Remy R Coeytaux

Effect of Clinical Decision-Support Systems: A Systematic Review

BACKGROUND Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking. PURPOSE To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. DATA SOURCES MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011. STUDY SELECTION Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes. DATA EXTRACTION Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality. DATA SYNTHESIS 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects. LIMITATIONS Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded. CONCLUSION Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Standard scales for measurement of functional outcome for cervical pain or dysfunction: A systematic review

Study Design. A systematic review was conducted. Objective. To identify, evaluate, and compare standard scales for assessing neck pain or dysfunction. Summary of Background Data. The degree of a patient’s neck pain or dysfunction can be evaluated using standardized scales at the time of a clinical encounter or during the performance of clinical research protocols. The choice of a scale with the most appropriate characteristics, however, is always a challenge to clinicians and researchers. Methods. Articles concerning scales for functional evaluation of neck pain or dysfunction were identified by computer searching of MEDLINE (January 1966 to June 1999) and CINAHL (1985 to 2000), citation tracking using the Citation Index, hand searching of relevant journals, and correspondence with experts. Results. Five standard scales were found. Three scales were remarkably similar in terms of structure and psychometric properties: the Neck Disability Index, the Copenhagen Neck Functional Disability Scale, and the Northwick Park Scale. However, only the first instrument has been revalidated in different study populations. The Neck Pain and Disability Scale provides a visual template for collection of information, but its usefulness is limited if the questionnaire must be read to the patient. The Patient-Specific Functional Scale is very sensitive to functional changes in individual patients, but comparisons between patients are virtually impossible. Conclusions. The five scales identified in this study have similar characteristics. The Neck Disability Index, however, has been revalidated more times for evaluation of patient groups. For individual patient follow-up evaluation, the Patient-Specific Functional Scale has high sensitivity to change, and thus represents a good choice for clinical use. The final choice should be tailored according to the target population and the purpose of the evaluation.

Dizziness: state of the science.

