealthy alcohol use, and added pressures on primary care practices, comes the need to better understand how we can continue practice-based research and address public health priorities amid the ongoing pandemic. The current study considers barriers and facilitators to conducting such research, especially during the COVID-19 pandemic, within the context of recruiting practices for the STop UNhealthy (STUN) Alcohol Use Now trial. The STUN trial uses practice facilitation to implement screening and interventions for unhealthy alcohol use in primary care practices across the state of North Carolina. Methods: Semistructured interviews were conducted with a purposive sample of 15 practice coaches to discuss their recruitment experiences before and after recruitment was paused due to the pandemic. An inductive thematic analysis was used to identify themes and subthemes. Results: Pandemic-related barriers, including challenges in staffing, finances, and new COVID-19-related workflows, were most prominent. Competing priorities, such as quality improvement measures, North Carolina's implementation of Medicaid managed care, and organizational structures hampered recruitment efforts. Coaches also described barriers specific to the project and to the topic of alcohol. Several facilitators were identified, including the rising importance of behavioral health due to the pandemic, as well as existing relationships between practice coaches and practices. Conclusions: Difficulty managing competing priorities and obstacles within existing practice infrastructure inhibit the ability to participate in practice-based research and implementation of evidence-based practices. Lessons learned from this trial may inform strategies to recruit practices into research and to gain buy-in from practices in adopting evidence-based practices more generally. Plain Language Summary What is known: Unhealthy alcohol use is a significant public health issue, which has been exacerbated during the COVID-19 pandemic. Screening and brief intervention for unhealthy alcohol use is an evidence-based practice shown to help reduce drinking-related behaviors, yet it remains rare in practice. What this study adds: Using a qualitative approach, we identify barriers and facilitators to recruiting primary care practices into a funded trial that uses practice facilitation to address unhealthy alcohol use. We identify general insights as well as those specific to the COVID-19 pandemic. Barriers are primarily related to competing priorities, incentives, and lack of infrastructure. Facilitators are related to framing of the project and the anticipated level and type of resources needed to address unhealthy alcohol use especially as the pandemic wanes. Implications: Our findings provide information on barriers and facilitators to recruiting primary care practices for behavioral health projects and to implementing these activities. Using our findings, we provide a discussion of suggestions for conducting these types of projects in the future which may be of interest to researchers, practice managers, and providers.
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Affiliation(s)
- Casey P. Balio
- Center for Rural Health Research, East Tennessee State University, Johnson City, TN, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean R. Riley
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Debbie Grammer
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chris Weathington
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Barclay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Daniel E. Jonas
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
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Feltner C, Peat C, Reddy S, Riley S, Berkman N, Middleton JC, Balio C, Coker-Schwimmer M, Jonas DE. Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:1068-1082. [PMID: 35289875 DOI: 10.1001/jama.2022.1807] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Eating disorders are associated with adverse health and social outcomes. OBJECTIVE To review the evidence on screening for eating disorders in adolescents and adults to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, PsycINFO, and trial registries through December 19, 2020; surveillance through January 1, 2022. STUDY SELECTION English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or interventions for eating disorders in populations with screen-detected or previously untreated eating disorders (trials limited to populations who are underweight were ineligible). DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of test accuracy studies and intervention trials. MAIN OUTCOMES AND MEASURES Test accuracy, eating disorder symptom severity, quality of life, depression, and harms. RESULTS Fifty-seven studies were included (N = 10 773); 3 (n = 1073) limited to adolescents (mean or median age, 14-15 years). No study directly evaluated the benefits and harms of screening. Seventeen studies (n = 6804) evaluated screening test accuracy. The SCOFF questionnaire (cut point ≥2) had a pooled sensitivity of 84% (95% CI, 74% to 90%) and pooled specificity of 80% (95% CI, 65% to 89%) in adults (10 studies, n = 3684). Forty RCTs (n = 3969) evaluated interventions for eating disorders; none enrolled a screen-detected population. Lisdexamfetamine for binge eating disorder (4 RCTs; n = 900) was associated with larger reductions in eating disorder symptom severity on the Yale-Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two RCTs (n = 465) of topiramate for binge eating disorder found larger reductions in YBOCS-BE scores associated with topiramate than placebo, from -6.40 (95% CI, -8.16 to -4.64) to -2.55 (95% CI, -4.22 to -0.88). Nine pharmacotherapy trials (n = 2006) reported on harms. Compared with placebo, lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty. Twenty-four trials (n = 1644) assessed psychological interventions. Guided self-help for binge eating disorder improved eating disorder symptom severity more than control (pooled standardized mean difference, -0.96 [95% CI, -1.26 to -0.67]) (5 studies, n = 391). Evidence on other interventions was limited. CONCLUSIONS AND RELEVANCE No studies directly assessed the benefits and harms of screening. The SCOFF questionnaire had adequate accuracy for detecting eating disorders among adults. No treatment trials enrolled screen-detected populations; guided self-help, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder, but pharmacotherapies were also associated with harms.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Christine Peat
- Department of Psychiatry, University of North Carolina at Chapel Hill
| | - Shivani Reddy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
| | - Sean Riley
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Nancy Berkman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey Balio
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Center for Rural Health Research, East Tennessee State University, Johnson City
| | - Manny Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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18
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Kahwati LC, Asher GN, Kadro ZO, Keen S, Ali R, Coker-Schwimmer E, Jonas DE. Screening for Atrial Fibrillation: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:368-383. [PMID: 35076660 DOI: 10.1001/jama.2021.21811] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Atrial fibrillation (AF), the most common arrhythmia, increases the risk of stroke. OBJECTIVE To review the evidence on screening for AF in adults without prior stroke to inform the US Preventive Services Task Force. DATA SOURCES PubMed, Cochrane Library, and trial registries through October 5, 2020; references, experts, and literature surveillance through October 31, 2021. STUDY SELECTION Randomized clinical trials (RCTs) of screening among asymptomatic persons without known AF or prior stroke; test accuracy studies; RCTs of anticoagulation among persons with AF; systematic reviews; and observational studies reporting harms. DATA EXTRACTION AND SYNTHESIS Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Detection of undiagnosed AF, test accuracy, mortality, stroke, stroke-related morbidity, and harms. RESULTS Twenty-six studies (N = 113 784) were included. In 1 RCT (n = 28 768) of twice-daily electrocardiography (ECG) screening for 2 weeks, the likelihood of a composite end point (ischemic stroke, hemorrhagic stroke, systemic embolism, all-cause mortality, and hospitalization for bleeding) was lower in the screened group over 6.9 years (hazard ratio, 0.96 [95% CI, 0.92-1.00]; P = .045), but that study had numerous limitations. In 4 RCTs (n = 32 491), significantly more AF was detected with intermittent and continuous ECG screening compared with no screening (risk difference range, 1.0%-4.8%). Treatment with warfarin over a mean of 1.5 years in populations with clinical, mostly persistent AF was associated with fewer ischemic strokes (pooled risk ratio [RR], 0.32 [95% CI, 0.20-0.51]; 5 RCTs; n = 2415) and lower all-cause mortality (pooled RR, 0.68 [95% CI, 0.50-0.93]) compared with placebo. Treatment with direct oral anticoagulants was also associated with lower incidence of stroke (adjusted odds ratios range, 0.32-0.44) in indirect comparisons with placebo. The pooled RR for major bleeding for warfarin compared with placebo was 1.8 (95% CI, 0.85-3.7; 5 RCTs; n = 2415), and the adjusted odds ratio for major bleeding for direct oral anticoagulants compared with placebo or no treatment ranged from 1.38 to 2.21, but CIs did not exclude a null effect. CONCLUSIONS AND RELEVANCE Although screening can detect more cases of unknown AF, evidence regarding effects on health outcomes is limited. Anticoagulation was associated with lower risk of first stroke and mortality but with increased risk of major bleeding, although estimates for this harm are imprecise; no trials assessed benefits and harms of anticoagulation among screen-detected populations.
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Affiliation(s)
- Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Gary N Asher
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Zachary O Kadro
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill
| | - Susan Keen
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Rania Ali
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Emmanuel Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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19
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Jonas DE, Barclay C, Grammer D, Weathington C, Birken SA, DeWalt DA, Shoenbill KA, Boynton MH, Mackey M, Riley S, Cykert S. The STUN (STop UNhealthy) Alcohol Use Now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care. Trials 2021; 22:810. [PMID: 34784953 PMCID: PMC8593635 DOI: 10.1186/s13063-021-05641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unhealthy alcohol use is a leading cause of preventable deaths in the USA and is associated with many societal and health problems. Less than a third of people who visit primary care providers in the USA are asked about or ever discuss alcohol use with a health professional. METHODS/DESIGN This study is an adaptive, randomized, controlled trial to evaluate the effect of primary care practice facilitation and telehealth services on evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use in small-to-medium-sized primary care practices. Study participants will include primary care practices in North Carolina with 10 or fewer providers. All enrolled practices will receive a practice facilitation intervention that includes quality improvement (QI) coaching, electronic health record (EHR) support, training, and expert consultation. After 6 months, practices in the lower 50th percentile (based on performance) will be randomized to continued practice facilitation or provision of telehealth services plus ongoing facilitation for the next 6 months. Practices in the upper 50th percentile after the initial 6 months of intervention will continue to receive practice facilitation alone. The main outcome measures include the number (and %) of patients in the target population who are screened for unhealthy alcohol use, screen positive, and receive brief counseling. Additional measures include the number (and %) of patients who receive pharmacotherapy for AUD or are referred for AUD services. Sample size calculations determined that 35 practices are needed to detect a 10% increase in the main outcome (percent screened for unhealthy alcohol use) over 6 months. DISCUSSION A successful intervention would significantly reduce morbidity among adults from unhealthy alcohol use by increasing counseling and other treatment opportunities. The study will produce important evidence about the effect of practice facilitation on uptake of evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use when delivered on a large scale to small and medium-sized practices. It will also generate scientific knowledge about whether embedded telehealth services can improve the use of evidence-based screening and interventions for practices with slower uptake. The results of this rigorously conducted evaluation are expected to have a positive impact by accelerating the dissemination and implementation of evidence related to unhealthy alcohol use into primary care practices. TRIAL REGISTRATION ClinicalTrials.gov NCT04317989 . Registered on March 23, 2020.
