Christina Slee

Posttreatment human papillomavirus testing for recurrent cervical intraepithelial neoplasia: a systematic review

OBJECTIVE We conducted a systematic review to evaluate the characteristics of human papillomavirus testing, particularly Hybrid Capture 2, in follow-up evaluations after treatment for cervical intraepithelial neoplasia for the detection of residual or recurrent cervical intraepithelial neoplasia grade >/= 2. STUDY DESIGN Medline was searched for relevant studies that were published between 1992 and September 2007. Of the 1107 citations that were identified, 20 articles met the inclusion criteria. RESULTS Studies that used polymerase chain reaction testing were too heterogeneous to combine. We identified 5 studies that performed both Hybrid Capture 2 and colposcopy. Pooled sensitivity for Hybrid Capture 2 was 90.7% (95% CI, 75.4-96.9%), and pooled specificity was 74.6% (95% CI, 60.4-85.0%). Pooled sensitivity for cervical cytologic testing was 76.6% (95% CI, 62.0-86.8%), and pooled specificity was 89.7% (95% CI, 22.7-99.6%). CONCLUSION Hybrid Capture 2 testing can identify approximately 91% of women with residual or recurrent cervical intraepithelial neoplasia grade >/= 2; however, approximately 30% of women would undergo colposcopy in follow-up evaluation.

Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care: A Randomized Trial

IMPORTANCE Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment. OBJECTIVE To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California. INTERVENTIONS DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control). MAIN OUTCOMES AND MEASURES Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted. RESULTS Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority). CONCLUSIONS AND RELEVANCE A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01144104.

Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development.

OBJECTIVE To assess the message preferences of individuals affected by depression as part of a project that will evaluate interventions to encourage at-risk patients to talk to their physicians about depression. METHODS Adaptive Conjoint Analysis (ACA) of 32 messages defined by 10 message attributes. Messages were developed based on input from three focus groups comprised of individuals with a personal and/or family history of depression, then tested using volunteers from an Internet health community. In an online conjoint survey, 249 respondents with depression rated their liking of the messages constructed for each attribute. They were then presented with two message sets and rated their preferences. Preference utilities were generated using hierarchical Bayes estimation. RESULTS The optimal communication approach described both psychological and physical symptoms of depression, recognized multiple treatment options, offered lifetime prevalence data, noted that depression can affect anyone, and acknowledged that finding an effective treatment can take time. CONCLUSION Individuals with depression respond differently to depression care messages, underscoring the need for careful message development and evaluation. PRACTICE IMPLICATIONS ACA, used in conjunction with focus groups, is a promising approach for developing and testing messages in the formative research stage of intervention development.

Surveillance After Treatment for Cervical Intraepithelial Neoplasia: Outcomes, Costs, and Cost-Effectiveness

OBJECTIVE: To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN). METHODS: A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year. RESULTS: Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of

Sociopsychological Tailoring to Address Colorectal Cancer Screening Disparities: A Randomized Controlled Trial

69,000 to

Mental DisordersEncouraging patients with depressive symptoms to seek care: A mixed methods approach to message development

81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from

Cancer Health Empowerment for Living without Pain (Ca-HELP): study design and rationale for a tailored education and coaching intervention to enhance care of cancer-related pain

70,000 to more than

Tamoxifen for breast cancer risk reduction: impact of alternative approaches to quality-of-life adjustment on cost-effectiveness analysis.

1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as

Program-Specific Cost-Effectiveness Analysis: Breast Cancer Screening Policies for a Safety-Net Program

822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program

5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs. CONCLUSION: Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.