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AHRQ Annual Highlights, 2010 (continued) |
Patient-Centered Outcomes Research/Comparative Effectiveness Portfolio
AHRQ's Effective Health Care Program is a
Federal leader in the growing field of comparative
effectiveness research. Research that evaluates the
benefits and harms of different health care
interventions and ways to deliver health care helps
clinicians and patients work together to choose the
most appropriate treatment for an illness or
condition.
The Effective Health Care Program, created by
Congress in Section 1013 of the Medicare
Prescription Drug, Improvement, and
Modernization Act of 2003, produces rigorous
reviews of existing scientific evidence for different
health care interventions, funds new research to
help fill gaps in our knowledge about effectiveness
of different health care options, and provides
concise, plain language guides for several audiences,
including Spanish-speaking patients. Additional
products are intended to specifically reach
clinicians, nurses, pharmacists, and medical
students include continuing education activities,
training modules, downloadable presentations,
Webcasts, videos, and podcasts in English and
Spanish.
In FY10, the Effective Health Care Program
released a total of 51 comparative effectiveness
research reviews, original research findings, and
summary guides for clinicians and patients. These
publications included comparative effectiveness
reviews of treatment options for common
conditions such as nonoperative and operative
treatments for rotator cuff tears, comparing core
needle and surgical excision biopsy for diagnosing
breast lesions, and radiotherapy treatments for
patients with head and neck cancer. For emerging
treatment options, the program released a technical
report on percutaneous heart valve replacement.
The program also published new research findings
on using electronic medical records and
administrative claims data for assessing type 2
diabetes care and quality measures for end-of-life
care. In 2010, consumer summary guides and
clinician guides remained the most popular
products disseminated through
http://www.effectivehealthcare.ahrq.gov and the AHRQ
publications clearinghouse.
Healthcare 411
Healthcare 411 is an audio podcast series produced by AHRQ that supports AHRQ's mission to
improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Using the latest
multimedia technologies, our Healthcare 411 stories offer helpful information about new findings from
AHRQ-sponsored research to a broad audience of consumers, employers, health care providers,
researchers, educators, and others in the form of concise 60-second audio news programs that feature
current research on important health care topics. Archived programs on the Healthcare 411 Web site
include longer-format interviews that range from 60 seconds to 15 minutes on a variety of health topics.
Most previously released programs remain available and searchable on the Healthcare 411 site. The site
also hosts audio and video public service announcements produced by AHRQ and provides links to
related consumer publications and other studies and guides funded by AHRQ. In FY10, podcasts
released included:
- Creating a Personal Medical Record—Creating a personal medical record can help consumers receive
better medical care, especially in an emergency.
- Online Health Information—Tips on how to find reliable online sources of health information.
- New Guides for Spanish-Speaking Patients—New Spanish-language guides serve as helpful resources
to understand and compare treatment options.
- Treating High Cholesterol—Understanding the benefits and risks of various medicines used to treat
high cholesterol.
- Keep Track of Your Medicines—Encourages health care consumers to take an active role in their
health care by keeping a readily available pill card that lists all the medications they take.
- Tips for Going Home from the Hospital—Emphasizes the need to clarify all aspects of medical care,
including medications, in preparation for leaving the hospital.
- Bring a Health Advocate to Appointments—Encourages health care consumers to bring a friend or
family member to doctor appointments to ensure they collect accurate information about their
condition.
- Men's Health—More men than women are hospitalized for preventable conditions.
- Asking Questions To Get the Care You Need—Be prepared for doctor visits by writing down
questions and bringing them to the visit. Patients who ask questions get better quality health care.
- Where Medical Errors Occur and How To Avoid Them—Many of the medical errors that occur
could have been prevented. Taking steps to reduce the chance of a medical error.
- Diabetes and the Flu—More adults with diabetes are getting flu shots.
- Healthcare-Associated Infections—How patients can reduce their risk.
- How to Avoid the Round-Trip Visit to the Hospital—Medical problems that send patients back to
the hospital can be avoided.
Visit Healthcare 411 at http://healthcare411.ahrq.gov.