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Affiliation(s)
- Daniel E Jonas
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA.
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Colleen Barclay
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Debbie Grammer
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Chris Weathington
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, 27101, USA
| | - Darren A DeWalt
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Kimberly A Shoenbill
- Department of Family Medicine, CB 7370, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Program on Health and Clinical Informatics, CB 7064, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Marcella H Boynton
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Monique Mackey
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sean Riley
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Samuel Cykert
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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20
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Jonas DE, Crotty K, Yun JDY, Middleton JC, Feltner C, Taylor-Phillips S, Barclay C, Dotson A, Baker C, Balio CP, Voisin CE, Harris RP. Screening for Prediabetes and Type 2 Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 326:744-760. [PMID: 34427595 DOI: 10.1001/jama.2021.10403] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Type 2 diabetes is common and is a leading cause of morbidity and disability. OBJECTIVE To review the evidence on screening for prediabetes and diabetes to inform the US Preventive Services Task Force (USPSTF). DATA SOURCES PubMed/MEDLINE, Cochrane Library, and trial registries through September 2019; references; and experts; literature surveillance through May 21, 2021. STUDY SELECTION English-language controlled studies evaluating screening or interventions for prediabetes or diabetes that was screen detected or recently diagnosed. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when at least 3 similar studies were available. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular morbidity, diabetes-related morbidity, development of diabetes, quality of life, and harms. RESULTS The review included 89 publications (N = 68 882). Two randomized clinical trials (RCTs) (25 120 participants) found no significant difference between screening and control groups for all-cause or cause-specific mortality at 10 years. For harms (eg, anxiety or worry), the trials reported no significant differences between screening and control groups. For recently diagnosed (not screen-detected) diabetes, 5 RCTs (5138 participants) were included. In the UK Prospective Diabetes Study, health outcomes were improved with intensive glucose control with sulfonylureas or insulin. For example, for all-cause mortality the relative risk (RR) was 0.87 (95% CI, 0.79 to 0.96) over 20 years (10-year posttrial assessment). For overweight persons, intensive glucose control with metformin improved health outcomes at the 10-year follow-up (eg, all-cause mortality: RR, 0.64 [95% CI, 0.45 to 0.91]), and benefits were maintained longer term. Lifestyle interventions (most involving >360 minutes) for obese or overweight persons with prediabetes were associated with reductions in the incidence of diabetes (23 RCTs; pooled RR, 0.78 [95% CI, 0.69 to 0.88]). Lifestyle interventions were also associated with improved intermediate outcomes, such as reduced weight, body mass index, systolic blood pressure, and diastolic blood pressure (pooled weighted mean difference, -1.7 mm Hg [95% CI, -2.6 to -0.8] and -1.2 mm Hg [95% CI, -2.0 to -0.4], respectively). Metformin was associated with a significant reduction in diabetes incidence (pooled RR, 0.73 [95% CI, 0.64 to 0.83]) and reduction in weight and body mass index. CONCLUSIONS AND RELEVANCE Trials of screening for diabetes found no significant mortality benefit but had insufficient data to assess other health outcomes; evidence on harms of screening was limited. For persons with recently diagnosed (not screen-detected) diabetes, interventions improved health outcomes; for obese or overweight persons with prediabetes, interventions were associated with reduced incidence of diabetes and improvement in other intermediate outcomes.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Karen Crotty
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- RTI International, Research Triangle Park, North Carolina
| | - Jonathan D Y Yun
- Thayer Internal Medicine, MaineGeneral Health, Waterville, Maine
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Sian Taylor-Phillips
- Warwick Medical School, University of Warwick, Coventry, West Midlands, United Kingdom
| | - Colleen Barclay
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Andrea Dotson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey P Balio
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Russell P Harris
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
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21
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Viera AJ, Yano Y, Lin FC, Simel DL, Yun J, Dave G, Von Holle A, Viera LA, Shimbo D, Hardy ST, Donahue KE, Hinderliter A, Voisin CE, Jonas DE. Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review. JAMA 2021; 326:339-347. [PMID: 34313682 DOI: 10.1001/jama.2021.4533] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment. OBJECTIVE To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM. DATA SOURCES PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles. DATA EXTRACTION AND SYNTHESIS Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed. MAIN OUTCOMES AND MEASURES Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard. RESULTS A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%). CONCLUSIONS AND RELEVANCE Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.
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Affiliation(s)
- Anthony J Viera
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
| | - Yuichiro Yano
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
- Center for Novel and Exploratory Clinical Trials, Yokohama City University, Yokohama, Japan
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - David L Simel
- Durham Veterans Affairs Health System and Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Gaurav Dave
- Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill
| | | | - Laura A Viera
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Shakia T Hardy
- Department of Epidemiology, University of Alabama at Birmingham
| | - Katrina E Donahue
- Department of Family Medicine, University of North Carolina at Chapel Hill
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Alan Hinderliter
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Daniel E Jonas
- Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- now with Department of Internal Medicine, Division of General Internal Medicine, The Ohio State University
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22
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Feltner C, Wallace IF, Kistler CE, Coker-Schwimmer M, Jonas DE. Screening for Hearing Loss in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:1202-1215. [PMID: 33755082 DOI: 10.1001/jama.2020.24855] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Hearing loss is common in older adults and associated with adverse health and social outcomes. OBJECTIVE To update the evidence review on screening for hearing loss in adults 50 years or older to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries through January 17, 2020; references; and experts; literature surveillance through October 8, 2020. STUDY SELECTION English-language studies of accuracy, screening, and interventions for screen-detected or newly detected hearing loss. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of screening test accuracy studies. MAIN OUTCOMES AND MEASURES Quality of life and function, other health and social outcomes, test accuracy, and harms. RESULTS Forty-one studies (N = 26 386) were included, 18 of which were new since the previous review. One trial enrolling US veterans (n = 2305) assessed the benefits of screening; there was no significant difference in the proportion of participants experiencing a minimum clinically important difference in hearing-related function at 1 year (36%-40% in the screened groups vs 36% in the nonscreened group). Thirty-four studies (n = 23 228) evaluated test accuracy. For detecting mild hearing loss (>20-25 dB), single-question screening had a pooled sensitivity of 66% (95% CI, 58%-73%) and a pooled specificity of 76% (95% CI, 68%-83%) (10 studies, n = 12 637); for detecting moderate hearing loss (>35-40 dB), pooled sensitivity was 80% (95% CI, 68%-88%) and pooled specificity was 74% (95% CI, 59%-85%) (6 studies, n = 8774). In 5 studies (n = 2820) on the Hearing Handicap Inventory for the Elderly-Screening to detect moderate hearing loss (>40 dB), pooled sensitivity was 68% (95% CI, 52%-81%) and pooled specificity was 78% (95% CI, 67%-86%). Six trials (n = 853) evaluated amplification vs control in populations with screen-detected or recently detected hearing loss over 6 weeks to 4 months. Five measured hearing-related function via the Hearing Handicap Inventory for the Elderly; only 3 that enrolled veterans (n = 684) found a significant difference considered to represent a minimal important difference (>18.7 points). Few trials reported on other eligible outcomes, and no studies reported on harms of screening or interventions. CONCLUSIONS AND RELEVANCE Several screening tests can adequately detect hearing loss in older adults; no studies reported on the harms of screening or treatment. Evidence showing benefit from hearing aids on hearing-related function among adults with screen-detected or newly detected hearing loss is limited to studies enrolling veterans.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- RTI International, Research Triangle Park, North Carolina
| | - Christine E Kistler
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Jonas DE, Reuland DS, Reddy SM, Nagle M, Clark SD, Weber RP, Enyioha C, Malo TL, Brenner AT, Armstrong C, Coker-Schwimmer M, Middleton JC, Voisin C, Harris RP. Screening for Lung Cancer With Low-Dose Computed Tomography: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:971-987. [PMID: 33687468 DOI: 10.1001/jama.2021.0377] [Citation(s) in RCA: 196] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Lung cancer is the leading cause of cancer-related death in the US. OBJECTIVE To review the evidence on screening for lung cancer with low-dose computed tomography (LDCT) to inform the US Preventive Services Task Force (USPSTF). DATA SOURCES MEDLINE, Cochrane Library, and trial registries through May 2019; references; experts; and literature surveillance through November 20, 2020. STUDY SELECTION English-language studies of screening with LDCT, accuracy of LDCT, risk prediction models, or treatment for early-stage lung cancer. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled because of heterogeneity of populations and screening protocols. MAIN OUTCOMES AND MEASURES Lung cancer incidence, lung cancer mortality, all-cause mortality, test accuracy, and harms. RESULTS This review included 223 publications. Seven randomized clinical trials (RCTs) (N = 86 486) evaluated lung cancer screening with LDCT; the National Lung Screening Trial (NLST, N = 53 454) and Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON, N = 15 792) were the largest RCTs. Participants were more likely to benefit than the US screening-eligible population (eg, based on life expectancy). The NLST found a reduction in lung cancer mortality (incidence rate ratio [IRR], 0.85 [95% CI, 0.75-0.96]; number needed to screen [NNS] to prevent 1 lung cancer death, 323 over 6.5 years of follow-up) with 3 rounds of annual LDCT screening compared with chest radiograph for high-risk current and former smokers aged 55 to 74 years. NELSON found a reduction in lung cancer mortality (IRR, 0.75 [95% CI, 0.61-0.90]; NNS to prevent 1 lung cancer death of 130 over 10 years of follow-up) with 4 rounds of LDCT screening with increasing intervals compared with no screening for high-risk current and former smokers aged 50 to 74 years. Harms of screening included radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress. For every 1000 persons screened in the NLST, false-positive results led to 17 invasive procedures (number needed to harm, 59) and fewer than 1 person having a major complication. Overdiagnosis estimates varied greatly (0%-67% chance that a lung cancer was overdiagnosed). Incidental findings were common, and estimates varied widely (4.4%-40.7% of persons screened). CONCLUSIONS AND RELEVANCE Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.
