Daniel E. Jonas

Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient Settings: A Systematic Review and Meta-analysis

IMPORTANCEnAlcohol use disorders cause substantial morbidity and early mortality yet remain greatly undertreated. Medications are considerably underused.nnnOBJECTIVEnTo conduct a systematic review and meta-analysis of the benefits and harms of medications (US FDA-approved and others) for adults with alcohol use disorders.nnnDATA SOURCESnPubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and clinical trials registries (January 1, 1970, to March 1, 2014).nnnSTUDY SELECTIONnTwo reviewers selected randomized clinical trials (RCTs) with at least 12 weeks duration that reported eligible outcomes and head-to-head prospective cohort studies reporting health outcomes or harms.nnnDATA EXTRACTION AND SYNTHESISnWe conducted meta-analyses using random-effects models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs).nnnMAIN OUTCOMES AND MEASURESnAlcohol consumption, motor vehicle crashes, injuries, quality of life, function, mortality, and harms.nnnRESULTSnWe included 122 RCTs and 1 cohort study (total 22,803 participants). Most assessed acamprosate (27 studies, nu2009=u20097519), naltrexone (53 studies, nu2009=u20099140), or both. The NNT to prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD], -0.09; 95% CI, -0.14 to -0.04) and was 20 (95% CI, 11 to 500; RD, -0.05; 95% CI, -0.10 to -0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 (95% CI, 8 to 26; RD -0.09; 95% CI, -0.13 to -0.04) for oral naltrexone (50 mg/d). Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant difference between them for return to any drinking (RD, 0.02; 95% CI, -0.03 to 0.08) or heavy drinking (RD, 0.01; 95% CI, -0.05 to 0.06). For injectable naltrexone, meta-analyses found no association with return to any drinking (RD, -0.04; 95% CI, -0.10 to 0.03) or heavy drinking (RD, -0.01; 95% CI, -0.14 to 0.13) but found an association with reduction in heavy drinking days (weighted mean difference [WMD], -4.6%; 95% CI, -8.5% to -0.56%). Among medications used off-label, moderate evidence supports an association with improvement in some consumption outcomes for nalmefene (heavy drinking days per month: WMD, -2.0; 95% CI, -3.0 to -1.0; drinks per drinking day: WMD, -1.02; 95% CI, -1.77 to -0.28) and topiramate (% heavy drinking days: WMD, -9.0%; 95% CI, -15.3% to -2.7%; drinks per drinking day: WMD, -1.0; 95% CI, -1.6 to -0.48). For naltrexone and nalmefene, NNHs for withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to 50), respectively; risk was not significantly increased for acamprosate or topiramate.nnnCONCLUSIONS AND RELEVANCEnBoth acamprosate and oral naltrexone were associated with reduction in return to drinking. When directly compared with one another, no significant differences were found between acamprosate and naltrexone for controlling alcohol consumption. Factors such as dosing frequency, potential adverse events, and availability of treatments may guide medication choice.

Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force

BACKGROUNDnAlcohol misuse, which includes the full spectrum from risky drinking to alcohol dependence, is a leading cause of preventable death in the United States.nnnPURPOSEnTo evaluate the benefits and harms of behavioral counseling interventions for adolescents and adults who misuse alcohol.nnnDATA SOURCESnMEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and reference lists of published literature (January 1985 through January 2012, limited to English-language articles).nnnSTUDY SELECTIONnControlled trials at least 6 months duration that enrolled persons with alcohol misuse identified by screening in primary care settings and evaluated behavioral counseling interventions.nnnDATA EXTRACTIONnOne reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings and graded the strength of the evidence.nnnDATA SYNTHESISnThe 23 included trials generally excluded persons with alcohol dependence. The best evidence was for brief (10- to 15-minute) multicontact interventions. Among adults receiving behavioral interventions, consumption decreased by 3.6 drinks per week from baseline (weighted mean difference, 3.6 drinks/wk [95% CI, 2.4 to 4.8 drinks/wk]; 10 trials; 4332 participants), 12% fewer adults reported heavy drinking episodes (risk difference, 0.12 [CI, 0.07 to 0.16]; 7 trials; 2737 participants), and 11% more adults reported drinking less than the recommended limits (risk difference, 0.11 [CI, 0.08 to 0.13]; 9 trials; 5973 participants) over 12 months compared with control participants (moderate strength of evidence). Evidence was insufficient to draw conclusions about accidents, injuries, or alcohol-related liver problems. Trials enrolling young adults or college students showed reduced consumption and fewer heavy drinking episodes (moderate strength of evidence). Little or no evidence of harms was found.nnnLIMITATIONSnResults may be biased to the null because the behavior of control participants could have been affected by alcohol misuse assessments. In addition, evidence is probably inapplicable to persons with alcohol dependence and selective reporting may have occurred.nnnCONCLUSIONnBehavioral counseling interventions improve behavioral outcomes for adults with risky drinking.nnnPRIMARY FUNDING SOURCEnAgency for Healthcare Research and Quality.

