Linda J Lux

A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention.

This systematic review focuses on outcomes of gestational weight gain, specifically birthweight, fetal growth, and postpartum weight retention, for singleton pregnancies with respect to the 1990 Institute of Medicine weight gain recommendations. A total of 35 studies met the inclusion criteria and were reviewed. There was strong evidence to support associations between excessive gestational weight gain and increased birthweight and fetal growth (large for gestational age) as well as inadequate gestational weight gain and decreased birthweight and fetal growth (small for gestational age). There was moderate evidence to support the association between excessive gestational weight gain and postpartum weight retention. Clear clinical recommendations based on this review are challenging because of several limitations in the literature. Improvements in future research include the use of consistent definitions of gestational weight gain and outcomes of interest, assessment of confounders, and better collection of weight and weight gain data.

Systematic Review: Comparative Effectiveness and Harms of Disease-Modifying Medications for Rheumatoid Arthritis

Context Which disease-modifying antirheumatic drugs (DMARDs) best reduce symptoms, improve function, and prevent radiographic progression in patients with rheumatoid arthritis? Contribution This systematic review of trials that compared DMARDs in adults with rheumatoid arthritis found few direct comparisons of different agents but no important differences among synthetic DMARDs or antitumor necrosis factor drugs. Combination therapy improved response rates and functional outcomes in patients whose monotherapy failed. Numbers and types of short-term adverse events were similar among DMARDs. Implication Of several monotherapies for adults with rheumatoid arthritis, no regimen is clearly superior. Combination therapies improve response rates in some patients previously receiving monotherapy. The Editors Rheumatoid arthritis is an autoimmune disease that affects more than 2 million adults in the United States. Disease onset generally occurs between 30 and 55 years of age, and women are affected more often than men. Disease hallmarks are inflammation of the synovium, progressive bone erosion, joint malalignment and destruction, and subsequent weakness of surrounding tissues and muscles. Presentations range from mild to severe, although the typical patient has a progressive course leading to functional limitations. Treatment aims at controlling pain and inflammation and slowing or arresting the progression of joint destruction. Therapies generally used in the United States include corticosteroids; synthetic disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine, leflunomide, methotrexate, and sulfasalazine; and biological DMARDs, such as abatacept, adalimumab, anakinra, etanercept, infliximab, and rituximab. The American College of Rheumatology (ACR) recommends beginning DMARD therapy within 3 months of diagnosis (1). Often, treatment with a single DMARD does not adequately control symptoms, leading clinicians to consider various combination strategies. Experts do not agree about the comparative benefits of different combination therapies. Many questions remain about the risks of these agents across a spectrum of adverse events from relatively minor side effects to severe and possibly life-threatening problems. Given this uncertainty, the Agency for Healthcare Research and Quality (AHRQ) commissioned a systematic review to compare the benefits and safety of rheumatoid arthritis drugs (2). Methods We developed and followed a standardized protocol for all steps of the review. The full technical report (2) describes study methods in detail and gives evidence tables of individual studies. Literature Search We searched MEDLINE, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts for studies from 1980 to September 2007. Search terms included Medical Subject Headings or keywords when appropriate. We combined terms for rheumatoid arthritis with 11 drugs of interest (corticosteroid, methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, etanercept, infliximab, adalimumab, abatacept, anakinra, and rituximab). We limited electronic searches to studies involving adults and humans and studies in English. We manually searched reference lists of review articles and letters to the editor. In addition, we searched the Center for Drug Evaluation and Research database (September 2007) to identify unpublished research submitted to the U.S. Food and Drug Administration. In early to mid-2006, the Oregon Scientific Resource Center invited pharmaceutical manufacturers to submit dossiers on all published and unpublished studies on a specific drug. Five companies (Abbott, Amgen, Bristol-Myers Squibb, Centocor, and Genentech) provided dossiers. Study Selection Two persons, each blinded to the others results, independently reviewed titles, abstracts, and sometimes full text to identify studies meeting preestablished criteria. To assess efficacy regarding symptoms, quality of life, functional capacity, and radiographic progression, we included head-to-head controlled trials and prospective cohort studies comparing any of the therapies. For harms (specific adverse events, rates of adverse events, and discontinuation attributable to adverse events) and subgroups, we also examined data from retrospective observational studies and placebo-controlled trials. For efficacy and harm data, we selected studies