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Affiliation(s)
- Daniel E Jonas
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel S Reuland
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Shivani M Reddy
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Max Nagle
- Michigan Medicine, University of Michigan, Ann Arbor
| | - Stephen D Clark
- Department of Internal Medicine, Virginia Commonwealth University, Richmond
| | - Rachel Palmieri Weber
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Chineme Enyioha
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Teri L Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Charli Armstrong
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Christiane Voisin
- RTI International, University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Russell P Harris
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Meza R, Jeon J, Toumazis I, Haaf KT, Cao P, Bastani M, Han SS, Blom EF, Jonas DE, Feuer EJ, Plevritis SK, de Koning HJ, Kong CY. Evaluation of the Benefits and Harms of Lung Cancer Screening With Low-Dose Computed Tomography: Modeling Study for the US Preventive Services Task Force. JAMA 2021; 325:988-997. [PMID: 33687469 PMCID: PMC9208912 DOI: 10.1001/jama.2021.1077] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) is updating its 2013 lung cancer screening guidelines, which recommend annual screening for adults aged 55 through 80 years who have a smoking history of at least 30 pack-years and currently smoke or have quit within the past 15 years. OBJECTIVE To inform the USPSTF guidelines by estimating the benefits and harms associated with various low-dose computed tomography (LDCT) screening strategies. DESIGN, SETTING, AND PARTICIPANTS Comparative simulation modeling with 4 lung cancer natural history models for individuals from the 1950 and 1960 US birth cohorts who were followed up from aged 45 through 90 years. EXPOSURES Screening with varying starting ages, stopping ages, and screening frequency. Eligibility criteria based on age, cumulative pack-years, and years since quitting smoking (risk factor-based) or on age and individual lung cancer risk estimation using risk prediction models with varying eligibility thresholds (risk model-based). A total of 1092 LDCT screening strategies were modeled. Full uptake and adherence were assumed for all scenarios. MAIN OUTCOMES AND MEASURES Estimated lung cancer deaths averted and life-years gained (benefits) compared with no screening. Estimated lifetime number of LDCT screenings, false-positive results, biopsies, overdiagnosed cases, and radiation-related lung cancer deaths (harms). RESULTS Efficient screening programs estimated to yield the most benefits for a given number of screenings were identified. Most of the efficient risk factor-based strategies started screening at aged 50 or 55 years and stopped at aged 80 years. The 2013 USPSTF-recommended criteria were not among the efficient strategies for the 1960 US birth cohort. Annual strategies with a minimum criterion of 20 pack-years of smoking were efficient and, compared with the 2013 USPSTF-recommended criteria, were estimated to increase screening eligibility (20.6%-23.6% vs 14.1% of the population ever eligible), lung cancer deaths averted (469-558 per 100 000 vs 381 per 100 000), and life-years gained (6018-7596 per 100 000 vs 4882 per 100 000). However, these strategies were estimated to result in more false-positive test results (1.9-2.5 per person screened vs 1.9 per person screened with the USPSTF strategy), overdiagnosed lung cancer cases (83-94 per 100 000 vs 69 per 100 000), and radiation-related lung cancer deaths (29.0-42.5 per 100 000 vs 20.6 per 100 000). Risk model-based vs risk factor-based strategies were estimated to be associated with more benefits and fewer radiation-related deaths but more overdiagnosed cases. CONCLUSIONS AND RELEVANCE Microsimulation modeling studies suggested that LDCT screening for lung cancer compared with no screening may increase lung cancer deaths averted and life-years gained when optimally targeted and implemented. Screening individuals at aged 50 or 55 years through aged 80 years with 20 pack-years or more of smoking exposure was estimated to result in more benefits than the 2013 USPSTF-recommended criteria and less disparity in screening eligibility by sex and race/ethnicity.
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Affiliation(s)
- Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Iakovos Toumazis
- Department of Biomedical Data Sciences, Stanford University, Stanford, California
- Department of Radiology, Stanford University, Stanford, California
| | | | - Pianpian Cao
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Mehrad Bastani
- Department of Biomedical Data Sciences, Stanford University, Stanford, California
- Department of Radiology, Stanford University, Stanford, California
| | - Summer S. Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
| | | | - Daniel E. Jonas
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Eric J. Feuer
- Division of Cancer Control & population sciences, National Cancer Institute, Bethesda, Maryland
| | - Sylvia K. Plevritis
- Department of Biomedical Data Sciences, Stanford University, Stanford, California
| | | | - Chung Yin Kong
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York
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Barclay C, Viswanathan M, Ratner S, Tompkins J, Jonas DE. Implementing Evidence-Based Screening and Counseling for Unhealthy Alcohol Use with Epic-Based Electronic Health Record Tools. Jt Comm J Qual Patient Saf 2020; 45:566-574. [PMID: 31378277 DOI: 10.1016/j.jcjq.2019.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multiple national organizations recommend screening and counseling adults for unhealthy alcohol use. METHODS An evidence-based approach to screening and counseling using Epic electronic health record (EHR) tools was implemented in a general medicine clinic. A dissemination package with actionable steps for clinics and systems wishing to implement similar processes was then produced. To evaluate the initial implementation and quality improvement project, run charts were created to track patients screened, patients counseled, and fidelity to protocols, and members of the original project team were interviewed to assess facilitators and barriers. The draft dissemination package was revised after feedback from health system representatives (key informants). RESULTS More than 9,000 patients (73.9% of those eligible) were screened in 20 months. Sixty-four percent of patients with positive initial screens had documented screening-related assessment; 39.7% (141/355) were offered counseling when indicated. Initial project team members identified EHR tools, clinic leadership, quality improvement culture, a multidisciplinary team, and training for providers and nurses as facilitators; and competing demands, patient population size, and nursing staff/resident turnover as barriers. Six key informants evaluated the dissemination package. Most rated 10 of the 12 sections as very useful; all rated components specific to implementing alcohol screening and counseling as very useful. Ratings for general guidance on implementing evidence-based services in primary care were more mixed. CONCLUSION Evidence-based screening and counseling for unhealthy alcohol use can be implemented with EHR tools. A dissemination guide was viewed favorably by key informants and can serve as a guide for other clinics and systems.
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Dolan-Soto DR, Jonas DE, Reed RM, Weil AB. Development of NAMASTE (New Anxiety Management Algorithm Standardizing Treatment Experience) and Implementation in Primary Care. Psychiatr Serv 2020; 71:627-630. [PMID: 32041510 DOI: 10.1176/appi.ps.201900378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence-based depression treatment in primary care is well established. However, clinicians are less likely to be trained to diagnose and treat anxiety disorder, which is frequently comorbid, poses an independent risk for suicidality, and complicates disease management. The University of North Carolina's Internal Medicine Clinic developed a measurement-guided approach to identifying and treating anxiety disorder using the seven-item Generalized Anxiety Disorder Scale, treatment algorithms, medication charts, case-based training for best practices, onsite behavioral counseling, and psychiatric consultation. NAMASTE (new anxiety management algorithm standardizing treatment experience) offers a treatment approach for primary care and addresses a major unmet need in public health and medical education.
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Affiliation(s)
- Diane R Dolan-Soto
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill. Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Daniel E Jonas
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill. Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Robin M Reed
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill. Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
| | - Amy B Weil
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill. Benjamin G. Druss, M.D., M.P.H., and Gail Daumit, M.D., M.H.S., are editors of this column
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Abstract
IMPORTANCE The US Preventive Services Task Force recommends that individuals at high risk for lung cancer consider benefits and harms before pursuing lung cancer screening. Medical centers develop websites for their lung cancer screening programs, but to date little is known about the websites' portrayal of benefits and harms or what next steps they recommend for individuals considering screening. OBJECTIVE To assess the presentation of potential benefits and harms and recommended next steps on lung cancer screening program websites. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional content analysis of 162 lung cancer screening program websites of academic medical centers (n = 81) and state-matched community medical centers (n = 81) that were randomly selected from American College of Radiology lung cancer screening-designated centers was conducted. The study was performed from December 1, 2018, to January 31, 2019. MAIN OUTCOMES AND MEASURES Website presentation of screening-associated benefits and harms was the primary outcome. Benefit was defined as any description related to the potential reduction in lung cancer mortality. Harms were based on the US Preventive Services Task Force recommendations and included false positives, false negatives, overdiagnosis, radiation exposure, and incidental findings. The secondary outcome was next steps that are recommended by websites. RESULTS Overall, the 162 lung cancer screening program websites described the potential benefits more frequently than they described any potential harms (159 [98%] vs 78 [48%], P < .01). False-positive findings were the most frequently reported (72 [44%]) potential harm. Community centers were less likely than academic centers to report any potential harm (32 [40%] vs 46 [57%], P = .03), potential harm from radiation (20 [25%] vs 35 [43%], P = .01), and overdiagnosis (0% vs 11 [14%], P < .01). One hundred nineteen websites (73%) did not explicitly recommend that individuals personally consider the potential benefits and harms of screening; community centers were less likely than academic centers to give this recommendation (15 [19%] vs 28 [35%], P = .02). Most institutions (157 [97%]) listed follow-up steps for screening, but few institutions (35 [22%]) recommended that individuals discuss benefits and harms with a health care professional. CONCLUSIONS AND RELEVANCE Information on public-facing websites of US lung cancer screening programs appears to lack balance with respect to portrayal of potential benefits and harms of screening. Important harms, such as overdiagnosis, were commonly ignored in the sites evaluated, and most of the centers did not explicitly guide individuals toward a guideline-recommended, shared decision-making discussion of harms and benefits.
