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AHRQ releases five new evidence reports

Five new evidence report summaries were released recently by the Agency for Healthcare Research and Quality. They represent the results of systematic reviews of the evidence on diagnosis and management of dental caries, management of cancer pain, management of newly diagnosed epilepsy patients, management of uterine fibroids, and the use of telemedicine for the Medicare population. The reports were prepared by Evidence-based Practice Centers (EPCs) supported by the Agency for Healthcare Research and Quality. They provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies.

There are 12 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.

Evidence report summaries are now available from AHRQ, both online and in print copies from the AHRQ Publications Clearinghouse. Copies of the full evidence reports will be available in the near future.

Diagnosis and Management of Dental Caries

Dental caries, or cavities, affect more than 90 percent of adults in the United States. Due to changes in the epidemiology of this chronic infectious disease, about 25 percent of children aged 5 to 17 suffer about 75 percent of the disease burden in this population. Today, there are interventions to arrest or reverse the demineralization process that characterizes the development of a carious lesion, and there are several strategies for identifying individuals who are likely to experience an elevated incidence of dental caries.

The Research Triangle Institute/University of North Carolina at Chapel Hill EPC (contract 290-97-0011) developed this evidence report for AHRQ. The National Institute of Dental and Craniofacial Research cosponsored the development of this report. It focuses on the methods used in caries diagnosis, the efficacy of nonsurgical strategies to arrest or reverse the progress of carious lesions before tooth tissue is lost, and the efficacy of preventive methods among individuals at risk for an elevated incidence of carious lesions.

The review revealed few assessments of the performance of any diagnostic methods for primary or anterior teeth and no assessments of performance on root surfaces. There was insufficient evidence to make definitive statements about performance of most diagnostic methods. The EPC found only five studies addressing management of noncavitated carious lesions, and thus, the evidence was rated as incomplete. With regard to the management of caries-active individuals, the EPC researchers evaluated nine management methods: fluoride varnishes, topical solutions, and rinses; chlorhexidine varnishes, topicals, and rinses; combined chlorhexidine-fluoride applications and sealants; and other approaches. The evidence was rated as fair for the efficacy of fluoride varnishes; for all other methods, the evidence was deemed incomplete.

A summary (AHRQ Publication No. 01-E055) of the report is now available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E056) from which this summary was drawn is expected to be available from AHRQ in spring 2001.

Management of Cancer Pain

Although there is a huge body of scientific research on cancer biology, the quality and quantity of research on the management of cancer pain lags far behind, according to researchers at the New England Medical Center EPC (contract 290-97-0019). They conducted a systematic literature review on the topic for AHRQ. The EPC found, overall, that the solid evidence which exists on specific therapies—such as antiinflammatory drugs or opioids—is overshadowed by inadequate guidance on more complex choices now expected of front-line clinicians.

In particular, the EPC found little research on quality of life in relation to pain control, drug interactions during long-term cancer pain treatment, the optimal sequence of adding drugs to improve pain control, how best to combine drug with non-drug therapies, and the impact that ethnicity has on cancer pain and patients' responses to treatment. Also, the researchers found almost no analgesic drug trials in children with cancer pain, and vulnerable populations—minorities, women, children and the elderly—continue to be at increased risk of being underassessed and undertreated for pain.

The EPC found that the number of patients enrolled in methodologically sound studies of cancer pain relief is a tiny fraction of those receiving care, about 1 in 10,000 patients, a much lower percentage than for nearly all other high-impact, costly conditions. In addition, there often are too few patients enrolled in trials of cancer pain treatments to draw firm conclusions about the treatments under study. These new findings echo earlier calls by pioneers in the field to improve the quality and statistical power of clinical trials in cancer pain relief.

A summary (AHRQ Publication No. 01-E033) is available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E034) will be available from AHRQ in the near future.

Management of Newly Diagnosed Patients with Epilepsy

This evidence report was developed for AHRQ and the Centers for Disease Control and Prevention by the MetaWorks Evidence-based Practice Center (contract 290-97-0016). It indicates that the scientific literature supports the use of a complete history and physical examination—including neuropsychologic assessment and a standard EEG—to diagnose epilepsy, prevent delayed or missed diagnoses, and predict remission outcomes.

