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Completed Systematic Reviews




Total Worker Health® (TWH)


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Statistics: 24 Studies, 6 Key Questions, 2 Extraction Forms,
Date Published: Feb 17, 2016 06:40PM
Description: The purpose of this review is to provide an evidence report that the National Institutes of Health, Office of Disease Prevention, Pathways to Prevention Workshop Program can use to inform a workshop focused on Total Worker Health® (TWH). TWH is defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being. This review describes the body of evidence evaluating TWH interventions, assesses the benefits and harms of interventions, and highlights research gaps and future research needs.
Contributor(s): Cynthia Feltner, M.D., M.P.H., Kristina Peterson, Ph.D., Rachel Palmieri Weber, Ph.D., Laurie Cluff, Ph.D., Emmanuel Coker-Schwimmer, M.P.H., Meera Viswanathan, Ph.D., Kathleen N. Lohr, Ph.D.
Funding Source: This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00008-I_HHSA 2903
Methodology Description: Data Sources: We searched MEDLINE®, the Cochrane Library, the Cochrane Central Trials Registry, and PsycINFO from January 1, 1990, to September 21, 2015. Eligible studies included randomized controlled trials (RCTs), nonrandomized trials, prospective cohort studies with a concurrent control group; single-group pre-post studies were also eligible for Key Questions (KQs) describing interventions or identifying contextual factors, research gaps, and future research needs. Review Methods: Pairs of reviewers independently selected, extracted data from, and rated the risk of bias of relevant studies; they graded the strength of evidence (SOE) using established criteria. We synthesized all evidence qualitatively.

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Low-Calorie Sweeteners and Health: An Evidence Map Database


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Statistics: 223 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Feb 17, 2016 06:39PM
Description: Low-calorie sweeteners (LCS), also known as sugar substitutes, non-nutritive sweeteners, or artificial sweeteners, are ingredients added to foods and beverages to provide sweetness without adding a significant amount of calories. A large body of literature evidence exists on low-calorie sweeteners yet the health effects of LCS beyond body weight or composition remain unknown and have not been systematically reviewed. As evidence and interest on LCS continues to grow, there is the need to understand the potential effects of low-calorie sweeteners. LCS evidence map is a database that collects the features and characteristics of the LCS studies. (Paper PMID:26728979). LCS database includes data on study design (study design and duration), population (baseline health status, age, sample size, anthropometrics), intervention/comparison (type of LCS, comparisons or control groups, numbers of people analyzed, forms of administration), and outcomes/study endpoint. In addition, study aim/hypothesis and funding source were also collected. (LCS Manual and database Code book available through: http://static-content.springer.com/esm/art%3A10.1186%2Fs12874-015-0105-z/MediaObjects/12874_2015_105_MOESM2_ESM.docx). Outcomes were also coded into clinically and biologically relevant outcome groups, classified by the research team and a stakeholder panel, to better describe data in the map (See Outcome Groups Table in the codebook). Database Objectives • Provide a database of existing literature on LCS and health outcomes. • Index key features and characteristics for quick summary report generation. • Help identify LCS and health effect of interest and identify gaps in LCS research • Systematically collect information to support further evidence synthesis
Contributor(s): Ding Ding Wang, BS, MPH; Marissa Shams-White, L.Ac, MS, MPH; Oliver John Bright, BS; Mei Chung, PhD, MPH (Principal Investigator)
Funding Source: Supported by North American branch of the International Life Sciences Institutes (ILSI), Carbohydrates Committee. More information on Low-calorie sweeteners can be found at: http://www.ilsi.org/NorthAmerica/Pages/LowCalorieSweeteners.aspx.
Methodology Description: The goal of this Low-calorie sweetener evidence map is to provide existing low-calorie sweeteners studies readily in a database, describe the studies, and assist health researches in linking LCS to health outcomes efficiently. The following six areas of research regarding the potential effects of LCS were all considered and included: 1) energy sensing by the brain, 2) gut hormones that may influence energy homeostasis, 3) taste preference and satiety, 4) Dietary intake, and 5) body weight and composition.

