|
EPCs produce evidence reports, technical reviews (covering nonclinical methodological topics), and technology assessments
that are based on rigorous, comprehensive syntheses and analyses of the scientific literature on topics relevant to clinical,
social science/behavioral, economic, and other health care organization and delivery issues. These reports and assessments
emphasize explicit and detailed documentation of methods, rationale, and assumptions and may include meta-analyses and
cost analyses. EPCs collaborate with other medical and research organizations so that a broad range of experts is included
in the development process. The resulting evidence reports and technology assessments are used by Federal and State agencies,
private sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based
health care.
PROJECTS COMPLETED BY THE
MINNESOTA EPC: (click on project title to access list of publications for this project)
Total Knee Replacement (AHRQ Evidence Report/Technology
Assessment Number 86) December 2003
Investigators Robert L. Kane, MD Khaled J. Saleh, MD, MSc, FRCSC
Timothy J. Wilt, MD, MPH Boris Bershadsky, PhD William W. Cross III, BA
Roderick MacDonald, MS Indulis Rutks, BS
In collaboration with the Office of Medical Applications of Research (OMAR), the National Institute
for Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and the TKR Planning Committee, the Agency for Healthcare Research
and Quality (AHRQ) defined the work to be performed for a comprehensive evidence report on the indications for primary TKR
and revisions. The scope of the project specified that it address the following key questions regarding total knee arthroplasty:
|
1. What are the current indications for, and outcomes from, primary total knee
replacement?
|
2. How do specific characteristics of the patient, material and design of the
prosthesis, and surgical factors, affect the short-term and long-term outcomes of primary total knee replacement?
|
3. Are there important perioperative interventions that influence
outcomes?
|
4. What are the indications, approaches, and outcomes for revision total knee
replacement?
|
5. What factors explain disparities in the utilization of total knee replacement
in different populations?
|
6. What are the directions for future research?
|
Jeremy
Holtzman, MD, MS Kathryn Schmitz, PhD, MPH Gail Babes, BA Robert L. Kane, PhD Sue Duval, PhD Timothy J. Wilt, MD, MPH
Roderick MacDonald, MS Indulis Rutks, BS
A majority of adults and over a third of children do not engage in adequate physical activity. Further,
it has been suggested that exercise may have physiologic and psychological benefits for cancer survivors, from the point of
diagnosis and through the balance of life. A review of the literature was conducted to address:
1. What is the evidence that physical activity interventions alone, or combined with diet modification or smoking cessation,
are effective in helping individuals sustainably increase their aerobic physical activity?
a. Is the effectiveness of theoretically-based interventions different?
b. Do hypothesized moderators affect the results of these interventions?
c. Do these interventions affect theoretically-hypothesized mediators?
d. In these interventions, is there a relationship between changes in theoretically hypothesized mediators and changes in
physical activity? 2. What is the evidence that physical activity interventions,
alone or combined with diet modification or smoking cessation, are effective in helping cancer survivors improve their
psychosocial or physiological outcomes?
|
Economic Incentives for Preventive Care (AHRQ Evidence Report/Technology Assessment Number 101) August 2004
Investigators Robert L. Kane, MD Paul E. Johnson, PhD Robert J. Town, PhD Mary Butler, MBA
Evidence was evaluated on the impact of explicit economic incentives targeted at motivating providers
and consumers to adopt preventive health behaviors. The review is designed to 1) help develop more effective preventive strategies
(evidence-based practice) and 2) help inform key stakeholders about the role of such practices (evidence-based policymaking).
The key research questions identified were:
1. How have “preventive care” and “economic
incentive” been defined in the literature?
3. Is there evidence of a dose/response curve?
4. What is the evidence for cost-effectiveness of economic
incentive interventions?
Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic Obstructive Pulmonary Disease (COPD) (AHRQ Evidence Report/Technology Assessment Number 121) September
2005
Investigators
Timothy J. Wilt, MD, MPH Dennis Niewoehner, MD Chun-Bae Kim, MD Robert
L. Kane, MD Amy Linabery, BS James Tacklind, BS Roderick MacDonald,
MS Indulis Rutks, BS
This report was conducted to provide objective evidence and recommendations to inform the work of the
American Thoracic Society, in collaboration with the American Academy of Family Practitioners, the American College of Physicians,
and the American Academy of Pediatrics Spirometry Task Force in clarifying usage of spirometry as part of the management of
COPD. A systematic literature review was undertaken to address four questions:
|
1. What is the prevalence of COPD and airflow obstructions in various adult populations
as defined by 1) spirometry and 2) clinical examination?
