Caring for high-need patients.

OBJECTIVE: We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions. METHODS: We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus. RESULTS: The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately. CONCLUSIONS: Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Methods for Identifying Health Research Gaps, Needs, and Priorities: a Scoping Review.

BACKGROUND: Well-defined, systematic, and transparent processes to identify health research gaps, needs, and priorities are vital to ensuring that available funds target areas with the greatest potential for impact. OBJECTIVE: The purpose of this review is to characterize methods conducted or supported by research funding organizations to identify health research gaps, needs, or priorities. METHOD: We searched MEDLINE, PsycINFO, and the Web of Science up to September 2019. Eligible studies reported on methods to identify health research gaps, needs, and priorities that had been conducted or supported by research funding organizations. Using a published protocol, we extracted data on the method, criteria, involvement of stakeholders, evaluations, and whether the method had been replicated (i.e., used in other studies). RESULTS: Among 10,832 citations, 167 studies were eligible for full data extraction. More than half of the studies employed methods to identify both needs and priorities, whereas about a quarter of studies focused singularly on identifying gaps (7%), needs (6%), or priorities (14%) only. The most frequently used methods were the convening of workshops or meetings (37%), quantitative methods (32%), and the James Lind Alliance approach, a multi-stakeholder research needs and priority setting process (28%). The most widely applied criteria were importance to stakeholders (72%), potential value (29%), and feasibility (18%). Stakeholder involvement was most prominent among clinicians (69%), researchers (66%), and patients and the public (59%). Stakeholders were identified through stakeholder organizations (51%) and purposive (26%) and convenience sampling (11%). Only 4% of studies evaluated the effectiveness of the methods and 37% employed methods that were reproducible and used in other studies. DISCUSSION: To ensure optimal targeting of funds to meet the greatest areas of need and maximize outcomes, a much more robust evidence base is needed to ascertain the effectiveness of methods used to identify research gaps, needs, and priorities.

Quality Indicators for High-Need Patients: a Systematic Review.

BACKGROUND: Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS: This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS: The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION: We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.

Evidence-Based Quality Improvement: a Scoping Review of the Literature.

BACKGROUND: Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development. METHODS: In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI? RESULTS: We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes. CONCLUSIONS: EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review.

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

Clinical interventions for adults with comorbid alcohol use and depressive disorders: A systematic review and network meta-analysis.

BACKGROUND: Uncertainty remains regarding the effectiveness of treatments for patients diagnosed with both an alcohol use disorder (AUD) and depressive disorder. This study aimed to compare the effectiveness of clinical interventions for improving symptoms of adults with co-occurring AUDs and depressive disorders. METHODS AND FINDINGS: We searched CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Excerpta Medica Database, International Clinical Trials Registry Platform (ICTRP), PubMed, PsycINFO, and Web of Science from inception to December 2020. We included randomized controlled trials (RCTs) evaluating clinical interventions for adults with co-occurring AUDs and depressive disorders. Two independent reviewers extracted study-level information and outcome data. We assessed risk of bias using the Cochrane Risk of Bias tool, used frequentist random effects models for network meta-analyses, and rated our confidence in effect estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Primary outcomes were remission from depression and alcohol use. Secondary outcomes were depressive symptoms, alcohol use, heavy drinking, health-related quality of life, functional status, and adverse events. We used standardized mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for dichotomous outcomes to estimate intervention effects. Overall, 36 RCTs with 2,729 participants evaluated 14 pharmacological and 4 psychological interventions adjunctive to treatment as usual (TAU). Studies were published from 1971 to 2019, conducted in 13 countries, and had a median sample size of 50 participants (range: 14 to 350 participants). We have very low confidence in all estimates of intervention effects on our primary outcomes (i.e., remission from depression and remission from alcohol use). We have moderate confidence that cognitive behavioral therapies (CBTs) demonstrated greater benefit than no additional treatment (SMD = -0.84; 95% confidence interval [CI], -1.05 to -0.63; p < 0.001) for depressive symptoms and low confidence (SMD = -0.25; 95% CI, -0.47 to -0.04; p = 0.021) for alcohol use. We have low confidence that tricyclic antidepressants (TCAs) demonstrated greater benefit than placebo (SMD = -0.37; 95% CI, -0.72 to -0.02, p = 0.038) for depressive symptoms. Compared with placebo, we have moderate confidence that selective serotonin reuptake inhibitors (SSRIs) demonstrated greater benefit for functional status (SMD = -0.92; 95% CI, -1.36 to -0.47, p < 0.001) and low confidence for alcohol use (SMD = -0.30; 95% CI, -0.59 to -0.02, p = 0.039). However, we have moderate confidence that patients receiving SSRIs also were more likely to experience an adverse event (OR = 2.20; 95% CI, 0.94 to 5.16, p = 0.07). We have very low confidence in all other effect estimates, and we did not have high confidence in any effect estimates. Limitations include the sparsity of evidence on intervention effects over the long term, risks of attrition bias, and heterogeneous definitions of adverse events in the evidence base. CONCLUSIONS: We are very uncertain about the existence (or not) of any non-null effects for our primary outcomes of remission from depression and remission from alcohol use. The available evidence does suggest that CBTs likely reduced, and TCAs may have resulted in a slight reduction of depressive symptoms. SSRIs likely increased functional status, and SSRIs and CBTs may have resulted in a slight reduction of alcohol use. However, patients receiving SSRIs also likely had an increased risk of experiencing an adverse event. In addition, these conclusions only apply to postintervention and are not against active comparators, limiting the understanding of the efficacy of interventions in the long term as well as the comparative effectiveness of active treatments. As we did not have high confidence in any outcomes, additional studies are warranted to provide more conclusive evidence.