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Recommendations for decision and simulation modeling


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Statistics: 69 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Feb 17, 2016 06:36PM
Description: Purpose: We aimed to update and expand previous syntheses of evidence- and consensus-based guidance on decision and simulation modeling using a systematic review-driven stakeholder-led process.
Contributor(s): Issa J. Dahabreh, MD, MS; Ethan M. Balk, MD, MPH; Denish Moorthy, MD; Jeffrey A. Chan, BS; Thomas A. Trikalinos, MD; Esther E. Avendano, BA; Natasha Stout, PhD; Jeroen P. Jansen, PhD, MSc; John B. Wong, MD
Funding Source: AHRQ Contract No. HHSA 290 2007 10055 I
Methodology Description: Data sources: We searched MEDLINE, the Cochrane Methodology Register, the Health Technology Assessment Database, and the NHS Economic Evaluation Database (through October 30, 2012) Study selection: We selected articles presenting evidence- or consensus-based recommendations for the conduct and dissemination of decision and simulation modeling.

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Improving Cultural Competence to Reduce Health Disparities [Entered Retrospectively]


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Statistics: 86 Studies, 5 Key Questions, 1 Extraction Form,
Date Published: Feb 17, 2016 06:34PM
Description: Objective. To examine existing system-, clinic-, provider-, and individual-level interventions to improve culturally appropriate health care for people with disabilities; lesbian, gay, bisexual, and transgender (LGBT) populations; and racial-ethnic minority populations. Data sources. Ovid MEDLINE®, PsycINFO®, Ovid Embase®, and the Cochrane EPOC; hand searches of references of relevant studies. Review methods. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and other observational studies with comparators that evaluated cultural competence interventions aimed at reducing health disparities in the formal healthcare system. Two investigators abstracted data and assessed risk of bias. Given the sparse and patchy literature that precluded pooling, a qualitative analysis is provided. Results. Over 37,000 nonduplicated, English language citations were reviewed; 56 unique studies were identified as of June, 2015: 20 RCTs and five observational studies for individuals with disabilities; five RCTs (six manuscripts) and six observational studies for LGBT populations; and 14 RCTs (15 manuscripts), four observational studies, and two systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing culturally competent care at the point of service. Educational programs and trainings to improve professional students’ and providers’ cultural competence behavior is the most prevalent type of cultural competence intervention. Two existing, high quality systematic reviews of provider educational interventions for racial/ethnic minority populations found low-strength evidence that cultural competence training had mixed effects for intermediate outcomes and no effect on treatment outcomes. Sixteen studies aimed at changing provider attitudes and beliefs through training or curricula were identified for the disability population. Eleven of these studies focused on reducing professional stigma toward people with serious or chronic mental illness; five focused on changing professional attitudes and beliefs about people with physical or intellectual disability. Three educational interventions were identified for the LGBT population. Several short-term effects were evaluated; however, long-term effects of provider training on provider cultural competence behavior in the clinical setting and subsequent patient health outcomes have not been evaluated for the disability and LGBT populations. Two included studies reported a potential harm from provider training, an increase in negative attitudes, or stigma resulting from intervention. Interventions providing alterations of an established protocol were concentrated in the racial/ethnic minority populations. The 12 studies of culturally tailored health care interventions for racial/ethnic minority populations focused primarily on treatment of chronic physical or mental health conditions (e.g., diabetes, depression, substance abuse). Two psychological interventions were also tailored for members of the LGBT population. Another common type of intervention was to provide additional resources to encourage or empower patients to interact with the formal health care system and/or health care providers. The stated aims of these types of interventions were to increase receipt of screenings for which disparities are well-documented (e.g., papanicolaou tests for people with mobility impairments or colorectal cancer screening among Latino immigrants), or to help patients engage in medical decisionmaking. These studies met inclusion criteria if the intervention was conducted by a medical professional in a formal health care system. One potential limitation of these types of interventions is that they rely on strong identification with a common culture. The population groups highlighted in this review are large and diverse. Creating an intervention for “African Americans” or “women who have sex with women” may be differentially effective for specific subpopulations. The most common culturally competent point of service interventions were documents, similar to a handheld medical record, that patients carried to their appointments to prompt providers to evaluate areas of known disparity for a specific population. These interventions may be coupled with provider notices or trainings. Virtual interventions were also considered culturally competent point of service interventions for some people with disabilities, as they create access in a unique way. These interventions are seen as conceptually parallel to infrastructure changes that improve access for people with physical disabilities. For the majority of included studies, the risk of bias was high. The most common methodological problems were: lack of randomization to treatment; lack of attention control; little or no followup; and failure to report unintended consequences. Large segments of vulnerable or disadvantaged populations, such as children with disabilities, people who may be gender nonconforming or transgender, or numerous racial or ethnic groups, including Native Americans or Alaskan Natives, remain essentially invisible in the cultural competence literature. This is compounded for people who are members of more than one priority population. Conclusions. None of the included studies measured the effect of cultural competence interventions on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population of interest, but did not measure the downstream effect of changing provider beliefs on the care delivered to patients. Interventions that altered existing protocols, empowered patients to interact with the formal health care system, or prompted provider behavior at the point of care were more likely to measure patient-centered outcomes. The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term cultural competence is not well defined for the LGBT and disability populations, and is often conflated with patient-centered or individualized care. There are many gaps in the literature; many large subpopulations are not represented.
Contributor(s): Mary Butler, Ph.D. M.B.A Ellen McCreedy, M.P.H. Natalie Schwer, M.A.c. Diana Burgess, Ph.D. Kathleen Call, Ph.D. Julia Przedworski, B.S. Simon Rosser, Ph.D. Sheryl Larson, Ph.D. Michele Allen, M.D. Steve Fu, M.D. Robert L. Kane, M.D.
Funding Source: AHRQ
Methodology Description: None Provided

