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Completed Systematic Reviews




Noninvasive Treatments for Low Back Pain [Entered Retrospectively]


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Statistics: 156 Studies, 2 Key Questions, 1 Extraction Form,
Date Published: Apr 30, 2021 03:58AM
Description: Objectives. Low back pain is common and many pharmacological and nonpharmacological therapies are available. This review examines the evidence on the comparative benefits and harms of noninvasive treatments for low back pain. Data Sources. A prior systematic review (searches through October 2008), electronic databases (Ovid MEDLINE and the Cochrane Libraries, January 2008 to April 2015), reference lists, and clinical trials registries. Review Methods. Using predefined criteria, we selected systematic reviews of randomized trials of pharmacological treatments (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAID]s, opioids, skeletal muscle relaxants, benzodiazepines, antidepressants, antiseizure medications, and systemic corticosteroids) and nonpharmacological treatments (psychological therapies, multidisciplinary rehabilitation, spinal manipulation, acupuncture, massage, exercise and related therapies, and various physical modalities) for nonradicular or radicular low back pain that addressed effectiveness or harms versus placebo, no treatment, usual care, a sham therapy, an inactive therapy, or another active therapy. We also included randomized trials that were not in systematic reviews. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively based on the totality of the evidence. Results. Of the 2,545 citations identified at the title and abstract level, a total of 156 publications were included. Most trials enrolled patients with pain symptoms of at least moderate intensity (e.g., >5 on a 0- to 10-point NRS for pain). Across interventions, pain intensity was the most commonly reported outcome, followed by back-specific function. When present, observed benefits for pain were generally in the small (5 to 10 points on a 0- to 100-point visual analogue scale [VAS] or 0.5 to 1.0 points on a 0- to 10-point numerical rating scale) to moderate (10 to 20 points) range. Effects on function were generally smaller than effects on pain; in some cases there were positive effects on pain but no effects on function, and fewer studies measured function than pain. Benefits were mostly measured at short-term followup. For acute low back pain, evidence suggested that NSAIDs (strength of evidence [SOE]: low to moderate), skeletal muscle relaxants (SOE: moderate), opioids (SOE: low), exercise (SOE: low), and superficial heat (SOE: moderate) are more effective than placebo, no intervention, or usual care and that acetaminophen (SOE: low) and systemic corticosteroids (SOE: low) are no more effective than placebo. For chronic low back pain, effective therapies versus placebo, sham, no treatment, usual care, or wait list are NSAIDs, opioids, tramadol, duloxetine, multidisciplinary rehabilitation, acupuncture, and exercise (SOE: moderate) and benzodiazepines, psychological therapies, massage, yoga, tai chi, and low-level laser therapy (SOE: low); spinal manipulation was as effective as other active interventions (SOE: moderate). Few trials evaluated the effectiveness of treatments for radicular low back pain, but the available evidence found that benzodiazepines, corticosteroids, traction, and spinal manipulation were not effective or associated with small effects (SOE: low). Relatively few trials directly compared the effectiveness of different medications, different nonpharmacological therapies, or compared pharmacological versus nonpharmacological therapies, and generally found no clear differences in effects. Pharmacological therapies were associated with increased risk of adverse events versus placebo (SOE: low to moderate). Trials were not designed or powered to detect serious harms from pharmacological therapies. Although rates appeared to be low, and there was not an increased risk of serious harms versus placebo, this does not rule out significant risk from some treatments. For nonpharmacological therapies, assessment of harms was suboptimal, but serious harms appeared rare (SOE: low). Conclusions. A number of pharmacological and nonpharmacological, noninvasive treatments for low back pain are associated with small to moderate, primarily short-term effects on pain versus placebo, sham, wait list, or no treatment. Effects on function were generally smaller than effects on pain. More research is needed to understand optimal selection of treatments, effective combinations and sequencing of treatments, effectiveness of treatments for radicular low back pain, and effectiveness on outcomes other than pain and function.
Contributor(s): Roger Chou, M.D., FACP Rick (Richard) Deyo, M.D., M.P.H. Janna Friedly, M.D. Andrea Skelly, Ph.D., M.P.H. Robin Hashimoto, Ph.D. Melissa Weimer, D.O., M.C.R. Rochelle Fu, Ph.D. Tracy Dana, M.L.S. Paul Kraegel, M.S.W. Jessica Griffin, M.S. Sara Grusing, B.A. Erika Brodt, B.S.
Funding Source: This project was funded under Contract No. HHSA 290-2012-00014-I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
Methodology Description: Review Methods. Using predefined criteria, we selected systematic reviews of randomized trials of pharmacological treatments (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAID]s, opioids, skeletal muscle relaxants, benzodiazepines, antidepressants, antiseizure medications, and systemic corticosteroids) and nonpharmacological treatments (psychological therapies, multidisciplinary rehabilitation, spinal manipulation, acupuncture, massage, exercise and related therapies, and various physical modalities) for nonradicular or radicular low back pain that addressed effectiveness or harms versus placebo, no treatment, usual care, a sham therapy, an inactive therapy, or another active therapy. We also included randomized trials that were not in systematic reviews. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively based on the totality of the evidence.

