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New AHRQ evidence reports focus on allergic rhinitis among U.S. workers and jaundice in newborns

The Agency for Healthcare Research and Quality recently released two new evidence reports, one on allergic rhinitis in the U.S. working population, prepared by the Duke Evidence-based Practice Center (EPC), and the other on managing jaundice in newborn infants, prepared by the Tufts-New England Medical Center EPC. There are 13 AHRQ-supported EPCs. They systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

The goal is to inform health plans, providers, purchasers, and the health care system as a whole by providing essential information to improve health care quality. EPC reports and summaries are published by AHRQ and are available from the AHRQ Publications Clearinghouse.

Allergic rhinitis. Although no studies have found effective treatments for allergic rhinitis, common allergies that affect more than 19 million U.S. workers each year, a review of the scientific literature confirms that some patients can take steps to relieve symptoms, according to this AHRQ evidence report. Direct medical costs for common allergies—which often are caused by pollen, dust mites and pet dander—can range from $1.2 billion to $4.5 billion annually, with an additional $3.2 billion in indirect costs, including the cost of lost work productivity.

The EPC researchers who developed the report, which focuses specifically on management of allergic rhinitis in working adults, did not find much evidence of a direct association between allergic rhinitis and work performance. However, they noted that the physical symptoms of allergies—such as sneezing, nasal congestion, headache, poor concentration, and fatigue—may cause problems on the job for workers affected by the condition. The report, which was requested by the American Association of Health Plans, concludes that treatments that improve symptoms and have minimal side effects will likely improve work performance.

The EPC researchers found evidence that some patients may attain relief with simple steps. For example, those allergic to dust mites can reduce their symptoms by using bedding specifically designed to keep out the mites or by cleaning their homes more often. The evidence report also notes that injections to build immunity can help reduce or eliminate symptoms for both seasonal causes, such as trees and pollen, and year-round causes, such as dust mites and cat dander. In addition, combination treatments such as antihistamines plus decongestants or antihistamines plus steroid nasal sprays work better than using any of these medications alone. The researchers did not find strong evidence that air filtration systems decrease symptoms.

The evidence report outlines potential areas for future research, including identifying which patients are most likely to benefit from injection therapy, studying the effectiveness of longer duration combination treatments for both seasonal and year-round allergic rhinitis, and more thoroughly measuring the effectiveness of environmental controls on the reduction of symptoms. The researchers also call for future studies to include more complete descriptions of the patients being studied that might identify racial or ethnic differences in the use and outcomes of treatment options.

A summary of the report, Allergic Rhinitis in the Working-Age Population, Evidence Report/Technology Assessment No. 67 (AHRQ Publication No. 03-E006), is available from the AHRQ Publications Clearinghouse.

Select to access the summary online. The summary is also available from the National Guideline Clearinghouse™. Select NGC Resources.

The full report (AHRQ Publication No. 03-E015) is in press.

Neonatal jaundice. More research is needed to determine whether using standardized data charts used to plot results from bilirubin measurements based on hours since birth can help clinicians do a better job of predicting potentially serious cases of jaundice in newborns, according to this AHRQ evidence report. Although the EPC researchers who prepared the report did not directly address the appropriateness of universal screening for hyperbilirubinemia, a condition caused by excessive concentrations of bilirubin in the blood, they did examine the various strategies for identifying the condition.

High bilirubin levels cause jaundice and are a major reason for readmission of newborns to the hospital in the first 2 weeks of life. Jaundice, usually indicated by yellow-colored skin and eyes, affects over half of the infants born in the United States each year, but it generally is a temporary condition that clears up without any clinical intervention. However, in rare instances, some babies with high bilirubin levels could develop a potentially fatal disorder known as kernicterus. Kernicterus has a death rate of at least 10 percent and causes brain damage and other serious long-term complications in at least 70 percent of newborns who have it.

This evidence report is based on a review of almost 5,000 abstracts and articles, including a summary of 123 cases of kernicterus in term/near-term infants that spanned more than 30 years. The report was requested by the American Academy of Pediatrics, which last published guidelines on managing hyperbilirubinemia in 1994.

The current practice for diagnosing and treating significant hyperbilirubinemia begins with a visual assessment of the infant for jaundice. If significant hyperbilirubinemia is suspected, a blood test is done to determine the level of bilirubin. Phototherapy (light therapy) is then performed in babies with high bilirubin levels.

Researchers reviewed the literature to determine whether measurements by noninvasive instruments are reliable in identifying babies who need blood tests to confirm high bilirubin levels. They found that measurements by several noninvasive devices traditionally used to examine the pigment of a baby's skin correlated well with bilirubin levels directly measured from blood. They concluded that use of these devices could serve as reliable screening tools to determine which infants should have blood tests performed and, if necessary, be treated with phototherapy. This approach could lead to earlier detection of potentially serious cases of hyperbilirubinemia and may decrease the need for invasive blood tests in those infants found to be at lower risk.

Researchers also suggested that future research is needed to validate newer noninvasive measurement devices and to address issues of cost-effectiveness and reproducibility in clinical practice. In addition, future research should be conducted to validate an hourly age-specific data chart (nomogram) for bilirubin blood levels in healthy full-term infants. An important part of this validation should be an evaluation of potential differences by sex, race, and ethnicity, as well as prenatal, natal, and postnatal factors. Finally, future research in kernicterus would benefit from a uniform definition of the disease, they said.

A summary of the report, Management of Neonatal Hyperbilirubinemia, Evidence Report/Technology Assessment No. 65 (AHRQ Publication No. 03-E005), is available from the AHRQ Publications Clearinghouse.

Select to access the summary online. The summary is also available from the National Guideline Clearinghouse™. Select NGC Resources.

The full report (AHRQ Publication No. 03-E011) is available in print form from the AHRQ Publications Clearinghouse.

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