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Completed Systematic Reviews




Treatment Strategies for Patients with Lower Extremity Chronic Venous Disease (LECVD)


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Statistics: 111 Studies, 3 Key Questions, 3 Extraction Forms,
Date Published: Mar 21, 2019 09:12AM
Description: Objectives. For patients with lower extremity chronic venous disease (LECVD), the optimal diagnostic testing and treatment for symptom relief, preservation of limb function, and improvement in quality of life is not known. This systematic review included a narrative review of diagnostic testing modalities and assessed the comparative effectiveness of exercise training, medical therapy, weight reduction, mechanical compression therapy, and invasive procedures (i.e., surgical and endovascular procedures) in patients with LECVD. Data sources. We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2000 to June 30, 2016. Review methods. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects. Results. A total of 111 studies contributed evidence, as follows: Diagnosis of LECVD: A narrative review was conducted due to the scant literature and availability of only 10 observational studies evaluating the comparative effectiveness of diagnostic testing modalities in a heterogeneous population of patients with LECVD. In addition to the history and physical exam, multiple physiologic and imaging modalities (plethysmography, duplex ultrasound, intravascular ultrasonography, magnetic resonance venography, computed tomography venography, and invasive venography) are useful to confirm LECVD and/or localize the disease and guide therapy. There was insufficient evidence to support or refute the recommendations from current clinical guidelines that duplex ultrasound should be used as the firstline diagnostic test for patients being evaluated for LECVD or for those for whom invasive treatment is planned. Treatment of lower extremity chronic venous insufficiency/incompetence/reflux: Ninety-three studies (87 randomized controlled trials, 6 observational) evaluated the comparative effectiveness of exercise training, medical therapy, weight reduction, mechanical compression therapy, surgical intervention, and endovenous intervention in patients with lower extremity chronic venous insufficiency/incompetence/reflux. There was no long-term difference in effectiveness between radiofrequency ablation (RFA) and high ligation plus stripping, but RFA was associated with less periprocedural pain, faster improvement in symptom scores and quality of life, and fewer adverse events. Among patients undergoing endovenous interventions, RFA, endovenous laser ablation (EVLA), and sclerotherapy demonstrated improvement in quality-of-life scores and standardized symptom scores. When compared with patients treated with EVLA, those treated with foam sclerotherapy had significantly less periprocedural pain but lower rates of vein occlusion and higher rates of repeat intervention, and patients treated with RFA had significantly less periprocedural pain but also less short-term improvement in Venous Clinical Severity Score. When compared with patients treated with placebo, those treated with foam sclerotherapy had statistically significant improvement in standardized symptom scores, occlusion rates, and quality of life. When compared with patients treated with placebo or no compression therapy, those treated with compression therapy had significant improvement in standardized symptom scores and quality of life. Treatment of lower extremity chronic venous obstruction/thrombosis: Eight studies (3 randomized controlled trials, 5 observational) evaluated the comparative effectiveness of exercise training, medical therapy, weight reduction, mechanical compression therapy, surgical intervention, and endovenous intervention in patients with lower extremity chronic venous obstruction/thrombosis. In patients with post-thrombotic syndrome, exercise training plus patient education and monthly phone follow-up resulted in improved quality of life but not improved symptom severity when compared with patient education and monthly phone follow-up. In patients with both May-Thurner Syndrome and superficial venous reflux who were treated with EVLA (with or without stent placement), there were fewer recurrent ulcerations, improvement in reflux severity and symptoms, and improvement in quality of life in long-term follow-up. In patients with chronic proximal iliac vein obstruction, treatment with catheter-directed urokinase at the time of endovenous stenting resulted in similar effectiveness but catheter-directed urokinase had higher technical failure rates and bleeding risk when compared with endovenous stenting alone. Very few studies evaluated modifiers of effectiveness in the study population. Conclusions. The available evidence for treatment of patients with LECVD is limited by heterogeneous studies that compared multiple treatment options, measured varied outcomes, and assessed disparate outcome timepoints. Very limited comparative effectiveness data have been generated to study new and existing diagnostic testing modalities for patients with LECVD. When compared with patients’ baseline measures, endovenous interventions (e.g. EVLA, sclerotherapy, and RFA) and surgical ligation demonstrated improvement in quality-of-life scores and Venous Clinical Severity Score at various timepoints after treatment; however, there were no statistically significant differences in outcomes between treatment groups (e.g. endovenous vs. endovenous; endovenous vs. surgical). Several advances in care in endovenous interventional therapy have not yet been rigorously tested, and there are very few studies on conservative measures (e.g., lifestyle modification, compression therapy, exercise training) in the literature published since 2000. Additionally, the potential additive effects of many of these therapies are unknown. The presence of significant clinical heterogeneity of these results makes conclusions for clinical outcomes uncertain and provides an impetus for further research to improve the care of patients with LECVD.
Contributor(s): W. Schuyler Jones, M.D. Sreekanth Vemulapalli, M.D. Kishan S. Parikh, M.D. Remy R. Coeytaux, MD, Ph.D. Matthew J. Crowley, M.D., M.H.Sc Giselle Raitz, M.D. Abigail L. Johnston, B.A. Vic Hasselblad, Ph.D. Amanda J. McBroom, Ph.D. Kathryn R. Lallinger, M.S.L.S. Gillian D. Sanders-Schmidler, Ph.D.
Funding Source: The Centers for Medicare & Medicaid Services (CMS); Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2000 to June 30, 2016. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects. See the review protocol (http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/lecvd_protocol.pdf) for full details.

