Emily S. Walsh

Screening for Obesity and Intervention for Weight Management in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Obesity is common in children and adolescents in the United States, is associated with negative health effects, and increases the likelihood of obesity in adulthood. Objective To systematically review the benefits and harms of screening and treatment for obesity and overweight in children and adolescents to inform the US Preventive Services Task Force. Data Sources MEDLINE, PubMed, PsycINFO, Cochrane Collaboration Registry of Controlled Trials, and the Education Resources Information Center through January 22, 2016; references of relevant publications; government websites. Surveillance continued through December 5, 2016. Study Selection English-language trials of benefits or harms of screening or treatment (behavior-based, orlistat, metformin) for overweight or obesity in children aged 2 through 18 years, conducted in or recruited from health care settings. Data Extraction and Synthesis Two investigators independently reviewed abstracts and full-text articles, then extracted data from fair- and good-quality trials. Random-effects meta-analysis was used to estimate the benefits of lifestyle-based programs and metformin. Main Outcomes and Measures Weight or excess weight (eg, body mass index [BMI]; BMI z score, measuring the number of standard deviations from the median BMI for age and sex), cardiometabolic outcomes, quality of life, other health outcomes, harms. Results There was no direct evidence on the benefits or harms of screening children and adolescents for excess weight. Among 42 trials of lifestyle-based interventions to reduce excess weight (N = 6956), those with an estimated 26 hours or more of contact consistently demonstrated mean reductions in excess weight compared with usual care or other control groups after 6 to 12 months, with no evidence of causing harm. Generally, intervention groups showed absolute reductions in BMI z score of 0.20 or more and maintained their baseline weight within a mean of approximately 5 lb, while control groups showed small increases or no change in BMI z score, typically gaining a mean of 5 to 17 lb. Only 3 of 26 interventions with fewer contact hours showed a benefit in weight reduction. Use of metformin (8 studies, n = 616) and orlistat (3 studies, n = 779) were associated with greater BMI reductions compared with placebo: −0.86 (95% CI, −1.44 to −0.29; 6 studies; I2 = 0%) for metformin and −0.50 to −0.94 for orlistat. Groups receiving lifestyle-based interventions offering 52 or more hours of contact showed greater improvements in blood pressure than control groups: −6.4 mm Hg (95% CI, −8.6 to −4.2; 6 studies; I2 = 51%) for systolic blood pressure and −4.0 mm Hg (95% CI, −5.6 to −2.5; 6 studies; I2 = 17%) for diastolic blood pressure. There were mixed findings for insulin or glucose measures and no benefit for lipids. Medications showed small or no benefit for cardiometabolic outcomes, including fasting glucose level. Nonserious harms were common with medication use, although discontinuation due to adverse effects was usually less than 5%. Conclusions and Relevance Lifestyle-based weight loss interventions with 26 or more hours of intervention contact are likely to help reduce excess weight in children and adolescents. The clinical significance of the small benefit of medication use is unclear.

Pap, Mammography, and Clinical Breast Examination Screening Among Women with Disabilities: A Systematic Review

BACKGROUND Research has found some disparities between U.S. women with and without disabilities in receiving clinical preventive services. Substantial differences may also exist within the population of women with disabilities. The current study examined published research on Pap smears, mammography, and clinical breast examinations across disability severity levels among women with disabilities. METHODS Informed by an expert panel, we followed guidelines for systematic literature reviews and searched MEDLINE, PsycINFO, and Cinahl databases. We also reviewed in-depth four disability- or preventive service-relevant journals. Two reviewers independently extracted data from all selected articles. FINDINGS Five of 74 reviewed publications of met all our inclusion criteria and all five reported data on Pap smears, mammography, and clinical breast examination. Articles classified disability severity groups by functional and/or activity levels. Associations between disability severity and Pap smear use were inconsistent across the publications. Mammography screening fell as disability level increased according to three of the five studies. Results demonstrated modestly lower screening, but also were inconsistent for clinical breast examinations across studies. CONCLUSION Evidence is inconsistent concerning disparities in these important cancer screening services with increasing disability levels. Published studies used differing methods and definitions, adding to concerns about the evidence for screening disparities rising along with increasing disability. More focused research is required to determine whether significant disparities exist in cancer screening among women with differing disability levels. This information is essential for national and local public health and health care organizations to target interventions to improve care for women with disabilities.