HIV Interventions to Reduce HIV/AIDS Stigma: A Systematic Review

We reviewed the literature to determine the effectiveness of HIV-related interventions in reducing HIV/AIDS stigma. Studies selected had randomized controlled trial (RCT), pretest–posttest with a non-randomized control group, or pretest–posttest one group study designs in which HIV-related interventions were being evaluated, and in which HIV/AIDS stigma was one of the outcomes being measured. A checklist was used to extract data from accepted studies, assess their internal validity, and overall quality. Data were extracted from 19 studies, and 14 of these studies demonstrated effectiveness in reducing HIV/AIDS stigma. Only 2 of these 14 effective studies were considered good studies, based on quality, the extent to which the intervention focused on reducing HIV/AIDS stigma, and the statistics reported to demonstrate effectiveness. Future studies to reduce HIV/AIDS stigma could improve by designing interventions that pay greater attention to internal validity, use validated HIV/AIDS stigma instruments, and achieve both statistical and public health significance.

Auriculotherapy for Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVESnSide-effects of standard pain medications can limit their use. Therefore, nonpharmacologic pain relief techniques such as auriculotherapy may play an important role in pain management. Our aim was to conduct a systematic review and meta-analysis of studies evaluating auriculotherapy for pain management.nnnDESIGNnMEDLINE,(®) ISI Web of Science, CINAHL, AMED, and Cochrane Library were searched through December 2008. Randomized trials comparing auriculotherapy to sham, placebo, or standard-of-care control were included that measured outcomes of pain or medication use and were published in English. Two (2) reviewers independently assessed trial eligibility, quality, and abstracted data to a standardized form. Standardized mean differences (SMD) were calculated for studies using a pain score or analgesic requirement as a primary outcome.nnnRESULTSnSeventeen (17) studies met inclusion criteria (8 perioperative, 4 acute, and 5 chronic pain). Auriculotherapy was superior to controls for studies evaluating pain intensity (SMD, 1.56 [95% confidence interval (CI): 0.85, 2.26]; 8 studies). For perioperative pain, auriculotherapy reduced analgesic use (SMD, 0.54 [95% CI: 0.30, 0.77]; 5 studies). For acute pain and chronic pain, auriculotherapy reduced pain intensity (SMD for acute pain, 1.35 [95% CI: 0.08, 2.64], 2 studies; SMD for chronic pain, 1.84 [95% CI: 0.60, 3.07], 5 studies). Removal of poor quality studies did not alter the conclusions. Significant heterogeneity existed among studies of acute and chronic pain, but not perioperative pain.nnnCONCLUSIONSnAuriculotherapy may be effective for the treatment of a variety of types of pain, especially postoperative pain. However, a more accurate estimate of the effect will require further large, well-designed trials.

Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force

Stroke is a leading cause of death and disability (1). An estimated 7 million U.S. adults have had a stroke, and roughly 75% were first attacks (2). Ischemic strokes account for nearly 90% of all strokes in the United States (3). Carotid artery stenosis (CAS) causes approximately 10% of ischemic strokes (4). Carotid artery stenosis refers to atherosclerotic narrowing of the extracranial carotid arteriesspecifically, the internal carotid arteries or the common and internal carotid arteries. The best available data for the prevalence of asymptomatic CAS from large U.S.-based studies of the general population were published in the 1990s and enrolled adults aged 65 years or older (5, 6). Data published in 1992 showed a prevalence of just more than 1% for CAS of 75% to 99% (6), and those published in 1998 suggested a prevalence of 0.5% for CAS of 70% to 99% (5). Several studies have attempted to estimate the rate of progression of asymptomatic CAS and predict neurologic events (5, 711). The best available data from large U.S.-based studies of the general population revealed a 5-year risk for ipsilateral stroke of 5% for CAS of 70% or greater (5441 participants) (5). The main purpose of this review is to evaluate the current evidence on whether screening asymptomatic adults for CAS reduces the risk for ipsilateral stroke and on harms associated with screening and interventions for CAS. We also evaluated evidence on the incremental benefit of medical therapy and on risk-stratification tools. Despite a D recommendation from the U.S. Preventive Services Task Force in 2007 (12), many surgeries or interventions for asymptomatic CAS continue to be performed, and free or cash-on-the-barrel screenings are offered in public locations across the country (13). Methods We developed an analytic framework (Supplement 1) and key questions (Table 1 of Supplement 2) that guided the review. Detailed methods and additional results are publicly available in our full evidence report (www.uspreventiveservicestaskforce.org) (14). Supplement 1. Analytic Framework for Screening for Asymptomatic Carotid Artery Stenosis Supplement 2. Tables Data Sources and Searches We searched MEDLINE, the Cochrane Library, and EMBASE for English-language articles published through September 2013 (Tables 2 and 3 of Supplement 2). We conducted a targeted update search of MEDLINE for trials published through 31 March 2014 and searched clinical trial registries for unpublished literature. To supplement electronic searches, we reviewed reference lists of included studies and literature suggested by reviewers. Study Selection Two investigators independently reviewed abstracts and full-text articles against prespecified eligibility criteria (Table 4 of Supplement 2). We included studies that focused on asymptomatic adults with CAS and studies that analyzed the asymptomatic group separately. We included randomized, controlled trials (RCTs) of screening for CAS, RCTs and systematic reviews of treatment effectiveness, multi-institution trials or cohort studies that reported harms, and studies that attempted to externally validate risk-stratification tools. For evaluation of accuracy and reliability of ultrasonography, we focused on systematic reviews but also included primary studies that were published after the literature search cutoff of the most recent good-quality systematic review. Data Extraction and Quality Assessment One investigator extracted pertinent information from each article. Another investigator reviewed extractions for completeness and accuracy. Two independent investigators assigned quality ratings (good, fair, or poor) for each study using predefined criteria (14, 15). Disagreements were resolved with team discussion. Poor-quality studies are described in the full report (14). Data Synthesis and Analysis We qualitatively synthesized findings for each key question by summarizing the characteristics and results of included studies in tabular or narrative format. To determine whether meta-analyses were appropriate, we assessed the clinical and methodological heterogeneity of the studies following established guidance (16). We conducted meta-analysis of RCTs that compared carotid endarterectomy (CEA) with medical therapy for relevant outcomes reported by several studies. We used DerSimonianLaird random-effects models to estimate pooled effects (17) and calculated risk differences between CEA and medical therapy to show the absolute differences between groups. Absolute measures are more easily interpreted, show more directly relevant information, and better allow decision makers to assess tradeoffs between benefits and harms (1820). We calculated chi-square and I 2 statistics to assess statistical heterogeneity in effects among studies (21, 22). To allow the comparison of rates of perioperative harms reported in RCTs with those from sources that may be more representative of real-world clinical practice, we conducted