Eight Priorities for Improving Primary Care Access Management in Healthcare Organizations: Results of a Modified Delphi Stakeholder Panel.

OBJECTIVE: To identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. BACKGROUND: Studies on healthcare access show its importance for ensuring population health. Few studies show how healthcare organizations can improve access. METHODS: We conducted a modified Delphi stakeholder panel anchored by a systematic review. Panelists (N = 20) represented diverse stakeholder groups including patients, providers, policy makers, purchasers, and payers of healthcare services, predominantly from the Veterans Health Administration. A pre-panel survey addressed over 80 aspects of healthcare organization management of access, including defining access management. Panelists discussed survey-based ratings during a 2-day in-person meeting and re-voted afterward. A second panel process focused on each final priority and developed recommendations and suggestions for implementation. RESULTS: The panel achieved consensus on definitions of optimal access and access management on eight urgent and important priorities for guiding access management improvement, and on 1-3 recommendations per priority. Each recommendation is supported by referenced, panel-approved suggestions for implementation. Priorities address two organizational structure targets (interdisciplinary primary care site leadership; clearly identified group practice management structure); four process improvements (patient telephone access management; contingency staffing; nurse management of demand through care coordination; proactive demand management by optimizing provider visit schedules), and two outcomes (quality of patients' experiences of access; provider and staff morale). Recommendations and suggestions for implementation, including literature references, are summarized in a panelist-approved, ready-to-use tool. CONCLUSIONS: A stakeholder panel informed by a pre-panel systematic review identified eight action-oriented priorities for improving access and recommendations for implementing each priority. The resulting tool is suitable for guiding the VA and other integrated healthcare delivery organizations in assessing and initiating improvements in access management, and for supporting continued research.

Identifying Research Gaps and Prioritizing Psychological Health Evidence Synthesis Needs.

BACKGROUND: Evidence synthesis is key in promoting evidence-based health care, but it is resource-intense. Methods are needed to identify and prioritize evidence synthesis needs within health care systems. We describe a collaboration between an agency charged with facilitating the implementation of evidence-based research and practices across the Military Health System and a research center specializing in evidence synthesis. METHODS: Scoping searches targeted 15 sources, including the Veterans Affairs/Department of Defense Guidelines and National Defense Authorization Acts. We screened for evidence gaps in psychological health management approaches relevant to the target population. We translated gaps into potential topics for evidence maps and/or systematic reviews. Gaps amenable to evidence synthesis format provided the basis for stakeholder input. Stakeholders rated topics for their potential to inform psychological health care in the military health system. Feasibility scans determined whether topics were ready to be pursued, that is, sufficient literature exists, and duplicative efforts are avoided. RESULTS: We identified 58 intervention, 9 diagnostics, 12 outcome, 19 population, and 24 health services evidence synthesis gaps. Areas included: posttraumatic stress disorder (PTSD) (19), suicide prevention (14), depression (9), bipolar disorder (9), substance use (24), traumatic brain injury (20), anxiety (1), and cross-cutting (14) synthesis topics. Stakeholder input helped prioritize 19 potential PTSD topics and 22 other psychological health topics. To date, 46 topics have undergone feasibility scans. We document lessons learned across clinical topics and research methods. CONCLUSION: We describe a transparent and structured approach to evidence synthesis topic selection for a health care system using scoping searches, translation into evidence synthesis format, stakeholder input, and feasibility scans.