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Affiliation(s)
- Stephen D Clark
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Chineme Enyioha
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Daniel E Jonas
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill
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Hart LC, Mouw MS, Teal R, Jonas DE. What Care Models Have Generalists Implemented to Address Transition from Pediatric to Adult Care?: a Qualitative Study. J Gen Intern Med 2019; 34:2083-2090. [PMID: 31410810 PMCID: PMC6816717 DOI: 10.1007/s11606-019-05226-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND The transition from pediatric to adult care is a critical period for young adults with childhood-onset conditions. General internists are tasked with participating in the care of this vulnerable population. Existing guidelines regarding transition do not fully address structural or organizational characteristics of practices that facilitate transition. Moreover, literature regarding transition has focused on pediatric subspecialty settings, leaving internists with little guidance after transfer. OBJECTIVES To better understand post-transfer transitional care by describing care models that primary care providers have implemented, and examining common features of generalist physicians' experiences providing transitional care. DESIGN Qualitative methods, semi-structured interviews. PARTICIPANTS Nineteen generalist-trained physicians from across the USA, engaged in transition-focused and/or ongoing care of adolescents and young adults with childhood-onset conditions. APPROACH Content and grounded theory analyses. KEY RESULTS Participants included nineteen physicians from seventeen institutions. Most (89%) were from academic medical centers. About 80% had completed a combined internal medicine-pediatrics residency. About 70% worked with clinic staff who were dedicated to transition. Practice structures fell into four main care models: (1) primary care in adult settings; (2) transition support and primary care in pediatric settings; (3) a blend of pediatric and adult care elements forming a bridge during transition; and (4) a transition consultative service. Most provided primary care for adults with childhood-onset conditions within larger adult-oriented primary care practices. Common features across interviews included taking extra time with patients both during and between visits and an interdisciplinary team-based approach. Shared practice strategies and philosophies emphasized care coordination, focus on the whole patient beyond immediate health concerns, and willingness to learn from practice and from families. CONCLUSIONS Participants used disparate care models. Common features and strategies among interviews highlight key functions and attributes of transitional care across settings, suggest important elements of care post-transfer, and clarify the role of generalists.
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Affiliation(s)
- Laura C Hart
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Mary S Mouw
- Division of Geriatrics, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Randall Teal
- Connected Health Applications and Interventions (CHAI-Core), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Hart LC, Patel-Nguyen SV, Merkley MG, Jonas DE. An Evidence Map for Interventions Addressing Transition from Pediatric to Adult Care: A Systematic Review of Systematic Reviews. J Pediatr Nurs 2019; 48:18-34. [PMID: 31220801 DOI: 10.1016/j.pedn.2019.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 11/28/2022]
Abstract
PROBLEM Adolescents and young adults with chronic illnesses continue to face barriers as they transition from pediatric to adult care. An evidence map can help to identify gaps in the transition literature to determine targets for future research. ELIGIBILITY CRITERIA We searched PubMed, CINAHL, PsycInfo, and Cochrane for systematic reviews published through February 2018. Eligible reviews included at least one comparative study testing a youth-focused intervention for improving transition with at least one quantitative health-related outcome reported. SAMPLE We identified 431 unique reviews in our search, and 37 reviews (containing 71 eligible primary studies) met inclusion criteria. RESULTS Most reviews (20 of 37) summarized some aspect of transition across diagnoses. Type 1 diabetes was the most common diagnosis studied (7 of 37 reviews and 24 of 71 primary studies). Only 14 of 71 primary studies focused on care after transfer to adult care. CONCLUSIONS The literature on interventions to improve transition to adult care has focused on a limited number of diagnoses, most commonly Type 1 diabetes. Common pediatric conditions, such as asthma, have not been studied with regard to transition. Efforts have been mainly targeted on transition preparation, with less focus on transition needs after transfer to adult care. IMPLICATIONS There is a need for transition research focused on common pediatric conditions and transition needs after transfer to adult care.
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Affiliation(s)
- Laura C Hart
- Nationwide Children's Hospital, Columbus, OH, United States of America; The Ohio State University College of Medicine, Departments of Pediatrics and Medicine, United States of America; The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America.
| | | | | | - Daniel E Jonas
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, United States of America; University of North Carolina at Chapel Hill, Department of Medicine, United States of America.
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Viswanathan M, Fraser JG, Pan H, Morgenlander M, McKeeman JL, Forman-Hoffman VL, Hart LC, Zolotor AJ, Lohr KN, Patel S, Jonas DE. Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:2129-2140. [PMID: 30480734 DOI: 10.1001/jama.2018.17647] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences. OBJECTIVE To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force. DATA SOURCES PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018. STUDY SELECTION English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization). DATA EXTRACTION AND SYNTHESIS Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms. RESULTS Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified. CONCLUSIONS AND RELEVANCE Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | | | - Huiling Pan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Marcia Morgenlander
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Joni L McKeeman
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill
| | - Valerie L Forman-Hoffman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Laura C Hart
- Nationwide Children's Hospital, Columbus, Ohio
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Adam J Zolotor
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Kathleen N Lohr
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
| | - Sheila Patel
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
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O'Connor EA, Perdue LA, Senger CA, Rushkin M, Patnode CD, Bean SI, Jonas DE. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:1910-1928. [PMID: 30422198 DOI: 10.1001/jama.2018.12086] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Unhealthy alcohol use is common, increasing, and a leading cause of premature mortality. OBJECTIVE To review literature on the effectiveness and harms of screening and counseling for unhealthy alcohol use to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through October 12, 2017; literature surveillance through August 1, 2018. STUDY SELECTION Test accuracy studies and randomized clinical trials of screening and counseling to reduce unhealthy alcohol use. DATA EXTRACTION AND SYNTHESIS Independent critical appraisal and data abstraction by 2 reviewers. Counseling trials were pooled using random-effects meta-analyses. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, drinks per week, exceeding recommended limits, heavy use episodes, abstinence (for pregnant women), and other health, family, social, and legal outcomes. RESULTS One hundred thirteen studies (N = 314 466) were included. No studies examined benefits or harms of screening programs to reduce unhealthy alcohol use. For adolescents (10 studies [n = 171 363]), 1 study (n = 225) reported a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) using the AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) to detect the full spectrum of unhealthy alcohol use. For adults (35 studies [n = 114 182]), brief screening instruments commonly reported sensitivity and specificity between 0.70 and 0.85. Two trials of the effects of interventions to reduce unhealthy alcohol use in adolescents (n = 588) found mixed results: one reported a benefit in high-risk but not moderate-risk drinkers, and the other reported a statistically significant reduction in drinking frequency for boys but not girls; neither reported health or related outcomes. Across all populations (68 studies [n = 36 528]), counseling interventions were associated with a decrease in drinks per week (weighted mean difference, -1.6 [95% CI, -2.2 to -1.0]; 32 studies [37 effects; n = 15 974]), the proportion exceeding recommended drinking limits (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; 15 studies [16 effects; n = 9760]), and the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]; 12 studies [14 effects; n = 8108]), and an increase in the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]; 5 studies [n = 796]) after 6 to 12 months. Health outcomes were sparsely reported and generally did not demonstrate group differences in effect. There was no evidence that these interventions could be harmful. CONCLUSIONS AND RELEVANCE Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Megan Rushkin
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Carrie D Patnode
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Sarah I Bean
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Feltner C, Wallace I, Berkman N, Kistler CE, Middleton JC, Barclay C, Higginbotham L, Green JT, Jonas DE. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:1688-1701. [PMID: 30357304 DOI: 10.1001/jama.2018.13212] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Intimate partner violence (IPV), elder abuse, and abuse of vulnerable adults are common and result in adverse health outcomes. OBJECTIVE To review the evidence on screening and interventions for IPV, elder abuse, and abuse of vulnerable adults to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries through October 4, 2017; references; experts; literature surveillance through August 1, 2018. STUDY SELECTION English-language randomized clinical trials (RCTs), studies evaluating test accuracy, and cohort studies with a concurrent control group assessing harms. DATA EXTRACTION AND SYNTHESIS Dual review of titles and abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled, primarily because of heterogeneity of populations, interventions, and outcomes. MAIN OUTCOMES AND MEASURES Abuse or neglect, morbidity caused by abuse, test accuracy, and harms. RESULTS Thirty studies were included (N = 14 959). Three RCTs (n = 3759) compared IPV screening with no screening; none found significant improvements in outcomes (eg, IPV or quality of life) over 3 to 18 months and 2 (n = 935) reported no harms of screening. Nine studies assessed tools to detect any past-year or current IPV in women; for past-year IPV (5 studies [n = 6331]), sensitivity of 5 tools ranged from 65% to 87% and specificity ranged from 80% to 95%. The accuracy of 5 tools (4 studies [n = 1795]) for detecting current abuse varied widely; sensitivity ranged from 46% to 94% and specificity ranged from 38% to 95%. Eleven RCTs (n = 6740) evaluated interventions for women with screen-detected IPV. Two enrolling pregnant women (n = 575) found significantly less IPV among women in the intervention group: 1 home visiting intervention (standardized mean difference [SMD], -0.34 [95% CI, -0.59 to -0.08]) and 1 behavioral counseling intervention for multiple risks (IPV, smoking, depression, tobacco exposure) (SMD, -0.40 [95% CI, -0.68 to -0.12]). No studies evaluated screening or interventions for elder abuse or abuse of vulnerable adults. One study assessing a screening tool for elder abuse had poor accuracy (sensitivity, 46% and specificity, 73% for detecting physical or verbal abuse). CONCLUSIONS AND RELEVANCE Although available screening tools may reasonably identify women experiencing IPV, trials of IPV screening in adult women did not show a reduction in IPV or improvement in quality of life over 3 to 18 months. Limited evidence suggested that home visiting and behavioral counseling interventions that address multiple risk factors may lead to reduced IPV among pregnant or postpartum women. No studies assessed screening or treatment for elder abuse and abuse of vulnerable adults.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Nancy Berkman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Christine E Kistler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Collen Barclay
