Biomedical subjects

Kathleen N Lohr

Publications and source records attributed to Kathleen N Lohr.

At least 19 recordsLinked to original sources

PubMed2006

How to develop a business case for quality.

OBJECTIVE: To describe the steps in developing a business case for quality-enhancing interventions (QEIs) in health care. ANALYSIS: The development of a business case for QEIs in health care involves 11 steps. These steps include (1) describing the intervention, (2) determining perspective, (3) identifying the effects of the intervention on quality, (4) designing the study, (5) identifying and measuring cash flows, (6) considering the effects of capacity constraints, (7) selecting a measure of return on investment, (8) determining the time horizon for the analysis, (9) determining the discount rate, (10) adjusting costs and savings for inflation, and (11) determining organizational readiness for business case development. A checklist offers guidance on assessing readiness for the business case. CONCLUSION: The absence of a 'business case' for quality is frequently cited as the reason health care organizations do not implement QEIs, despite decades of careful research demonstrating their effectiveness. Our continuing commitment to advancing the discipline of business case analysis is based on a belief that delineating the cost and economic implications of investments in QEIs is a critical threshold issue to widespread adoption of evidence-based quality improvements. We believe it is appropriate and timely to consider how best to standardize approaches and move the field of business case analysis forward.

Diffusion of Innovation↗

PubMed2006

Systematic review: smoking cessation intervention strategies for adults and adults in special populations.

BACKGROUND: While smoking cessation interventions have been shown to work, questions remain about how to increase their efficacy. PURPOSE: To examine strategies for effective tobacco treatment in adults and special populations. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane Library, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts (1 January 1980 to 10 June 2005). STUDY SELECTION: Systematic reviews; randomized, controlled trials; and observational studies. DATA EXTRACTION: Two reviewers independently abstracted data on study design, population, sample size, treatment, outcomes, and quality. DATA SYNTHESIS: Findings from systematic reviews were summarized and compared with findings from original research published beyond date ranges included in the reviews. Strength of evidence was used to assess the body of evidence. Our review included studies evaluating the efficacy of cessation strategies, such as self-help, counseling, single pharmaceutical agents, combined pharmacotherapies, and pharmacotherapies combined with psychological counseling. Research findings consistent with previous reviews show that self-help strategies alone are ineffective, but counseling and pharmacotherapy used either alone or in combination can improve rates of success with quit attempts. Two studies of self-help materials reported discrepancies across effects. Five studies provided mixed results for counseling interventions. Fourteen studies provided sufficient evidence of the efficacy of single pharmacotherapy, combined pharmacotherapy, and psychological interventions either with or without pharmacotherapy. Few studies focused on ways to reach or treat special populations. Three studies with hospitalized patients had findings consistent with a previous review showing no strong evidence that clinical diagnosis affected the likelihood of quitting. New evidence was insufficient to address the effectiveness of interventions for persons with coexisting psychiatric conditions and substance abuse problems. LIMITATIONS: Previous systematic reviews variably cover the range of issues we addressed. More recent studies do not fill all gaps, especially those for persons with coexisting disease. CONCLUSIONS: Although self-help strategies alone marginally affect quit rates, individual and combined pharmacotherapies and counseling either alone or in combination can significantly increase cessation. Using effective smoking treatments is strongly encouraged for all populations, especially those with high and heavy rates of smoking, such as psychiatric and substance abuse populations.

Adolescent↗

PubMed2006

A simple and valid tool distinguished efficacy from effectiveness studies.

OBJECTIVE: To propose and test a simple instrument based on seven criteria of study design to distinguish effectiveness (pragmatic) from efficacy (explanatory) trials. STUDY DESIGN: Currently no validated definition of effectiveness studies exists. We asked the directors of 12 Evidence-based Practice Centers to select six studies each: four that they considered to be examples of effectiveness trials and two considered efficacy studies. We then applied our proposed criteria to test the construct validity using the selected studies as if they had been identified by a gold standard. RESULTS: Based on the rationale to identify effectiveness studies reliably with minimal false positives (i.e., a high specificity), a cutoff of six criteria produced the most desirable balance between sensitivity and specificity. This setting produced a specificity of 0.83 and a sensitivity of 0.72. CONCLUSION: When applied in a standardized manner, our proposed criteria can provide a valid and simple tool to distinguish effectiveness from efficacy studies. The applicability of systematic reviews can improve when analysts place more emphasis on the generalizability of included studies. In addition, clinicians can also use our criteria to determine the external validity of individual studies, given an appropriate population of interest.