with 100 or more participants and at least 12 weeks of follow-up. Finally, if we found no evidence about efficacy from direct head-to-head comparison studies, we included evidence from fair- or good-quality meta-analyses that indirectly compared placebo-controlled trial data across drugs. Data Abstraction and Quality Assessment Trained reviewers abstracted each study by using a Web-based system (SRS 4.0, TrialStat, Ottawa, Ontario, Canada). A senior reviewer read each abstracted article and evaluated completeness of data extraction. We recorded intention-to-treat results if available. We assessed the internal validity (quality) of trials on the basis of predefined criteria from the U.S. Preventive Services Task Force (rating of good, fair, or poor) (3) and the National Health Service Centre for Reviews and Dissemination (4). Elements of internal validity for trials included randomization, allocation concealment, similarity of compared groups at baseline, intention-to-treat analysis, and overall and differential loss to follow-up. To assess the quality of observational studies, we used criteria outlined by Deeks and colleagues (5). Items assessed included sample selection, adjustment for confounders, methods of outcomes assessment, length of follow-up, and statistical analysis. Data Synthesis We primarily synthesized the literature qualitatively; we reported some quantitative syntheses from fair- to good-quality meta-analyses. Drug comparisons that were not quantitatively analyzed in meta-analyses had insufficient data or noncomparable study samples and did not merit additional quantitative analyses. We examined data within 3 main drug classes (corticosteroids, synthetic DMARDs, and biological DMARDs) and between drug classes and combination therapies. Strength of Evidence Ratings We rated the strength of the available evidence in a 3-part hierarchy (high, moderate, and low) (2) based on a modified Grading of Recommendations, Assessment, Development, and Evaluation approach (6, 7). Grades reflect the strength of evidence for a given comparison with respect to specific outcomes, such as 20% improvement in ACR response criteria (ACR 20), radiographic changes, or adverse events. Role of the Funding Source Agency for Healthcare Research and Quality staff participated in formulating initial study questions and reviewed methods, data analysis, and the draft report. The funding source did not participate in the literature search, determination of study eligibility, or evaluation of individual studies. Results Characteristics of Reviewed Studies We identified 2395 citations (Figure). Working from 635 articles retrieved for full review, we included 143 published articles reporting on 101 studies (Table 1). Of the 101 included studies, 49 (48.5%) were supported by pharmaceutical companies, 20 (19.8%) by governmental or independent funds, and 11 (10.9%) by a combination of pharmaceutical and governmental funding. We could not determine the source of support for 21 (20.8%) studies. Table 1. Summary of Head-to-Head Reviewed Studies, by Drug Comparison* Figure. Study flow diagram. Numbers of included articles and included studies differ because some studies have multiple publications. RCT = randomized, controlled trial. Comparative Effectiveness and Harms We found few fair- or good-quality head-to-head trials for each drug comparison (Table 1). Most trials were efficacy trials in highly selected populations with few comorbid conditions. Most trials used ACR 20, disease activity scores to measure clinical improvement, and Sharp or Sharpvan der Heijde scores to measure radiologic progression of the disease. Trials examining quality of life used the Health Assessment Questionnaire (HAQ) or Medical Outcomes Study Short Form 36 (SF-36). Table 2 summarizes results. Table 2. Summary of Comparative Findings on Efficacy and Harms of Rheumatoid Arthritis Drugs Monotherapy versus Monotherapy Synthetic DMARDs One good systematic review that included a meta-analysis of 2 trials suggested that more patients receiving methotrexate achieved ACR 20 at 1 year than did patients receiving leflunomide (odds ratio, 1.43 [95% CI, 1.15 to 1.77]). The ACR 20 benefit was lower and more uncertain at 2 years (odds ratio, 1.28 [CI, 0.98 to 1.67]) (8). However, patients receiving methotrexate showed less improvement in health-related quality of life than did patients receiving leflunomide (odds ratio for SF-36 physical component, 3.00 [CI, 5.41 to 0.59]). Radiographic outcomes over 2 years seemed similar. For leflunomide versus sulfasalazine, data are limited to 1 trial (9) involving 358 participants with 2-year follow-up (10, 11). Leflunomide yielded more patients achieving ACR 20, ACR 50, and greater improvement in functional capacity (ACR 20, 82% vs. 60% [P= 0.008]; ACR 50, 52% vs. 25% [P= 0.040]; HAQ, 0.50 vs. 0.29 [P 0.030]). Radiographic changes were similar for the 2 drugs (Larsen score change at 2 years, 0.010 for either drug) (9). Three trials involving 479 participants and lasting up to 52 weeks compared methotrexate with sulfasalazine and found similar response rates in ACR 20, disease activity scores, or functional capacity (1214). Two trials included patients with disease for longer than 1 year and used a lower dose of weekly methotrexate (7.5 mg) than that generally used in the United States (13, 14). The overall attrition rate for these studies ranged from 19% to 28.5%. We found no statistically significant differences in frequency of serious adverse events for leflunomide, methotrexate, and sulfasalazine in 3 efficacy trial