Dizziness is one of the most challenging symptoms in medicine. It is difficult to define, impossible to measure, a challenge to diagnose, and troublesome to treat. The word dizziness is used to mean various sensations of body orientation and position that are frequently difficult for patients to describe (1, 2). Dizziness can be caused by a wide range of benign and serious conditions, many of which are not well understood. For most patients, the symptom resolves spontaneously, but an important minority of patients develop chronic, disabling symptoms, and a few have a life-threatening condition (3-5). Most of those with chronic symptoms are not relieved by medical treatment (6). The past decade has seen an increasing focus on evidence-based practice in medicine (7). In this context, a series of steps develop an empirical approach to a symptom such as dizziness (Figure). First, the symptom must be defined and its subtypes delineated in a consistent, widely accepted format. Second, these definitions must be used in epidemiologic studies across many clinical settings, so that the clinical epidemiology of the symptom can be appreciated. Third, the conditions that the symptom may represent must be clearly delineated, with diagnostic criteria. Fourth, the diagnostic criteria must be used in epidemiologic studies to elucidate the clinical picture of the symptom and its diagnoses. Certain life-threatening or potentially remediable diagnoses that practicing physicians need to rule in or out should be targeted. For each of these diagnoses, data should be gathered on clinical diagnostic maneuvers and tests (sensitivity, specificity, and likelihood ratios) and the effectiveness of treatment. Once these steps have been completed, we will have adequate data for development of empirically based practice guidelines, clinical pathways, and other methods of ensuring quality, consistency, and cost-effectiveness in medical practice. Figure 1. Steps in the development of a scientific database for medical management of a symptom. We review current knowledge about dizziness by following the steps outlined in the Figure and make recommendations for clinical practice and further research. Defining and Describing Dizziness Dizziness refers to various abnormal sensations relating to perception of the bodys relationship to space (8). In a classic paper, Drachman and Hart (1) described four subtypes: vertigo, presyncopal lightheadedness, disequilibrium, and other dizziness. Nearly 30 years later, this typology remains the basis of dizziness definition and classification, having long since displaced the narrower definition (vertigo) used in earlier studies (9, 10). The dizziness subtypes are described in Table 1. Vertigo is a false sensation that the body or the environment is moving (usually spinning). It suggests a disturbance of the vestibular system, although psychological states, such as panic disorder, can also produce it (11). Presyncope is a feeling of lightheadedness that is often described as a sensation of an impending faint. It is episodic and usually results from diffuse temporary cerebral ischemia. Disequilibrium is a sense of imbalance (postural instability) that is generally described as involving the legs and trunk without a sensation in the head. Isolated symptoms of disequilibrium are generally attributed to neuromuscular problems; imbalance that accompanies other types of dizziness is generally a secondary symptom. Other dizziness is typically described as vague or floating, or the patient may have difficulty describing the sensation. Such dizziness is generally present much of the time and is most often caused by psychological disturbances (1). It is often accompanied by other somatic symptoms, such as headache and abdominal pain (1, 9). In the category of other dizziness are also two distinct though rare forms of dizziness: ocular dizziness due to rapid vision change, as after cataract surgery or a change in a corrective prescription (12), and dizziness described as a tilting of the environment, which is generally attributed to an otolith problem (13, 14). Table 1. Approach to the Differentiation of Dizziness Subtypes This typology is not without problems. Many patients, particularly elderly ones, cannot place their dizziness in one category; approximately half of older persons describe two or more subtypes (2, 15). This is largely because disequilibrium often accompanies other kinds of dizziness in older persons who do not have intact compensatory systems, making it necessary to distinguish between the primary symptom and the secondary disequilibrium. In addition, the causes of presyncope almost completely overlap those of syncope (9, 16), so from the standpoint of differential diagnosis, the differentiation of one from the other is probably artificial. Finally, distinguishing between acute and chronic dizziness may be important because increased symptom duration is a risk factor for functional impairment (4). No consensus exists, however, on the dividing line between acute and chronic dizziness. Epidemiology of Dizziness Many studies have described the epidemiology of dizziness in the community and in primary care settings [3, 6, 15, 17-21]. Although the studies have been inconsistent in their definition of dizziness, the accumulated evidence indicates that 1) dizziness is common in all adult age groups and is more common in women than in men and 2) the prevalence of dizziness increases modestly with age in the community and markedly with age in medical practice (Table 2). In both the primary care and the referral setting, dizziness symptoms often involve more than one dizziness subtype, especially in the elderly, and dizziness is more often reported to be episodic rather than continuous (2, 5). Table 2. Prevalence of Dizziness in Selected Studies In recent decades, several studies have reported that dizziness in older persons is associated with an accumulation of cardiovascular, neurosensory, and psychiatric conditions and with use of multiple medications (1, 3, 15, 18, 22, 23). These findings led Tinetti and colleagues (15) to suggest that dizziness in older persons may constitute a geriatric syndromea final common pathway resulting from the interplay of multiple impairments. Such a viewpoint would support the idea of approaching dizziness from a functional point of view rather than trying to define a symptom subtype, a single mechanism, and a unifying diagnosis. Such an approach is untried, but several recently developed instruments could provide a framework (Table 3) (24-27), and research in this area should be encouraged. Caution is warranted, however. As Drachman noted (28), calling dizziness in the elderly a geriatric syndrome runs the risk of implying that it is due to old age and therefore not treatable, whereas it is usually possible to identify one or more underlying disorders or diseases. Table 3. Standardized Instruments for Evaluating the Severity and Effect of Dizziness on Quality of Life The prognosis of dizziness is generally benign. In one study (4), nearly three quarters of patients who presented with dizziness to primary care offices reported no effect on their lives 3 months later, and two population-based outcome studies (3, 23) suggested that dizziness is not an independent predictor of institutionalization, death, or functional decline. However, it should be noted that most epidemiologic studies of dizziness have oversampled persons with chronic dizziness and underrepresented persons with acute forms of dizziness, who would be most likely to have life-threatening illnesses. Further, many persons with dizziness and a benign prognosis report great impairment of daily activities, depressed mood, and symptom-related fears [4, 23, 24, 27]. Nevertheless, the fact that most dizziness-related conditions are self-limited suggests that 1) seeking out unreported dizziness in community populations and asking about dizziness on a routine symptom review may not be warranted and 2) other symptoms may have greater specificity in screening for serious disease. Diagnosing Dizziness Effective clinical decision making uses data on which diagnoses are common and, therefore, most likely in a given patient (29). Data on the frequency of diagnoses in similar settings are particularly useful in the evaluation of symptoms, like dizziness, that have a broad range of diagnostic possibilities. Table 4 summarizes 11 studies reporting diagnoses for patients with dizziness (1, 2, 5, 30-37). Peripheral vestibular problems constitute a sizeable minority of diagnoses. Acute labyrinthitis (or vestibular neuronitis) is the most common peripheral vestibular disorder seen in primary care offices (30). In referral settings, recurrent peripheral vestibular disorders, such as benign paroxysmal positional vertigo, recurrent vestibulopathy (38), and Mnire disease (39), predominate (1, 2, 35, 36). Central vestibular causes, such as brain tumors, cerebellar atrophy, migraine, multiple sclerosis, and seizure disorders, are rare or unreported in most studies; of 4536 patients from various settings, 0.7% had brain tumor and 1.2% had other central vestibular causes (39). Table 4. Reported Frequency of Causes of Dizziness in Selected Clinical Studies Most patients with dizziness have nonvestibular diagnoses, and the relative frequencies of specific diagnoses vary widely across settings. In primary care, infections, metabolic problems, and adverse effects of drugs are relatively common. Almost any patient with a systemic viral or bacterial infection can present with dizziness, which is presumably due to postural hypotension (30). Metabolic disturbances reported to cause dizziness include hypoglycemia, hyperglycemia, electrolyte disturbances, thyrotoxicosis, and anemia (39, 40). A wide variety of medications may lead to dizziness (see the Appendix Table) (41-44). Benign positional vertigo, other vestibular problems, and psychiatric disorders p