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Comparative Effectiveness
Research Reviews (CERs)
Evidence-based Practice Centers (EPCs) thoroughly
review existing scientific studies to compare
treatments and health strategies to characterize
benefits and harms of different options to identify
where more research is needed.
Three of the CERs published in FY10 are briefly
summarized here:
- Comparative Effectiveness of Core-Needle and
Open Surgical Biopsy for the Diagnosis of Breast
Lesions. Breast cancer is the second most
common malignancy of women, with
approximately 250,000 new cases diagnosed
each year. More than 180,000 of these cases are
invasive breast cancer. Early detection and
treatment improves survival. Routine screening
with physical examination and mammography
is widely used in the United States. Suspicious
findings on mammography may require a
biopsy for diagnosis. Over 1 million women
have breast biopsies each year in the United
States. Between 20 and 30 percent of these
biopsies yield a diagnosis of breast cancer. This
review compares traditional surgical biopsies
with various types of core-needle biopsies,
which involve removing tissue through a
hollow-core needle inserted through the skin.
The researchers found that certain core-needle
biopsies could distinguish between malignant
and benign lesions approximately as accurately
as open surgical biopsy, which is commonly
considered the "gold standard" method of
evaluating suspicious lesions. The report
indicates that women who are initially
diagnosed with breast cancer by surgical biopsy
are more likely to undergo multiple surgical
procedures during treatment than women who
are initially diagnosed with breast cancer by core
needle biopsy. Because it is less invasive, core-needle
biopsy costs less than open surgical
biopsy, consumes fewer resources, and generally
is preferred by patients, according to the report.
- Comparative Effectiveness and Safety of
Radiotherapy Treatments for Head and Neck
Cancer. According to the National Cancer
Institute, head and neck cancer accounts for
nearly 3 to 5 percent of all cancer in the United
States. These types of cancer are more common
in men and in people older than age 50.
Around 47,560 men and women in this
country develop head and neck cancer every
year. Tobacco and alcohol use are common risk
factors for this cancer. This review found that
intensity-modulated radiation therapy (IMRT)
reduces side effects when treating head and neck
cancers. IMRT employs three-dimensional imaging and other technological and treatment
enhancements that tightly control and target
the amount of radiation delivered to the target
area. The researchers found that IMRT leads to
fewer cases of xerostomia (dry mouth) than
traditional two-dimensional or three-dimensional
radiation therapies. However, the
researchers did not find evidence that IMRT is
more successful than any other kind of
radiation therapy in reducing tumors. In
examining the evidence regarding proton beam
radiation therapy, a technology that some
clinicians believe targets radiation even more
precisely than IMRT, the researchers did not
find enough evidence to draw conclusions
regarding its benefits or potential side effects.
- Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II
Receptor Blockers Added to Standard Medical
Therapy for Treating Stable Ischemic Heart
Disease. This review found that two
medications—angiotensin-converting enzyme
(ACE) inhibitors and angiotensin II receptor
blockers (ARBs)—commonly used to treat high
blood pressure appear to be effective in treating
stable ischemic heart disease. Researchers found
that treatment with these two medications can
lead to a reduction in death, risk of heart
attack, risk of stroke, and fewer hospitalizations
for heart failure for patients suffering from
stable ischemic heart disease. However, the
drugs have risks. The risks associated with ACE
inhibitors include a persistent cough, sudden
fainting, too much potassium in the blood, and
dangerously low blood pressure. Risks
associated with ARBs include too much
potassium in the blood and low blood pressure.
Patients with stable ischemic heart disease who
take an ACE inhibitor in addition to standard
treatment can reduce their likelihood of death
from heart attack or heart failure, non-fatal
heart attacks, hospitalization for heart failure,
and revascularization. Patients who take an
ARB in addition to standard medications can
reduce their risk of death from a heart-related
cause, heart attack, or stroke.
Technical Briefs
A Technical Brief provides an overview of key issues
related to a clinical intervention or health care
service—for example, current indications for the
intervention, relevant patient population and
subgroups of interest, outcomes measured, and
contextual factors that may affect decisions
regarding the intervention. Technical Briefs
generally focus on interventions for which there are
limited published data and too few completed
protocol-driven studies to support definitive
conclusions. The emphasis, therefore, is on
providing an early objective description of the state
of the science, a potential framework for assessing
the applications and implications of the new
interventions, a summary of ongoing research, and
information on future research needs. The
Technical Brief published in FY10 is summarized
below:
- Percutaneous Heart Valve Replacement. A newer,
less invasive method of heart valve replacement
shows promise and may be appropriate for
patients who cannot tolerate traditional open
heart surgery, but more research is needed to
understand its potential risks and benefits.