Systematic Review: Smoking Cessation Intervention Strategies for Adults and Adults in Special Populations

Tobacco use is the leading cause of preventable illness and death in the United States. Once users are dependent on tobacco, quitting is difficult. Nicotine dependence resulting from tobacco use hampers efforts to sustain abstinence from tobacco for a prolonged period or a lifetime (1). Many users make multiple attempts to quit, often without the assistance that could double or even triple their chances of success (1). Proven individual cessation strategies include counseling and behavioral therapy and, except when contraindicated, first-line and second-line medications (1). These strategies may prove especially helpful for individuals motivated to quit smoking in response to pregnancy or hospitalization for a smoking-related condition. Populations with psychiatric conditions and substance abuse problems have higher rates of smoking and show a lack of responsiveness to smoking cessation treatments (2, 3). More sensitive or specialized strategies and services for smoking cessation may be needed to help patients with overlapping conditions, such as multiple addictions or psychiatric, cognitive, or medical conditions (2, 3). As background for a National Institutes of Health conference, our full systematic review (4) synthesized new evidence on individual-based strategies designed to increase the likelihood that adult tobacco users (with and without selected coexisting conditions) will quit. We also compared findings from new studies with those summarized in previous systematic reviews and meta-analyses. Methods We searched MEDLINE, the Cumulative Index to Nursing and Applied Health (CINAHL), the Cochrane Library, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts from 1 January 1980 through 10 June 2005 using Medical Subject Headings (Appendix Table 1) as search terms or key words when appropriate. We also manually searched reference lists. A technical expert panel helped us to ensure that we included important literature in our search. Appendix Table 1. Medical Subject Headings and Text Words We limited our review to human studies conducted in developed countries and published in English (Appendix Table 2 gives specific inclusion and exclusion criteria). We considered studies with samples that consisted of participants who were age 13 years and older, that included both sexes, and that were racially and ethnically diverse. We limited studies to those with 6 months or greater follow-up periods and minimum sample sizes of 30 patients for randomized, controlled trials and 100 patients for other experimental or observational studies. We excluded articles that did not report outcomes related to quit rates; articles that did not provide the minimum information required; and all editorials, letters, and commentaries. Appendix Table 2. Smoking Cessation Strategies: Inclusion and Exclusion Criteria for New Studies All studies were dually reviewed. We assessed the quality of studies according to how well they met the criteria from the U.S. Preventive Services Task Force (5) and the National Health Service Centre for Reviews and Dissemination (6). We rated the strength of the evidence using the criteria from the Task Force on Community Preventive Services (7). To determine whether the strength of evidence for each study was strong, sufficient, or insufficient, we evaluated the study design, study execution, and the size and consistency of reported effects. For 4 of the 5 key questions in the evidence report (Appendix Table 3), we relied on several well-conducted systematic reviews. The Table documents the type, quality, treatment format, and outcome for each review. We included original research studies that 1) were published beyond the date range in the systematic reviews, 2) covered topics not covered by the reviews, and 3) provided sufficient detail about their methods and outcomes. Appendix Table 3. Key Questions for the Full Evidence Report prepared for the Agency for Healthcare Research and Quality Table. Summary of Review Article Outcomes This review was funded by a contract from the Agency for Healthcare Research and Quality. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service. Data Synthesis Literature Reviewed Of 1288 abstracts, we examined 488 for full article review and retained 102 (Appendix Figure). Of 43 studies relevant to this article, 5 were of good quality (1620), 23 were fair (2143), and 15 were poor (not presented here) (4458). Appendix Figure. Tobacco use: prevention, cessation, and control article disposition. KQ = key question. *Two studies counted as one because they used the same sample. One study addressed both KQ2 and KQ5. One study used adolescents and was excluded from the review. We report on 28 new studies not included in previous reviews (Appendix Table 4). Twenty-one studies addressed strategies to improve success rates for cessation (16, 17, 21, 22, 2434, 36, 37, 39, 4143), including self-help, counseling, pharmaceutical agents, and combinations of pharmaceutical and counseling therapies. Seven studies examined interventions in patients with coexisting