Sequelae of an Evidence-based Approach to Management for Access to Care in the Veterans Health Administration.

BACKGROUND: Access to health care is a critical concept in the design, delivery, and evaluation of high quality care. Meaningful evaluation of access requires research evidence and the integration of perspectives of patients, providers, and administrators. OBJECTIVE: Because of high-profile access challenges, the Department of Veterans Affairs (VA) invested in research and implemented initiatives to address access management. We describe a 2-year evidence-based approach to improving access in primary care. METHODS: The approach included an Evidence Synthesis Program (ESP) report, a 22-site in-person qualitative evaluation of VA initiatives, and in-person and online stakeholder panel meetings facilitated by the RAND corporation. Subsequent work products were disseminated in a targeted strategy to increase impact on policy and practice. RESULTS: The ESP report summarized existing research evidence in primary care management and an evaluation of ongoing initiatives provided organizational data and novel metrics. The stakeholder panel served as a source of insights and information, as well as a knowledge dissemination vector. Work products included the ESP report, a RAND report, peer-reviewed manuscripts, presentations at key conferences, and training materials for VA Group Practice Managers. Resulting policy and practice implications are discussed. CONCLUSIONS: The commissioning of an evidence report was the beginning of a cascade of work including exploration of unanswered questions, novel research and measurement discoveries, and policy changes and innovation. These results demonstrate what can be achieved in a learning health care system that employs evidence and expertise to address complex issues such as access management.

Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System.

BACKGROUND: To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies. OBJECTIVE: This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics. RESEARCH DESIGNS: The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics. RESULTS: We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature. CONCLUSIONS: Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain.

OBJECTIVE: Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi. DESIGN: We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an "evidence map," or a visual display, of the literature size and broad estimates of effectiveness for pain. RESULTS: Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs. CONCLUSIONS: There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.

Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.

Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices.

BACKGROUND: Rural areas have historically struggled with shortages of healthcare providers; however, advanced communication technologies have transformed rural healthcare, and practice in underserved areas has been recognized as a policy priority. This systematic review aims to assess reasons for current providers' geographic choices and the success of training programs aimed at increasing rural provider recruitment. METHODS: This systematic review (PROSPERO: CRD42015025403) searched seven databases for published and gray literature on the current cohort of US rural healthcare practitioners (2005 to March 2017). Two reviewers independently screened citations for inclusion; one reviewer extracted data and assessed risk of bias, with a senior systematic reviewer checking the data; quality of evidence was assessed using the GRADE approach. RESULTS: Of 7276 screened citations, we identified 31 studies exploring reasons for geographic choices and 24 studies documenting the impact of training programs. Growing up in a rural community is a key determinant and is consistently associated with choosing rural practice. Most existing studies assess physicians, and only a few are based on multivariate analyses that take competing and potentially correlated predictors into account. The success rate of placing providers-in-training in rural practice after graduation, on average, is 44% (range 20-84%; N = 31 programs). We did not identify program characteristics that are consistently associated with program success. Data are primarily based on rural tracks for medical residents. DISCUSSION: The review provides insight into the relative importance of demographic characteristics and motivational factors in determining which providers should be targeted to maximize return on recruitment efforts. Existing programs exposing students to rural practice during their training are promising but require further refining. Public policy must include a specific focus on the trajectory of the healthcare workforce and must consider alternative models of healthcare delivery that promote a more diverse, interdisciplinary combination of providers.

Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis.