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Laura Higginbotham
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Joshua T Green
- RTI International, Research Triangle Park, North Carolina
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Jonas DE, Kahwati LC, Yun JDY, Middleton JC, Coker-Schwimmer M, Asher GN. Screening for Atrial Fibrillation With Electrocardiography: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:485-498. [PMID: 30088015 DOI: 10.1001/jama.2018.4190] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Atrial fibrillation is the most common arrhythmia and increases the risk of stroke. OBJECTIVE To review the evidence on screening for nonvalvular atrial fibrillation with electrocardiography (ECG) and stroke prevention treatment in asymptomatic adults 65 years or older to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, and trial registries through May 2017; references; experts; literature surveillance through June 6, 2018. STUDY SELECTION English-language randomized clinical trials (RCTs), prospective cohort studies evaluating detection rates of atrial fibrillation or harms of screening, and systematic reviews evaluating stroke prevention treatment. Eligible treatment studies compared warfarin, aspirin, or novel oral anticoagulants (NOACs) with placebo or no treatment. Studies were excluded that focused on persons with a history of cardiovascular disease. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. When at least 3 similar studies were available, random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Detection of previously undiagnosed atrial fibrillation, mortality, stroke, stroke-related morbidity, and harms. RESULTS Seventeen studies were included (n = 135 300). No studies evaluated screening compared with no screening and focused on health outcomes. Systematic screening with ECG identified more new cases of atrial fibrillation than no screening (absolute increase, from 0.6% [95% CI, 0.1%-0.9%] to 2.8% [95% CI, 0.9%-4.7%] over 12 months; 2 RCTs, n = 15 803), but a systematic approach using ECG did not detect more cases than an approach using pulse palpation (2 RCTs, n = 17 803). For potential harms, no eligible studies compared screening with no screening. Warfarin (mean, 1.5 years) was associated with a reduced risk of ischemic stroke (relative risk [RR], 0.32 [95% CI, 0.20-0.51]) and all-cause mortality (RR, 0.68 [95% CI, 0.50-0.93]) and with increased risk of bleeding (5 trials, n = 2415). Participants in treatment trials were not screen detected, and most had long-standing persistent atrial fibrillation. A network meta-analysis reported that NOACs were associated with a significantly lower risk of a composite outcome of stroke and systemic embolism (adjusted odds ratios compared with placebo or control ranged from 0.32-0.44); the risk of bleeding was increased (adjusted odds ratios, 1.4-2.2), but confidence intervals were wide and differences between groups were not statistically significant. CONCLUSIONS AND RELEVANCE Although screening with ECG can detect previously unknown cases of atrial fibrillation, it has not been shown to detect more cases than screening focused on pulse palpation. Treatments for atrial fibrillation reduce the risk of stroke and all-cause mortality and increase the risk of bleeding, but trials have not assessed whether treatment of screen-detected asymptomatic older adults results in better health outcomes than treatment after detection by usual care or after symptoms develop.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jonathan D Y Yun
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Gary N Asher
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
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Jonas DE, Reddy S, Middleton JC, Barclay C, Green J, Baker C, Asher GN. Screening for Cardiovascular Disease Risk With Resting or Exercise Electrocardiography: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 319:2315-2328. [PMID: 29896633 DOI: 10.1001/jama.2018.6897] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Cardiovascular disease (CVD) is the leading cause of death in the United States. OBJECTIVE To review the evidence on screening asymptomatic adults for CVD risk using electrocardiography (ECG) to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, and trial registries through May 2017; references; experts; literature surveillance through April 4, 2018. STUDY SELECTION English-language randomized clinical trials (RCTs); prospective cohort studies reporting reclassification, calibration, or discrimination that compared risk assessment using ECG plus traditional risk factors vs traditional risk factors alone. For harms, additional study designs were eligible. Studies of persons with symptoms or a CVD diagnosis were excluded. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular events, reclassification, calibration, discrimination, and harms. RESULTS Sixteen studies were included (N = 77 140). Two RCTs (n = 1151) found no significant improvement for screening with exercise ECG (vs no screening) in adults aged 50 to 75 years with diabetes for the primary cardiovascular composite outcomes (hazard ratios, 1.00 [95% CI, 0.59-1.71] and 0.85 [95% CI, 0.39-1.84] for each study). No RCTs evaluated screening with resting ECG. Evidence from 5 cohort studies (n = 9582) showed that adding exercise ECG to traditional risk factors such as age, sex, current smoking, diabetes, total cholesterol level, and high-density lipoprotein cholesterol level produced small improvements in discrimination (absolute improvements in area under the curve [AUC] or C statistics, 0.02-0.03, reported by 3 studies); whether calibration or appropriate risk classification improves is uncertain. Evidence from 9 cohort studies (n = 66 407) showed that adding resting ECG to traditional risk factors produced small improvements in discrimination (absolute improvement in AUC or C statistics, 0.001-0.05) and appropriate risk classification for prediction of multiple cardiovascular outcomes, although evidence was limited by imprecision, quality, considerable heterogeneity, and inconsistent use of risk thresholds used for clinical decision making. Total net reclassification improvements ranged from 3.6% (2.7% event; 0.6% nonevent) to 30% (17% event; 19% nonevent) for studies using the Framingham Risk Score or Pooled Cohort Equations base models. Evidence on potential harms (eg, from subsequent angiography or revascularization) in asymptomatic persons was limited. CONCLUSIONS AND RELEVANCE RCTs of screening with exercise ECG found no improvement in health outcomes, despite focusing on higher-risk populations with diabetes. The addition of resting ECG to traditional risk factors accurately reclassified persons, but evidence for this finding had many limitations. The frequency of harms from screening is uncertain.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Shivani Reddy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Colleen Barclay
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Joshua Green
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Gary N Asher
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
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Jarmul J, Pletcher MJ, Hassmiller Lich K, Wheeler SB, Weinberger M, Avery CL, Jonas DE, Earnshaw S, Pignone M. Cardiovascular Genetic Risk Testing for Targeting Statin Therapy in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Cost-Effectiveness Analysis. Circ Cardiovasc Qual Outcomes 2018; 11:e004171. [PMID: 29650716 DOI: 10.1161/circoutcomes.117.004171] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/27/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND It is unclear whether testing for novel risk factors, such as a cardiovascular genetic risk score (cGRS), improves clinical decision making or health outcomes when used for targeting statin initiation in the primary prevention of atherosclerotic cardiovascular disease (ASCVD). Our objective was to estimate the cost-effectiveness of cGRS testing to inform clinical decision making about statin initiation in individuals with low-to-intermediate (2.5%-7.5%) 10-year predicted risk of ASCVD. METHODS AND RESULTS We evaluated the cost-effectiveness of testing for a 27-single-nucleotide polymorphism cGRS comparing 4 test/treat strategies: treat all, treat none, test/treat if cGRS is high, and test/treat if cGRS is intermediate or high. We tested a set of clinical scenarios of men and women, aged 45 to 65 years, with 10-year ASCVD risks between 2.5% and 7.5%. Our primary outcome measure was cost per quality-adjusted life-year gained. Under base case assumptions for statin disutility and cost, the preferred strategy is to treat all patients with ASCVD risk >2.5% without cGRS testing. For certain clinical scenarios, such as a 57-year-old man with a 10-year ASCVD risk of 7.5%, cGRS testing can be cost-effective under a limited set of assumptions; for example, when statins cost $15 per month and statin disutility is 0.013 (ie, willing to trade 3 months of life in perfect health to avoid 20 years of statin therapy), the preferred strategy (using a willingness-to-pay threshold of $50 000 per quality-adjusted life-year gained) is to test and treat if cGRS is intermediate or high. Overall, the results were not sensitive to assumptions about statin efficacy and harms. CONCLUSIONS Testing for a 27-single-nucleotide polymorphism cGRS is generally not a cost-effective approach for targeting statin therapy in the primary prevention of ASCVD for low- to intermediate-risk patients.
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Affiliation(s)
- Jamie Jarmul
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Mark J Pletcher
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Christy L Avery
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Daniel E Jonas
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Stephanie Earnshaw
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
| | - Michael Pignone
- Department of Health Policy and Management, Gillings School of Public Health (J.J., K.H.L., S.B.W., M.W.), UNC School of Medicine (J.J., D.E.J.), Department of Epidemiology, Gillings School of Public Health (C.L.A.), Carolina Population Center (C.L.A.), and Cecil G. Sheps Center for Health Services Research (D.E.J.), University of North Carolina-Chapel Hill. Department of Internal Medicine, Dell Medical School, University of Texas-Austin (M.P.). Department of Epidemiology and Biostatistics (M.J.P.) and Department of Medicine (M.J.P.), University of California, San Francisco
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Stephens JR, Moore C, Stepanek KV, Garbutt JC, Starke B, Liles A, Jonas DE. Implementation of a Process for Initiating Naltrexone in Patients Hospitalized for Alcohol Detoxification or Withdrawal. J Hosp Med 2018; 13:221-228. [PMID: 29364992 DOI: 10.12788/jhm.2900] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Naltrexone trials have demonstrated improved outcomes for patients with alcohol use disorders. Hospital initiation of naltrexone has had limited study. OBJECTIVE To describe the implementation and impact of a process for counseling hospitalized patients with alcohol withdrawal about naltrexone. DESIGN A pre-post study analysis. SETTING A tertiary academic center. PATIENTS Patients hospitalized for alcohol withdrawal. INTERVENTION (1) Provider education about the efficacy and contraindications of naltrexone and (2) algorithms for evaluating patients for naltrexone. MEASUREMENTS The percentages of patients counseled about and prescribed naltrexone before discharge and the percentages of pre- and postintervention patients with 30-day emergency department (ED) revisits and rehospitalizations. RESULTS We identified 128 patient encounters before and 114 after implementation. The percentage of patients counseled about naltrexone rose from 1.6% preimplementation to 63.2% postimplementation (P<.001); the percentage of patients prescribed naltrexone rose from 1.6% to 28.1% (P<.001). Comparing preintervention versus postintervention groups, there were no unadjusted differences in 30-day ED revisits (25.8% vs 19.3%; P=.23) or rehospitalizations (10.2% vs 11.4%; P=.75). When adjusted for demographics and comorbidities, postintervention patients had lower odds of 30-day ED revisits (odds ratio [OR]=0.47; 95% confidence interval [CI], 0.24-0.94) but no significant difference in rehospitalizations (OR=0.76; 95% CI, 0.30-1.92). In subgroup analysis, postintervention patients counseled versus those not counseled about naltrexone were less likely to have 30-day ED revisits (9.7% vs 35.7%; P=.001) and rehospitalizations (2.8% vs 26.2%; P<.001). CONCLUSIONS The implementation of a process for counseling patients hospitalized for alcohol withdrawal about using naltrexone for the maintenance of sobriety was associated with lower 30-day ED revisits but no statistically significant difference in rehospitalizations.
