Leslie A Perdue

Screening for Cognitive Impairment in Older Adults: A Systematic Review for the U.S. Preventive Services Task Force

BACKGROUND Earlier identification of cognitive impairment may reduce patient and caregiver morbidity. PURPOSE To systematically review the diagnostic accuracy of brief cognitive screening instruments and the benefits and harms of pharmacologic and nonpharmacologic interventions for early cognitive impairment. DATA SOURCES MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials through December 2012; systematic reviews; clinical trial registries; and experts. STUDY SELECTION English-language studies of fair to good quality, primary care–feasible screening instruments, and treatments aimed at persons with mild cognitive impairment or mild to moderate dementia. DATA EXTRACTION Dual quality assessment and abstraction of relevant study details. DATA SYNTHESIS The Mini-Mental State Examination (k = 25) is the most thoroughly studied instrument but is not available for use without cost. Publicly available instruments with adequate test performance to detect dementia include the Clock Drawing Test (k = 7), Mini-Cog (k = 4), Memory Impairment Screen (k = 5), Abbreviated Mental Test (k = 4), Short Portable Mental Status Questionnaire (k = 4), Free and Cued Selective Reminding Test (k = 2), 7-Minute Screen (k = 2), and Informant Questionnaire on Cognitive Decline in the Elderly (k = 5). Medications approved by the U.S. Food and Drug Administration for Alzheimer disease (k = 58) and caregiver interventions (k = 59) show a small benefit of uncertain clinical importance for patients and their caregivers. Small benefits are also limited by common adverse effects of acetylcholinesterase inhibitors and limited availability of complex caregiver interventions. Although promising, cognitive stimulation (k = 6) and exercise (k = 10) have limited evidence to support their use in persons with mild to moderate dementia or mild cognitive impairment. LIMITATION Limited studies in persons with dementia other than Alzheimer disease and sparse reporting of important health outcomes. CONCLUSION Brief instruments to screen for cognitive impairment can adequately detect dementia, but there is no empirical evidence that screening improves decision making. Whether interventions for patients or their caregivers have a clinically significant effect in persons with earlier detected cognitive impairment is still unclear. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Physical activity resources and changes in walking in a cohort of older men

OBJECTIVES We evaluated the influence of physical activity resources and neighborhood-level socioeconomic status (SES) on walking among community-dwelling older men. METHODS Participants reported time walked per day at baseline (2000-2002) and follow-up. Residential addresses were linked to a geographic information system database to assess proximity to parks, trails, and recreational facilities. Log-binomial regression analyses were conducted to test the hypothesis that men living near physical activity resources were more likely to increase or maintain time walked. RESULTS Average time walked per day declined by 6 minutes between baseline and follow-up (P < .05). There was a significant interaction of neighborhood SES and physical activity with walking time (P < .1). Proximity to parks and proximity to trails, respectively, were associated with a 22% (95% confidence interval [CI] = 1.01, 1.47) and 34% (95% CI = 1.16, 1.55) higher likelihood of maintaining or increasing walking time in high-SES neighborhoods, but there was no association in low-SES neighborhoods. Proximity to recreational facilities was not associated with walking. CONCLUSIONS Uncovering reasons that proximity to parks and trails is not associated with maintenance of walking activity among men in low-SES neighborhoods could provide new insight into ways to promote physical activity.

Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force

BACKGROUND Interventions to prevent smoking uptake or encourage cessation among young persons might help prevent tobacco-related illness. PURPOSE To review the evidence for the efficacy and harms of primary care-relevant interventions that aim to reduce tobacco use among children and adolescents. DATA SOURCES Three systematic reviews that collectively covered the relevant literature; MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects through 14 September 2012; and manual searches of reference lists and gray literature. STUDY SELECTION Two investigators independently reviewed 2453 abstracts and 111 full-text articles. English-language trials of behavior-based or medication interventions that were relevant to primary care and reported tobacco use, health outcomes, or harms were included. DATA EXTRACTION One investigator abstracted data from good- and fair-quality trials into an evidence table, and a second checked these data. DATA SYNTHESIS 19 trials (4 good-quality and 15 fair-quality) that were designed to prevent tobacco use initiation or promote cessation (or both) and reported self-reported smoking status or harms were included. Pooled analyses from a random-effects meta-analysis suggested a 19% relative reduction (risk ratio, 0.81 [95% CI, 0.70 to 0.93]; absolute risk difference, -0.02 [CI, -0.03 to 0.00]) in smoking initiation among participants in behavior-based prevention interventions compared with control participants. Neither behavior-based nor bupropion cessation interventions improved cessation rates. Findings about the harms related to bupropion use were mixed. LIMITATIONS No studies reported health outcomes. Interventions and measures were heterogeneous. Most trials examined only cigarette smoking. The body of evidence was largely published 5 to 15 years ago. CONCLUSION Primary care-relevant interventions may prevent smoking initiation over 12 months in children and adolescents.

Challenges in Synthesizing and Interpreting the Evidence From a Systematic Review of Multifactorial Interventions to Prevent Functional Decline in Older Adults

A systematic review of multifactorial assessment and management interventions to prevent functional decline in older adults was undertaken for the U.S. Preventive Services Task Force. It was not possible to determine net benefit because of heterogeneity of studies, including how older adults were selected and their risk of functional decline; the broad spectrum and multifactorial nature of interventions evaluated; the suboptimal and inconsistent use of outcomes measured; and the inconsistent and inadequate reporting of data that might allow comparison of populations, interventions, and outcomes between studies. This review process illustrated the complexities encountered when synthesizing and interpreting the evidence in geriatric research and methods of reviewing complex interventions and multiple interrelated health outcomes. This article summarizes the review findings, focusing on methodological challenges, and offers suggestions to researchers on the design, reporting, and analysis of trials that would help address these challenges and allow for better interpretation of evidence in the future.

Primary Care Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance Although 80% of infants in the United States start breastfeeding, only 22% are exclusively breastfed up to around 6 months as recommended by a number of professional organizations. Objective To systematically review the evidence on the benefits and harms of breastfeeding interventions to support the US Preventive Services Task Force in updating its 2008 recommendation. Data Sources MEDLINE, PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published in the English language between January 1, 2008, and September 25, 2015. Studies included in the previous review were re-evaluated for inclusion. Surveillance for new evidence in targeted publications was conducted through January 26, 2016. Study Selection Review of randomized clinical trials and before-and-after studies with concurrent controls conducted in a developed country that evaluated a primary care-relevant breastfeeding intervention among mothers of full- or near-term infants. Of 211 full-text articles reviewed, 52 studies met inclusion criteria. Thirty-one studies were newly identified, and 21 studies were carried forward from the previous review. Data Extraction and Synthesis Independent critical appraisal of all provisionally included studies. Data were independently abstracted by one reviewer and confirmed by another. Main Outcomes and Measures Child and maternal health outcomes, rates and duration of breastfeeding, and harms related to interventions as prespecified before data collection. Results Fifty-two studies (n = 66 757) in 57 publications were included. Six trials (n = 2219) reported inconsistent effects of the interventions on infant health outcomes; no studies reported maternal health outcomes. Pooled estimates based on random-effects meta-analyses using the DerSimonian and Laird method indicated beneficial associations between individual-level breastfeeding interventions and any breastfeeding for less than 3 months (risk ratio [RR], 1.07 [95% CI, 1.03-1.11]; 26 studies [n = 11 588]), at 3 to less than 6 months (RR, 1.11 [95% CI, 1.04-1.18]; 23 studies [n = 8942]), and for exclusive breastfeeding for less than 3 months (RR, 1.21 [95% CI, 1.11-1.33]; 22 studies [n = 8246]), 3 to less than 6 months (RR, 1.20 [95% CI, 1.05-1.38]; 18 studies [n = 7027]), and at 6 months (RR, 1.16 [95% CI, 1.02-1.32]; 17 studies [n = 7690]). Absolute differences in the rates of any breastfeeding ranged from 14.1% in favor of the control group to 18.4% in favor of the intervention group. There was no significant association between interventions and breastfeeding initiation (RR, 1.00 [95% CI, 0.99-1.02]; 14 studies [n = 9428]). There was limited mixed evidence of an association between system-level interventions and rates of breastfeeding from well-controlled studies as well as for harms related to breastfeeding interventions, including maternal anxiety scores, decreased confidence, and concerns about confidentiality. Conclusions and Relevance The updated evidence confirms that breastfeeding support interventions are associated with an increase in the rates of any and exclusive breastfeeding. There are limited well-controlled studies examining the effectiveness of system-level policies and practices on rates of breastfeeding or child health and none for maternal health.