Acupuncture has been suggested as a treatment for posttraumatic stress disorder (PTSD), yet its clinical effects are unclear. This review aims to estimate effects of acupuncture on PTSD symptoms, depressive symptoms, anxiety symptoms, and sleep quality for adults with PTSD. We searched 10 databases in January 2016 to identify eligible randomized controlled trials (RCTs). We performed random effects meta-analyses and examined quality of the body of evidence (QoE) using the GRADE approach to rate confidence in meta-analytic effect estimates. Seven RCTs with 709 participants met inclusion criteria. We identified very low QoE indicating significant differences favoring acupuncture (versus any comparator) at post-intervention on PTSD symptoms (standardized mean difference [SMD] = -0.80, 95% confidence interval [CI] [-1.59, -0.01], 6 RCTs), and low QoE at longer follow-up on PTSD (SMD = -0.46, 95% CI [-0.85, -0.06], 4 RCTs) and depressive symptoms (SMD = -0.56; 95% CI [-0.88, -0.23], 4 RCTs). No significant differences were observed between acupuncture and comparators at post-intervention for depressive symptoms (SMD = -0.58, 95% CI [-1.18, 0.01], 6 RCTs, very low QoE), anxiety symptoms (SMD = -0.82, 95% CI [-2.16, 0.53], 4 RCTs, very low QoE), and sleep quality (SMD = -0.46, 95% CI [-3.95, 3.03], 2 RCTs, low QoE). Safety data (7 RCTs) suggest little risk of serious adverse events, though some participants experienced minor/moderate pain, superficial bleeding, and hematoma at needle insertion sites. To increase confidence in findings, sufficiently powered replication trials are needed that measure all relevant clinical outcomes and dedicate study resources to minimizing participant attrition.

A systematic review of modifiable risk factors in the progression of multiple sclerosis.

BACKGROUND: The presenting symptoms and rate of progression of multiple sclerosis (MS) are very heterogeneous. The diverse clinical manifestations and the clinical course of the disease may vary with modifiable risk factors. OBJECTIVE: To systematically review modifiable risk factors and exposures associated with MS progression. METHODS: We searched six databases till March 2015, reference-mined reviews, and consulted with experts (PROSPERO 2015:CRD42015016461). Two reviewers screened and extracted data. We used random meta-analysis models and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the quality of evidence. RESULTS: In total, 59 studies met inclusion criteria. Lower vitamin D levels were associated with higher Expanded Disability Status Scale (EDSS) scores ( r = -0.22; confidence interval (CI) = -0.32, -0.12; 11 studies; I2 = 66%), smokers had an increased risk of MS progression (hazard ratio (HR) = 1.55; CI = 1.10, 2.19; I2 = 72%; seven studies), and there was no association of MS progression with the use of epidural analgesics during childbirth delivery (three studies). There was insufficient evidence to draw conclusions for 11 risk factors due to conflicting results or use of different predictor and outcome measures. CONCLUSION: MS progression was consistently associated with low vitamin D levels, and smoking was associated with a more rapid decline in MS disability. Studies used a variety of methods, predictors, and outcomes making it difficult to draw conclusions. Future studies should focus on prospective assessments.

A systematic review of the effects of modifiable risk factor interventions on the progression of multiple sclerosis.

BACKGROUND: Several risk factors are associated with multiple sclerosis (MS) progression and may be amenable to intervention. OBJECTIVE: To systematically review the evidence for interventions targeting risk factors for MS progression. METHODS: We searched six databases and existing reviews till March 2015 and consulted with experts to identify randomized controlled trials (RCTs) of interventions targeting MS risk factors (PROSPERO 2015:CRD42015016461). RESULTS: In total, 37 RCTs met inclusion criteria. Expanded Disability Status Scale (EDSS) scores after exercise interventions did not differ compared with untreated controls (standardized mean differences (SMDs): 0.02; confidence interval (CI): -0.40, 0.44; I2: 0%; seven RCTs; very low quality of evidence (QoE)). Dietary interventions did not show a statistically significant effect on the relative risk (RR) of progression (RR: 0.86; CI: 0.67, 1.05; I2: 0%; four RCTs; moderate QoE) compared to placebo. EDSS scores after vitamin D supplementation were not significantly different from placebo (SMD: -0.15; CI: -0.33, 0.02; I2: 0%; five RCTs; very low QoE). CONCLUSION: We did not identify any risk factor interventions with significant effects on MS progression, but the overall QoE was limited. More adequately powered trials are needed on vitamin D supplementation, long-term exercise, and smoking cessation.