Drug Therapy↗

PubMed2006

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.

Cesarean Section↗

PubMed2006

The comparative efficacy and safety of biologics for the treatment of rheumatoid arthritis: a systematic review and metaanalysis.

OBJECTIVE: Biologics are an important therapeutic option for treating patients with rheumatoid arthritis (RA). However, they are associated with rare but severe adverse events such as serious infections, lymphoma, or chronic heart failure. In addition, dosing regimens and routes of administration differ substantially among biologics. In a systematic review, we assessed the comparative efficacy and safety of biologic agents for RA. METHODS: We searched electronic databases up to May 2006. We limited evidence to controlled trials for efficacy but included observational evidence for safety. Outcomes of interest were clinical response, radiographic progression, and quality of life. Given the paucity of head-to-head evidence, we conducted adjusted, indirect comparisons of placebo-controlled trials. RESULTS: Twenty-six controlled trials provided efficacy data; 18 additional studies assessed safety. The only evidence directly comparing 2 biologic agents was a nonrandomized, open-label trial that found no differences in effectiveness and safety between etanercept and infliximab. Adjusted indirect comparisons indicate no significant differences in efficacy between anti-tumor necrosis factor (TNF) drugs. However, anti-TNF drugs appear to be more efficacious than anakinra, although not all comparisons reached statistical significance. Because of the lack of sound longterm safety data, evidence is insufficient to draw firm conclusions about the comparative safety of biologics. CONCLUSION: Anti-TNF drugs appear to be more efficacious than anakinra but do not differ significantly among each other. Clinical considerations such as comorbidities, route of administration, dosing regimens, and specific side effect profiles may guide the choice of an anti-TNF drug.

Antirheumatic Agents↗

PubMed2005

Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder.

BACKGROUND: Reviews have compared the efficacy and tolerability of newer second-generation antidepressants with those of placebo or older treatments, but comparative evidence for use of second-generation antidepressants to treat major depressive disorder has not been evaluated. PURPOSE: To systematically evaluate comparative data on the efficacy, effectiveness, and tolerability of commonly prescribed second-generation antidepressants (selective serotonin reuptake inhibitors, bupropion, duloxetine, mirtazapine, and venlafaxine) in the treatment of major depressive disorder. DATA SOURCES: MEDLINE, EMBASE, and PsychLit; the Cochrane Library; and the International Pharmaceutical Abstracts were searched from January 1980 through February 2005 for reviews; randomized, controlled trials; meta-analyses; and observational studies. STUDY SELECTION: The authors reviewed 46 head-to-head randomized, controlled trials comparing one second-generation antidepressant with another. Twenty-four observational studies and placebo-controlled trials were also included for assessment of safety and tolerability. DATA EXTRACTION: Two researchers independently reviewed titles and abstracts. Trained reviewers abstracted data from each study and assigned an initial quality rating. A second reviewer verified the data extraction and quality rating. DATA SYNTHESIS: According to fair to good evidence, the second-generation antidepressants that were compared had only minimal differences in efficacy, and 88% of comparative efficacy studies reported no statistically significant difference in any outcome measure at the end of the study. One effectiveness trial rated good and 2 effectiveness trials rated fair reported no statistically significant differences in primary outcome measures for compared drugs. Meta-analyses showed a modest but statistically significant additional treatment effect for sertraline and venlafaxine compared with fluoxetine. About 96% of comparative trials were sponsored by or had at least 1 author affiliated with a pharmaceutical company; the remaining trials did not report funding sources. Adverse event profiles differed among drugs; however, the degree and quality of adverse event assessment varied and only 13% of trials used a standardized scale to assess adverse events. LIMITATIONS: Quantitative analyses could not be done for many drug comparisons because the quantity and quality of the evidence were inadequate. Most published evidence was from trials sponsored by pharmaceutical companies, and publication bias may have occurred. CONCLUSIONS: Overall, second-generation antidepressants probably do not differ substantially for treatment of major depressive disorder. Choosing the agent that is most appropriate for a given patient is difficult.