Percutaneous heart valve replacement is a
realistic option for some patients with heart
valve disease, especially older or sicker patients.
Approximately 92 percent of patients who
received a percutaneous valve survived the
procedure; of those, 86 percent survived for at
least 30 days. However, information is lacking
on the potential long-term benefits and risks of
this procedure, particularly compared with open
heart valve replacement surgery. The report did
not conclude that any of the seven replacement
valves studied is safer or more effective than
another.
Technical brief topics expected to be published in
FY11 include:
- Evaluation of Suspicious Skin Lesions Using
Noninvasive Diagnostic Techniques.
- Stereotactic Radiosurgery for Extracranial Solid
Tumors.
- Wheeled Mobility (Wheelchair) Service
Delivery.
- Neurothrombectomy Devices for Treatment of
Acute Ischemic Stroke.
- Use and Safety of Positional Magnetic
Resonance Imaging in the Management of
Patients with Musculoskeletal Pain.
- Fetal Surgery.
New Research Reports
These reports are based on clinical research and
studies that use health care databases and other
scientific resources and approaches to explore
practical questions about the effectiveness, safety,
and appropriateness of health care items and
services. They are produced by research centers
that are part of AHRQ's Developing Evidence to
Inform Decisions about Effectiveness (DEcIDE)
Network and AHRQ's Centers for Education &
Research on Therapeutics (CERTs).
In FY10, the Effective Health Care Program
released 14 new research reports, two of which are
summarized below:
- Who Uses Exenatide for Glucose Control in
Diabetes Mellitus? A Retrospective Cohort Study of
a New Therapy. Exenatide was approved by the
Food and Drug Administration (FDA) in April 2005 as adjunctive therapy for type 2 diabetes
mellitus (DM). Researchers evaluated whether
early use of this drug was consistent with the
FDA-approved indications for use. Beginning in
June 2005, 3,225 people filled a prescription for
exenatide. Of these, 22 percent of users were
obese, compared to 11 to 15 percent using
other medications. Fourteen percent of users
had used no other medication for DM in the
preceding year, suggesting that exenatide was
their initial therapy. Thirty percent filled a
thiazolidinedione prescription within 60 days of
filling exenatide. The researchers concluded that
exenatide was used frequently early after its
approval as monotherapy or with a
thiazolidinedione (neither is an FDA-approved
indication). Exenatide users had a higher
prevalence of obesity than patients using other
therapies, suggesting that its weight-lowering
benefits may be widely known.
- Effectiveness of Isosorbide Dinitrate and
Hydralazine in Racial/Ethnic Subgroups With
Heart Failure. Researchers assessed the
associations between treatment with
hydralazine-isosorbide dinitrate (H-ISDN) and
mortality or heart failure hospitalization in
veterans with heart failure. Their findings
showed that H-ISDN prescription was not
associated with risk of death in five of nine
subgroups predefined by race/ethnicity (black,
white, Hispanic) and time of initiation of H-ISDN
(1 to 4, 5 to 12, or more than 12
months following heart failure diagnosis), but
was associated with an increased risk of death in
the four subgroups with longer times to
initiation. H-ISDN was associated with a
significantly increased risk of heart failure
hospitalization in all but one subgroup. H-ISDN
was associated with significantly lower
risk for both mortality and hospitalization in
blacks than in Hispanics or whites. Other
evidence-based heart failure therapies (e.g.,
angiotensin converting enzyme inhibitors, beta-blockers,
and combinations) had a strong
association with reduced mortality. The
researchers concluded that H-ISDN was not
associated with significant reduction in
mortality or hospitalization for heart failure in
any subgroups analyzed. Blacks had lower risks
of adverse outcomes with H-ISDN than
Hispanics or whites.
