Mark H. Ebell

Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults. METHODS The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. POPULATION This recommendation applies to adults 18 years and older. RECOMMENDATION The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation).

Answering physicians' clinical questions: obstacles and potential solutions.

OBJECTIVE To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources. DESIGN Qualitative analysis of questions asked by 48 randomly selected generalist physicians during ambulatory care. MEASUREMENTS Frequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources. RESULTS The physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physicians doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose. CONCLUSION Physicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.

Survival After In-Hospital Cardiopulmonary Resuscitation: A Meta-Analysis

OBJECTIVE: To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes.MEASUREMENTS AND MAIN RESULTS: The MEDLARS database of the National Library of Medicine was searched. In addition, the authors’ extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12.6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2.8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8).CONCLUSIONS: When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults. METHODS The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension. POPULATION This recommendation applies to adults aged 18 years or older without known hypertension. RECOMMENDATION The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Screening for Vitamin D Deficiency in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION New USPSTF recommendation on screening for vitamin D deficiency in adults. METHODS The USPSTF reviewed the evidence on screening for and treatment of vitamin D deficiency, including the benefits and harms of screening and early treatment. POPULATION This recommendation applies to community-dwelling, nonpregnant adults aged 18 years or older who are seen in primary care settings and are not known to have signs or symptoms of vitamin D deficiency or conditions for which vitamin D treatment is recommended. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement).

Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis

PURPOSE Our objective was to perform a systematic review of pre-arrest predictors of the outcome of in-hospital cardiopulmonary resuscitation (CPR) in adults. METHODS We searched PubMed for studies published since 1985 and bibliographies of previous meta-analyses. We included studies with predominantly adult patients, limited to in-hospital arrest, using an explicit definition of cardiopulmonary arrest and CPR and reporting survival to discharge by at least one pre-arrest variable. A total of 35 studies were included in the final analysis. Inclusion criteria, design elements and results were abstracted in parallel by both investigators. Discrepancies were resolved by consensus. RESULTS The rate of survival to discharge was 17.5%; we found a trend towards increasing survival in more recent studies. Metastatic malignancy [odds ratio (OR) 3.9] or haematologic malignancy (OR 3.9), age over 70, 75 or 80 years (OR 1.5, 2.8 and 2.7, respectively), black race (OR 2.1), altered mental status (OR 2.2), dependency for activities of daily living (range OR 3.2-7.0 depending on specific activity), impaired renal function (OR 1.9), hypotension on admission (OR 1.8) and admission for pneumonia (OR 1.7), trauma (OR 1.7) or medical non-cardiac diagnosis (OR 2.2) were significantly associated with failure to survive to discharge; cardiovascular diagnoses and co-morbidities were associated with improved survival (range OR 0.23-0.53). Elevated CPR risk scores predicted failure to survive but have not been validated consistently in different populations. CONCLUSIONS We identified several pre-arrest variables associated with failure to survive to discharge. This information should be shared with patients as part of a shared decision-making process regarding the use of do not resuscitate orders.

Information at the point of care: answering clinical questions.

As physicians, we gather infonnation from patients in the fonn of answers to questions, patient stories, physical examination maneuvers, and test results. We integrate that infonnation with what we already know about our patient, his or her family and community, and infonnation from original research, colleagues, textbooks, and other sources. We then develop a plan for evaluation and management, and implement it by communicating it to the patient and other parts of the health system. This flow of infonnation is expensive: physicians spend more than one third of their time recording and synthesizing infonnation. Further, communications eat up one third of a typical hospitals budget.1 Unfortunately, as we approach the 21st century, most physicians are still using outdated tools to manage medical infonnation. We scribble illegible notes in a chart, try to keep problem and medication lists up-to-date by hand, send letters to consultants, and telephone the laboratory for results. Questions arise at the point of care but go unanswered. Practice patterns ossify, and our textbooks grow out-of-date. Several questions arise as we consider this dilemma: 1. Just what questions do clinicians ask at the point of care? 2. What is the relationship between clinical

Screening for Oral Cancer: U.S. Preventive Services Task Force Recommendation Statement