Antidepressive Agents, Second-Generation↗

PubMed2005

Challenges in systematic reviews of economic analyses.

Economic analyses can provide valuable information for health care decision makers. Systematic reviews of economic analyses can integrate information from multiple studies and provide important insights by systematically examining how differences between models lead to different results. We use our experience in developing and implementing systematic reviews of economic analyses for the U.S. Preventive Services T ask Force, particularly our systematic review of the cost-effectiveness of colorectal cancer screening, to illustrate key methodologic challenges and suggest a framework for other researchers in this area.

Colorectal Neoplasms↗

PubMed2005

Outcomes of routine episiotomy: a systematic review.

CONTEXT: Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use. OBJECTIVE: To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. EVIDENCE ACQUISITION: We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality. EVIDENCE SYNTHESIS: Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function--pain with intercourse was more common among women with episiotomy. CONCLUSIONS: Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.

Episiotomy↗

PubMed2005

The insufficiency of evidence to establish the business case for quality.

PURPOSE: To determine whether a positive financial return on investment for quality-enhancing interventions is more likely for particular health conditions, in specific organizational settings, or with the use of particular interventions. DATA SOURCES: Electronic search of MEDLINE. DATA EXTRACTION: Search keywords included: business case, cost-effectiveness, cost-benefit, return on investment, costs, cost savings, quality, quality improvement, and program evaluation. RESULTS: Only 15 of 1968 articles identified contained sufficient information on both the costs of implementing quality-enhancing interventions and the resultant changes in costs of care or revenues to permit the calculation of a return on investment. CONCLUSIONS: Scant attention is currently paid in the quality-of-care literature to the cost of implementing quality-enhancing interventions. To understand which quality-enhancing interventions are likely to produce positive returns on investments, data collection and analysis must include tracking the investment and operating costs of implementing the intervention as well as the changes in revenues and costs that result from the intervention.

Cost-Benefit Analysis↗

PubMed2005

Discontinuation rates for selective serotonin reuptake inhibitors and other second-generation antidepressants in outpatients with major depressive disorder: a systematic review and meta-analysis.

The present study aimed to systematically compare overall loss to follow-up, discontinuation rates because of adverse events and discontinuation rates because of a lack of efficacy in published studies assessing the efficacy and tolerability of selective serotonin reuptake inhibitors (SSRIs) compared to other second-generation antidepressants in treating outpatients with major depressive disorder (MDD). We searched MEDLINE, Embase, The Cochrane Library, PsychLit and the International Pharmaceutical Abstracts from 1980 to 2004 (April). Twenty double-blinded, randomized controlled trials met our eligibility criteria and compared SSRIs to other second-generation antidepressants in adult outpatients with MDD. Pooled relative risks of discontinuation rates because of (i) any reason (overall loss to follow-up), (ii) adverse events and (iii) a lack of efficacy did not differ substantially between SSRIs as a class and other second-generation antidepressants. Taking the similar efficacy of second-generation antidepressant into account, our findings suggest that clinicians can focus on other practically or clinically relevant considerations such as costs, differences in side-effect profiles, onset of action or aspects of health-related quality of life to tailor a treatment to an individual patient's needs.

Antidepressive Agents, Second-Generation↗

PubMed2005

Perinatal depression: a systematic review of prevalence and incidence.

OBJECTIVE: We systematically review evidence on the prevalence and incidence of perinatal depression and compare these rates with those of depression in women at non-childbearing times. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, and Sociofile for English-language articles published from 1980 through March 2004, conducted hand searches of bibliographies, and consulted with experts. METHODS OF STUDY SELECTION: We included cross-sectional, cohort, and case-control studies from developed countries that assessed women for depression during pregnancy or the first year postpartum with a structured clinical interview. TABULATION, INTEGRATION, AND RESULTS: Of the 109 articles reviewed, 28 met our inclusion criteria. For major and minor depression (major depression alone), the combined point prevalence estimates from meta-analyses ranged from 6.5% to 12.9% (1.0-5.6%) at different trimesters of pregnancy and months in the first postpartum year. The combined period prevalence shows that as many as 19.2% (7.1%) of women have a depressive episode (major depressive episode) during the first 3 months postpartum; most of these episodes have onset following delivery. All estimates have wide 95% confidence intervals, showing significant uncertainty in their true levels. No conclusions could be made regarding the relative incidence of depression among pregnant and postpartum women compared with women at non-childbearing times. CONCLUSION: To better delineate periods of peak prevalence and incidence for perinatal depression and identify high risk subpopulations, we need studies with larger and more representative samples.

