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Completed Systematic Reviews




Health Information Exchange [Entered Retrospectively]


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Statistics: 136 Studies, 8 Key Questions, 1 Extraction Form,
Date Published: Jun 29, 2018 03:32PM
Description: Objectives: This review sought to systematically review the available literature on health information exchange (HIE), the electronic sharing of clinical information across the boundaries of health care organizations. HIE has been promoted as an important application of technology in medicine that can improve the efficiency, cost-effectiveness, quality, and safety of health care delivery. However, HIE also requires considerable investment by sponsors, which have included governments as well as health care organizations. This review aims to synthesize the currently available research addressing HIE effectiveness, use, usability, barriers and facilitators to actual use, implementation; and sustainability, and to present this information as a foundation on which future implementation, expansion, and research can be based. Results: We included 136 studies overall, with 34 on effectiveness, 26 of which reported intermediate clinical, economic, or patient outcomes, and eight that reported on clinical perceptions of HIE. We also found 58 studies on the use of HIE, 22 on usability and other facilitators and barriers to actual use of HIE, 45 on facilitators or barriers to HIE implementation, and 17 on factors related to sustainability of HIE. No studies of HIE effectiveness reported impact on primary clinical outcomes (e.g., mortality and morbidity) or identified harms. Low-quality evidence somewhat supports the value of HIE for reducing duplicative laboratory and radiology test ordering, lowering emergency department costs, reducing hospital admissions (less so for readmissions), improving public health reporting, increasing ambulatory quality of care, and improving disability claims processing. In studies of clinician perceptions of HIE most respondents attributed positive changes to the HIE such as improvements in coordination, communication and knowledge about the patient. However in one study clinicians reported that the HIE did not save time and may not be worth the cost. Studies of HIE use found that HIE adoption has increased over time, with 76 percent of U.S. hospitals exchanging information in 2014, an 85 percent increase since 2008 and a 23 percent increase since 2013. HIE systems were used by 38 percent of office-based physicians in 2012 while use remains low, less than 1 percent, among long-term care providers. Within organizations with HIE, the number of users or the number of visits in which the HIE was used was generally very low. The degree of usability of an HIE was associated with increased rates of use, but not was not associated with effectiveness outcomes. The most commonly cited barriers to HIE use were lack of critical mass electronically exchanging data, inefficient workflow, and poorly designed interface and update features. Information was insufficient to allow us to assess usability by HIE function or architecture. Studies provided information on both external environmental and internal organizational characteristics that affect implementation and sustainability. General characteristics of the HIE organization (e.g. strong leadership) or specific characteristics of the HIE system were the most frequently cited facilitators while disincentives such as competition or lack of a business case for HIE were the most frequently identified barriers. Conclusions: The full impact of HIE on clinical outcomes and potential harms is inadequately studied, although evidence provides some support for benefit in reducing use of some specific resources and achieving improvements in quality of care measures. Use of HIE has risen over time and is highest in hospitals and lowest in long-term care settings. However, use of HIE within organizations that offer it is still low. Barriers to HIE use include lack of critical mass participating in the exchange, inefficient workflow, and poorly designed interface and update features. Studies have identified numerous facilitators and barriers to implementation and sustainability but the studies have not ranked or compared their impact. To advance our understanding of HIE, future studies need to address comprehensive questions, use more rigorous designs, use a standard for describing types of HIE, and be part of a coordinated, systematic approach to studying HIE.
Contributor(s): William Hersh, MD Annette Totten, PhD Karen Eden, PhD Beth Devine, PhD, PharmD Paul Gorman, MD Steve Kassakian, MD Susan Woods, MD Monica Daeges, BA Miranda Pappas, MA Marian McDonagh, PharmD
Funding Source: This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA290201200014I).
Methodology Description: Abstracts and the selected full-text articles were reviewed by two investigators for inclusion based on predefined criteria. Discrepancies were resolved through discussion and consensus, with a third investigator making the final decision as needed. Data were abstracted from each included article by one person and verified by another. All analyses were qualitative, and they were customized according to the topic.

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Noninvasive, Nonpharmacological Treatment for Chronic Pain: A Systematic Review [Entered Retrospectively]