|
2. Can use of spirometry lead to increased smoking cessation rates?
|
3. Does the effectiveness of COPD specific therapies to improve clinically relevant
outcomes vary based on baseline severity or change in spirometry?
|
4. Is prediction of future COPD status based on spirometry, with or without clinical
indicators, more accurate than prediction based on clinical indicators alone?
|
The Minnesota EPC was asked to answer the following questions related to elective treatment of nonruptured
AAA that were nominated by America’s Health Insurance Plans:
|
1. What are the comparative effectiveness and adverse effects of treatment options
of AAA including active surveillance, open repair, and endovascular repair?
|
2. What is the relationship of volume, both hospital and
physician, to the benefits and harms of endovascular procedures to repair AAA?
|
3. How do the characteristics of the aneurysm (size/location/shape) and the patient
(age/gender) affect the benefits and harms of endovascular and open-surgical repair?
|
4. What are the costs-benefits for each of the procedures?
|
Nurse Staffing and Quality of Patient Care (AHRQ Evidence Report/Technology Assessment Number 151 March 2007
Investigators Robert L. Kane,
MD Tatyana Shamliyan, MD, MS Christine Mueller, PhD, RN Sue Duval, PhD Timothy J. Wilt, MD, MPH
A shortage of registered nurses, in combination with increased workload, has the potential to threaten
quality of care. Increasing the nurse to patient ratios has been recommended as a means to improve patient safety. However,
the cost effectiveness of increasing RN staffing is controversial. This systematic review analyzes associations between hospital
nurse staffing and patient outcomes with consideration of variables that could influence the primary association. The basic
research questions were:
|
1. How is a specific nurse to patient ratio associated
with patient outcomes (i.e., mortality; adverse drug events, nurse quality outcomes, length of stay; patient satisfaction
with nurse care)? How does this association vary by patient characteristics, nurse characteristics, organizational characteristics,
and nursing outcomes?
|
2. How is a measure of nurse work hours (hours per patient or patient day) associated
with the same patient outcomes?
|
3. What factors influence nurse staffing policies?
|
4. What nurse staffing strategies are effective for improving the patient outcomes
listed in question 1?
|
5. What gaps in research on nurse staffing and patient outcomes can be identified
to address in future studies?
|
Prevention of Fecal and Urinary Incontinence in Adults (AHRQ Evidence Report/Technology Assessment Number 161 December 2007
Investigators Tatyana Shamliyan, MD, MS Jean Wyman, PhD Donna Z. Bliss, PhD, RN, FAAN Robert L. Kane, MD Timothy J. Wilt, MD, MPH
This systematic review was commissioned as background material for an NIH/OMAR State of-the-Science Conference
on the Prevention of Fecal and Urinary Incontinence in Adults. The aims of this review are to synthesize the published evidence
of effective methods to identify individuals at risk and patients with undiagnosed UI and FI in the community and in LTC settings
and to compare the effectiveness of different clinical interventions to prevent the occurrence and progression of UI and FI
in adults. The following questions were developed for this review:
|
|
1. What are the prevalence and incidence of urinary and fecal incontinence in the
community and long-term care settings? How does prevalence differ in race, ethnicity, and gender groups?
|
|
2. What are the independent contributions of risk factors for urinary and fecal incontinence,
including age, functional impairment, institutionalization, parity, childbirth, and postpartum state, menopause, dietary factors,
smoking, obesity, genetic factors, prostate disorders, dementia, psychiatric disorders, specifically depression, diabetes,
urinary tract infection, chronic gastrointestinal conditions, cardiovascular and pulmonary diseases, gastrointestinal, gynecologic,
and urological procedures, neurological disorders, such as stroke and spinal cord problems?
|
|
3. What is the evidence to support specific clinical interventions to reduce the risk
of urinary and fecal incontinence?
|
|
4. What are the strategies to improve the identification of persons at risk and patients
who have urinary and fecal incontinence?
|
|
5. What are the research priorities for identifying effective strategies to reduce
the burden of illness in these conditions?
|
Comparison of Therapies for Clinically Localized Prostate Cancer (AHRQ Comparative Effectiveness Review Number 13) February 2008
Investigators Timothy J. Wilt, MD, MPH
Tatyana Shamliyan, MD, MS Brent Taylor, PhD Roderick MadcDonald, MS
James Tacklind, BS Indulis Rutks, BS Kenneth Koeneman, MD Chin-Soo Cho,
MD Robert L. Kane, MD
This report summarizes evidence comparing the relative effectiveness and safety of treatment options for
clinically localized prostate cancer. The report addresses the following questions:
|
1. What are the comparative risks, benefits, short- and
long-term outcomes of therapies for clinically localized prostate cancer?