Individualizing Cancer Screening in Older Adults: A Narrative Review and Framework for Future Research

ABSTRACTOlder adults often have multiple chronic conditions that may decrease additional life expectancy. Research evaluating the benefits and harms of screening must include consideration of competing morbidities and patient heterogeneity (beyond age), potentially increased harms of screening, and patient preferences. Other areas in need of additional research include the lack of evidence for older adults on the harms of screening tests; the overdiagnosis of disease; the burden of disease labeling; the effects of inaccurate test results; the harms of disease treatment; and harms related to prioritization of healthcare (e.g., for a particular patient, lifestyle counseling may be more important than screening). Nontraditional outcomes, such as the effects on family caregivers, are also relevant. Studies comparing trajectories of quality-adjusted survival with and without screening to assess net benefit are typically lacking. There is little evidence on the preferences of older adults for deciding whether to be screened, the process of being screened, and the health states associated with being or not being screened. To enhance the quality and quantity of evidence, older adults need to be enrolled in screening trials and clinical studies. Measures of functional status and health-related quality of life (HRQL) need to be included in trials, registries, and cohort studies. This article addresses these challenges, and presents a framework for what research is needed to better inform screening decisions in older adults.

Primary care behavioral interventions to prevent or reduce illicit drug use and nonmedical pharmaceutical use in children and adolescents: a systematic evidence review for the U.S. Preventive Services Task Force.