Behavioral Sexual Risk Reduction Counseling in Primary Care to Prevent Sexually Transmitted Infections: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

The Centers for Disease Control and Prevention estimates that approximately 20 million new cases of sexually transmitted infections (STIs) occur each year in the United States, half of which are among persons aged 15 to 24 years (1). In 2003 and 2004, 38% of sexually active female adolescents aged 14 to 19 years had an STI (2). In 2010, the inflation-adjusted annual direct medical costs of STIs were estimated to be

Barriers to health care among people with disabilities who are members of underserved racial/ethnic groups: a scoping review of the literature.

16.9 billion in the United States (3). In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended high-intensity behavioral counseling interventions for sexually active adolescents and in adults at increased risk for STIs (B recommendation). The evidence was insufficient, however, to assess the balance of benefits and harms of behavioral counseling to prevent STIs in nonsexually active adolescents and in adults not at increased risk for STIs (I statement). This systematic review updates the previous review that formed the basis of the 2008 recommendation. We developed an analytic framework (Appendix Figure 1) with 4 key questions (Appendix Table 1) that address counselings effects on patient health outcomes (key question 1), behavioral outcomes (key question 2), other positive outcomes (key question 3), and harms of counseling (key question 4). Appendix Figure 1. Analytic framework. STI = sexually transmitted infection. Appendix Table 1. Key Questions Methods The full report describes our methods in detail (4). Data Sources and Searches To identify the cumulative body of literature, we examined all studies included in the previous USPSTF review and searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and CINAHL from 1 January 2007 through 4 November 2013 to identify relevant articles published since the previous review (5). We also searched the bibliographies of relevant reviews and Web sites of governmental agencies and professional organizations, and we consulted with outside experts. Between 4 November 2013 and this publication, we actively monitored published literature for potentially important new trials directly relevant to the key questions in this systematic review; none were located. Study Selection Two investigators independently reviewed abstracts and relevant full-text articles against prespecified inclusion criteria. We included trials evaluating counseling interventions targeting risky sexual behaviors to prevent STIs in adults and adolescents. We excluded studies limited to persons with HIV (or populations with very high prevalence of HIV [>10% in the study sample]), inmates and parolees, and persons in inpatient or residential settings because results limited to these groups may not be applicable to general primary care populations. We required that included interventions be conducted in, or participants be recruited from, primary care or other outpatient clinical settings, including reproductive health clinics, STI clinics, and mental health clinics. We included English-language trials conducted in very high human development countries according to the World Health Organization (6). We accepted the following comparators as control groups: usual care, attention control, minimal intervention (<15 minutes of intervention contact), wait list, or no intervention. We included trials reporting 1 or more of the following at 3 months or later after baseline: patient health outcomes (STI incidence and morbidity or mortality related to STIs), sexual behavioral outcomes (for example, condom use or number of sexual partners), and harms of the intervention (for example, care avoidance). Data Extraction and Quality Assessment Two investigators independently assessed the methodological quality of each study using USPSTF criteria (7). Studies were rated as good, fair, or poor quality. Good-quality studies had adequate randomization procedures, allocation concealment, blinding of outcome assessors, reliable outcome measures (for example, at least standard laboratory procedures or efforts to minimize demand characteristics for self-reported outcomes), similar groups at baseline and follow-up, low attrition, acceptable statistical methods, and adequate adherence to the intervention. Fair-quality trials met some but not all of these criteria. Poor-quality studies had a serious flaw (for example, attrition >40%, differential attrition >20% between groups, or substantial baseline differences between groups) or multiple important limitations that would invalidate the study findings. We excluded all poor-quality studies. We resolved disagreements through discussion and, if necessary, consultation with a third investigator. One investigator abstracted data from all included studies into a standard evidence table. A second investigator checked the data for accuracy. Data Synthesis and Analysis We created summary tables for each key