|
2. How do specific patient characteristics, e.g., age, race/ethnicity, presence
or absence of comorbid illness, preferences (e.g., tradeoff of treatment-related adverse effects vs. potential for disease
progression), affect the outcomes of these therapies, overall and differentially?
|
3. How do provider/hospital characteristics affect outcomes
overall and differentially (e.g., geographic region and volume)?
|
4. How do tumor characteristics, e.g., Gleason score, tumor volume, screen vs.
clinically detected tumors, affect the outcomes of these therapies, overall and differentially?
|
Carbohydrate & Lipid Disorders & Relevant Consideration in Persons with Spinal Cord Injury (AHRQ Evidence Report/Technology Assessment Number 163) January
2008
Investigators Timothy
J. Wilt, MD, MPH Kathleen F. Carlson, PhD Gary D. Goldish, MD Roderick
MacDonald, MS Catherine Niewoehner, MS Indulis Rutks, BS Tatyana Shamliyan,
MD, MS James Tacklind, BS Brent C. Taylor, PhD Robert L. Kane, MD
|
Based on a topic and key questions nominated by the Consortium for Spinal Cord Medicine, we conducted a systematic
review of published evidence to address the following questions:
|
|
1a. What proportion of adult patients with chronic posttraumatic spinal cord injuries
have been diagnosed with: a. Insulin resistance syndrome, metabolic
syndrome b. Diabetes mellitus Type 2, impaired glucose tolerance c. Dyslipidemia d.
Obesity 1b. Is the prevalence of carbohydrate and lipid disorders higher in the subgroups of
patients by age, race, and gender compared to the general population? Does the prevalence of carbohydrate and lipid disorders
differ by the time after trauma, the level of trauma, and functional impairment? 2. Regarding
risk of cardiovascular disease for people with SCI: a. What is cardiovascular
prevalence and mortality in adults with chronic posttraumatic spinal cord injuries?
b. Does cardiovascular incidence and mortality in adults with chronic posttraumatic spinal cord injuries differ compared to
the general population based on age, race, and gender categories? c.
What is the strength of the association between cardiovascular incidence and mortality and abnormalities in lipid and glucose
metabolism including Type 2 diabetes mellitus after adjustment for possible confounding factors?
d. Does association vary depending on age, gender, race, the duration after SCI, the level of SCI, and functional impairment? 3. What are the effects on carbohydrate or lipid-related outcomes in adults with SCI of:
a. Exercise b. Dietary and pharmacologic interventions
|
Integration of Mental Health/Substance Abuse and Primary Care (AHRQ Evidence Report/Technology Assessment Number 173) October 2008
Investigators Mary Butler, PhD, MBA Robert L. Kane, MD Donna McAlpine, PhD Roger G. Kathol, MD Steven S. Fu, MD, MSCE
Hildi Hagedorn, PhD Timothy J. Wilt, MD, MPH
|
This comprehensive systematic review addresses the evidence for integration of mental health services into
primary care settings and primary services into specialty outpatient settings. The research questions were:
|
|
1. What models of integration have been used?
a. What theoretical models support these programs? b. What is the evidence
that integrated care leads to better outcomes? 2. To what extent does the impact of integrated
care programs on outcomes vary for different populations (e.g., specific mental illness conditions, chronically ill, racial/ethnic
groups, elderly/youth)? 3. What are the identified barriers to successful integration?
a. How were barriers overcome? b. What are the barriers to sustainability? 4. To what extent did successful integration programs make use of health information technology
(IT)? 5. What financial and/or reimbursement structure was employed in successful integration
programs? Is there evidence to suggest that any specific financial/reimbursement strategy is superior to another?
6. What are the key elements of programs that have been successfully implemented and sustained in large health systems? To
what extent do they follow, or how do they differ from, models that have been studied in published research studies?
|
Management of Chronic Hepatitis B (AHRQ Evidence Report/Technology Assessment Number 174) October
2008
Investigators Timothy J. Wilt, MD, MPH Tatyana Shamliyan, MD, MS Aasma Shaukat, MD Brent C. Taylor, PhD, MPH Roderick MacDonald, MS Jian-Min Yuan, MD, PhD James R. Johnson, MD
James Tacklind, BS Indulis Rutks, BS Robert L. Kane, MD
The Minnesota EPC conducted a systematic review to address the following questions for a National Institutes
of Health (NIH) Consensus Conference related to Management of Chronic Hepatitis B in Adults.
|
Consensus conference question 1. What is the natural history of Hepatitis B? EPC question 1. What is the evidence that the following population characteristics or clinical
features associated with hepatitis B are predictive of hepatocellular carcinoma, liver failure, cirrhosis, liver-related death,
and all-cause mortality? Consensus conference question 2. What are the benefits and risks of
the current therapeutic options for hepatitis B with defined or continuous courses of treatment?
