Advanced Search

Completed Systematic Reviews




Home-Based Primary Care Interventions [Retrospectively Entered]


Public Project Complete

Statistics: 20 Studies, 3 Key Questions, 1 Extraction Form,
Date Published: Feb 17, 2016 06:22PM
Description: Objective. To assess the available evidence about home-based primary care (HBPC) interventions for adults with serious or disabling chronic conditions. Data sources. Articles from January 1998 through May 2015 were identified using Ovid MEDLINE, CINAHL, Clinical Trials.gov, Cochrane Database of Systematic Reviews, reference lists, and gray literature databases. Review methods. We included randomized controlled trials (RCTs) and observational studies of HBPC, including home visits by a primary care provider, longitudinal management, and comprehensive care. Study quality was assessed, data extracted, and results summarized qualitatively. Results. We identified 4,406 citations and reviewed 219 full-text articles; 19 studies were included. Two were RCTs while 17 were observational studies. The strongest evidence (moderate) was that HBPC reduces hospitalizations and hospital days. Reductions in emergency and specialty visits and in costs were supported by less strong evidence, while no or unclear effects were identified on hospital readmissions and nursing home days. Evidence about clinical outcomes was limited to studies that reported no significant differences in function or mortality. HBPC had a positive impact on patient and caregiver experience, including satisfaction, quality of life, and caregiver needs, but the strength of evidence for these outcomes was low. In studies that reported on the impact of patient characteristics, moderate evidence indicated frail or sicker patients are more likely to benefit from HBPC. No identified studies assessed the impact of organizational characteristics. No adverse events were reported. Only one study examined the potential for a negative impact; none was found. The services included in the HBPC interventions varied widely, and no identifiable combination was related to more positive outcomes. We did identify four studies that evaluated the addition of specific services. Combining palliative care and primary care home visits increased the likelihood of death at home (low strength of evidence), while studies on adding caregiver support (one study) or transitional care (one study) to HBPC were rated as insufficient evidence. Conclusions. Current research evidence is generally positive, providing moderate-strength evidence that HBPC reduces utilization of inpatient care, and providing low-strength evidence about its impact on utilization of other health services, costs, and patient and caregiver experience. Future research should focus on the content and organizational context of HBPC interventions so that experiences can be replicated or improved on by others. Additional research is also needed about which patients benefit most from HBPC and how HBPC can be best used in the continuum of care.
Contributor(s): Annette M. Totten, Ph.D. E. Foy White-Chu, M.D. Ngoc Wasson, M.P.H. Emily Morgan, M.D. Devan Kansagara, M.D. Cynthia Davis-O'Reilly, B.A. Sarah Goodlin, M.D.
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. HHSA 2902012-00014-I.).
Methodology Description: We included randomized controlled trials (RCTs) and observational studies of HBPC, including home visits by a primary care provider, longitudinal management, and comprehensive care. Study quality was assessed, data extracted, and results summarized qualitatively.

Zoom Preview | Show Downloadable Content

Strategies to Improve Mental Health Care for Children and Adolescents


Public Project Complete

Statistics: 16 Studies, 3 Key Questions, 1 Extraction Form,
Date Published: Feb 17, 2016 06:21PM
Description: To increase knowledge about the effectiveness of quality improvement (QI), implementation, and dissemination strategies that seek to improve the mental health care of children and adolescents; to examine harms associated with these strategies; and to determine whether effectiveness or harms vary in subgroups based on system, organizational, practitioner, or patient characteristics.
Contributor(s): Valerie Hoffman, Robert Christian, Leyla Stambaugh, Joni McKeeman, Bradley Gaynes, Jennifer Middleton, Emmanuel Coker-Schwimmer, Catherine Grodensky, Meera Viswanathan
Funding Source: AHRQ
Methodology Description: Systematic Review

Zoom Preview | Show Downloadable Content

Imaging for the Pretreatment Staging of Small Cell Lung Cancer


Public Project Complete

Statistics: 7 Studies, 3 Key Questions, 1 Extraction Form,
Date Published: Feb 17, 2016 06:21PM
Description: Systematic Review for AHRQ EPC Program
Contributor(s): Jonathan Treadwell Ph.D. (lead investigator) Matthew Mitchell, PhD, (methodologist co-investigator) Amy Tsou MD, MSCE, (co-investigator) Drew Torigan, MD, MA, (clinical co-investigator) Charu Aggarwal, MD, MPH, (clinical co-investigator) Craig Umscheid, MD, MSCE, ECRI-Penn EPC Sr. Associate Director Karen Schoelles MD, SM, ECRI - Penn EPC Director
Funding Source: AHRQ
Methodology Description: Using EPC methods, we systematically review data on the pretreatment staging of small cell lung cancer