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Affiliation(s)
- John R Stephens
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Carlton Moore
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kelly V Stepanek
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - James C Garbutt
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Britta Starke
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Allen Liles
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Daniel E Jonas
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Vuong KT, Walker J, Powell HB, Thomas NE, Jonas DE, Adamson AS. Surgical re-excision vs. observation for histologically dysplastic naevi: a systematic review of associated clinical outcomes. Br J Dermatol 2018; 179:590-598. [PMID: 29570779 DOI: 10.1111/bjd.16557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The management of histologically dysplastic naevi (HDN) with re-excision vs. observation remains controversial because of lack of evidence about associated melanoma outcomes. OBJECTIVES To assess published data on the development of biopsy-site primary cutaneous melanoma among biopsy-proven HDN managed with either re-excision or observation. METHODS A systematic review of all published data: a total of 5293 records were screened, 18 articles were assessed in full text and 12 studies met inclusion criteria. No controlled trials were identified. RESULTS Most studies (11 of 12, 92%) were retrospective chart reviews, and one was both a cross-sectional and cohort study. Many studies (nine of 12, 75%) had no head-to-head comparison groups and either only reported HDN that were re-excised or observed. A total of 2673 (1535 observed vs. 1138 re-excised) HDN of various grades were included. Follow-up varied between 2 weeks and 30 years. Nine studies reported that no melanomas developed. Eleven biopsy-site melanomas developed across three of the studies, six among observed lesions (0·39%) and five among re-excised lesions (0·44%). CONCLUSIONS Based upon the available evidence the rates of biopsy-site primary melanoma were similarly low among observed lesions and re-excised lesions. This suggests that HDNs can be observed with minimal adverse melanoma-associated outcomes. However, all included articles were of low quality and further prospective trials could better guide clinical decision making.
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Affiliation(s)
- K T Vuong
- University of North Carolina School of Medicine, Chapel Hill, NC, U.S.A
| | - J Walker
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A
| | - H B Powell
- University of North Carolina School of Medicine, Chapel Hill, NC, U.S.A
| | - N E Thomas
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A
| | - D E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A
| | - A S Adamson
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, U.S.A
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Caulfield CA, Stephens J, Sharalaya Z, Laux JP, Moore C, Jonas DE, Liles EA. Patients discharged from the emergency department after referral for hospitalist admission. Am J Manag Care 2018; 24:152-156. [PMID: 29553278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians. STUDY DESIGN Retrospective cohort study at a tertiary academic medical center. METHODS We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days. RESULTS There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; P <.001) and alcohol dependence (OR, 3.1; P = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005). CONCLUSIONS A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.
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Affiliation(s)
- Christopher A Caulfield
- University of North Carolina School of Medicine, 101 Manning Dr, CB #7085, Chapel Hill, NC 27599-7085.
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Krist AH, Wolff TA, Jonas DE, Harris RP, LeFevre ML, Kemper AR, Mangione CM, Tseng CW, Grossman DC. Update on the Methods of the U.S. Preventive Services Task Force: Methods for Understanding Certainty and Net Benefit When Making Recommendations. Am J Prev Med 2018; 54:S11-S18. [PMID: 29254521 DOI: 10.1016/j.amepre.2017.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 12/29/2022]
Abstract
Since the 1980s, the U.S. Preventive Services Task Force (USPSTF) has developed and used rigorous methods to make evidence-based recommendations about preventive services to promote health and well-being for all Americans. Recommendations are based on the evidence of magnitude of net benefit (benefits minus harms). Expert opinion is not substituted when evidence is lacking. Evidence gaps are common. Few preventive services are supported by high-quality studies that directly and comprehensively determine the overall magnitude of benefits and harms in the same study. When assessing the body of evidence, studies may not have been conducted in primary care settings, studies may not have sufficiently included populations of interest, and long-term outcomes may not have been directly assessed. When direct evidence is not available, the USPSTF uses the methodologies of applicability to determine whether evidence can be generalized to an asymptomatic primary care population; coherence to link bodies of evidence and create an indirect evidence pathway; extrapolation to make inferences across the indirect evidence pathway, extend evidence to populations not specifically studied, consider service delivery intervals, and infer long-term outcomes; and conceptual bounding to set theoretical lower or upper limits for plausible benefits or harms. The USPSTF extends the evidence only so far as to maintain at least moderate certainty that its findings are preserved. This manuscript details with examples of how the USPSTF uses these methods to make recommendations that truly reflect the evidence.
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Affiliation(s)
- Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia.
| | - Tracy A Wolff
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Daniel E Jonas
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill, North Carolina
| | - Russell P Harris
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Chapel Hill, North Carolina
| | - Michael L LeFevre
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Alex R Kemper
- Ambulatory Pediatrics Division, Nationwide Children's Hospital, Columbus, Ohio
| | - Carol M Mangione
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California
| | - Chien-Wen Tseng
- Department of Family Medicine and Community Health, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii; Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - David C Grossman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Health Services and Pediatrics, University of Washington, Seattle, Washington
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Jonas DE, Ferrari RM, Wines RC, Vuong KT, Cotter A, Harris RP. Evaluating Evidence on Intermediate Outcomes: Considerations for Groups Making Healthcare Recommendations. Am J Prev Med 2018; 54:S38-S52. [PMID: 29254524 DOI: 10.1016/j.amepre.2017.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/28/2017] [Accepted: 08/28/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Groups making recommendations need evidence about whether preventive services improve health outcomes (HOs). When such evidence is not available, groups may choose to evaluate evidence about effects on intermediate outcomes (IOs) and the link between IOs and HOs. This paper aims to describe considerations for assessing the evidence linking changes in IOs to changes in HOs. METHODS Working definitions of IOs, HOs, and other outcomes were developed. All current U.S. Preventive Services Task Force (USPSTF) recommendations through April 2016 were examined to identify how evidence of the IO-HO link was gathered and the criteria that appeared to be used to determine the adequacy of the evidence. Methods of other expert and recommendation-making groups were also examined. RESULTS Forty-four USPSTF recommendations involved a relevant IO-HO link. The approaches used most commonly to gather evidence about the link were selected review (19 of 44, 43%) and systematic review (12 of 44, 27%). Some key considerations when assessing the adequacy of evidence about the IO-HO link include adjustment for confounding, proximity of the IO to the HO in the causal pathway, and independence of IO-HO relationship from specific treatments. CONCLUSIONS Considerations were identified for recommendation-making groups to use when gathering and assessing the adequacy of evidence about the IO-HO link. Using a standard set of written principles could improve the transparency of assessments of the IO-HO link, especially if used together with judgment in a reasoned conjecture and refutation process. Ideally, the process would result in an estimate of the magnitude of change in HOs that is expected for specified changes in IOs.
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Affiliation(s)
- Daniel E Jonas
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.
| | - Renée M Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Roberta C Wines
- Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Kim T Vuong
- School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Anne Cotter
- School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Russell P Harris
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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Wolff TA, Krist AH, LeFevre M, Jonas DE, Harris RP, Siu A, Owens DK, Gillman MW, Ebell MH, Herzstein J, Chou R, Whitlock E, Bibbins-Domingo K. Update on the Methods of the U.S. Preventive Services Task Force: Linking Intermediate Outcomes and Health Outcomes in Prevention. Am J Prev Med 2018; 54:S4-S10. [PMID: 29254525 DOI: 10.1016/j.amepre.2017.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/01/2017] [Accepted: 08/25/2017] [Indexed: 11/30/2022]
Abstract
The U.S. Preventive Services Task Force (USPSTF) is an independent body of experts who make evidence-based recommendations about clinical preventive services using a transparent and objective process. Developing recommendations on a clinical preventive service requires evidence of its effect on health outcomes. Health outcomes are symptoms, functional levels, and conditions that affect a patient's quantity or quality of life and are measured by assessments of physical or psychologic well-being. Intermediate outcomes are pathologic, physiologic, psychologic, social, or behavioral measures related to a preventive service. Given the frequent lack of evidence on health outcomes, the USPSTF uses evidence on intermediate outcomes when appropriate. The ultimate goal is to determine precisely a consistent relationship between the direction and magnitude of change in an intermediate outcome with a predictable resultant direction and magnitude of change in the health outcomes. The USPSTF reviewed its historical use of intermediate outcomes, reviewed methods of other evidence-based guideline-making bodies, consulted with other experts, and reviewed scientific literature. Most important were the established criteria for causation, tenets of evidence-based medicine, and consistency with its current standards. Studies that follow participants over time following early treatment, stratify patients according to treatment response, and adjust for important confounders can provide useful information about the association between intermediate and health outcomes. However, such studies remain susceptible to residual confounding. The USPSTF will exercise great caution when making a recommendation that depends on the evidence linking intermediate and health outcomes because of inherent evidence limitations.
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Affiliation(s)
- Tracy A Wolff
- Agency for Healthcare Research and Quality, Rockville, Maryland.