Summary Guides
These short, plain-language guides—tailored to
clinicians, consumers and patients, or
policymakers—summarize research reviews'
findings on the effectiveness and risks of treatment
options. Patient guides provide background on
health conditions, while clinician and policymaker
guides rate the strength of evidence behind a
report's conclusions. The guides on medications
also contain basic wholesale price information.
Among the new consumer and clinical guides
released in FY10 were:
- Thinking About Having Your Labor Induced?—This guide provides women with information
about elective induction and helps answer
questions, including: What are the possible
problems with elective induction? What don't
we know yet about elective induction?
- Elective Induction of Labor: Safety and Harms—This guide for clinicians summarizes evidence
comparing the safety of elective induction of
labor (induction at term without a medical
indication) with expectant management
(waiting for spontaneous labor in a term
pregnancy). It also includes information about
maternal and fetal outcomes when elective
induction of labor is used.
- Adding ACEIs and/or ARBs to Standard Therapy
for Stable Ischemic Heart Disease: Benefits and
Harms—This guide summarizes evidence for
clinicians to help address this question: "Should
standard medical therapy in patients with stable
ischemic heart disease be augmented with an
ACEI (angiotensin-converting enzyme
inhibitor) or an ARB (angiotensin II receptor
blocker)?"
- "ACE Inhibitors" and "ARBs" To Protect Your
Heart?—By providing simple text with a
diagram, chart, and graph, this guide helps
patients with stable coronary heart disease
compare the benefits and possible side effects of
ACEIs and ARBs.
- Having a Breast Biopsy—This guide for patients
provides information about the different kinds
of biopsies, what to expect during a breast
biopsy, possible side effects, and research about
how well different kinds of biopsies work to
find cancer.
- Core-Needle Biopsy for Breast Abnormalities—This clinician guide compares core-needle
biopsy with open surgical biopsy for diagnosing
breast lesions. It also summarizes the accuracy
and possible harms of various core-needle
biopsy methods.
Slide Sets and CME/CE Credit
In FY10, AHRQ created the Effective Health Care
Program Slide Library, which contains lectures
created for faculty engaged in educating clinicians,
researchers, and other health professionals in
training. The lectures have slides, talking points,
references that are linked to PubMed®, and key
words to find additional slides on a similar topic.
Each slide can be individually viewed and
downloaded, or the library can be searched by key
word to assemble a customized presentation. In
addition, presentations can be downloaded for
faculty who are instructing clinicians, researchers,
and other health professionals. Presentations can be
downloaded in their entirety or searched by key
word to assemble a customized presentation.
- Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin
II Receptor Blockers Added to Standard Medical
Therapy for Treating Patients With Stable Ischemic
Heart Disease and Preserved Left Ventricular
Systolic Function. This slide set is based on a
CER of this topic.
- Management of the Patient with Stable Ischemic
Heart Disease and Preserved Left Ventricular
Systolic Function. This slide set is based on the
CER Clinician and Consumer Guides for
Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) or
Angiotensin II-Receptor Blockers (ARBs) Added to
Standard Medical Therapy for Treating Stable
Ischemic Heart Disease (IHD).
- AHRQ Training Modules for the Systematic
Reviews Methods Guide. This collection of 27
presentations was developed for instructors
teaching clinical researchers and students about
the science of systematic reviews and for
Evidence-based Practice Center directors to use
in mentoring and teaching new investigators.
The presentations and quizzes are based on the
Methods Guide for Effectiveness and Comparative
Effectiveness Reviews and other resources.
AHRQ also developed continuing medical
education (CME) and continuing education (CE)
modules for health practitioners as well as
continuing pharmacy education (CPE).
EHC Program Webcasts
Effective Health Care Program Webcasts are offered
periodically to bring methodologists, researchers,
and clinicians together to discuss research findings
and the impact on future research needs.
- New and Improved: Registries for Evaluating
Patient Outcomes and HIT. In this live Webcast
from the AHRQ 2010 Annual Conference, the
Registries for Evaluating Patient Outcomes: A
User's Guide: 2nd Edition, was introduced.
Following the presentations, participants
discussed potential topics for future updates of
this handbook.