conditions and nicotine dependence, including psychiatric conditions and substance abuse problems (1820, 23, 35, 38, 40), and 5 studies overlapped both categories (24, 30, 31, 33, 39). We reviewed this new body of evidence both independently and within the context of previous reviews. Appendix Table 4. Smoking Cessation Intervention Strategies To Improve Success Rates for Quit Attempts Alternative Approaches to Smoking Cessation Self-Help Approaches Two studies examined a self-help approach to improving cessation rates (26, 33). One study involved patients recently discharged from intensive care units (ICUs) (33); the other included patients undergoing lung cancer screening (26). Patients discharged from intensive care received verbal encouragement to remain nonsmoking at ICU discharge, a self-help ICU rehabilitation manual, and instructions to the immediate family not to smoke near the patient. Patients undergoing lung cancer screening received either a handout listing 10 smoking cessationrelated Internet sites or 2 self-help booklets, 1 of which provided information on available pharmacotherapies for nicotine dependence (26). Patients receiving the ICU rehabilitation package were much less likely to return to smoking after discharge than were the control patients (relative risk, 0.11 [95% CI, 0.02 to 0.64]); the investigators could not determine whether just the smoking cessation advice or the whole package (including an exercise program) was responsible for the high quit rate (33). Seven-day point-prevalence quit rates did not differ significantly between patients in the intervention and control groups undergoing lung cancer screening, although at 1-year follow-up more patients in the intervention group reported an attempt to stop smoking (26). We found insufficient evidence of efficacy for self-help strategies, given the small number of new studies and discrepancies between studies for the same outcome. Counseling Five studies evaluated the effects of counseling2 studies in hospital settings (30, 39), 1 in both primary care clinics and hospitals (24), and 2 in private practices (21, 36). All interventions included nurse counseling, self-help materials, and follow-up contact either in person or by telephone; all were compared with usual care (brief advice to quit smoking, related self-help materials, or both). Although self-reported abstinence rates were higher in the more comprehensive treatment in 1 study (30), neither hospital-based intervention increased biochemically verified abstinence rates at 12 months after discharge (30, 39). At 6-month follow-up, diabetic patients seen in primary clinics and hospitals who received nurse-managed assistance in quitting were significantly more likely to quit smoking than controls (24). Biochemically validated quit rates were 17.0% for the intervention group compared with 2.3% for the control group (P= 0.001). Three different counseling interventions showed no significant differences in quit rates at 12-month follow-up (21, 36, 39). Two studies reported increased abstinence with counseling treatment (24, 30); only 1 study verified cessation biochemically (24). Although previous reviews showed that counseling was effective, these new studies show mixed results. Pharmaceutical Monotherapy Five studies examined the effect of a single pharmaceutical agent on smoking cessation (27, 28, 32, 37, 41): 3 of bupropion (27, 32, 41) and 1 each of nicotine gum (28) and transdermal nicotine and nicotine nasal spray (37). Two studies were based in hospitals (27, 41), and 3 were population-based (28, 32, 37). Two studies compared 7 weeks of sustained-release bupropion with placebo. In a 6-month study, health care workers motivated to quit smoking received behavioral counseling and sustained-release bupropion or placebo (27). Continuous smoking abstinence at week 7 was achieved by 43% of patients in the bupropion group and 18% of patients in the placebo group (P< 0.001). Side effects, although frequent, were reversible in both groups and generally consistent with those noted in previous studies. In the other study, all participants received 2 months of transdermal nicotine replacement therapy and 3 months of cognitive behavioral counseling and either sustained-release bupropion or placebo (41). The investigators observed a nonsignificant trend for abstinence at 3 months but not at 6 or 12 months among participants randomly assigned to bupropion; biochemical measures of smoking did not significantly differ between groups. Holt and colleagues (32) attempted to determine whether bupropion combined with smoking cessation counseling was effective for the indigenous Maori population of New Zealand. A

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis

OBJECTIVE To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older. STUDY SELECTION We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013. DATA EXTRACTION We abstracted relevant data, assessed each studys internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates. RESULTS rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear. CONCLUSIONS For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.