meta-analyses of cohort studies that reported perioperative (30-day) stroke or death rates. We also conducted meta-analyses of such rates reported in trials that involved CEA or carotid angioplasty and stenting (CAAS), regardless of the comparator. We conducted sensitivity analyses using profile likelihood random-effects methods when our meta-analyses included few studies (2326). We did not include poor-quality studies in our analyses. Analyses were conducted using Stata, version 11.1 (StataCorp). Role of the Funding Source The Agency for Healthcare Research and Quality funded the review. Members of the U.S. Preventive Services Task Force and Agency for Healthcare Research and Quality assisted in developing the reviews scope and reviewed draft manuscripts, but the authors are solely responsible for the content. Results We included 78 published articles that reported on 56 studies (Figure 1) . Figure 1. Summary of evidence search and selection. WHO ICTRP = World Health Organization International Clinical Trials Registry Platform. Direct Evidence that Screening Reduces Ipsilateral Stroke We found no eligible studies that provided evidence on whether screening reduced ipsilateral stroke. Accuracy and Reliability of Duplex Ultrasonography We included 3 meta-analyses (2729) and 1 fair-quality primary study (30) (Table 5 of Supplement 2). The most recent good-quality meta-analysis (28) included 47 studies published through 2003 that used digital subtraction angiography as the reference standard. It reported sensitivity and specificity for detecting stenosis of 50% or greater (1716 participants) of 98% (95% CI, 97% to 100%) and 88% (CI, 76% to 100%), respectively. Sensitivity and specificity for detecting stenosis of 70% or greater (2140 participants) were 90% (CI, 84% to 94%) and 94% (CI, 88% to 97%). Using data from this meta-analysis, the last evidence report for the U.S. Preventive Services Task Force estimated the sensitivity and specificity for detecting stenosis of 60% or greater as 94% and 92%, respectively (31). The meta-analysis reported wide, clinically important variation in measurement properties among laboratories (28). The findings of the other meta-analyses were generally consistent with these results, but specificity in the primary study was lower (66% for detecting CAS of 70% to 99% [CI, 63% to 71%]; 503 participants) (30). Additional results are provided in our full report (14). Benefits of CEA or CAAS Beyond Medical Therapy We included 3 RCTs (Table 1) described in 12 publications (3243) that compared CEA with medical therapy and 3 systematic reviews described in 5 publications (31, 4447). We found no eligible studies that compared CAAS with medical therapy and no studies that compared CEA with current standard medical therapy. Table 1. Characteristics and Main Results of Included Fair- or Good-Quality Randomized, Controlled Trials of CEA Compared With MM for Asymptomatic CAS* The ACAS (Asymptomatic Carotid Atherosclerosis Study) and the VACS (Veterans Affairs Cooperative Study) were conducted in North America; the ACST (Asymptomatic Carotid Surgery Trial) involved 30 countries, primarily in Europe. Medical therapy varied across trials and was often not clearly defined or standardized. Surgeons with a history of low complication rates were selected. They submitted records of their last 50 cases or previous 24 months of experience with CEA and were selected on the basis of review by a committee or morbidity and mortality rates less than 3%. Our meta-analyses found that fewer persons treated with CEA had perioperative stroke or death or subsequent ipsilateral stroke, perioperative stroke or death or any subsequent stroke, any stroke or death, nonperioperative ipsilateral stroke, and any nonperioperative stroke than those in medical therapy groups (Table 2 and Figure 2). For all-cause mortality, we found no significant difference. Results for sensitivity analyses using profile likelihood methods were very similar to those of our main analyses, with only minor variation in width of CIs (Table 2). Table 2. Summary of Main Results of Meta-analyses Figure 2. Meta-analyses of randomized, controlled trials comparing CEA with medical therapy, by outcome. ACAS = Asymptomatic Carotid Atherosclerosis Study; ACST = Asymptomatic Carotid Surgery Trial; CEA = carotid endarterectomy; MM = medical management; RD = risk difference; VACS = Veterans Affairs Cooperative Study. In the ACST, more than one half (57.8% [166 of 287]) of nonperioperative strokes were disabling or fatal, and the proportional reduction in disabling or fatal stroke (relative risk, 0.61 [CI, 0.41 to 0.92]) was similar to that for any stroke (relative risk, 0.54 [CI, 0.43 to 0.68]) (37). Subgroup analyses of the ACAS showed a statistically significant reduction for men (relative risk reduction, 66% [CI, 36% to 82%]) but not for women (relative risk reduction, 17% [CI, 96% to 65%]) for estimated 5-year rate of perioperative stroke or death and subsequent ipsilateral stroke.

Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Many adverse health outcomes are associated with obstructive sleep apnea (OSA). Objective To review primary care–relevant evidence on screening adults for OSA, test accuracy, and treatment of OSA, to inform the US Preventive Services Task Force. Data Sources MEDLINE, Cochrane Library, EMBASE, and trial registries through October 2015, references, and experts, with surveillance of the literature through October 5, 2016. Study Selection English-language randomized clinical trials (RCTs); studies evaluating accuracy of screening questionnaires or prediction tools, diagnostic accuracy of portable monitors, or association between apnea-hypopnea index (AHI) and health outcomes among community-based participants. Data Extraction and Synthesis Two investigators independently reviewed abstracts and full-text articles. When multiple similar studies were available, random-effects meta-analyses were conducted. Main Outcomes and Measures Sensitivity, specificity, area under the curve (AUC), AHI, Epworth Sleepiness Scale (ESS) scores, blood pressure, mortality, cardiovascular events, motor vehicle crashes, quality of life, and harms. Results A total of 110 studies were included (Nu2009=u200946u2009188). No RCTs compared screening with no screening. In 2 studies (nu2009=u2009702), the screening accuracy of the multivariable apnea prediction score followed by home portable monitor testing for detecting severe OSA syndrome (AHI ≥30 and ESS score >10) was AUC 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively, but the studies oversampled high-risk participants and those with OSA and OSA syndrome. No studies prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Meta-analysis found that continuous positive airway pressure (CPAP) compared with sham was significantly associated with reduction of AHI (weighted mean difference [WMD], −33.8 [95% CI, −42.0 to −25.6]; 13 trials, 543 participants), excessive sleepiness assessed by ESS score (WMD, −2.0 [95% CI, −2.6 to −1.4]; 22 trials, 2721 participants), diurnal systolic blood pressure (WMD, −2.4 points [95% CI, −3.9 to −0.9]; 15 trials, 1190 participants), and diurnal diastolic blood pressure (WMD, −1.3 points [95% CI, −2.2 to −0.4]; 15 trials, 1190 participants). CPAP was associated with modest improvement in sleep-related quality of life (Cohen d, 0.28 [95% CI, 0.14 to 0.42]; 13 trials, 2325 participants). Mandibular advancement devices (MADs) and weight loss programs were also associated with reduced AHI and excessive sleepiness. Common adverse effects of CPAP and MADs included oral or nasal dryness, irritation, and pain, among others. In cohort studies, there was a consistent association between AHI and all-cause mortality. Conclusions and Relevance There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.