- Carotid Revascularization: Present Patterns of Use,
What Will the Future Hold? This Web conference
featured speakers who described a DEcIDE
study with two main objectives: (1) to evaluate
temporal trends and geographical variation in
the use of diagnostic imaging for carotid artery
disease; and (2) to examine geographic variation
in and predictors of carotid treatments and
treatments for carotid artery disease. Medicare
claims—one of the richest, most comprehensive
sources of publicly available health care
information—were used to gather retrospective
data for analysis.
For more information on AHRQ's Effective Health
Care Program, go to
http://www.effectivehealthcare.ahrq.gov.
Evidence-based Practice Centers
Under the Evidence-based Practice Center (EPC)
Program, institutions in the United States and
Canada receive multiyear contracts to systematically
review and critically appraise all relevant scientific
literature on clinical, behavioral, organizational,
and financing topics; methodology of systematic
reviews; and other health care delivery issues. They
also produce Evidence Reviews, Technical Briefs,
and Updates (also see Research Reviews under
Comparative Effectiveness Portfolio). The
information in these reports is used by Federal and
State agencies; private sector professional societies;
health delivery systems; providers; payers; and
others committed to evidence-based health care for
informing and developing coverage decisions,
quality measures, educational materials and tools,
guidelines, and research agendas.
Recent Research Findings From the
EPC Program
Some of the new evidence reports and technology
assessments released by the 14 EPCs include:
- Alzheimer's Disease and Cognitive Decline. This
report concluded there is insufficient evidence
to identify which factors or interventions may
increase or decrease the risks of developing
Alzheimer's disease (AD) or other cognitive
declines. Some studies suggest that diabetes,
certain alleles of the apolipoprotein E gene,
smoking, and depression increase the risk of AD
and cognitive decline. Other studies suggest
cognitive engagement and physical activity
decrease risks. With the exception of the
apolipoprotein E gene, however, evidence
supporting these findings tended to be weak.
The researchers noted that the data were often
limited and the quality of evidence was low.
The degree to which these factors modified risk
was typically small to moderate for AD and
small for cognitive decline.
- Enhancing Use and Quality of Colorectal Cancer
Screening. This review found that factors such as
low income or less education, being uninsured
or of Hispanic or Asian descent, not being
acculturated into the United States, and having
less or reduced access to health care are
associated with lower screening rates for
colorectal cancer (CRC). Factors that are
associated with higher screening rates include
being insured, of higher income or education,
being non-Hispanic white, participating in
other cancer screenings, having a family history
of CRC or personal history of another cancer,
and receiving a physician's recommendation to
be screened. Interventions that effectively
increased CRC screening with high strength of
evidence include patient reminders, one-on-one
interactions, eliminating structural barriers, and
system-level changes. The largest magnitude of
improvement came from one-on-one
interactions and eliminating barriers. Purely
educational small-media interventions did not
improve screening rates.
- Impact of Consumer Health Informatics
Applications. This review found that certain
consumer health informatics (CHI) applications
may effectively engage consumers, enhance
traditional clinical interventions, and improve
both intermediate and clinical health outcomes.
In terms of the impact of CHI on intermediate
health outcomes, the researchers found a
significant positive impact for at least one
intermediate health outcome for breast cancer,
diet, exercise, alcohol abuse, smoking cessation,
obesity, diabetes, mental health, asthma/chronic obstructive
pulmonary disease (COPD)
studies, and menopause/hormone replacement
therapy (HRT) utilization. Five
out of the eight studies demonstrated a
significant positive impact of CHI on at least
one aspect of the doctor-patient relationship. In
terms of the impact of CHI on clinical
outcomes, significant positive impact was
demonstrated in at least one clinical outcome
for breast cancer, diet, exercise, or physical
activity, mental health, and diabetes. No studies
included in this review found any evidence of
consumer harm attributable to a CHI
application.
- Vaginal Birth After Cesarean: New Insights.
Researchers synthesized studies on vaginal birth
after cesarean (VBAC) and found evidence that,
while rare for both trial of labor and elective
repeat cesarean, maternal mortality was
significantly higher for elective repeat cesarean
delivery. Risks for uterine rupture and perinatal
death remain rare but elevated for trial of labor.