The EPC researchers also found that other diagnostic tests, such as CT scan or MRI, are more important in ruling out secondary causes of seizures or to resolve uncertain diagnoses. The researchers also note that the clinical and pharmacologic expertise of the treatment team in selecting and monitoring antiepileptic drugs, periodic blood tests, and cognitive tests in children plays an important role in determining patient outcomes.

This topic was nominated as an EPC evidence report by the Centers for Disease Control and Prevention as part of an effort to develop a framework for providing optimal care to patients with chronic diseases that are limited in prevalence. The EPC reviewed 120 studies taken from 13,128 citations; they conclude that there are limitations in the available evidence, such as no gold standard for diagnosis, poorly defined and inconsistent patient populations, inconsistent terminology, and lack of patient-centered outcomes.

A summary (AHRQ Publication No. 01-E037) of the report is available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E038) will be available from AHRQ in spring 2001.

Management of Uterine Fibroids

Uterine leiomyomata, or fibroids, are benign tumors of the uterus made up of smooth muscle and the extracellular matrix proteins collagen and elastin. They are very common; as many as three in ten women aged 25 to 45 are affected. Fibroids can cause abnormal uterine bleeding, dysmenorrhea, and noncyclic pelvic pain. They also are associated with infertility and an increased risk of complications of pregnancy, and they can contribute to symptoms related to an enlarging pelvic mass.

Researchers at the Duke University Evidence-based Practice Center (contract 290-97-0014) reviewed the available evidence on the benefits, risks, and costs of commonly used medical and invasive therapies for uterine fibroids, primarily those treatments currently available in the United States. Their most significant findings have to do with treatment for uterine fibroids in black women. Black women of any age who have uterine myomata—commonly called fibroids—are more likely to have them surgically removed through a myomectomy, a procedure that preserves the uterus, than are white or Hispanic women with fibroids. While the EPCs' research confirmed earlier studies which showed that black women have higher rates of hysterectomy than any other racial group, the researchers found that black women also have higher rates of myomectomy.

The incidence of fibroids is higher in black women than in other racial groups, and black women tend to have larger and more numerous fibroids when first diagnosed, so they are more likely to need treatment than any other racial group. The rate of hysterectomies among black women with fibroids is higher than that for white women (50 percent vs. 30 percent), and the EPC found that black women are more likely than women of other racial groups to undergo surgery, either by myomectomy or hysterectomy, to treat their fibroids. The EPC researchers conclude that the high rate of hysterectomy among black women with fibroids does not appear to be because they are not offered more conservative surgery. The scope of the report did not include an examination of reasons why black women have so many hysterectomies in general.

In their review of the available evidence on uterine fibroids, the EPC found that the majority of published studies did not provide clear answers about optimal treatments. The researchers found tremendous differences in incidence and outcomes among racial groups, and they urge that more research be conducted to provide clear evidence to help women make informed decisions about the best treatment for their situation.

A summary (AHRQ Publication No. 01-E051) of the report is available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E052) will be available from AHRQ in late spring 2001.

Telemedicine for the Medicare Population

Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes when distance separates the users. The Oregon Health Sciences University EPC (contract 290-97-0018) developed an evidence report on this topic for AHRQ. The researchers assessed specific telemedicine study areas, with a focus on practices that would substitute for face-to-face medical diagnosis and treatment in the Medicare population.

In the report, the EPC researchers identify health care services that could be provided using telemedicine and describe existing programs in three categories: store-and-forward, self-monitoring/testing, and clinician-interactive services. They also summarize scientific evidence on the efficacy, safety, and cost-effectiveness of these services; identify gaps in the evidence; and make recommendations for evaluating telemedicine services.

The EPC researchers found that the use of telemedicine is limited at this time but growing. Active programs demonstrate that the technology can work, and the growing number of programs indicates that telemedicine can be used beneficially from clinical and economic standpoints. The evidence for the efficacy of telemedicine is less clear. In many of the studies reviewed by the EPC, the study methodology precluded definitive statements. Studies often had small sample sizes, did not focus on clinical settings, and/or involved patient populations that might be less likely than others to benefit from improved health services, such as people with complex chronic diseases.

A summary (AHRQ Publication No. 01-E011) of the report is available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E012) will be available in spring 2001.

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