Tobacco promotion and susceptibility to tobacco use among adolescents aged 12 through 17 years in a nationally representative sample.

OBJECTIVES The purpose of this study was to examine whether youth participation in tobacco promotion campaigns is associated with susceptibility to tobacco use. METHODS Data were collected from telephone interviews of a national random sample of 1047 adolescents 12 to 17 years of age. RESULTS A proportional odds model was used to estimate the effects of age, gender, presence of a tobacco user in the household, awareness of tobacco promotions, knowledge of a young adult or adolescent friend owning a promotional item, participation in tobacco promotions, and receipt of free tobacco samples or direct mail from tobacco companies on susceptibility to tobacco use. All of the covariates, except for receiving direct mailings and knowing a young adult friend who owned a promotional item, were significantly associated with susceptibility. CONCLUSIONS There is a strong association between an awareness of and involvement with tobacco promotions and being susceptible to tobacco use or a user of tobacco products.

Oral Contraceptive Use and Risk of Breast, Cervical, Colorectal, and Endometrial Cancers: A Systematic Review

Oral contraceptives may influence the risk of certain cancers. As part of the AHRQ Evidence Report, Oral Contraceptive Use for the Primary Prevention of Ovarian Cancer, we conducted a systematic review to estimate associations between oral contraceptive use and breast, cervical, colorectal, and endometrial cancer incidence. We searched PubMed, Embase, and Cochrane Database of Systematic Reviews. Study inclusion criteria were women taking oral contraceptives for contraception or ovarian cancer prevention; includes comparison group with no oral contraceptive use; study reports quantitative associations between oral contraceptive exposure and relevant cancers; controlled study or pooled patient-level meta-analyses; sample size for nonrandomized studies ≥100; peer-reviewed, English-language; published from January 1, 2000 forward. Random-effects meta-analyses were conducted by estimating pooled ORs with 95% confidence intervals (CIs). We included 44 breast, 12 cervical, 11 colorectal, and 9 endometrial cancers studies. Breast cancer incidence was slightly but significantly increased in users (OR, 1.08; CI, 1.00–1.17); results show a higher risk associated with more recent use of oral contraceptives. Risk of cervical cancer was increased with duration of oral contraceptive use in women with human papillomavirus infection; heterogeneity prevented meta-analysis. Colorectal cancer (OR, 0.86; CI, 0.79–0.95) and endometrial cancer incidences (OR, 0.57; CI, 0.43–0.77) were significantly reduced by oral contraceptive use. Compared with never use, ever use of oral contraceptives is significantly associated with decreases in colorectal and endometrial cancers and increases in breast cancers. Although elevated breast cancer risk was small, relatively high incidence of breast cancers means that oral contraceptives may contribute to a substantial number of cases. Cancer Epidemiol Biomarkers Prev; 22(11); 1931–43. ©2013 AACR.