Zoom Preview | Show Downloadable Content

Management Strategies to Reduce Psychiatric Readmissions: Technical Brief


Public Project Complete

Statistics: 72 Studies, 4 Key Questions, 4 Extraction Forms,
Date Published: Feb 17, 2016 06:20PM
Description: Background: Repeated psychiatric hospitalizations, affecting primarily those individuals with a serious mental illness, are a substantial problem. Little is known about the effectiveness of different lengths of hospital stay for these patients, transition support services after discharge, or short- or long-term alternatives to psychiatric hospitalization. Purpose: To describe and compare four core management strategies to reduce psychiatric readmissions—length of stay for inpatient care, transition support services (i.e., care provided as the individual moves to outpatient care), short-term alternatives to psychiatric hospitalizations (i.e., short-term outpatient care provided in place of psychiatric hospitalization for those not at significant risk of harm to self or others), and long-term alternatives to psychiatric hospitalization—for patients at high risk of psychiatric readmission. Methods: We searched published and unpublished sources for information about the effectiveness of these strategies. We also interviewed key informants, representing mental health providers, health services researchers, policymakers, payers, and patient advocacy groups, to confirm and augment our findings. Findings: Other than Assertive Community Treatment (ACT), an alternative to psychiatric hospitalization, we did not identify an overall theoretical model that identified key intervention components. Components of the various strategies overlap and are likely interdependent. Evidence suggests that the most commonly measured outcome, psychiatric readmissions, probably undercounts true readmission rates; other measures of well-being and functioning need to be measured. Of the 63 studies that assessed the link between a management strategy and readmission, two addressed LOS, five addressed transition support services, four addressed short-term alternatives to psychiatric hospitalization, and 52 addressed long-term alternatives to psychiatric hospitalization. The bulk of these studies address two interventions: intensive case management (a transitional support service) and ACT. The availability and implementation of the various management strategies can vary substantially across the country. Conclusions: Important next steps include determining (1) the key components, or packages of components, that are most effective in keeping those at high risk of psychiatric rehospitalization functioning in the community; (2) how to accurately measure the most meaningful outcomes; and (3) how to most efficiently apply effective strategies to areas with varying resources.
Contributor(s): Bradley N. Gaynes, M.D., M.P.H.; Carrie Brown, M.D., M.P.H.; Linda J. Lux, M.P.A.; Mahima Ashok, Ph.D.; Emmanuel Coker-Schwimmer, M.P.H.; Valerie Hoffman, Ph.D.; Brian Sheitman, M.D.; Meera Viswanathan, Ph.D.
Funding Source: The Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: Published Literature Search: An experienced research librarian developed our search strategy (Appendix B). Given that contemporary resources, finances, and needs relevant to psychiatric hospitalization have changed substantially from approximately 25 years ago, we systematically searched the published literature from January 1, 1990, through June 23, 2014. We searched in PubMed (MEDLINE), PsycINFO, and the Cochrane Library. We reviewed the reference lists of relevant papers, and we examined any literature suggested by KIs. We will update the literature review by repeating our searches concurrent with the peer-review process. Gray Literature Search: We searched the gray literature to identify information beyond the published literature on management strategies to reduce psychiatric readmissions. Sources for the gray literature included the following: HAPI, OpenSIGLE, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Academic Search Complete, NIH RePORTER, and ERIC. We also searched Web sites of the relevant professional associations such as the American Psychiatric Association, the National Alliance on Mental Illness, the National Association of Psychiatric Health Systems, and the National Institute of Mental Health. Appendix A provides a brief description of each of these gray literature sources.