Impact of genotype-guided dosing on anticoagulation visits for adults starting warfarin: A randomized controlled trial

AIMnThis study aimed to assess the effectiveness of genotype-guided warfarin dosing.nnnPATIENTS & METHODSnA total of 109 adults were randomized to receive initial dosing as determined by an algorithm containing genetic (VKORC1 and CYP2C9) plus clinical information or only clinical information. Primary end points were the number of anticoagulation visits and the time in therapeutic range (TTR) over 90 days. Secondary end points included time to therapeutic dose, International Normalized Ratios of >4, emergency visits, hospitalizations, hemorrhagic events, thrombotic events and mortality.nnnRESULTSnNeither primary end point was significantly different between groups (anticoagulation visits: 6.96 vs 6.37, p = 0.51; TTR: 0.40 vs 0.43, p = 0.59). Fewer emergency visits, hospitalizations, major hemorrhagic events, thrombotic events and deaths occurred in the genetic plus clinical group than in the clinical only group, but these differences were not statistically significant.nnnCONCLUSIONnGenotype-guided dosing did not decrease the number of anticoagulation visits or improve TTR. Our trial was not powered to detect anything but large differences for utilization and health outcomes.

Primary Care Screening and Treatment for Latent Tuberculosis Infection in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCEnFive to ten percent of individuals with latent tuberculosis infection (LTBI) progress to active tuberculosis (TB) disease. Identifying and treating LTBI is a key component of the strategy for reducing the burden of TB disease.nnnOBJECTIVEnTo review the evidence about targeted screening and treatment for LTBI among adults in primary care settings to support the US Preventive Services Task Force in updating its 1996 recommendation.nnnDATA SOURCESnMEDLINE, Cochrane Library, and trial registries, searched through August 3, 2015; references from pertinent articles; and experts. Literature surveillance was conducted through May 31, 2016.nnnSTUDY SELECTIONnEnglish-language studies of LTBI screening, LTBI treatment with recommended pharmacotherapy, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of individuals for whom LTBI screening and treatment is part of public health surveillance or disease management were excluded.nnnDATA EXTRACTION AND SYNTHESISnTwo investigators independently reviewed abstracts and full-text articles. When at least 3 similar studies were available, random-effects meta-analysis was used to generate pooled estimates of outcomes.nnnMAIN OUTCOMES AND MEASURESnSensitivity, specificity, reliability, active TB disease, mortality, hepatotoxicity, and other harms.nnnRESULTSnThe review included 72 studies (nu2009=u200951u202f711). No studies evaluated benefits and harms of screening compared with no screening. Pooled estimates for sensitivity of the TST at both 5-mm and 10-mm induration thresholds were 0.79 (5-mm: 95% CI, 0.69-0.89 [8 studies, nu2009=u2009803]; 10 mm: 95% CI, 0.71-0.87 [11 studies; nu2009=u2009988]), and those for IGRAs ranged from 0.77 to 0.90 (57 studies; nu2009=u20094378). Pooled estimates for specificity of the TST at the 10-mm and 15-mm thresholds and for IGRAs ranged from 0.95 to 0.99 (34 studies; nu2009=u200923u202f853). A randomized clinical trial (RCT) of 24 weeks of isoniazid in individuals with pulmonary fibrotic lesions and LTBI (nu2009=u200927u202f830) found a reduction in absolute risk of active TB at 5 years from 1.4% to 0.5% (relative risk [RR], 0.35 [95% CI, 0.24-0.52]) and an increase in absolute risk for hepatoxicity from 0.1% to 0.5% (RR, 4.59 [95% CI, 2.03-10.39]) for 24 weeks of daily isoniazid compared with placebo. An RCT (nu2009=u20096886) found that 3 months of once-weekly rifapentine plus isoniazid was noninferior to 9 months of isoniazid alone for preventing active TB. The risk difference for hepatoxicity comparing isoniazid with rifampin ranged from 3% to 7%, with a pooled RR of 3.29 (95% CI, 1.72-6.28 [3 RCTs; nu2009=u20091327]).nnnCONCLUSIONS AND RELEVANCEnNo studies evaluated the benefits and harms of screening compared with no screening. Both the TST and IGRAs are moderately sensitive and highly specific within countries with low TB burden. Treatment reduced the risk of active TB among the populations included in this review. Isoniazid is associated with higher rates of hepatotoxicity than placebo or rifampin.

How Much Time Do Adults Spend on Health-related Self-care? Results from the American Time Use Survey

Background: The amount of time individuals spend on health-related self-care is not known. Objective: The aim of this study was to describe how much time American adults reported spending on health-related self-care (eg, taking insulin, dressing a wound). Methods: We analyzed data from the first 5 years, 2003 to 2007, of the population-based American Time Use Survey. Of 64,310 respondents 25 years of age and older, 4267 reported 7022 episodes of health-related self-care on their survey day. We used descriptive statistics, weighted to represent US adults, to describe self-reported time and logit regressions to analyze the odds of engaging in self-care as a function of age, sex, race, and other characteristics. Because health status was collected only in 2006 to 2007, analyses were conducted separately for 2003 to 2007 and 2006 to 2007. Results: Of Americans 25 years of age and older, 6.6% engaged in health-related self-care each day. Among those reporting self-care, mean time reported was 90 minutes (median, 15 minutes); 20.6% reported 2 hours or more. Regressions for 2006 to 2007 show that people aged 75 or older were 3.9 times as likely (95% CI, 2.7–5.8) to report self-care as persons aged 25 to 44. Compared with persons in excellent health, those in fair health were 2.0 times as likely (95% CI, 1.4–2.8) and those in poor health were 3.7 times as likely (95% CI, 2.5–5.6) to report engaging in self-care. Nonworking disabled persons reported self-care 4 times (95% CI, 3.1–5.3) as often as employed persons. Sex, race/ethnicity, presence of children, and body mass index were also significant. Conclusions: Time spent on health-related self-care is disproportionately distributed across the population, with a larger amount of time reported by those in poor health (3.6 hours/week) and the nonworking disabled (3.2 hours/week). To provide patient-centered care and to promote optimal decisions about health-related time management when making recommendations for additional self-care tasks, clinicians need to talk to patients about how much time they are already spending on self-care.

Genomic screening of the general adult population: key concepts for assessing net benefit with systematic evidence reviews.

Genomic screening of the general adult population: key concepts for assessing net benefit with systematic evidence reviews