Hispanic and black women were less likely than
their white counterparts to have a vaginal
delivery. The researchers found insufficient
evidence on nonmedical factors such as medical
liability, economics, hospital staffing, and
structure and setting, which all appear to be
important drivers for VBAC.
The EPCs are currently researching the following
topics:
- Safety of Probiotics Used to Reduce Risk and
Prevent or Treat Disease.
- Management of Acute Otitis Media, Update.
- Enabling Health Care Decisionmaking
Through the Use of Health IT.
- Assessment of Thiopurine Methyltransferase
Activity in Patients Prescribed Azathioprine or
Other Thiopurine-based Drugs.
- Alcohol Consumption and Cancer Risk.
- Inhaled Nitric Oxide in Preterm Infants.
- Comparative Effectiveness of Treatments for
Carotid Artery Stenosis.
- Effectiveness of Cochlear Implants.
- Lifestyle Interventions for Four Conditions:
Breast Cancer, Prostate Cancer, Type 2 Diabetes
Mellitus, and Metabolic Syndrome.
For more information about the EPC Program, go
to http://www.ahrq.gov/clinic/epcix.htm.
Centers for Education and
Research on Therapeutics
The Centers for Education and Research on
Therapeutics (CERTs) is a national program that
conducts research and provides education to
advance the optimal use of drugs, biologicals, and
medical devices. The CERTs program, funded and
overseen by AHRQ in consultation with the U.S.
Food and Drug Administration (FDA), was
originally authorized by Congress in 1997 to
examine the benefits, risks, and cost effectiveness of
therapeutic products; educate patients, consumers,
doctors, pharmacists, and other clinical personnel;
and improve quality of care while reducing
unnecessary costs by increasing the appropriate use
of therapeutics and preventing adverse effects and
their medical consequences.
Clinician-Consumer Health
Advisory Information Network
(CHAIN)
Launched in 2009, this educational Web site offers
expert perspectives, advice, and guidance on drugs,
biological products, and medical devices. The
Clinician-Consumer Health Advisory Information
Network (CHAIN) links clinicians and consumers
with information on therapeutics to assist in
clinical practice and health care decisionmaking in
areas where evidence is undergoing significant and
rapid changes. The site also provides access to
educational and informational resources developed
from research conducted by CERTs. An
educational section includes an online medication
record and materials to assist consumers with
clinician-patient conversations and decisionmaking.
Resources for clinicians include a slide library that
can be adapted to educate clinical audiences and
educational materials that provide continuing
medical education credit. For more information, go
to http://www.chainonline.org.
Recent Research Findings From the
CERTs Program
- Proton-pump inhibitors and preventing bleeding
ulcers. Heart patients who took a stomach acid-suppressing
proton-pump inhibitor along with
clopidogrel—a drug that prevents blood clots—were only half as likely to be hospitalized for
upper digestive tract bleeding than those who
used clopidogrel alone, according to a study by
researchers from the Vanderbilt University
Medical Center CERT (Annals of Internal
Medicine, March 2010).
- Team-based care interventions for hypertension.
Adding pharmacists and nurses to the teams
that help patients control their blood pressure
(BP) improves outcomes, according to a
systematic review of intervention studies by
researchers at the University of Iowa CERT.
Although nurses, pharmacists within primary
care clinics, and community pharmacists all
served to improve BP control, the greatest
impact was seen for interventions that involved
community pharmacists. The researchers found
that team-based interventions that provided
education about blood pressure medications
were associated with a reduction in mean
systolic BP (SBP) of 8.75 mm Hg and diastolic
BP of 3.6 mm Hg. Pharmacist treatment
recommendations were associated with a mean
SBP reduction of 9.30 mm Hg; intervention by
nurses a 4.80 mm Hg SBP mean reduction;
and use of a treatment algorithm, 4.00 mm Hg
mean SBP reduction. Compared with patients
who received no intervention, patients who
received a nurse intervention were nearly twice
as likely to have controlled BP. Patients who
received interventions from pharmacists in
primary care clinics and community
pharmacists were two to nearly three times
more likely to have controlled BP (Archives of
Internal Medicine, October 2009).