Cesarean delivery on maternal : Request maternal and neonatal outcomes

OBJECTIVE: To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION: We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS: We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION: The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.

COMPARATIVE EFFECTIVENESS OF SECOND-GENERATION ANTIDEPRESSANTS FOR ACCOMPANYING ANXIETY, INSOMNIA, AND PAIN IN DEPRESSED PATIENTS: A SYSTEMATIC REVIEW

Patients with major depressive disorder (MDD) often suffer from accompanying symptoms that influence the choice of pharmacotherapy with second‐generation antidepressants (SGAs). We conducted a systematic review to determine the comparative effectiveness of citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, desvenlafaxine, duloxetine, venlafaxine, bupropion, mirtazapine, nefazodone, and trazodone, for accompanying anxiety, insomnia, and pain in patients with MDD.

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 (N = 46 188). No RCTs compared screening with no screening. In 2 studies (n = 702), 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.

Systematic Review: Effective Characteristics of Nursing Homes and Other Residential Long-Term Care Settings for People with Dementia

In response to the need for an evidence‐based review of factors within long‐term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long‐term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes.

Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis

Study question What are the benefits and harms of second generation antidepressants and cognitive behavioral therapies (CBTs) in the initial treatment of a current episode of major depressive disorder in adults? Methods This was a systematic review including qualitative assessment and meta-analyses using random and fixed effects models. Medline, Embase, the Cochrane Library, the Allied and Complementary Medicine Database, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from January1990 through January 2015. The 11 randomized controlled trials included compared a second generation antidepressant CBT. Ten trials compared antidepressant monotherapy with CBT alone; three compared antidepressant monotherapy with antidepressant plus CBT. Summary answer and limitations Meta-analyses found no statistically significant difference in effectiveness between second generation antidepressants and CBT for response (risk ratio 0.91, 0.77 to 1.07), remission (0.98, 0.73 to 1.32), or change in 17 item Hamilton Rating Scale for Depression score (weighted mean difference, −0.38, −2.87 to 2.10). Similarly, no significant differences were found in rates of overall study discontinuation (risk ratio 0.90, 0.49 to 1.65) or discontinuation attributable to lack of efficacy (0.40, 0.05 to 2.91). Although more patients treated with a second generation antidepressant than receiving CBT withdrew from studies because of adverse events, the difference was not statistically significant (risk ratio 3.29, 0.42 to 25.72). No conclusions could be drawn about other outcomes because of lack of evidence. Results should be interpreted cautiously given the low strength of evidence for most outcomes. The scope of this review was limited to trials that enrolled adult patients with major depressive disorder and compared a second generation antidepressant with CBT, and many of the included trials had methodological shortcomings that may limit confidence in some of the findings. What this study adds Second generation antidepressants and CBT have evidence bases of benefits and harms in major depressive disorder. Available evidence suggests no difference in treatment effects of second generation antidepressants and CBT, either alone or in combination, although small numbers may preclude detection of small but clinically meaningful differences. Funding, competing interests, data sharing This project was funded under contract from the Agency for Healthcare Research and Quality by the RTI-UNC Evidence-based Practice Center. Detailed methods and additional information are available in the full report, available at http://effectivehealthcare.ahrq.gov/.

Updating comparative effectiveness reviews: Current efforts in AHRQ's Effective Health Care Program

OBJECTIVES To review the current knowledge and efforts on updating systematic reviews (SRs) as applied to comparative effectiveness reviews (CERs). STUDY DESIGN AND SETTING This article outlines considerations for updating CERs by including a definition of the updating process, describing issues around assessing whether to update, and providing general guidelines for the update process. Key points to consider include (1) identifying when to update CERs, (2) how to update CERs, and (3) how to present, report, and interpret updated results in CERs. RESULTS Currently, there is little information about what proportion of SRs needs updating. Similarly, there is no consensus on when to initiate updating and how best to carry it out. CONCLUSION CERs need to be regularly updated as new evidence is produced. Lack of attention to updating may lead to outdated and sometimes misleading conclusions that compromise health care and policy decisions. The article outlines several specific goals for future research, one of them being the development of efficient guideline for updating CERs applicable across evidence-based practice centers.