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Screening for Bacterial Vaginosis in Pregnant Adolescents and Women to Prevent Preterm Delivery


Public Project Complete

Statistics: 45 Studies, 5 Key Questions, 1 Extraction Form,
Date Published: Apr 21, 2021 06:30PM
Description: A review of the evidence about screening for bacterial vaginosis during pregnancy to prevent preterm delivery.
Contributor(s): The authors gratefully acknowledge the following individuals for their contributions to this project: Tina Fan, MD, MPH, AHRQ Medical Officer; Tracy Wolff, MD, MPH, AHRQ Associate Scientific Director; Quyen Ngo-Metzger, MD, MPH, Professor at Kaiser Permanente School of Medicine; current members of the U.S. Preventive Services Task Force; expert peer reviewers Mark Klebanoff, MD, MPH; John Thorp, MD; Valerie J. King, MD, MPH; and Julie van Schalkwyk, MD; two Federal partner reviewers; and RTI International–University of North Carolina EPC staff: Carol Woodell, BSPH; B. Lynn Whitener, DrPH; Sharon Barrell, MA; and Loraine Monroe.
DOI: DOI pending.
Funding Source: AHRQ
Methodology Description: We conducted a systematic review to evaluate the benefits and harms of screening and treatment for bacterial vaginosis during pregnancy to prevent preterm delivery and the diagnostic accuracy of tests used to screen for bacterial vaginosis. We searched 3 databases from January 1, 2006, through May 29, 2019, building on the literature included in the prior 2008 evidence review for the USPSTF. Because the previous reviews on this topic for the USPSTF did not include a systematic search for KQ 2 (diagnostic test accuracy), we conducted a separate PubMed search from inception through December 31, 2005, to supplement our main search for this update. Two investigators screened each abstract and full-text article for inclusion; abstracted data; and performed quality ratings, applicability ratings, and evidence grading. Where appropriate, we performed a quantitative synthesis by fitting the bivariate model to generate a summary receiver operating characteristics curve (SROC) and a pooled summary point estimate of sensitivity and specificity.

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Prehospital Airway Management: A Systematic Review


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Statistics: 98 Studies, 4 Key Questions, 1 Extraction Form,
Date Published: Apr 14, 2021 04:26PM
Description: Objective. To assess the comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) by emergency medical services in the prehospital setting and how the benefits and harms differ based on patient characteristics, techniques, and devices. Data sources. We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020, reference lists, and posted a Federal Register notice request for data. Review methods. Review methods followed Agency for Healthcare Research and Quality Evidence-based Practice Center Program Methods guidance. Using pre-established criteria, studies were selected, dual reviewed, data abstracted, and evaluated for risk of bias. Meta-analyses using profile-likelihood random effects models were conducted when data were available from studies reporting on similar outcomes, with analyses stratified by study design, emergency type, and age. We qualitatively synthesized results when meta-analysis was not indicated. Strength of evidence (SOE) was assessed for primary outcomes (survival, neurological function, return of spontaneous circulation [ROSC], and successful advanced airway insertion [for SGA and ETI only]). Results. We included 99 studies (22 randomized controlled trials and 77 observational studies) involving 630,397 patients. Overall, we found few differences in primary outcomes when airway management approaches were compared. • For survival, there was moderate SOE for findings of no difference for BVM versus ETI in adult and mixed-age cardiac arrest patients. There was low SOE for no difference in these patients for BVM versus SGA and SGA versus ETI. There was low SOE for all three comparisons in pediatric cardiac arrest patients, and in adult trauma patients when BVM was compared with ETI. • For neurological function, there was moderate SOE for no difference for BVM compared with ETI in adults with cardiac arrest. There was low SOE for no difference in pediatric cardiac arrest for BVM versus ETI and SGA versus ETI. In adults with cardiac arrest, neurological function was better for BVM and ETI compared with SGA (both low SOE). • ROSC was only applicable in cardiac arrest. For adults, there was low SOE that ROSC was more frequent with SGA compared with ETI, and no difference for BVM versus SGA or BVM versus ETI. In pediatric patients there was also low SOE of no difference for BVM versus ETI and SGA versus ETI. • For successful advanced airway insertion, low SOE supported better first-pass success with SGA in adult and pediatric cardiac arrest patients and adult patients in studies that mixed emergency types. Low SOE also supported no difference for first-pass success in adult medical patients. For overall success, there was moderate SOE of no difference for adults with cardiac arrest, medical, and mixed emergency types. • While harms were not always measured or reported, moderate SOE supported all available findings. There were no differences in harms for BVM versus SGA or ETI. When SGA was compared with ETI, there were no differences for aspiration, oral/airway trauma, and regurgitation; multiple insertion attempts was better for SGA, and inadequate ventilation was better for ETI. Conclusions. The most common findings, across emergency types and age groups, was of no differences in primary outcomes when prehospital airway management approaches were compared. As most of the included studies were observational, these findings may reflect study design and methodological limitations. Due to the dynamic nature of the prehospital environment, the results are susceptible to indication and survival biases as well as confounding; however, the current evidence does not favor more invasive airway approaches. No conclusion was supported by high SOE for any comparison and patient group. This supports the need for high-quality randomized controlled trials designed to account for the variability and dynamic nature of prehospital airway management to advance and inform clinical practice, emergency medical services education and policy, and improve patient-centered outcomes.
Contributor(s): Nancy Carney, Ph.D. Tamara Cheney, M.D. Annette M. Totten, Ph.D. Rebecca Jungbauer, DrPH Matthew R. Neth, M.D. Chandler Weeks, M.P.H. Cynthia Davis-O'Reilly, B.S. Rochelle Fu, Ph.D. Yun Yu, M.S. Roger Chou, M.D. Mohamud Daya, M.D., M.S.
DOI: DOI pending.
Funding Source: This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center under contract for the Agency for Healthcare Research and Quality, Rockville, MD (Contract No. HHSA29022015000091)
Methodology Description: Data sources. We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020, reference lists, and posted a Federal Register notice request for data. Review methods. Review methods followed Agency for Healthcare Research and Quality Evidence-based Practice Center Program Methods guidance. Using pre-established criteria, studies were selected, dual reviewed, data abstracted, and evaluated for risk of bias. Meta-analyses using profile-likelihood random effects models were conducted when data were available from studies reporting on similar outcomes, with analyses stratified by study design, emergency type, and age. We qualitatively synthesized results when meta-analysis was not indicated. Strength of evidence (SOE) was assessed for primary outcomes (survival, neurological function, return of spontaneous circulation [ROSC], and successful advanced airway insertion [for SGA and ETI only]).