Depression, Postpartum↗

PubMed2005

Interventions to improve health outcomes for patients with low literacy. A systematic review.

OBJECTIVE: To perform a systematic review of interventions designed to improve health outcomes for persons with low literacy skills. DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsycInfo, and Ageline from 1980 to 2003. STUDY SELECTION: We included controlled and uncontrolled trials that measured literacy and examined the effect of interventions for people with low literacy on health outcomes, including health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity or mortality. Two abstractors reviewed each study for inclusion. Disagreements were resolved by consensus among the research team. DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. Disagreements about information in evidence tables were resolved by team consensus. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality. DATA SYNTHESIS: We identified 20 articles examining interventions designed to improve health among people with low literacy. The most common outcome studied was health knowledge; fewer studies examined health behaviors, intermediate markers, or measures of disease prevalence or severity. The effectiveness of interventions appeared mixed. Limitations in research quality and heterogeneity in outcome measures make drawing firm conclusions about effective strategies difficult. Only 5 articles examined the interaction between literacy level and the effect of the intervention; they also found mixed results. CONCLUSIONS: Several interventions have been developed to improve health for people with low literacy. Limitations in study design, interventions tested, and outcomes assessed make drawing conclusions about effectiveness difficult. Further research is required to understand better the types of interventions that are most effective and efficient for overcoming literacy-related barriers to good health.

Clinical Trials as Topic↗

PubMed2005

Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review.

BACKGROUND: Chronic periodontitis affects many adults in the United States, some severely enough to threaten tooth loss. Of particular clinical importance is whether scaling and root planing (SRP) accompanied by a local adjunctive therapeutic agent improves outcomes over time compared to SRP alone. The adjunctive therapeutic agents investigated include: tetracycline, minocycline, metronidazole, a group of other antibiotics, chlorhexidine, and a group of antimicrobials. Primary outcomes considered are reductions in probing depth (PD) and gains in clinical attachment level (CAL). METHODS: RTI-UNC Evidence-Based Practice Center staff searched MEDLINE (1966 through December 2002) and EMBASE (through February 2002) to identify clinical trials published in English that 1) involved adults with chronic periodontitis but no serious comorbidities; 2) tested one or more chemical antimicrobial agents as an adjunct to SRP alone or with a placebo; 3) had a concurrent control group that received the same SRP as the treatment group; 4) reported outcomes for specified, fixed time periods; and 5) if multiple antimicrobials were tested, reported outcomes for each agent separately. We performed qualitative analyses and meta-analyses of PD and CAL effect sizes when the necessary data were available from at least three studies at 6-month follow-up. RESULTS: Among the locally administered adjunctive antimicrobials, the most positive results occurred for tetracycline, minocycline, metronidazole, and chlorhexidine. Adjunctive local therapy generally reduced PD levels. Differences between treatment and SRP-only groups in the baseline-to-follow-up period typically favored treatment groups but usually only modestly (e.g., from about 0.1 mm to nearly 0.5 mm) even when the differences were statistically significant. Effects for CAL gains were smaller and statistical significance less common. The marginal improvements in PD and CAL were a fraction of the improvement from SRP alone. CONCLUSIONS: Whether such improvements, even if statistically significant, are clinically meaningful remains a question. A substantial agenda of future research to address this and other issues (e.g., costs, patient-oriented outcomes) is suggested.