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Statistics: 206 Studies, 5 Key Questions, 5 Extraction Forms,
Date Published: Jun 18, 2018 06:34PM
Description: Structured Abstract Objectives. Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive, nonpharmacological treatment for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment. Data sources. Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews), through November 2017, reference lists, and ClinicalTrials.gov. Review methods. Using predefined criteria, we selected randomized controlled trials of noninvasive, nonpharmacological treatments for five common chronic pain conditions (chronic low back pain, chronic neck pain, osteoarthritis of the knee, hip, or hand, fibromyalgia, and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to < 6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months). Results. 218 publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily cognitive behavioral therapy [CBT]) (Strength of evidence [SOE]: Moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: Low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: Low), and psychological therapies (SOE: Moderate). Improvements in pain continued into intermediate term for exercise, massage and yoga (moderate effect, SOE: Low), mindfulness-based stress reduction (small effect, SOE: Low), spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: Moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: Low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: Moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: Moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than nonhigh-intensity programs. Chronic neck pain: At short- and intermediate-terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: Low), but no improvement in pain was seen at any time (SOE: Low). Short-term, low-level laser therapy was associated with moderate improvement in function and pain (SOE: Moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long-term (SOE: Low). Osteoarthritis: For knee osteoarthritis, at short-term exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control or sham procedure (SOE: Moderate for exercise, Low for ultrasound), which persisted into the intermediate term only for exercise (SOE: Low). Exercise was also associated with moderate improvement in pain (SOE: Low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: Low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: Low). The effect on function was sustained intermediate term (SOE: Low). Fibromyalgia: In the short term, acupuncture (SOE: Moderate), CBT, tai chi, qigong, and exercise (SOE: Low) were associated with slight improvements in function compared with an attention control, sham, no treatment or usual care. Exercise (SOE: Moderate) and CBT improved pain slightly and tai chi and qigong (SOE: Low) improved pain moderately in the short term. At intermediate term for exercise (SOE: Moderate), acupuncture and CBT (SOE: Low), slight functional improvements persisted and were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: Low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate-term (SOE: Low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: Low for all); massage (SOE: Low) improved long-term pain slightly but no clear impact on pain for exercise (SOE: Moderate) or multidisciplinary rehabilitation (SOE: Low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short-term versus usual care and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE Low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited. Conclusions. Exercise, multidisciplinary rehabilitation, acupuncture, cognitive behavioral therapy, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
Contributor(s): Andrea Skelly, Ph.D., M.P.H., Roger Chou, M.D., Joseph Dettori, Ph.D., M.P.H., M.P.T., Judith Turner, Ph.D., Janna Friedly, M.D., Sean Rundell, Ph.D., D.P.T., Rochelle Fu, Ph.D., Erika Brodt, B.S., Ngoc Wasson, M.P.H., Cassandra Winter, B.S., Aaron Ferguson, B.S.
Funding Source: Agency for Healthcare Research and Quality. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA290201500009I.) AHRQ Publication No. XXX.
Methodology Description: Using predefined criteria, we selected randomized controlled trials of noninvasive, nonpharmacological treatments for five common chronic pain conditions (chronic low back pain, chronic neck pain, osteoarthritis of the knee, hip, or hand, fibromyalgia, and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to < 6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).

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Management of Suspected Opioid Overdose with Naloxone by Emergency Medical Services Personnel [Entered Retrospectively]


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Statistics: 13 Studies, 5 Key Questions, 5 Extraction Forms,
Date Published: Dec 06, 2017 04:46AM
Description: Objectives. To compare different routes, doses, and dosing strategies of naloxone administration for suspected opioid overdose by emergency medical services (EMS) personnel in field settings, and to compare effects of transport to a health care facility versus nontransport following successful reversal of opioid overdose with naloxone. Methods. Four databases were searched through March 2017. Additional studies were identified from reference lists and technical experts. We included randomized controlled trials (RCTs) and cohort studies comparing different naloxone routes of administration, doses, or dosing strategies and on effects of transport or nontransport following successful reversal of opioid overdose with naloxone. Two investigators independently applied prespecified criteria to rate study quality. The strength of evidence was determined based on the overall risk of bias, consistency, directness, precision, and reporting bias. Results. Twelve studies met inclusion criteria. Three RCTs and four cohort studies compared different routes of administration. Two trials compared intranasal (IN) with intramuscular (IM) naloxone administration (strength of evidence [SOE] for all outcomes: low). While 2 mg of a higher-concentration formulation of IN naloxone (2 mg/1 mL) is similar in efficacy to 2 mg of IM naloxone, 2 mg of a lower-concentration formulation of IN naloxone (2 mg/5 mL formulation) is less effective than the same dose IM but associated with decreased risk of agitation and/or irritation. The 2 mg/5 mL formulation of IN naloxone studied in this trial is lower than concentrations used in the United States. In both trials, IN naloxone was associated with increased likelihood of rescue naloxone use. Although one RCT and two observational studies evaluated intravenous (IV) versus IN naloxone, evidence was insufficient to determine comparative benefits and harms, due to methodological limitations and poor applicability to U.S. EMS settings (SOE: insufficient). There was insufficient evidence from two observational studies to compare parenteral routes of administration (IM, IV, or subcutaneous [SQ]). No study compared outcomes of patients transported versus not transported following successful reversal of opioid overdose with naloxone. Five studies reported low rates of deaths and serious adverse events (0% to 1.25%) in patients not transported to a hospital after successful naloxone treatment, but used an uncontrolled design and had other methodological limitations (SOE: insufficient). Limitations. Few studies met inclusion criteria, all studies had methodological limitations, and no study evaluated naloxone auto-injectors or IN naloxone formulations recently approved by the US Food and Drug Administration (FDA). Conclusions. Low-strength evidence suggested that higher-concentration IN naloxone (2 mg/1 mL) is similar in efficacy to IM naloxone (2 mg), with no difference in adverse events. Research is needed on the comparative effectiveness of the FDA-approved naloxone auto-injectors (0.4 mg and 2 mg) and highly concentrated (4 mg/0.1 mL and 2 mg/0.1 mL) IN naloxone reformulation, different doses, and dosing strategies. Uncontrolled studies suggested that nontransport of patients following successful reversal of naloxone overdose might be associated with a low rate of serious harms, but patients were probably at low risk for such events, and there was insufficient evidence to determine risk of transport versus nontransport.
Contributor(s): Roger Chou, M.D. P. Todd Korthuis, M.D., M.P.H. Dennis McCarty, Ph.D. Phillip Coffin, M.D., M.I.A. Jessica Griffin, M.S. Cynthia Davis-O’Reilly, B.S. Sara Grusing, B.A. Mohamud Daya, M.D., M.S.
Funding Source: Prepared by The Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD
Methodology Description: Four databases were searched through March 2017. Additional studies were identified from reference lists and technical experts. We included randomized controlled trials (RCTs) and cohort studies comparing different naloxone routes of administration, doses, or dosing strategies and on effects of transport or nontransport following successful reversal of opioid overdose with naloxone. Two investigators independently applied prespecified criteria to rate study quality. The strength of evidence was determined based on the overall risk of bias, consistency, directness, precision, and reporting bias.