EPC question 2a. What is the efficacy (or effectiveness) of interferon therapy, oral therapy, and various combinations in
treating hepatitis B with defined or continuous courses of treatment? EPC question 2b. What
are the known harms of interferon therapy, oral therapy, and various combinations in treating hepatitis B with defined or
continuous courses of treatment? Surrogate outcomes of interest. Alanine aminotransferase (ALT) and/or aspartate
aminotransferase (AST) levels, HBV viral load, change in Hepatitis B e antigen (HBeAg) status, hepatitis B surface antigen
(HBsAg) conversion, liver biopsy findings (necroinflammatory activity or stage of fibrosis), and drug resistance. Clinical
outcomes of interest. hepatocellular carcinoma, liver failure, cirrhosis, liverrelated death, all-cause mortality. Consensus conference question 3. Which persons with hepatitis B should be treated?
EPC question 3a. Are there differences in efficacy/effectiveness of treatments for treatment naïve versus drug-resistant
patients, chronic HBeAg-positive versus HBeAg-negative patients, or for other subpopulations (as defined previously)?
EPC question 3b. Is there evidence that specific subpopulations do not require treatment for hepatitis B (i.e., that the surrogate
and/or clinical outcomes are equivalent or superior when not exposed to treatment?) Consensus
conference question 4. What measures are appropriate to monitor therapy and assess outcomes?
EPC question 4. What is the evidence that changes in surrogate endpoints in response to treatment are reliable predictors
of long-term resolution or slowed progression of disease? Patient Population: Adults (≥ 18 years of age),
including elderly and members of racial/ethnic minority populations.
|
Robert L. Kane, MD Siddharth
Joglekar, MD Susan J. Duval, PhD Marc Swiontkowski, MD Timothy Wilt, MD, MPH
The Minnesota EPC conducted
a systematic review and synthesized the evidence for the effects of surgical treatments for subcapital and intertrochanteric/subtrochanteric
hip fractures on patient-focused outcomes for elderly patients. The
following questions were addressed: 1.
What is the relationship between patient variables, the type of fracture and patient post-treatment outcomes, such as pain
and functioning? 2. What is the relationship between the type
of fracture and patient post-treatment outcomes? 3. What is the relationship between implant
variables and patient post-treatment outcomes? 4. What is the relationship between the type
of intervention and patient post-treatment outcomes?
Investigators
Beth A. Virnig, PhD, MPH Tatyana Shamliyan, MD Todd M. Tuttle, MD
Robert L. Kane, MD Timothy J. Wilt, MD, MPH
The Minnesota EPC conducted a systematic review to address the
following questions for a National Institutes of Health (NIH) Consensus Conference related to Ductal Carcinoma in Situ (DCIS). 1. What are the incidence and prevalence of DCIS and its specific pathologic
subtypes, and how are incidence and prevalence influenced by mode of detection, population characteristics, and other risk
factors? 2. How does the use of MRI or SLNB impact improtant outcomes in patients
diagnosed with DCIS? 3. How do local control and systemic outcomes vary
in DCIS based on tumor and patient characteristics? 4. In patients with
DCIS, what is the impact of surgery, radiation, and systemic treatment on outcomes?
PROJECTS CURRENTLY BEING CONDUCTED BY THE MINNESOTA EPC:
♦ Methods Research: Developing Criteria to Assess Quality and Standards to Report
the Epidemiologic Studies Evaluating the Incidence and Prevalence of Chronic Diseases
♦ Methods
Research: Correcting for Publication Bias in the Presence of Covariates
♦ Lactose Intolerance
and Health
♦ Urinary
Incontinence
♦ Clostridium
difficile (C. difficile) -- Associated Disease (CDAD) ♦
Prevention in Older Adults: Common Syndromes in Older Adults Related to Primary and
Secondary Prevention
♦ Prevention
in Older Adults: Values in Older Adults Related to Primary and Secondary Prevention
♦ Decision
and Simulation Modeling in Systematic Reviews
|