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Nonsurgical Treatments for Urinary Incontinence in Adult Women: A Systematic Review Update


Public Project Complete

Statistics: 106 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Mar 21, 2019 09:12AM
Description: SR of nonsurgical interventions for stress, urgency, and mixed urinary incontinence in women (excluding neuropathic UI and children). Network meta-analysis of "urinary incontinence outcomes" ("cure", improvement, and satisfaction with the level of incontinence achieved). Qualitative review of quality of life outcomes. Summary of adverse events. This is an update of a 2012 review done by the Minnesota EPC. Available data from eligible studies included in the prior review are uploaded as separate files.
Contributor(s): Brown University Evidence-based Practice Center: Ethan Balk, Gaelen Adam, Peter Jeppson (U New Mexico GYN), Hannah Kimmel, Georgios Markozannes, Iman Saeed, Gowri Raman (Tufts Medical Center [TMC]), Esther Avendano (TMC), Andrew Zullo, Katherine Corsi, Amanda Mogul, Mengyang Di, Valerie Langberg
Funding Source: AHRQ EPC Program
Methodology Description: We updated AHRQ’s 2012 systematic review with new literature searches in MEDLINE, the Cochrane Central Trials Registry, the Cochrane Database of Systematic Reviews, and EMBASE from 2011 through December 4, 2017. We included UI outcomes (cure, improvement, satisfaction), quality of life, and adverse events. For UI outcomes, we conducted network meta-analyses, combining direct and indirect comparisons across studies. Quality of life and adverse event outcomes are narratively described. See full report at AHRQ website for further details.

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Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents


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Statistics: 90 Studies, 3 Key Questions, 2 Extraction Forms,
Date Published: Mar 21, 2019 09:12AM
Description: Objectives. Attention deficit hyperactivity disorder (ADHD) is a common pediatric neurobehavioral disorder often treated in the primary care setting. This systematic review updates and extends two previous systematic evidence reviews and focuses on the comparative effectiveness of methods to establish the diagnosis of ADHD, updates the comparative effectiveness of pharmacologic and nonpharmacologic treatments, and evaluates different monitoring strategies in the primary care setting for individuals from birth through 17 years of age. Data sources. We searched PubMed®, Embase®, PsycINFO® and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2011, through November 7, 2016. Review methods. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects when sufficient data were available for meta-analysis.
Contributor(s): Alex R. Kemper, M.D., M.P.H, M.S.; Gary R. Maslow, M.D., M.P.H.; Sherika Hill, M.H.A., Ph.D.; Behrouz Namdari, M.D.; Nancy M. Allen LaPointe, Pharm.D., M.H.S.; Adam P. Goode, D.P.T., Ph.D.; Remy R. Coeytaux, M.D., Ph.D.; Deanna Befus, B.A., B.S.N.; Andrzej S. Kosinski, Ph.D.; Samantha E. Bowen, Ph.D.; Amanda J. McBroom, Ph.D.; Kathryn R. Lallinger, M.S.L.S.; Gillian D. Sanders, Ph.D.
Funding Source: Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We searched MEDLINE® (via PubMed), Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews (CDSR), limiting the search to studies conducted in children 17 years of age and younger and published from January 1, 2009, to November 7, 2016. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects. See the review protocol (https://www.effectivehealthcare.ahrq.gov/ehc/products/616/2148/ADHD-Update-protocol-160818.pdf) for full details.