Oral Contraceptives and Risk of Ovarian Cancer and Breast Cancer Among High-Risk Women: A Systematic Review and Meta-Analysis

PURPOSE To estimate the risks of ovarian cancer and breast cancer associated with oral contraceptive (OC) use among women at elevated risk owing to mutations in BRCA1/2 or a strong family history. METHODS We searched PubMed, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov for studies published 2000 to 2012 that evaluated associations between OC use and breast or ovarian cancer among women who are carriers of a BRCA1/2 mutation or have a family history of breast or ovarian cancer. RESULTS From 6,476 unique citations, we identified six studies examining ovarian cancer risk in BRCA1/2 mutation carriers and eight studies examining breast cancer risk in BRCA1/2 mutation carriers. For BRCA1/2 mutation carriers combined, meta-analysis showed an inverse association between OC use and ovarian cancer (odds ratio [OR], 0.58; 95% CI, 0.46 to 0.73) and a nonstatistically significant association with breast cancer (OR, 1.21; 95% CI, 0.93 to 1.58). Findings were similar when examining BRCA1 and BRCA2 mutation carriers separately. Data were inadequate to perform meta-analyses examining duration or timing of use. For women with a family history of ovarian or breast cancer, we identified four studies examining risk for ovarian cancer and three for breast cancer, but differences between studies precluded combining the data for meta-analyses, and no overall pattern could be discerned. CONCLUSION Our analyses suggest that associations between ever use of OCs and ovarian and breast cancer among women who are BRCA1 or BRCA2 mutation carriers are similar to those reported for the general population.

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

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

A randomized, controlled pilot study of acupuncture treatment for menopausal hot flashes

Objective:To investigate the feasibility of conducting a randomized trial of the effect of acupuncture in decreasing hot flashes in peri- and postmenopausal women. Design:Fifty-six women ages 44 to 55 with no menses in the past 3 months and at least four hot flashes per day were recruited from two clinical centers and randomized to one of three treatment groups: usual care (n = 19), sham acupuncture (n = 18), or Traditional Chinese Medicine acupuncture (n = 19). Acupuncture treatments were scheduled twice weekly for 8 consecutive weeks. The sham acupuncture group received shallow needling in nontherapeutic sites. The Traditional Chinese Medicine acupuncture group received one of four treatments based on a Traditional Chinese Medicine diagnosis. Usual care participants were instructed to not initiate any new treatments for hot flashes during the study. Daily diaries were used to track frequency and severity of hot flashes. The mean daily index score was based on the number of mild, moderate, and severe hot flashes. Follow-up analyses were adjusted for baseline values, clinical center, age, and body mass index. Results:There was a significant decrease in mean frequency of hot flashes between weeks 1 and 8 across all groups (P = 0.01), although the differences between the three study groups were not significant. However, the two acupuncture groups showed a significantly greater decrease than the usual care group (P < 0.05), but did not differ from each other. Results followed a similar pattern for the hot flash index score. There were no significant effects for changes in hot flash interference, sleep, mood, health-related quality of life, or psychological well-being. Conclusions:These results suggest either that there is a strong placebo effect or that both traditional and sham acupuncture significantly reduce hot flash frequency.

Oral contraceptive pills as primary prevention for ovarian cancer: a systematic review and meta-analysis.

OBJECTIVE: To estimate the overall reduction in ovarian cancer risk associated with the use of oral contraceptive pills (OCPs) and whether reduction in risk is affected by specifics of OCP use, such as formulation or duration of use. DATA SOURCES: We searched PubMed, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov for studies published from January 1990 to June 2012, with primary analysis of studies published since January 2000. METHODS OF STUDY SELECTION: We reviewed 6,476 citations. We included English-language controlled studies with human participants reporting a quantitative association between exposure to OCPs (in which the explicit or implicit indication for OCP use was prevention of pregnancy or ovarian cancer) compared with no use of OCPs. Two investigators independently reviewed the title and abstract and full-text of articles for inclusion or exclusion decision; discordant decisions were resolved by team review and consensus. TABULATION, INTEGRATION, AND RESULTS: Fifty-five studies met inclusion criteria. A random-effects meta-analysis of 24 case-control and cohort studies showed significant reduction in ovarian cancer incidence in ever-users compared with never-users (odds ratio 0.73, 95% confidence interval 0.66–0.81). There was a significant duration–response relationship, with reduction in incidence of more than 50% among women using OCPs for 10 or more years. The lifetime reduction in ovarian cancer attributable to the use of OCPs is approximately 0.54% for a number-needed-to-treat of approximately 185 for a use period of 5 years. CONCLUSION: Significant duration-dependent reductions in ovarian cancer incidence in the general population are associated with OCP use.

A randomized, controlled trial of acupuncture for chronic daily headache.

Background.—Approximately 4% of adults experience headaches nearly every day. Nonpharmacologic interventions for frequent headaches may be appropriate because medical management alone is often ineffective.