Drug use among adolescents is a serious public health problem in the United States. The 2012 National Survey on Drug Use and Health reported that 9.5% of children aged 12 to 17 years reported illicit drug use during the past month. Marijuana and prescription psychotherapeutics (including pain relievers) are the most commonly used drugs among children and adolescents. Seven percent of children aged 12 to 17 years reported current use of marijuana, and an estimated 5% used marijuana for the first time within the past year. In 2012, 2.8% of children aged 12 to 17 years reported using a prescription drug for nonmedical reasons, and 2.2% reported nonmedical use of opioid pain relievers. Illicit drug use was approximately 15 times higher among young persons who smoked cigarettes and drank alcohol during the past month (61.1%) than among those who neither smoked cigarettes nor drank alcohol during the past month (4.0%) (1). Drug and alcohol use are the primary health risk behaviors that contribute to unintentional injuries, homicide, and suicidethe leading causes of morbidity and mortality among adolescents and young adults (2). Even infrequent drug or alcohol use increases the risk for serious adverse events by increasing risk-taking behaviors in intoxicated or impaired persons. The Substance Abuse and Mental Health Services Administration and the American Academy of Pediatrics recommend that universal screening, brief intervention, and referral to treatment (SBIRT) for substance use should be a part of routine health care as a method to reduce the health burden associated with substance use (3, 4). Although SBIRT is appropriate for all levels of risk, it is a particularly useful early intervention approach to identifying and intervening with persons with nondependent substance use before they require extensive or specialized treatment. Among children and adolescents, primary care interventions can include positive feedback for nonusers as primary prevention; brief advice for those at low risk for abuse (secondary prevention); or a motivational intervention directed at high-risk patients for reducing use, reducing associated high-risk behaviors, or accepting a referral to treatment. In 2008, the U.S. Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend for or against screening adolescents, adults, and pregnant women for illicit drug use (5). We undertook the current review to synthesize the evidence on the benefits and harms of primary carerelevant behavioral interventions designed to prevent or reduce illicit drug use or the nonmedical use of prescription drugs among children and adolescents only. The USPSTF used this review to update its recommendation for this population. Methods With input from the USPSTF, we developed an analytic framework and 3 key questions (KQs) to guide our review (Appendix Figure 1). The proposed analytic framework and KQs were posted on the USPSTFs Web site for public comment for 4 weeks. On the basis of this input, we made appropriate revisions and received final approval for publication from USPSTF liaisons. The full report provides details on our methods and results, including search strategies and all evidence tables (www.uspreventiveservicestaskforce.org/uspstf13/drugmisuse/drugmisusedraftrep.htm). Appendix Figure 1. Analytic framework and key questions. Data Sources and Searches We searched for English-language publications in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1992 through 4 June 2013 and in MEDLINE through 31 August 2013. We also assessed the 2 trials that were specific to children and adolescents and were included in the 2008 review (6). We examined the reference lists of 6 relevant published reviews and meta-analyses (712), as well as the reference lists of included studies. We considered gray literature sources and recommendations from experts. Study Selection Two investigators independently reviewed abstracts against prespecified eligibility criteria. We dually reviewed all full-text articles for potential inclusion. We included randomized, controlled trials (RCTs) or controlled clinical trials designed to prevent or reduce drug use in children and adolescents (aged <18 years [no lower age restriction]) who were not diagnosed with a substance use disorder or seeking treatment for substance misuse. We included trials conducted in primary care or those that tested interventions we judged feasible for conduct in primary care that had a link to a health care setting or system, with or without referral to specialty treatment services. This included interventions employing the full SBIRT model and other approaches to primary prevention (to prevent initiation of use) or tertiary prevention (to prevent continued use and adverse effects in those already using). We also included interventions delivered exclusively through electronic media (such as the Internet or CD-ROMs) that were not linked to health care. We excluded trials among youths diagnosed with substance abuse or dependence because they represented specialty treatment only. We also excluded studies conducted among adolescents who were mandated or directly referred to substance abuse or dependence treatment via the juvenile justice system, social services, parents, or a similar referral system. In addition, we excluded interventions conducted in substance abuse treatment centers, schools, worksites, and other institutions (for example, juvenile detention centers). Included trials had control groups that offered minimal or no treatment and reported drug use or health or social outcomes at least 6 months after baseline. Data Extraction and Quality Assessment Two independent investigators rated the quality of all included trials as good, fair, or poor according to USPSTF standards (13). We excluded poor-quality trials. One reviewer abstracted data from studies that were rated fair or good. A second reviewer checked all abstracted data for accuracy and completeness. We resolved discrepancies through discussion. Data Synthesis and Analysis We summarized all included studies in narrative form and summary tables detailing the important features of the study populations, design, intervention, and results. We used the between-group differences that were reported by authors of included studies, when available. We identified too few trials to conduct any meta-analysis, as well as too much variability in several factors (such as population or intervention). As a result, we conducted a qualitative analysis for all KQs and stratified the results into 2 groups based on the intervention: primary carebased or computer-based. Primary carebased studies recruited directly from or were conducted in primary care clinics. Computer-based interventions were judged to be feasible for primary care because they used only electronic methods of delivery, although they did not recruit from or take place in primary care. Role of the Funding Source Agency for Healthcare Research and Quality (AHRQ) staff provided technical oversight for the project. Although USPSTF liaisons helped resolve issues around the reviews scope, they were not involved in the reviews conduct. Results We reviewed 2253 abstracts and 144 full-text articles for possible inclusion (Appendix Figure 2). We identified 6 trials (reported in 7 publications) that met our inclusion criteria (1420). The most common reasons for exclusion included settings (for example, not linked to or feasible for primary care [k= 45]), out-of-scope populations (for example, aged >18 years, seeking treatment, or diagnosed with substance abuse or dependence [k= 26]), and not reporting any relevant outcomes (k= 19) (Appendix Figure 2). Table 1 provides a summary of evidence for the benefits and harms of each included study by outcome (drug use behaviors [KQ 2], health and social outcomes [KQ 1], and harms [KQ 3]). Appendix Figure 2. Summary of evidence search and selection. Table 1. Summary of Evidence for Benefits and Harms of Drug Use Interventions Effects of Interventions on Drug Use Primary CareBased Interventions Three of the 6 studies were conducted in or recruited patients from primary care (Appendix Tables 1 and 2) (16, 17, 20) and tested 4 active treatment groups. We rated all 3 studies as fair-quality according to USPSTF standards (13), with various threats to internal validity (see the full report for more detail on study quality). The smallest study had 41 participants (17), and the largest had more than 2500 (16). Ages ranged from 12 to 20 years, and girls were overrepresented60% to 68% of participants were girls. All 3 studies took place in the United States, and 1 of them (16) also included a sample of adolescents in the Czech Republic. Two of the studies were conducted among a general primary care population (16, 20), whereas the remaining study was conducted among a sample of young persons diagnosed with asthma (17). One of the studies screened adolescents for drug use before enrollment; only those who reported any marijuana use in the past year were randomly assigned (20). In this trial, marijuana use was the primary focus; the other studies targeted drug, alcohol, or tobacco use. Appendix Table 1. Study Characteristics of Included Trials Appendix Table 2. Intervention Characteristics of Included Trials All 3 studies took place during 1 office visit. Three of the interventions included brief counseling (2 to 40 minutes) by the primary care physician (16), family nurse practitioner (17), or trained research therapist (20), and all included a computer-based, self-administered educational component. The study by Walton and colleagues randomly assigned adolescents to a therapist-led brief intervention, computer-based brief intervention, or usual care control group (20). Interventions provided information and advice about substance use along with a decision-making exercise. One of the trials (16) was consis