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Management of Insomnia Disorder [Entered Retrospectively]


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Statistics: 139 Studies, 2 Key Questions, 1 Extraction Form,
Date Published: Feb 17, 2016 06:33PM
Description: Objective. To assess the efficacy, comparative effectiveness, and harms of treatments for insomnia disorder in the general adult population and older adults. Data sources. Ovid MEDLINE®, the Cochrane Central Register of Controlled Trials, Embase®, and PsycINFO®SYCINFO bibliographic databases; hand searches of references of relevant studies. Review methods. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included systematic reviews, randomized controlled trials (RCTs), and long-term observational pharmacologic studies enrolling participants with insomnia disorder. We analyzed data for global outcomes (measures that assess both sleep and daytime functioning associated with sleep), sleep parameters, and harms. We assessed risk of bias for RCTs, extracted data, assessed quality of relevant systematic reviews, and evaluated strength of evidence for comparisons and outcomes. Pooled estimates were analyzed to assess the efficacy and comparative effectiveness of treatments. Results. We searched bibliographic databases through January 2015 for studies evaluating psychological, pharmacologic, and complementary, and alternative medicine interventions for insomnia disorder. We synthesized evidence from 181 unique studies (data from 128 unique RCTs and 3 systematic reviews that( synthesizeing data from 42 unique RCTs) and 12 observational studies. Sample sizes and enrollment criteria varied; most trials were short in duration. Outcome reporting and intervention effect sizes varied, and a large placebo response was often observed. Cognitive behavioral therapy for insomnia (CBT-I) improved global outcomes and nearly all sleep parameters in the general adult population, older adults, and adults with pain. We found insufficient evidence on adverse effects of these interventions. Evidence was less robust for psychological interventions other than CBT-I, but low -strength evidence shows that some interventions improve some sleep outcomes. Low- to moderate -strength evidence indicated that the nonbenzodiazepine hypnotics, eszopiclone and zolpidem, and the orexin receptor antagonist, suvorexant, improved short-term global and sleep outcomes in general adult populations. Doxepin improved sleep outcomes. The absolute mean effect was small. Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants in general populations and for most pharmacologic interventions in older adults was generally insufficient. Evidence on adverse effects from RCT data was generally insufficient or low strength. Observational studies suggest that hypnotics may be associated with dementia, fractures, and major injury. Food and Drug Administration (FDA) labels warn about cognitive and behavioral changes, including driving impairment, and other harms, and advise lower doses reduction in for females and older/debilitated adults. Evidence on complementary and alternative medicine was insufficient. Evidence was insufficient to compare hypnotic medications within or across classes or versus CBT-I. Conclusions. CBT-I or medical therapy with eszopiclone, zolpidem, and suvorexant improve global and sleep outcomes for insomnia disorder. Clinical significance, applicability, comparative effectiveness, and long-term efficacy, especially among older adults, are less well known. Effect sizes vary, and a large placebo response is sometimes observed. Observational studies suggest an association of hypnotics with infrequent but serious, harms. FDA labels provide specific warnings and precautions for drugs approved for insomnia.
Contributor(s): Michelle Brasure, Ph.D., M.S.P.H., M.L.I.S. Roderick MacDonald, M.S. Erika Fuchs, M.P.H. Carin M. Olson, M.D., M.S. Maureen Carlyle, M.P.H. Susan Diem, M.D., M.P.H. Erin Koffel, Ph.D. Imran S. Khawaja, M.D. Jeannine Ouellette Mary Butler, Ph.D. Robert L. Kane, M.D. Timothy J. Wilt, M.D., M.P.H.
Funding Source: AHRQ
Methodology Description: None Provided

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