| | - Alex H Krist
- Virginia Commonwealth University, Richmond, Virginia
| | - Michael LeFevre
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri
| | - Daniel E Jonas
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Russell P Harris
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, Mount Sinai Health System, New York, New York
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Medicine, School of Medicine, Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Matthew W Gillman
- Division of Chronic Disease Across the Lifecourse, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts; Environmental Influences on Child Health Outcomes Program, Office of the Director, NIH, Rockville, Maryland
| | - Mark H Ebell
- College of Public Health, University of Georgia, Athens, Georgia
| | - Jessica Herzstein
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
| | - Evelyn Whitlock
- Patient-Centered Outcomes Research Institute, Washington, District of Columbia
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Jonas DE, Amick HR, Wallace IF, Feltner C, Vander Schaaf EB, Brown CL, Baker C. Vision Screening in Children Aged 6 Months to 5 Years: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2017; 318:845-858. [PMID: 28873167 DOI: 10.1001/jama.2017.9900] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Preschool vision screening could allow detection and treatment of vision abnormalities during a critical developmental stage, preserving function and quality of life. OBJECTIVE To review the evidence on screening for and treatment of amblyopia, its risk factors, and refractive error in children aged 6 months to 5 years to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, CINAHL, and trial registries through June 2016; references; and experts, with surveillance of the literature through June 7, 2017. STUDY SELECTION English-language randomized clinical trials (RCTs) or prospective cohort studies that evaluated screening, studies evaluating test accuracy, RCTs of treatment vs inactive controls, and cohort studies or case-control studies assessing harms. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Studies were not quantitatively pooled because of clinical and methodological heterogeneity. MAIN OUTCOMES AND MEASURES Visual acuity, amblyopia, school performance, functioning, quality of life, test accuracy, testability, and harms. RESULTS Forty studies were included (N = 34 709); 34 evaluated test accuracy. No RCTs compared screening with no screening, and no studies evaluated school performance, function, or quality of life. Studies directly assessing earlier or more intensive screening were limited by high attrition. Positive likelihood ratios were between 5 and 10 for amblyopia risk factors or nonamblyogenic refractive error in most studies of test accuracy and were greater than 10 in most studies evaluating combinations of clinical tests. Inability to cooperate may limit use of some tests in children younger than 3 years. Studies with low prevalence (<10%) of vision abnormalities showed high false-positive rates (usually >75%). Among children with amblyopia risk factors (eg, strabismus or anisometropia), patching improved visual acuity of the amblyopic eye by a mean of less than 1 line on a standard chart after 5 to 12 weeks for children pretreated with glasses (2 RCTs, 240 participants); more children treated with patching than with no patching experienced improvement of at least 2 lines (45% vs 21%; P = .003; 1 RCT, 180 participants). Patching plus glasses improved visual acuity by about 1 line after 1 year (0.11 logMAR [95% CI, 0.05-0.17]) for children not pretreated with glasses (1 RCT, 177 participants). Glasses alone improved visual acuity by less than 1 line after 1 year (0.08 logMAR [95% CI, 0.02-0.15], 1 RCT, 177 participants). CONCLUSIONS AND RELEVANCE Studies directly evaluating the effectiveness of screening were limited and do not establish whether vision screening in preschool children is better than no screening. Indirect evidence supports the utility of multiple screening tests for identifying preschool children at higher risk for vision problems and the effectiveness of some treatments for improving visual acuity outcomes.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC)
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | | | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC)
- RTI International, Research Triangle Park, North Carolina
| | - Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC)
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | | | - Callie L Brown
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC)
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Abstract
Unhealthy alcohol use is a leading causes of preventable death in the United States. Reducing unhealthy alcohol use should be a high priority for health care providers. Well-validated screening instruments are available, and behavioral counseling interventions delivered in primary care can reduce risky drinking. For people with alcohol use disorder, treatment programs with or without medication can reduce consumption and promote abstinence. To overcome barriers to implementation of screening for alcohol use and subsequent delivery of appropriate interventions in primary care settings, support systems, changes in staffing or roles, formal protocols, and additional provider and staff training may be required.
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Affiliation(s)
- Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, CB#7110, Chapel Hill, NC 27599, USA; Program on Medical Practice and Prevention, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Boulevard, CB#7295, Chapel Hill, NC 27599, USA.
| | - James C Garbutt
- Department of Psychiatry, UNC Bowles Center for Alcohol Studies, School of Medicine, University of North Carolina at Chapel Hill, CB# 7160, Chapel Hill, NC 27599-7160, USA
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Whitlock EP, Eder M, Thompson JH, Jonas DE, Evans CV, Guirguis-Blake JM, Lin JS. An approach to addressing subpopulation considerations in systematic reviews: the experience of reviewers supporting the U.S. Preventive Services Task Force. Syst Rev 2017; 6:41. [PMID: 28253915 PMCID: PMC5335853 DOI: 10.1186/s13643-017-0437-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/17/2017] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Guideline developers and other users of systematic reviews need information about whether a medical or preventive intervention is likely to benefit or harm some patients more (or less) than the average in order to make clinical practice recommendations tailored to these populations. However, guidance is lacking on how to include patient subpopulation considerations into the systematic reviews upon which guidelines are often based. In this article, we describe methods developed to consistently consider the evidence for relevant subpopulations in systematic reviews conducted to support primary care clinical preventive service recommendations made by the U.S. Preventive Services Task Force (USPSTF). PROPOSED APPROACH Our approach is grounded in our experience conducting systematic reviews for the USPSTF and informed by a review of existing guidance on subgroup analysis and subpopulation issues. We developed and refined our approach based on feedback from the Subpopulation Workgroup of the USPSTF and pilot testing on reviews being conducted for the USPSTF. This paper provides processes and tools for incorporating evidence-based identification of important sources of potential heterogeneity of intervention effects into all phases of systematic reviews. Key components of our proposed approach include targeted literature searches and key informant interviews to identify the most important subpopulations a priori during topic scoping, a framework for assessing the credibility of subgroup analyses reported in studies, and structured investigation of sources of heterogeneity of intervention effects. CONCLUSIONS Further testing and evaluation are necessary to refine this proposed approach and demonstrate its utility to the producers and users of systematic reviews beyond the context of the USPSTF. Gaps in the evidence on important subpopulations identified by routinely applying this process in systematic reviews will also inform future research needs.
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Affiliation(s)
- Evelyn P. Whitlock
- Patient-Centered Outcomes Research Institute, 1919 M Street NW 2nd Floor, Washington DC, 20036 USA
| | - Michelle Eder
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Jamie H. Thompson
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Daniel E. Jonas
- Department of Medicine, University of North Carolina Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC 27599 USA
| | - Corinne V. Evans
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Janelle M. Guirguis-Blake
- Department of Family Medicine, Tacoma Family Medicine Residency Program, University of Washington, 521 Martin Luther King Jr. Way, Tacoma, WA 98405 USA
| | - Jennifer S. Lin
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
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Prince AER, Cadigan RJ, Henderson GE, Evans JP, Adams M, Coker-Schwimmer E, Penn DC, Van Riper M, Corbie-Smith G, Jonas DE. Is there evidence that we should screen the general population for Lynch syndrome with genetic testing? A systematic review. Pharmgenomics Pers Med 2017; 10:49-60. [PMID: 28260941 PMCID: PMC5325104 DOI: 10.2147/pgpm.s123808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The emerging dual imperatives of personalized medicine and technologic advances make population screening for preventable conditions resulting from genetic alterations a realistic possibility. Lynch syndrome is a potential screening target due to its prevalence, penetrance, and the availability of well-established, preventive interventions. However, while population screening may lower incidence of preventable conditions, implementation without evidence may lead to unintentional harms. We examined the literature to determine whether evidence exists that screening for Lynch-associated mismatch repair (MMR) gene mutations leads to improved overall survival, cancer-specific survival, or quality of life. Documenting evidence and gaps is critical to implementing genomic approaches in public health and guiding future research. MATERIALS AND METHODS Our 2014-2015 systematic review identified studies comparing screening with no screening in the general population, and controlled studies assessing analytic validity of targeted next-generation sequencing, and benefits or harms of interventions or screening. We conducted meta-analyses for the association between early or more frequent colonoscopies and health outcomes. RESULTS Twelve studies met our eligibility criteria. No adequate evidence directly addressed the main question or the harms of screening in the general population. Meta-analyses found relative reductions of 68% for colorectal cancer incidence (relative risk: 0.32, 95% confidence interval: 0.23-0.43, three cohort studies, 590 participants) and 78% for all-cause mortality (relative risk: 0.22, 95% confidence interval: 0.09-0.56, three cohort studies, 590 participants) for early or more frequent colonoscopies among family members of people with cancer who also had an associated MMR gene mutation. CONCLUSION Inadequate evidence exists examining harms and benefits of population-based screening for Lynch syndrome. Lack of evidence highlights the need for data that directly compare benefits and harms.
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Affiliation(s)
| | - R Jean Cadigan
- Center for Genomics and Society
- Department of Social Medicine
| | | | - James P Evans
- Center for Genomics and Society
- Department of Genetics
- Carolina Center for Genome Sciences
- Lineberger Comprehensive Cancer Center
- Department of Medicine
| | - Michael Adams
- Center for Genomics and Society
- Department of Genetics
| | | | | | - Marcia Van Riper
- Center for Genomics and Society
- School of Nursing, The University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Giselle Corbie-Smith
- Center for Genomics and Society
- Department of Social Medicine
- Department of Medicine
| | - Daniel E Jonas
- Center for Genomics and Society
- Department of Medicine
- Cecil G. Sheps Center for Health Services Research
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Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, Lux L, Harris RP. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2017; 317:415-433. [PMID: 28118460 DOI: 10.1001/jama.2016.19635] [Citation(s) in RCA: 178] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many adverse health outcomes are associated with obstructive sleep apnea (OSA). OBJECTIVE To review primary care-relevant evidence on screening adults for OSA, test accuracy, and treatment of OSA, to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries through October 2015, references, and experts, with surveillance of the literature through October 5, 2016. STUDY SELECTION English-language randomized clinical trials (RCTs); studies evaluating accuracy of screening questionnaires or prediction tools, diagnostic accuracy of portable monitors, or association between apnea-hypopnea index (AHI) and health outcomes among community-based participants. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles. When multiple similar studies were available, random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, area under the curve (AUC), AHI, Epworth Sleepiness Scale (ESS) scores, blood pressure, mortality, cardiovascular events, motor vehicle crashes, quality of life, and harms. RESULTS A total of 110 studies were included (N = 46 188). No RCTs compared screening with no screening. In 2 studies (n = 702), the screening accuracy of the multivariable apnea prediction score followed by home portable monitor testing for detecting severe OSA syndrome (AHI ≥30 and ESS score >10) was AUC 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively, but the studies oversampled high-risk participants and those with OSA and OSA syndrome. No studies prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Meta-analysis found that continuous positive airway pressure (CPAP) compared with sham was significantly associated with reduction of AHI (weighted mean difference [WMD], -33.8 [95% CI, -42.0 to -25.6]; 13 trials, 543 participants), excessive sleepiness assessed by ESS score (WMD, -2.0 [95% CI, -2.6 to -1.4]; 22 trials, 2721 participants), diurnal systolic blood pressure (WMD, -2.4 points [95% CI, -3.9 to -0.9]; 15 trials, 1190 participants), and diurnal diastolic blood pressure (WMD, -1.3 points [95% CI, -2.2 to -0.4]; 15 trials, 1190 participants). CPAP was associated with modest improvement in sleep-related quality of life (Cohen d, 0.28 [95% CI, 0.14 to 0.42]; 13 trials, 2325 participants). Mandibular advancement devices (MADs) and weight loss programs were also associated with reduced AHI and excessive sleepiness. Common adverse effects of CPAP and MADs included oral or nasal dryness, irritation, and pain, among others. In cohort studies, there was a consistent association between AHI and all-cause mortality. CONCLUSIONS AND RELEVANCE There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.