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Treatments for Adults with Schizophrenia: A Systematic Review [Entered Retrospectively]


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Statistics: 91 Studies, 4 Key Questions, 4 Extraction Forms,
Date Published: Nov 12, 2017 12:29PM
Description: Objectives. This systematic review (SR) provides evidence on pharmacological and psychosocial treatments for schizophrenia. Data sources. MEDLINE®, the Cochrane Library databases, PsycINFO® and included studies through February 2017. Study selection. We included studies comparing second generation antipsychotics (SGA) with each other or with a first generation antipsychotic (FGA) and studies comparing psychosocial interventions with usual care in adults with schizophrenia. Data extraction. We extracted study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source. Results. We included one SR of 138 trials (N=47,189) and 24 trials (N=6,672) for SGAs versus SGAs, one SR of 111 trials (N=118,503) and five trials (N=1,055) for FGAs versus SGAs, and 13 SRs of 271 trials (N=25,050) and 27 trials (n=6,404) for psychosocial interventions. Trials were mostly fair quality and strength of evidence was low or moderate. For drug therapy, the majority of the head to head evidence was on older SGAs, with sparse data on SGAs approved in the last 10 years (asenapine, lurasidone, iloperidone, cariprazine, brexpiprazole), and recent long-acting injection [LAI] formulations of aripiprazole and paliperidone. Older SGAs were similar in measures of function, quality of life, mortality, and overall adverse events, except that risperidone LAI had better social function than quetiapine. Core illness symptoms were improved more with olanzapine and risperidone than asenapine, quetiapine, and ziprasidone and more with paliperidone than lurasidone and iloperidone; all were superior to placebo. Risperidone LAI and olanzapine had less withdrawal due to adverse events. Compared with olanzapine and risperidone, haloperidol, the most studied FGA, had similar improvement in core illness symptoms, negative symptoms, symptom response, and remission but greater incidence of adverse event outcomes. In comparison with usual care, most psychosocial interventions reviewed were more effective in improving intervention-targeted outcomes, including core illness symptoms. Various functional outcomes were improved more with assertive community care, cognitive behavioral therapy, family interventions, psychoeducation, social skills training, supported employment, and early interventions for first episode psychosis (FEP) than with usual care. Quality of life was improved more with cognitive behavioral therapy and early interventions for FEP than usual care. Relapse was reduced with family interventions, psychoeducation, illness self-management, family interventions, and early interventions for FEP. Conclusions. Most comparative evidence on pharmacotherapy relates to the older drugs, with clozapine, olanzapine, and risperidone superior on more outcomes than other SGAs. Older SGAs were similar to haloperidol on benefit outcomes but had fewer adverse event outcomes. Most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse compared with usual care.
Contributor(s): Marian S. McDonagh, Pharm.D. Tracy Dana, M.L.S. Amy Cantor, M.D., M.P.H. Shelley Selph, M.D., M.P.H. Beth Devine, PharmD, Ph.D., M.B.A. Ian Blazina, M.P.H. Christina Bougatsos, M.P.H. Sara Grusing, B.A. Rochelle Fu, Ph.D. Maria Monroe-DeVita, Ph.D. Sarah Kopelovich, Ph.D. Daniel Haupt, M.D.
Funding Source: Agency for Healthcare Research and Quality. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA290201500009I.) AHRQ Publication No. XXX.
Methodology Description: Data sources. MEDLINE®, the Cochrane Library databases, PsycINFO® and included studies through February 2017. Study selection. We included studies comparing second generation antipsychotics (SGA) with each other or with a first generation antipsychotic (FGA) and studies comparing psychosocial interventions with usual care in adults with schizophrenia. Data extraction. We extracted study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source.

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Diet and PA for Prevention of Diabetes-Full Data Extraction


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Statistics: 50 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Sep 05, 2017 06:03PM
Description: None Provided
Contributor(s): None Provided
Funding Source: CDC
Methodology Description: None Provided

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