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Flavan-3ols intake and cardiovascular outcomes: Systematic Review


Public Project Complete

Statistics: 160 Studies, 2 Key Questions, 1 Extraction Form,
Date Published: Apr 14, 2021 04:12PM
Description: This proposed evidence mapping project will summarize the data related to Flavan-3-ols and its connection to vascular health outcomes and risk factors.
Contributor(s): Gowri Raman, MD, MS Esther E. Avendano, MS Siyu Chen, MS Jiaqi Wang, MS Bridget Gayer, MS Julia Matson, BS
DOI: DOI pending.
Funding Source: International Life Sciences Institute (ILSI) North America
Methodology Description: This study is a systematic review of published literature evaluating the effects of flavan-3-ol intake on CVD outcomes and risk factors. The review was conducted in 2 phases: a first phase of evidence mapping followed by a full systematic review. A comprehensive search of the scientific literature was conducted in MEDLINE, the Cochrane Central databases, and the Commonwealth Agricultural Bureau from inception through March 9, 2019. We included RCTs and prospective cohort studies conducted in adults (≥ 18 years) that quantified the amount of flavan-3-ols consumed per day or per week. Studies that provided sufficient serving size data were also included, provided that estimation of total flavan-3-ol consumption was possible using the USDA or Phenol Explorer databases. Citations were screened in duplicate using predefined eligibility criteria and any disagreements regarding study inclusion or exclusion were resolved in group meetings. The primary outcomes of interest included CVD clinical outcomes [e.g., CVD mortality, chronic heart disease (CHD), stroke, diabetes, and hypertension]; secondary outcomes included risk factors [serum lipids, blood pressures, glucose metabolism, and flow-mediated dilation (FMD)] and biomarkers [high-sensitivity CRP (hsCRP), IL-6, and TNF-α].

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Automated-Entry Patient Generated Health Data for Chronic Conditions: The Evidence on Health Outcomes


Public Project Complete

Statistics: 128 Studies, 50 Key Questions, 10 Extraction Forms,
Date Published: Feb 19, 2021 08:13PM
Description: Technical brief for AHRQ on the evidence for whether PGHD devices and apps improve health outcomes for chronic conditions
Contributor(s): Jonathan R. Treadwell, Ph.D., James T. Reston Ph.D., Benjamin Rouse, M.H.S., Joann Fontanarosa, Ph.D., Neha Patel, M.D., Nikhil K Mull, M.D.
DOI: DOI pending.
Funding Source: AHRQ
Methodology Description: None Provided

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