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Affiliation(s)
- Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Halle R Amick
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Rachel Palmieri Weber
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Marina Arvanitis
- Department of Medicine, University of North Carolina at Chapel Hill3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill4Now with the Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander Stine
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center5RTI International, Research Triangle Park, North Carolina6Now with the Center for Cognitive Neuroscience, Duke University, Durham, North Carolina
| | - Linda Lux
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center5RTI International, Research Triangle Park, North Carolina
| | - Russell P Harris
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Feltner C, Grodensky C, Ebel C, Middleton JC, Harris RP, Ashok M, Jonas DE. Serologic Screening for Genital Herpes: An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2016; 316:2531-2543. [PMID: 27997660 DOI: 10.1001/jama.2016.17138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Genital herpes simplex virus (HSV) infection is a prevalent sexually transmitted infection. Vertical transmission of HSV can lead to fetal morbidity and mortality. OBJECTIVE To assess the evidence on serologic screening and preventive interventions for genital HSV infection in asymptomatic adults and adolescents to support the US Preventive Services Task Force for an updated recommendation statement. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries through March 31, 2016. Surveillance for new evidence in targeted publications was conducted through October 31, 2016. STUDY SELECTION English-language randomized clinical trials (RCTs) comparing screening with no screening in persons without past or current symptoms of genital herpes; studies evaluating accuracy and harms of serologic screening tests for HSV-2; RCTs assessing preventive interventions in asymptomatic persons seropositive for HSV-2. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; pooled sensitivities and specificities of screening tests using a hierarchical summary receiver operating characteristic curve analysis when at least 3 similar studies were available. MAIN OUTCOMES AND MEASURES Accuracy of screening tests, benefits of screening, harms of screening, reduction in genital herpes outbreaks. RESULTS A total of 17 studies (n = 9736 participants; range, 24-3290) in 19 publications were included. No RCTs compared screening with no screening. Most studies of the accuracy of screening tests were from populations with high HSV-2 prevalence (greater than 40% based on Western blot). Pooled estimates of sensitivity and specificity of the most commonly used test at the manufacturer's cutpoint were 99% (95% CI, 97%-100%) and 81% (95% CI, 68%-90%), respectively (10 studies; n = 6537). At higher cutpoints, pooled estimates were 95% (95% CI, 91%-97%) and 89% (95% CI, 82%-93%), respectively (7 studies; n = 5516). Use of this test at the manufacturer's cutpoint in a population of 100 000 with a prevalence of HSV-2 of 16% (the seroprevalence in US adults with unknown symptom status) would result in 15 840 true-positive results and 15 960 false-positive results (positive predictive value, 50%). Serologic screening for genital herpes was associated with psychosocial harms, including distress and anxiety related to positive test results. Four RCTs compared preventive medications with placebo, 2 in nonpregnant asymptomatic adults who were HSV-2 seropositive and 2 in HSV-2-serodiscordant couples. Results in both populations were heterogeneous and inconsistent. CONCLUSIONS AND RELEVANCE Serologic screening for genital herpes is associated with a high rate of false-positive test results and potential psychosocial harms. Evidence from RCTs does not establish whether preventive antiviral medication for asymptomatic HSV-2 infection has benefit.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center2Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill3Department of Medicine, University of North Carolina at Chapel Hill
| | - Catherine Grodensky
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
| | - Charles Ebel
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer C Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center2Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Russell P Harris
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center2Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill3Department of Medicine, University of North Carolina at Chapel Hill
| | - Mahima Ashok
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center4RTI International, Research Triangle Park, North Carolina
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center2Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill3Department of Medicine, University of North Carolina at Chapel Hill
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Jonas DE, Garza D. An evidence-based approach to screening and providing appropriate interventions for unhealthy alcohol use in primary care settings. J Comp Eff Res 2016; 5:521-524. [PMID: 27582343 DOI: 10.2217/cer-2016-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diego Garza
- Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kahwati LC, Feltner C, Halpern M, Woodell CL, Boland E, Amick HR, Weber RP, Jonas DE. Primary Care Screening and Treatment for Latent Tuberculosis Infection in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2016; 316:970-83. [PMID: 27599332 DOI: 10.1001/jama.2016.10357] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Five to ten percent of individuals with latent tuberculosis infection (LTBI) progress to active tuberculosis (TB) disease. Identifying and treating LTBI is a key component of the strategy for reducing the burden of TB disease. OBJECTIVE To review the evidence about targeted screening and treatment for LTBI among adults in primary care settings to support the US Preventive Services Task Force in updating its 1996 recommendation. DATA SOURCES MEDLINE, Cochrane Library, and trial registries, searched through August 3, 2015; references from pertinent articles; and experts. Literature surveillance was conducted through May 31, 2016. STUDY SELECTION English-language studies of LTBI screening, LTBI treatment with recommended pharmacotherapy, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of individuals for whom LTBI screening and treatment is part of public health surveillance or disease management were excluded. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles. When at least 3 similar studies were available, random-effects meta-analysis was used to generate pooled estimates of outcomes. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, reliability, active TB disease, mortality, hepatotoxicity, and other harms. RESULTS The review included 72 studies (n = 51 711). No studies evaluated benefits and harms of screening compared with no screening. Pooled estimates for sensitivity of the TST at both 5-mm and 10-mm induration thresholds were 0.79 (5-mm: 95% CI, 0.69-0.89 [8 studies, n = 803]; 10 mm: 95% CI, 0.71-0.87 [11 studies; n = 988]), and those for IGRAs ranged from 0.77 to 0.90 (57 studies; n = 4378). Pooled estimates for specificity of the TST at the 10-mm and 15-mm thresholds and for IGRAs ranged from 0.95 to 0.99 (34 studies; n = 23 853). A randomized clinical trial (RCT) of 24 weeks of isoniazid in individuals with pulmonary fibrotic lesions and LTBI (n = 27 830) found a reduction in absolute risk of active TB at 5 years from 1.4% to 0.5% (relative risk [RR], 0.35 [95% CI, 0.24-0.52]) and an increase in absolute risk for hepatoxicity from 0.1% to 0.5% (RR, 4.59 [95% CI, 2.03-10.39]) for 24 weeks of daily isoniazid compared with placebo. An RCT (n = 6886) found that 3 months of once-weekly rifapentine plus isoniazid was noninferior to 9 months of isoniazid alone for preventing active TB. The risk difference for hepatoxicity comparing isoniazid with rifampin ranged from 3% to 7%, with a pooled RR of 3.29 (95% CI, 1.72-6.28 [3 RCTs; n = 1327]). CONCLUSIONS AND RELEVANCE No studies evaluated the benefits and harms of screening compared with no screening. Both the TST and IGRAs are moderately sensitive and highly specific within countries with low TB burden. Treatment reduced the risk of active TB among the populations included in this review. Isoniazid is associated with higher rates of hepatotoxicity than placebo or rifampin.
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Affiliation(s)
- Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina
| | - Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center3Department of Medicine, University of North Carolina at Chapel Hill4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Michael Halpern
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina
| | - Carol L Woodell
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina
| | - Erin Boland
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center2RTI International, Research Triangle Park, North Carolina
| | - Halle R Amick
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Rachel Palmieri Weber
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center3Department of Medicine, University of North Carolina at Chapel Hill4Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Cusack K, Jonas DE, Forneris CA, Wines C, Sonis J, Middleton JC, Feltner C, Brownley KA, Olmsted KR, Greenblatt A, Weil A, Gaynes BN. Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Rev 2015; 43:128-41. [PMID: 26574151 DOI: 10.1016/j.cpr.2015.10.003] [Citation(s) in RCA: 373] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/28/2022]
Abstract
Numerous guidelines have been developed over the past decade regarding treatments for Posttraumatic stress disorder (PTSD). However, given differences in guideline recommendations, some uncertainty exists regarding the selection of effective PTSD therapies. The current manuscript assessed the efficacy, comparative effectiveness, and adverse effects of psychological treatments for adults with PTSD. We searched MEDLINE, Cochrane Library, PILOTS, Embase, CINAHL, PsycINFO, and the Web of Science. Two reviewers independently selected trials. Two reviewers assessed risk of bias and graded strength of evidence (SOE). We included 64 trials; patients generally had severe PTSD. Evidence supports efficacy of exposure therapy (high SOE) including the manualized version Prolonged Exposure (PE); cognitive therapy (CT), cognitive processing therapy (CPT), cognitive behavioral therapy (CBT)-mixed therapies (moderate SOE); eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (low-moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., Cohen's d ~-1.0 or more compared with controls). Numbers needed to treat (NNTs) were <4 to achieve loss of PTSD diagnosis for exposure therapy, CPT, CT, CBT-mixed, and EMDR. Several psychological treatments are effective for adults with PTSD. Head-to-head evidence was insufficient to determine these treatments' comparative effectiveness, and data regarding adverse events was absent from most studies.
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Affiliation(s)
- Karen Cusack
- Raymond G. Murphy VA Medical Center, Albuquerque, NM, United States.
| | - Daniel E Jonas
- University of North Carolina (UNC) Department of Medicine, Chapel Hill, NC, United States; UNC, Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC, United States
| | | | - Candi Wines
- UNC, Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC, United States
| | - Jeffrey Sonis
- UNC Department of Social Medicine, Chapel Hill, NC, United States; UNC Department of Family Medicine, Chapel Hill, NC, United States
| | | | - Cynthia Feltner
- University of North Carolina (UNC) Department of Medicine, Chapel Hill, NC, United States; UNC, Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC, United States
| | | | - Kristine Rae Olmsted
- Triangle Institute (RTI) International, Research Triangle Park, NC, United States
| | - Amy Greenblatt
- Triangle Institute (RTI) International, Research Triangle Park, NC, United States
| | - Amy Weil
- University of North Carolina (UNC) Department of Medicine, Chapel Hill, NC, United States
| | - Bradley N Gaynes
- UNC, Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC, United States; UNC Department of Psychiatry, Chapel Hill, NC, United States
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