question that included trial characteristics and summaries of results and qualitatively examined the range of results and potential associations with effect size. We stratified our analyses on the basis of age (adolescents vs. adults, including age-based subgroup analyses when reported [810]) and estimated intervention intensity: high (>2 hours of intervention contact), moderate (0.5 to 2 hours of intervention contact), and low (brief single session or <0.5 hour of intervention contact). These cut points were selected to correspond with a typical, single brief session that would be feasible in a primary care office (low intensity); a longer single session or 2 to 3 brief sessions that may be feasible in selected primary care settings (medium intensity); and what would probably require multiple nonbrief sessions, usually necessitating specialized and trained staff that could be referred from primary care (high intensity). We categorized populations on the basis of STI risk. Low/mix referred to a mix of sexually active and presexually active participants (for adolescents only). General referred to sexually active adults with no further risk factors and not in a setting with increased risk (for adults only). Increased referred to participants with increased risk based on sociodemographics (sexually active teenagers, low-income inner-city residents, racial/ethnic subgroups with higher STI prevalence, men who have sex with men [MSM], and mentally ill or disabled persons), sexual history (for example, persons reporting high-risk behaviors), or setting (for example, STI clinics). The prior STI category was limited to persons with a current or recent STI at baseline. Additional potential moderators or mediators that we examined in exploratory qualitative analysis include characteristics of the interventions (degree of cultural tailoring, group vs. individual format, condom negotiation or other communication training as an intervention component, counselor characteristics, setting, type of control group, or number of sessions) and population (sex, sexual orientation, socioeconomic status, mental health issues, or history of abuse). We did random-effects meta-analyses for STI incidence using the DerSimonianLaird method (11). We analyzed odds ratios (ORs) because they were the most commonly reported outcome, which allowed us to include the largest number of studies in the meta-analysis. We ran sensitivity analyses using the profile likelihood method because some of our pooled estimates were derived from a small number of trials (12). Results were very similar, and all statistically significant results remained statistically significant with the profile likelihood method. Results shown on forest plots are from the DerSimonianLaird analyses. Statistical heterogeneity was assessed using the I 2 statistic (13). We used Stata, version 11.2 (StataCorp), for all meta-analyses. Role of Funding Source The Agency for Healthcare Research and Quality (AHRQ) funded this review under a contract to support the work of the USPSTF. Members of the USPSTF and an AHRQ medical officer assisted in defining this reviews scope. The AHRQ staff provided oversight for the project and assisted in the external review of the companion draft evidence synthesis. Although approval from AHRQ was required before submission of the manuscript, the authors are solely responsible for its content and the decision to submit it for publication. Results Thirty-one trials (810, 1441), reported in 57 publications (810, 1467), were selected from our review of 3241 abstracts and 218 full-text articles (Appendix Figure 2). Of the 31 included trials (n= 70324), 16 were newly published and not included in the previous review (n= 56110). Most evidence comes from trials in women and nonwhite or minority populations. Most trials targeted high-risk groups based on demographic characteristics, high-risk behaviors, or presence of a recent STI. Study details (including target populations) are presented in Appendix Tables 2 and 3 for adolescents and adults, respectively, and Supplements 1 and 2. Appendix Figure 2. Summary of evidence search and selection. CE = comparative effectiveness; KQ = key question. Appendix Table 2. Summary of Included Studies: Adolescents Appendix Table 3. Summary of Included Studies: Adults Supplement 1. Design and baseline population characteristics of included studies targeting adolescents Supplement 2. Design and baseline population characteristics of included studies targeting adults Although the interventions were very heterogeneous, there were some shared components. All interventions sought to minimize high-risk sexual behaviors (for example, unprotected sexual intercourse or multiple partners) and maximize protective behaviors (for example, condom use). Interventions provided basic information about STIs and commonly included risk assessment, hands-on skill training in condom use, problem solving, decision making, goal-setting, and communication surrounding condom use and safe sex. The depth with which topics were covered varied. Some interventions included additional components,