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis.

BACKGROUND: Chronic pain patients increasingly seek treatment through mindfulness meditation. PURPOSE: This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults. METHOD: We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use. RESULTS: Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life. CONCLUSIONS: While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

SPOCK3, a risk gene for adult ADHD and personality disorders.

Attention-deficit/hyperactivity disorder (ADHD) is the most frequent psychiatric disorder in children, where it displays a global prevalence of 5 %. In up to 50 % of the cases, ADHD may persist into adulthood (aADHD), where it is often comorbid with personality disorders. Due to a potentially heritable nature of this comorbidity, we hypothesized that their genetic framework may contain common risk-modifying genes. SPOCK3, a poorly characterized, putatively Ca(2+)-binding extracellular heparan/chondroitin sulfate proteoglycan gene encoded by the human chromosomal region 4q32.3, was found to be associated with polymorphisms among the top ranks in a genome-wide association study (GWAS) on ADHD and a pooled GWAS on personality disorder (PD). We therefore genotyped 48 single nucleotide polymorphisms (SNPs) representative of the SPOCK3 gene region in 1,790 individuals (n aADHD = 624, n PD = 630, n controls = 536). In this analysis, we found two SNPs to be nominally associated with aADHD (rs7689440, rs897511) and four PD-associated SNPs (rs7689440, rs897511, rs17052671 and rs1485318); the latter even reached marginal significance after rigorous Bonferroni correction. Bioinformatics tools predicted a possible influence of rs1485318 on transcription factor binding, whereas the other candidate SNPs may have effects on alternative splicing. Our results suggest that SPOCK3 may modify the genetic risk for ADHD and PD; further studies are, however, needed to identify the underlying mechanisms.

How can we recognize continuous quality improvement?

OBJECTIVE: Continuous quality improvement (CQI) methods are foundational approaches to improving healthcare delivery. Publications using the term CQI, however, are methodologically heterogeneous, and labels other than CQI are used to signify relevant approaches. Standards for identifying the use of CQI based on its key methodological features could enable more effective learning across quality improvement (QI) efforts. The objective was to identify essential methodological features for recognizing CQI. DESIGN: Previous work with a 12-member international expert panel identified reliably abstracted CQI methodological features. We tested which features met rigorous a priori standards as essential features of CQI using a three-phase online modified-Delphi process. SETTING: Primarily United States and Canada. PARTICIPANTS: 119 QI experts randomly assigned into four on-line panels. INTERVENTION: Participants rated CQI features and discussed their answers using online, anonymous and asynchronous discussion boards. We analyzed ratings quantitatively and discussion threads qualitatively. Main outcome measure(s) Panel consensus on definitional CQI features. RESULTS: /st> Seventy-nine (66%) panelists completed the process. Thirty-three completers self-identified as QI researchers, 18 as QI practitioners and 28 as both equally. The features 'systematic data guided activities,' 'designing with local conditions in mind' and 'iterative development and testing' met a priori standards as essential CQI features. Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI. CONCLUSIONS: We found consensus among a broad group of CQI researchers and practitioners on three features as essential for identifying QI work more specifically as 'CQI.' All three features are needed as a minimum standard for recognizing CQI methods.

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Falls are common among inpatients. Several reviews, including 4 meta-analyses involving 19 studies, show that multicomponent programs to prevent falls among inpatients reduce relative risk for falls by as much as 30%. The purpose of this updated review is to reassess the benefits and harms of fall prevention programs in acute care settings and to identify factors associated with successful implementation of these programs. We searched for new evidence using PubMed from 2005 to September 2012. Two new, large, randomized, controlled trials supported the conclusions of the existing meta-analyses. An optimal bundle of components was not identified. Harms were not systematically examined, but potential harms included increased use of restraints and sedating drugs and decreased efforts to mobilize patients. Eleven studies showed that the following themes were associated with successful implementation: leadership support, engagement of front-line staff in program design, guidance of the prevention program by a multidisciplinary committee, pilot-testing interventions, use of information technology systems to provide data about falls, staff education and training, and changes in nihilistic attitudes about fall prevention. Future research would advance knowledge by identifying optimal bundles of component interventions for particular patients and by determining whether effectiveness relies more on the mix of the components or use of certain implementation strategies.