Adult↗

PubMed2004

Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Suicide is the 11th leading cause of death and the seventh leading cause of years of potential life lost in the United States. Although suicide is of great public health significance, its clinical management is complicated. PURPOSE: The authors systematically reviewed the literature to determine whether screening for suicide risk in primary care settings decreases morbidity, mortality, or both. DATA SOURCES: MEDLINE (1966 to 17 October 2002), PsycINFO, Cochrane databases, hand-searched bibliographies, and experts. STUDY SELECTION: For screening, only English-language studies performed in primary care settings were examined. For treatment, randomized, controlled trials and cohort studies were included if they were performed in any setting where suicide completions, suicide attempts, or suicidal ideation were reported. DATA EXTRACTION: A primary reviewer abstracted data on key variables of study sample, design, and outcomes; a second reviewer checked information accuracy against the original articles. DATA SYNTHESIS: No study directly addressed whether screening for suicide in primary care reduces morbidity and mortality. The remainder of the review focused on the questions of reliable screening tests for suicide risk and the effectiveness of interventions to decrease depression, suicidal ideation, and suicide attempts or completion. One screening study provided limited evidence for the accuracy of suicide screening in a primary care setting. Intervention studies provided fair and mixed evidence that treating those at risk for suicide reduces the number of suicide attempts or completions. The evidence suggests mild to moderate improvement for interventions addressing intermediate outcomes such as suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of function. CONCLUSION: Because of the complexity of studying the risk for suicide and the paucity of well-designed research studies, only limited evidence guides the primary care clinician's assessment and management of suicide risk.

Age Factors↗

PubMed2004

Exercise tolerance testing to screen for coronary heart disease: a systematic review for the technical support for the U.S. Preventive Services Task Force.

BACKGROUND: Coronary heart disease is the leading cause of morbidity and mortality in the United States. Exercise tolerance testing has been proposed as a means of better identifying asymptomatic patients at high risk for coronary heart disease events. PURPOSE: To review the evidence on the use of exercise tolerance testing to screen adults with no history of cardiovascular disease for coronary heart disease. DATA SOURCES: The MEDLINE database from 1966 through February 2003, hand-searching of bibliographies, and expert input. STUDY SELECTION: Eligible studies evaluated the benefits or harms of exercise tolerance testing when added to traditional risk assessment for adults with no known history of cardiovascular events. DATA EXTRACTION: One reviewer extracted information from eligible articles into evidence tables, and another reviewer checked the tables. Disagreements were resolved by consensus. DATA SYNTHESIS: No study has directly examined the effect of screening asymptomatic patients with exercise tolerance testing on coronary heart disease outcomes or risk-reducing behaviors or therapies. Multiple cohort studies demonstrate that screening exercise tolerance testing identifies a small proportion of asymptomatic persons (up to 2.7% of those screened) with severe coronary artery obstruction who may benefit from revascularization. Several large prospective cohort studies, conducted principally in middle-aged men, suggest that exercise tolerance testing can provide independent prognostic information about the risk for future coronary heart disease events (relative risk with abnormal exercise tolerance testing, 2.0 to 5.0). However, when the risk for coronary heart disease events is low, most positive findings will be false and may result in unnecessary further testing or worry. The risk level at which the benefits of additional prognostic information outweigh the harms of false-positive results is unclear and requires further study. CONCLUSIONS: Although screening exercise tolerance testing detects severe coronary artery obstruction in a small proportion of persons screened and can provide independent prognostic information about the risk for coronary heart disease events, the effect of this information on clinical management and disease outcomes in asymptomatic patients is unclear.

Coronary Disease↗

PubMed2004

Diagnosis and testing in bronchiolitis: a systematic review.

BACKGROUND: The diagnosis of bronchiolitis is based on typical history and results of a physical examination. The indications for and utility of diagnostic and supportive laboratory testing (eg, chest x-ray films, complete blood cell counts, and respiratory syncytial virus testing) are unclear. OBJECTIVES: To review systematically the data on diagnostic and supportive testing in the management of bronchiolitis and to assess the utility of such testing. DESIGN: In conjunction with an expert panel, we generated admissibility criteria and derived relevant terms to search the literature published from 1980 to November 2002 in MEDLINE and the Cochrane Collaboration Database of Controlled Clinical Trials. Trained abstractors completed detailed data collection forms for each article. We summarized the data in tables after performing data integrity checks. RESULTS: Of the 797 abstracts identified, we present evidence from 82 trials that met our inclusion criteria (17 are primary articles on diagnosis of bronchiolitis and 65are reports of treatment or prevention trials). Numerous studies demonstrate that rapid respiratory syncytial virus tests have acceptable sensitivity and specificity, but no data show that respiratory syncytial virus testing affects clinical outcomes in typical cases of the disease. Seventeen studies presented chest x-ray film data. Abnormalities on chest x-ray films ranged from 20% to 96%. Insufficient data exist to show that chest x-ray films reliably distinguish between viral and bacterial disease or predict severity of disease. Ten studies included complete blood cell counts, but most did not present specific results. In one study, white blood cell counts correlated with radiologically defined disease categories of bronchiolitis. CONCLUSIONS: A large number of studies include diagnostic and supportive testing data. However, these studies do not define clear indications for such testing or the impact of testing on relevant patient outcomes. Given the high prevalence of this disease, prospective studies of the utility of such testing are needed and feasible.