Health outcome disparities among subgroups of people with disabilities: A scoping review

Background:Understanding barriers to health care access experienced by people with disabilities who are members of underserved racial/ethnic groups is key to developing interventions to improve access. Objective:To conduct a scoping review of the literature to examine the published literature on barriers to health care access for people with disabilities who are members of underserved racial/ethnic groups. Data Sources:Articles cited in MEDLINE, PsycINFO, and CINAHL between the year 2000 and June 19, 2013. In addition, table of contents of 4 journals and the reference lists of the included article were reviewed for potentially relevant titles. Study Selection and Extraction:Studies examining barriers to health care access among adults aged 18–64 with disabilities who are members of an underserved racial/ethnic group were included. Two reviewers screened abstracts, screened each full-text article and extracted data, and discrepancies were resolved by consensus. Results:Ten studies were identified that met all inclusion criteria. The most frequently described barriers were uninsurance, language, low education level, and no usual source of care. Barriers to health care access related to race or ethnicity (6 studies) and disability (1 study) were observed less often than those related to socioeconomic status or health care systems factors (9 studies). Conclusions:Our findings reflect a critical gap in the literature. Greater attention is needed to subgroup differences including race, ethnicity, and culture within the population of people with disabilities.

Clinical preventive service use disparities among subgroups of people with disabilities: A scoping review.

BACKGROUND A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences. OBJECTIVES To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities. METHODS We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article. RESULTS For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender. CONCLUSIONS There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

The use of rapid review methods for the U.S. Preventive Services Task Force

BACKGROUND Recommended use of clinical preventive services (CPS) reduces morbidity and mortality from preventable conditions. Disparities in CPS utilization between individuals with and without disabilities have been shown, but a greater understanding of the disability subpopulations with lowest utilization is needed to better inform research, policy, and practice. OBJECTIVE The objective was to conduct a scoping review of the literature to identify relevant studies on disparities in receipt of CPS among subgroups of individuals with disabilities. METHODS In July 2010, electronic and manual literature searches were conducted for years 2000-2009. Review for inclusion/exclusion and data analysis occurred in 2010 and 2011. In 2012, the review was updated to cover abstracts published in 2010 and 2011. Identified abstracts, and then full-text articles of included abstracts, were reviewed according to inclusion/exclusion criteria by multiple reviewers. For articles meeting all criteria, two reviewers performed independent data extraction. A gap analysis was performed to identify areas of concentration and gaps in the literature. RESULTS Twenty-seven articles met inclusion criteria for this review. Studies varied substantially in sample composition and research methods. CPS examined most often were cervical cancer screening (14 studies) and mammography (13 studies). Potential disparity factors studied most often were disability factors (i.e., disabling condition in 12 studies, disability severity in 10 studies). Stratification of CPS by disparity factors revealed substantial gaps in the literature. CONCLUSIONS The literature gaps point to a need for high quality research on access disparities among subgroups of individuals with disabilities.

Searching for disability in electronic databases of published literature

Rapid review products are intended to synthesize available evidence in a timely fashion while still meeting the needs of healthcare decision makers. Various methods and products have been applied for rapid evidence syntheses, but no single approach has been uniformly adopted. Methods to gain efficiency and compress the review time period include focusing on a narrow clinical topic and key questions; limiting the literature search; performing single (versus dual) screening of abstracts and full-text articles for relevance; and limiting the analysis and synthesis. In order to maintain the scientific integrity, including transparency, of rapid evidence syntheses, it is imperative that procedures used to streamline standard systematic review methods are prespecified, based on sound review principles and empiric evidence when possible, and provide the end user with an accurate and comprehensive synthesis. The collection of clinical preventive service recommendations maintained by the U.S. Preventive Services Task Force, along with its commitment to rigorous methods development, provide a unique opportunity to refine, implement, and evaluate rapid evidence synthesis methods and add to an emerging evidence base on rapid review methods. This paper summarizes the U.S. Preventive Services Task Forces use of rapid review methodology, its criteria for selecting topics for rapid evidence syntheses, and proposed methods to streamline the review process.