Zoom Preview | Show Downloadable Content

Management and Outcomes of Binge-Eating Disorder (BED)


Public Project Complete

Statistics: 84 Studies, 15 Key Questions, 3 Extraction Forms,
Date Published: Feb 17, 2016 06:19PM
Description: Objectives. To evaluate the effectiveness and comparative effectiveness of treatments for patients with binge-eating disorder (BED) and bariatric surgery patients and children with loss-of-control (LOC) eating. Studies of BED therapies include pharmacological interventions, psychological and behavioral interventions, or combinations of approaches. We examined whether treatment effectiveness differed in patient subgroups and described courses of illness for BED and LOC eating. Data Sources. We searched MEDLINE,® EMBASE,® the Cochrane Library, Academic OneFile, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) through 1/19/2015. Eligible studies included randomized controlled trials (RCTs), nonrandomized trials, meta-analyses, and, for course of illness, cohort and case-control studies. 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 using established criteria. We conducted meta-analysis for some treatment outcomes. Results. Of 52 included RCTs of treatment; 48 concerned BED therapy. Course of illness evidence came from 15 observational studies. We examined four major outcomes: binge eating and abstinence, eating-related psychopathology, weight, and general psychological and other outcomes. Second-generation antidepressants (as a class), topiramate (an anticonvulsant), and lisdexamfetamine (a stimulant) were superior to placebo in achieving abstinence and reducing binge episodes and/or binge days and eating-related obsessions and compulsions. Second-generation antidepressants decreased depression. Topiramate and lisdexamfetamine produced weight reduction in study populations that were virtually all overweight or obese. A few formats of cognitive behavioral therapy (CBT)—therapist-led, partially therapist-led, and guided self-help—were superior to placebo in achieving abstinence and reducing binge frequency. CBT for BED was generally ineffective for reducing weight or depression in this population. Therapist-led CBT was not superior to either partially therapist-led CBT or structured self-help CBT for binge-eating and weight outcomes. Behavioral weight loss treatment produced greater weight loss than CBT at the end of treatment but not over the longer run. Topiramate, fluvoxamine, and lisdexamfetamine were associated with sleep disturbance including insomnia; topiramate and lisdexamfetamine were associated with sympathetic nervous system arousal, headache, and GI upset. We found no evidence on bariatric surgery patients. Treatments for LOC eating in children did not achieve superior weight reduction outcomes. Evidence on course of either illness was limited. Early adolescent BED and LOC eating predicts such behaviors in the future. Conclusions. BED patients may benefit from treatment with second-generation antidepressants, lisdexamfetamine, topiramate, and CBT. Additional studies should address other treatments, combinations of treatment, and comparisons between treatments, treatment for postbariatric surgery patients and children, as well as the course of these illnesses.
Contributor(s): Nancy D. Berkman, PhD Kimberly A. Brownley, PhD Christine M. Peat, PhD Kathleen N. Lohr, PhD Katherine E. Cullen, BA Laura C. Morgan, MA Carla M. Bann, PhD Cynthia M. Bulik, PhD Ina F. Wallace, PhD
Funding Source: Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We conducted focused searches of MEDLINE® (via PubMed), EMBASE®, CINAHL (nursing and allied health database), Academic OneFile, and the Cochrane Library. An experienced research librarian used a predefined list of search terms and medical subject headings (MeSH). The librarian completed the searches for the draft report on 6/23/2014; she conducted a second (update) search on 1/19/2015 during peer review. We searched for relevant unpublished and grey literature, including trial registries, specifically ClinicalTrials.gov and Health Services Research Projects in Progress. AHRQ requested Scientific Information Packets (SIPs) from the developers and distributors of interventions identified in the literature review. We included unpublished studies that met all inclusion criteria and contained enough information to permit us to make a standard risk-of-bias assessment. We searched reference lists of pertinent review articles for studies that we should consider for inclusion in this review, including our earlier review on this topic. Trained members of the research team reviewed article abstracts and full-text articles. Two members independently reviewed each title and abstract using the predefined inclusion and exclusion criteria. Studies marked for possible inclusion by either reviewer underwent a full-text review. Two members of the team independently reviewed each full-text article. If both reviewers agreed that a study did not meet the eligibility criteria, it was excluded; each reviewer recorded the primary reason for exclusion. If reviewers disagreed, they resolved conflicts by discussion and consensus or by consulting a third member of the review team. We screened unpublished studies and reviewed SIPs using the same title/abstract and full-text review processes. The project coordinator tracked abstract and full-text reviews in an EndNote database (EndNote® X4). We developed a template for evidence tables using the PICOTS framework and abstracted relevant information into them using Microsoft Excel. We recorded characteristics of study populations, interventions, comparators, settings, study designs, methods, and results. Six trained members of the team participated in the data abstraction. One reviewer initially abstracted the relevant data from each included article; a second more senior member of the team reviewed each data abstraction against the original article for completeness and accuracy.

Zoom Preview | Show Downloadable Content