Bronchiolitis↗

PubMed2004

Pharmacologic treatment of bronchiolitis in infants and children: a systematic review.

BACKGROUND: Bronchiolitis is the most common lower respiratory tract infection in infants. Up to 3% of all children in their first year of life are hospitalized with bronchiolitis. Bronchodilators and corticosteroids are commonly used treatments, but little consensus exists about optimal management strategies. OBJECTIVE: To conduct a systematic review of the effectiveness of commonly used treatments for bronchiolitis in infants and children. DATA SOURCES: We searched MEDLINE and the Cochrane Controlled Trials Register for references to randomized controlled trials of bronchiolitis treatment published since 1980. STUDY SELECTION: Randomized controlled trials of interventions for bronchiolitis in infants and children were included if they were published in English between 1980 and November 2002 and had a minimum sample size of 10. DATA EXTRACTION: We abstracted data on characteristics of the study population, interventions used, and results of studies meeting entry criteria into evidence tables and analyzed them by drug category. DATA SYNTHESIS: Interventions were grouped by drug category and qualitatively synthesized. RESULTS: Of 797 abstracts identified in the literature search, we included 54 randomized controlled trials. This review includes 44 studies of the most common interventions: epinephrine (n = 8), beta2-agonist bronchodilators (n = 13), corticosteroids (n = 13), and ribavirin (n = 10). Studies were, in general, underpowered to detect statistically significant outcome differences between study groups. Few studies collected data on outcomes that are of great importance to parents and clinicians, such as the need for and duration of hospitalization. CONCLUSIONS: Overall, little evidence supports a routine role for any of these drugs in treating patients with bronchiolitis. A sufficiently large, well-designed pragmatic trial of the commonly used interventions for bronchiolitis is needed to determine the most effective treatment strategies for managing this condition.

Adrenal Cortex Hormones↗

PubMed2004

Physicians' roles in preventing dental caries in preschool children: a summary of the evidence for the U.S. Preventive Services Task Force.

CONTEXT: Almost 20% of children aged 2 to 5 years have untreated dental caries. Physician interventions to prevent and manage dental caries in preschool children could help address this common problem. OBJECTIVE: To review the evidence for effectiveness of five possible physician interventions- (1) screening and risk assessment, (2) referral, (3) provision of dietary supplemental fluoride, (4) application of fluoride varnish, and (5) counseling-for the prevention of dental caries for the U.S. Preventive Services Task Force. DATA SOURCES: Articles from 1966 to 2001 addressing the effectiveness of primary care clinicians' interventions to prevent or manage dental caries were identified in MEDLINE. The evidence for effectiveness of supplemental fluorides, fluoride varnish, and counseling for caries prevention performed by dental personnel was also examined through existing and new systematic reviews. DATA SYNTHESIS: For most key questions related to the five interventions, the evidence for primary care clinician effectiveness was rated as poor owing to the scarcity of studies. Ten surveys of physicians' knowledge and behavior about fluoride supplementation provided fair evidence, suggesting that supplementation decisions were often made without consideration of other fluoride exposures. Reviews of the dental literature identified fair evidence supporting the effectiveness of both fluoride supplements and varnish, although information describing effectiveness and adverse outcomes of supplementation with the most recent dosage schedule is not available. CONCLUSIONS: Evidence for the effectiveness of traditionally recommended primary care clinician interventions (screening, referral, counseling) to prevent dental caries in preschool children is lacking. There is fair evidence for the effectiveness of two fluoride-based interventions (fluoride supplementation and varnish) applicable in primary care practice. However, there is also fair evidence indicating that physicians' consideration of fluoride exposure is incomplete, thus increasing the risk for fluorosis among those prescribed supplements.

Child, Preschool↗