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Falls are the most common cause of injury-related morbidity and mortality among older adults. Objective To systematically review literature on the effectiveness and harms of fall prevention interventions in community-dwelling older adults to inform the US Preventive Services Task Force. Data Sources MEDLINE, PubMed, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials for relevant English-language literature published through August 2016, with ongoing surveillance through February 7, 2018. Study Selection Randomized clinical trials of interventions to prevent falls in community-dwelling adults 65 years and older. Data Extraction and Synthesis Independent critical appraisal and data abstraction by 2 reviewers. Random-effects meta-analyses using the method of DerSimonian and Laird. Main Outcomes and Measures Number of falls (number of unexpected events in which a person comes to rest on the ground, floor, or lower level), people experiencing 1 or more falls, injurious falls, people experiencing injurious falls, fractures, people experiencing fractures, mortality, hospitalizations, institutionalizations, changes in disability, and treatment harms. Results Sixty-two randomized clinical trials (N = 35 058) examining 7 fall prevention intervention types were identified. This article focused on the 3 most commonly studied intervention types: multifactorial (customized interventions based on initial comprehensive individualized falls risk assessment) (26 trials [n = 15 506]), exercise (21 trials [n = 7297]), and vitamin D supplementation (7 trials [n = 7531]). Multifactorial intervention trials were associated with a reduction in falls (incidence rate ratio [IRR], 0.79 [95% CI, 0.68-0.91]) but were not associated with a reduction in other fall-related morbidity and mortality outcomes. Exercise trials were associated with statistically significant reductions in people experiencing a fall (relative risk, 0.89 [95% 13 CI, 0.81-0.97]) and injurious falls (IRR, 0.81 [95% CI, 0.73-0.90]) and with a statistically nonsignificant reduction in falls (IRR, 0.87 [95% CI, 0.75-1.00]) but showed no association with mortality. Few exercise trials reported fall-related fractures. Seven heterogeneous trials of vitamin D formulations (with or without calcium) showed mixed results. One trial of annual high-dose cholecalciferol (500 000 IU), which has not been replicated, showed an increase in falls, people experiencing a fall, and injuries, while 1 trial of calcitriol showed a reduction in falls and people experiencing a fall; the remaining 5 trials showed no significant difference in falls, people experiencing a fall, or injuries. Harms of multifactorial and exercise trials were rarely reported but generally included minor musculoskeletal injuries. Conclusions and Relevance Multifactorial and exercise interventions were associated with fall-related benefit, but evidence was most consistent across multiple fall-related outcomes for exercise. Vitamin D supplementation interventions had mixed results, with a high dose being associated with higher rates of fall-related outcomes.