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. Summary of Recommendation and Evidence The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. (I statement) See the Clinical Considerations section for additional information and suggestions for practice regarding the I statement. See the Figure for a summary of the recommendation and suggestions for clinical practice. Figure. Screening for oral cancer: clinical summary of U.S. Preventive Services Task Force recommendation. Appendix Table 1 describes the USPSTF grades, and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit (both tables are available at www.annals.org). Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit Supplement. Consumer Fact Sheet Rationale Importance Oral cavity cancer (or oral cancer) and pharyngeal cancer include cancer of the lip, oral cavity, and pharynx (nasopharynx, oropharynx, and laryngopharynx). Ninety percent of all cases of oral cavity and pharyngeal cancer are classified as squamous cell carcinoma (1). An estimated 41 380 new cases of and 7890 deaths from cancer of the oral cavity and pharynx will occur in 2013 (2). At the time of diagnosis, more than 50% of persons with oral and pharyngeal cancer have regional or distant metastases (3). Screening for oral cancer may be helpful if potentially malignant disorders can be identified earlier and treated successfully. Oral and oropharyngeal cancer have different causes. Oral cavity cancer is predominantly caused by tobacco and alcohol use. Oropharyngeal cancer, another subset of neck and head cancer, includes human papillomavirus (HPV) as an important risk factor. The incidence and mortality rate of oral cancer has been decreasing in the United States, presumably because of reduced tobacco and alcohol use. However, HPV-related oropharyngeal cancer is increasing in incidence. Oropharyngeal cancer includes lesions of the tonsil, oropharynx, and base of the tongue. The epidemiology of HPV-related oropharyngeal cancer is evolving and could have important implications for identifying high-risk populations that might benefit from screening. Detection The USPSTF found inadequate evidence that the oral screening examination accurately detects oral cancer. Benefits of Detection and Early Treatment The USPSTF found inadequate evidence that screening for oral cancer and treatment of screen-detected oral cancer improves morbidity or mortality. Harms of Detection and Early Treatment The USPSTF found inadequate evidence on the harms of screening. No study reported on harms from the screening test or from false-positive or false-negative results. Potential diagnostic harms are primarily related to the harms of biopsy for suspected oral cancer or its potential precursors. Harms of treatment for screen-detected oral cancer and its potentially malignant precursors (leukoplakia and erythroplakia) may result from complications of surgery (first-line treatment), radiation, and chemotherapy. The natural history of screen-detected oral cancer or potentially malignant disorders is unclear; thus, the magnitude of overdiagnosis due to screening is unknown. USPSTF Assessment The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening for oral cancer in asymptomatic adults by primary care providers. Clinical Considerations Patient Population Under Consideration This recommendation applies to asymptomatic adults aged 18 years or older who are seen by primary care providers. This recommendation focuses on screening (visual inspection and palpation) of the oral cavity performed by primary care providers and not dental providers or otolaryngologists. Assessment of Risk Tobacco and alcohol use are major risk factors for oral cancer. A total of 20% to 30% of cases of oral cancer worldwide are attributable to cigarette smoking (1). In the United States, up to 75% of cases of oral cancer may be attributable to tobacco and alcohol use (4). Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system (1). Sexually transmitted oral HPV infection (HPV-16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer. In the United States, the prevalence of oropharyngeal cancer due to oral HPV infection is probably as high as 80% to 95% (5). The prevalence of oral HPV infection is associated with age, sex, number of sexual partners, and number of cigarettes smoked per day. The effect of multifactorial risk assessment and screening for risk factors on oral cancer morbidity and mortality is unknown (1). Screening Tests The primary screening test for oral cancer is a systematic clinical examination of the oral cavity. According to the World Health Organization and the National Institute of Dental and Craniofacial Research, an oral cancer screening examination should include a visual inspection of the face, neck, lips, labial mucosa, buccal mucosa, gingiva, floor of the mouth, tongue, and palate. Mouth mirrors can help visualize all surfaces. The examination also includes palpating the regional lymph nodes, tongue, and floor of the mouth. Any abnormality that lasts for more than 2 weeks should be reevaluated and considered for biopsy (1, 6). Oropharyngeal cancer is difficult to visualize and is usually located at the base of the tongue (the back third of the tongue), the soft palate (the back part of the roof of the mouth), the tonsils, and the side and back walls of the throat. A comprehensive examination of the oropharynx may require referral to a dental provider or specialist, which is outside the scope of this recommendation. Additional tests proposed as adjuncts to the oral cancer screening examination include toluidine blue dye staining, chemiluminescent and autofluorescent lighting devices, and brush cytopathology. These screening and adjunct tests have not been adequately tested in primary care nondental settings. Although there is interest in screening for oral HPV infection, medical and dental organizations do not recommend it. Currently, no screening test for oral HPV infection has been approved by the U.S. Food and Drug Administration (FDA). Evaluating the accuracy of tests that detect oral HPV infection is a potentially promising area of research. Suggestions for Practice Regarding the I Statement This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter. In deciding whether to screen for oral cancer, primary care providers should consider the following factors. Potential Preventable Burden Up to 75% of cases of oral cancer may be attributed to tobacco and alcohol use (4). Since 1979, the incidence rate of oral cavity cancer in the United States has been decreasing because of the reduced consumption of alcohol and smoking prevalence (1). During this period, the incidence of HPV-positive oropharyngeal squamous cell carcinoma has increased. Cancer registry data have shown that from 1988 to 2004, HPV-negative oropharyngeal cancer has decreased from 2.0 cases to 1.0 case per 100 000 persons and HPV-positive oropharyngeal cancer has increased more than 3-fold from 0.8 case to 2.6 cases per 100 000 persons (7). The overall prevalence of oral HPV infection is estimated to be 6.9% in adults aged 14 to 69 years in the United States. However, HPV prevalence can be as high as 20% for persons who have more than 20 lifetime sexual partners or currently use tobacco (more than 1 pack of cigarettes per day) (8). The prevalence of type-specific HPV-16 oral infection is estimated at 1% in adults aged 14 to 69 years (an estimated 2.13 million infected persons) (8). Human papillomavirus-16 is associated with approximately 85% to 95% of cases of HPV-positive oropharyngeal cancer (5). Therefore, the increasing role of oral HPV infection as a risk factor for oropharyngeal cancer may warrant future assessment of the independent effect of HPV-16 on incidence and outcomes of oropharyngeal cancer and the health effect of screening persons who are HPV-16positive. Potential Harms Suspected oral cancer or its precursors (such as erythroplakia, due to its high risk for transformation to cancer) detected through examination require confirmation by tissue biopsy, which may lead to harms. Harms of treatment of screen-detected oral cancer and its potential precursors (leukoplakia and erythroplakia) may result from complications of surgery, radiotherapy, and chemotherapy. The natural history of screen-detected oral cancer is not well-understood, and as a result, the harms from overdiagnosis and overtreatment are unknown. Current Practice In a 2008 survey of U.S. adults, 29.4% of those aged 18 years or older reported ever having an oral cancer examination in which a physician, dentist, or other health professional pulled on their tong

Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation

IMPORTANCE Informing patients and providers of the likelihood of survival after in-hospital cardiac arrest (IHCA), neurologically intact or with minimal deficits, may be useful when discussing do-not-attempt-resuscitation orders. OBJECTIVE To develop a simple prearrest point score that can identify patients unlikely to survive IHCA, neurologically intact or with minimal deficits. DESIGN, SETTING, AND PARTICIPANTS The study included 51,240 inpatients experiencing an index episode of IHCA between January 1, 2007, and December 31, 2009, in 366 hospitals participating in the Get With the Guidelines-Resuscitation registry. Dividing data into training (44.4%), test (22.2%), and validation (33.4%) data sets, we used multivariate methods to select the best independent predictors of good neurologic outcome, created a series of candidate decision models, and used the test data set to select the model that best classified patients as having a very low (<1%), low (1%-3%), average (>3%-15%), or higher than average (>15%) likelihood of survival after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status. The final model was evaluated using the validation data set. MAIN OUTCOMES AND MEASURES Survival to discharge after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status (neurologically intact or with minimal deficits) based on a Cerebral Performance Category score of 1. RESULTS The best performing model was a simple point score based on 13 prearrest variables. The C statistic was 0.78 when applied to the validation set. It identified the likelihood of a good outcome as very low in 9.4% of patients (good outcome in 0.9%), low in 18.9% (good outcome in 1.7%), average in 54.0% (good outcome in 9.4%), and above average in 17.7% (good outcome in 27.5%). Overall, the score can identify more than one-quarter of patients as having a low or very low likelihood of survival to discharge, neurologically intact or with minimal deficits after IHCA (good outcome in 1.4%). CONCLUSIONS AND RELEVANCE The Good Outcome Following Attempted Resuscitation (GO-FAR) scoring system identifies patients who are unlikely to benefit from a resuscitation attempt should they experience IHCA. This information can be used as part of a shared decision regarding do-not-attempt-resuscitation orders.

Screening for Autism Spectrum Disorder in Young Children: US Preventive Services Task Force Recommendation Statement

DESCRIPTION New US Preventive Services Task Force (USPSTF) recommendation on screening for autism spectrum disorder (ASD) in young children. METHODS The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits and the benefits and potential harms of early behavioral treatment for young children identified with ASD through screening. POPULATION This recommendation applies to children aged 18 to 30 months who have not been diagnosed with ASD or developmental delay and for whom no concerns of ASD have been raised by parents, other caregivers, or health care professionals. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young children for whom no concerns of ASD have been raised by their parents or a clinician. (I statement).