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Diagnostic Accuracy of Screening Tests and Treatment of Post-Acute Coronary Syndrome (ACS) Depression: A Systematic Review


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Statistics: 10 Studies, 2 Key Questions, 2 Extraction Forms,
Date Published: Mar 21, 2019 09:12AM
Description: Objective: To evaluate (1) the diagnostic accuracy of selected depression screening instruments and strategies versus a validated criterion standard in adult patients within 3 months of an acute coronary syndrome (ACS) event, and (2) the comparative safety and effectiveness of a broad range of pharmacologic and nonpharmacologic treatments for depression in adult patients who have received a criterion-based diagnosis of depression or had clinically important depressive symptoms using a validated depression scale, and who are within 3 months of an ACS event. Data Sources: We searched PubMed®, Embase®, PsycINFO®, CINAHL®, and the Cochrane Database of Systematic Reviews for English-language studies published from January 1, 2003, to April 27, 2017, that evaluated the accuracy of tools for diagnosing depression in patients after ACS or that evaluated interventions for treating post-ACS patients identified with depression. Review Methods: Two investigators individually screened each abstract and full-text article for inclusion; abstracted data; and rated quality, applicability, and strength of evidence. Where appropriate, random-effects models were used to compute summary estimates of effects.
Contributor(s): John W. Williams Jr., M.D., M.H.Sc.; Jason A. Nieuwsma, Ph.D.; Natasha Namdari, M.D. ; Jeffrey B. Washam, Pharm.D.; Giselle Raitz, M.D.; James A. Blumenthal, Ph.D.; Wei Jiang, M.D.; Roshini Yapa, M.B.B.S.; Amanda J. McBroom, Ph.D.; Kathryn Lallinger, M.S.L.S.; Robyn Schmidt, B.A.; Andrzej S. Kosinski, Ph.D.; Gillian D. Sanders, Ph.D.
Funding Source: Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We searched MEDLINE® (via PubMed), Embase®, PsycINFO®, CINAHL®, and the Cochrane Database of Systematic Reviews (CDSR), limiting the search to articles published from January 1, 2003, to April 27, 2017. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects. See the review protocol (https://effectivehealthcare.ahrq.gov/topics/acs-depression/research-protocol/) for full details.

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The Role of Immunotherapy in the Treatment of Asthma


Public Project Complete

Statistics: 130 Studies, 4 Key Questions, 2 Extraction Forms,
Date Published: Mar 21, 2019 09:12AM
Description: To evaluate the efficacy and safety of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) in the treatment of allergic asthma
Contributor(s): Sandra Y. Lin, M.D., Antoine Azar, M.D., Catalina Suarez-Cuervo, M.D., Gregory B. Diette, M.D., MHS, Emily Brigham, M.D., Jessica Rice, D.O., MHS, Murugappan Ramanathan, Jr., M.D., F.A.C.S., Jessica Gayleard, B.S. and Karen A. Robinson, Ph.D.
Funding Source: AHRQ and NHLBI
Methodology Description: We searched PubMed, Embase®, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 1,2005 through May 8, 2017. We followed the PICOTS framework in developing the criteria for inclusion of studies. Two reviewers independently screened to select randomized controlled trials (RCTs) of the efficacy of SCIT and SLIT and RCTs, observational studies, and case series or case reports on safety. Two reviewers independently assessed the risk of bias for each study and together graded the strength of the evidence.

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