Periodic Screening Pelvic Examination Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance Recent changes in the periodicity of cervical cancer screening have led to questions about the role of screening pelvic examinations among asymptomatic women. Objective To systematically review literature on health benefits, accuracy, and harms of the screening pelvic examination for gynecologic conditions for the US Preventive Services Task Force (USPSTF). Data Sources MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through January 13, 2016, with surveillance through August 3, 2016. Study Selection Two reviewers independently screened abstracts and studies. The search yielded 8678 unique citations; 316 full-text articles were reviewed, and 9 studies including 27 630 patients met inclusion criteria. Data Extraction and Synthesis Two reviewers rated study quality using USPSTF criteria. Main Outcomes and Measures Morbidity; mortality; diagnostic accuracy for any gynecologic cancer or condition except cervical cancer, gonorrhea, and chlamydia, which are covered by other USPSTF screening recommendations; harms (false-positive rates, false-negative rates, surgery rates). Results No trials examined the effectiveness of the pelvic examination in reducing all-cause mortality, reducing cancer- and disease-specific morbidity and mortality, or improving quality of life. Eight studies reported accuracy for the screening pelvic examination: ovarian cancer (4 studies; n = 26 432), bacterial vaginosis (2 studies; n = 930), trichomoniasis (1 study; n = 779), and genital herpes (1 study; n = 779). In the 4 ovarian cancer screening studies, low prevalence of ovarian cancer consistently resulted in low positive predictive values (PPVs) and false-positive rates, with a lack of precision in accuracy estimates (sensitivity range, 0%-100%; specificity range, 91%-99%; PPV range, 0%-3.6%; negative predictive value [NPV] range, ≥99%). Each diagnostic accuracy study for bacterial vaginosis, trichomoniasis, and genital herpes was performed in a high-prevalence population with substantial proportions of symptomatic patients and reported accuracy characteristics for individual physical examination findings (bacterial vaginosis, homogeneous discharge: sensitivity range, 69%-79%; specificity range, 54%-97%; PPV range, 52%-95%; NPV range, 79%-80%; herpes simplex virus, vulvar ulcerations: sensitivity, 20%; specificity, 98%; PPV, 88%; NPV, 57%; trichomoniasis, colpitis macularis: sensitivity, 2%; specificity, 100%; PPV, 100%; NPV, 85%). Surgery rates resulting from an abnormal screening pelvic examination for ovarian cancer ranged from 5% to 36% at 1 year, with the largest study reporting an 11% surgery rate and 1% complication rate within 1 year of a screening pelvic examination with abnormal findings. Conclusions and Relevance No direct evidence was identified for overall benefits and harms of the pelvic examination as a 1-time or periodic screening test. Limited evidence was identified regarding the diagnostic accuracy and harms of routine screening pelvic examinations in asymptomatic primary care populations.

Estimating data from figures with a Web-based program: Considerations for a systematic review

BACKGROUND Systematic reviewers often encounter incomplete or missing data, and the information desired may be difficult to obtain from a study author. Thus, systematic reviewers may have to resort to estimating data from figures with little or no raw data in a studys corresponding text or tables. METHODS We discuss a case study in which participants used a publically available Web-based program, called webplotdigitizer, to estimate data from 2 figures. We evaluated and used the intraclass coefficient and the accuracy of the estimates to the true data to inform considerations when using estimated data from figures in systematic reviews. RESULTS The estimates for both figures were consistent, although the distribution of estimates in the figure of a continuous outcome was slightly higher. For the continuous outcome, the percent difference ranged from 0.23% to 30.35% while the percent difference of the event rate ranged from 0.22% to 8.92%. For both figures, the intraclass coefficient was excellent (>0.95). CONCLUSIONS Systematic reviewers should consider and be transparent when estimating data from figures when the information cannot be obtained from study authors and perform sensitivity analyses of pooled results to reduce bias.