- Antibiotic prescriptions and increased patient
satisfaction with emergency department visits. Even
though antibiotics are ineffective in treating
viral conditions and contribute to antibiotic
resistance, some patients give higher satisfaction
ratings to emergency departments (EDs) that
provide prescriptions for antibiotics, according
to researchers from the University of
Pennsylvania CERT. Surveying 463 patients
who received care at 8 Veterans Administration (VA) EDs and 496 patients seen at 8 non-VA
EDs, researchers found that patients at the non-VA hospitals were more satisfied with their visits
when they received a prescription for
antibiotics. In fact, 64 percent of patients at
non-VA hospitals who received antibiotics
reported high levels of overall satisfaction
compared with 50 percent of patients who did
not receive prescriptions. Receiving antibiotics
did not affect satisfaction levels for patients seen
at VA sites. The authors suggest that because
EDs may be located at the same VA site where
patients receive their primary care services,
followup care may be easier to obtain (Academic Emergency Medicine, October 2009).
More information about the CERTs program can
be found at http://certs.hhs.gov.
Medicaid Medical Directors' Learning Network utilizes comparative effectiveness
review on use of atypical antipsychotic medications
As a result of participating in the Medicaid Medical Directors' Learning Network—an AHRQ
Knowledge Transfer project—three State Medicaid agencies implemented findings from AHRQ's
Effective Health Care Program. Alabama, Connecticut, and Oregon Medicaid agencies used the
Comparative Effectiveness Review Efficacy and Comparative Effectiveness of Off-Label Use of Atypical
Antipsychotics to develop an education program, legislation, and prescribing guidelines.
Atypical antipsychotic medications are second-generation drugs designed to cause fewer neurological
complications than conventional antipsychotics. Some atypical antipsychotics approved to treat
schizophrenia and bipolar disorders are being prescribed off-label for young children with behavior
problems such as attention-deficit disorder and aggression.
Robert Moon, M.D., Medical Director for the Alabama Medicaid Agency, used the review to raise
awareness in an effort to support an Alabama-specific analysis of off-label use. Alabama Medicaid claims
data identified more than 400 children ages 4 years and younger who had received atypical antipsychotic
medications during 2007. Approximately half of these children did not have an FDA-approved
diagnosis; the other half would have had an FDA-approved diagnosis had they been older. Alabama
Medicaid's Pharmacy and Therapeutics Committee convened a multi-agency task force to evaluate these
findings and make recommendations. A two-phase education program was then developed for providers.
In the first phase, educational letters were sent to providers whose prescribing practices differed from
practices generally accepted as evidence-based for antipsychotic medications prescribed to children aged
18 and younger. In the second phase, board-certified child psychiatrists made educational phone calls to
identified prescribers to discuss the use of these medications in children younger than 5 years of age. The
calls did not deny coverage, but explored evidence-based and/or guideline-supported prescribing.
Connecticut Medicaid officials consulted the report during development of legislation for the
Connecticut governor's 2009-2011 budget. That legislation adds behavioral health medications, such as
atypical antipsychotic drugs, to Medicaid's preferred drug list and also provides for the monitoring of the
drugs' use, particularly in children. Robert Zavoski, M.D., M.P.H., Medicaid Medical Director,
Connecticut Department of Social Services, reports that in the past, behavioral medications were exempt
from review by the Medicaid program. However, the AHRQ information, in combination with
Connecticut State data, demonstrated the clear need—not just from a financial point of view, but also
from a clinical point of view—to enhance the review of these medications and monitor their use far
more closely than they had been.
The Oregon Department of Human Services noted that the mental health needs of foster children were
a particular concern for the State. Walter Shaffer, M.D., Medical Director for Oregon's Division of
Medical Assistance, reported that 32 percent of foster children in Oregon were prescribed at least one
psychotropic medication between 2004 and 2006. Shaffer explored the safety concerns of secondgeneration
antipsychotic prescribing patterns in young children, and led a department workgroup on
psychotropic medications for foster children. The workgroup's review was presented to the Oregon Drug
Use Review Board, the body that sets Medicaid drug use policy. The Board used AHRQ's Comparative
Effectiveness Review findings as background material to develop prescribing guidelines for atypical
antipsychotic use in children. Subsequently, a bill was approved by the Oregon legislature in 2009
authorizing annual reviews according to these prescribing guidelines. |
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