The treatment of child and adolescent mental health problems in primary care: a systematic review

BACKGROUND: There is significant potential to increase the accessibility and effectiveness of child and adolescent mental health services through the involvement of primary care professionals and the delivery of interventions in the primary care setting. However, little is known about the actual clinical and cost-effectiveness of such service delivery. OBJECTIVE: The aim of the study was to review systematically the evidence concerning the effectiveness of interventions for child and adolescent mental health problems in primary care, and interventions designed to improve the skills of primary care staff. METHODS: Searches were made of The Cochrane Clinical Trials Register, MEDLINE, PSYCINFO, EMBASE and CINAHL, together with correspondence with subject experts and authors of studies, and checking of references in identified papers. RESULTS AND CONCLUSIONS: There was some preliminary evidence that treatments by specialist staff working in primary care were effective, although the quality of included studies was variable and no data were available on the cost-effectiveness of interventions. Equally, some educational interventions show potential for increasing the skills and confidence of primary care staff, but controlled evaluations were rare and few studies reported actual changes in professional behaviour or patient health outcomes. A significant programme of research is required if the potential for child and adolescent mental health services in primary care is to be realized in an effective and efficient way.     

Clinical and cost-effectiveness of donepezil, rivastigmine and galantamine for Alzheimer's disease: a rapid and systematic review

BACKGROUND: Alzheimer's disease is the most common cause of dementia and is characterised by an insidious onset and slow deterioration. The estimated prevalence of Alzheimer's disease for a standard health authority (500,000 people) is about 3330. Current service involves a wide range of agencies, and drug therapy for some patients. OBJECTIVES: To provide a rapid and systematic review of the clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine in the symptomatic treatment of people suffering from Alzheimer's disease. METHODS: A systematic review of the literature was undertaken. METHODS - DATA SOURCES: Searches were made of electronic databases, including MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effectiveness, NHS Economic Evaluation Database, National Research Register, Science Citation Index, BIOSIS, EconLit, MRC Trials database, Early Warning System, Current Controlled Trials, TOXLINE, Index of Scientific and Technical Proceedings, and Getting Easier Access to Reviews. All sources were searched over the period covered by the databases up to March/July 2000. Bibliographies of related papers were assessed for relevant studies and experts were contacted for advice and peer review, and to identify additional published and unpublished references. Manufacturer submissions to the National Institute for Clinical Excellence (NICE) were reviewed. METHODS - STUDY SELECTION: Studies were included if they fulfilled the following criteria: (1) Intervention: donepezil, rivastigmine or galantamine used to treat Alzheimer's disease. (2) Participants: people diagnosed with Alzheimer's disease who meet the criteria for treatment with donepezil, rivastigmine and galantamine. (3) Outcomes: measures assessing changes in cognition, function, behaviour and mood, quality of life (including studies assessing carer well-being and carer-input), and time to institutionalisation. (4) Design: systematic reviews of randomised controlled trials (RCTs) and RCTs comparing donepezil, rivastigmine or galantamine with placebo or each other or non-drug comparators were included in the review of effectiveness. Economic studies of donepezil, rivastigmine or galantamine used to treat Alzheimer's disease that included a comparator (or placebo) and both the costs and consequence (outcomes) of treatment were included in the review of cost-effectiveness. Studies in non-English language, and abstracts and conference poster presentations of systematic reviews, RCTs and economic evaluations were excluded. Two reviewers identified studies by independently screening study titles and abstracts, and then by examining the full text of selected studies to decide inclusion. METHODS - DATA EXTRACTION AND QUALITY ASSESSMENT: Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, with any disagreements resolved through discussion. The quality of RCTs was assessed using the Jadad scale and the quality of systematic reviews was assessed using criteria developed by the NHS Centre for Reviews and Dissemination. The quality of economic evaluation studies was assessed by their internal validity (i.e. the methods used) using a standard checklist, and external validity (i.e. the generalisability of the economic study to the population of interest) using a series of relevant questions. METHODS - DATA SYNTHESIS: The clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine were synthesised through a narrative review with full tabulation of results of all included studies. In the economic evaluation, the reviewers assessed whether adjustments could be made to existing models to reflect the current situation in England and Wales. RESULTS - CLINICAL EFFECTIVENESS: (1) Donepezil--three systematic reviews and five RCTs (plus four studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that donepezil is beneficial when assessed using global and cognitive outcome measures. (2) Rivastigmine--three systematic reviews and five RCTs (plus two studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that rivastigmine is beneficial in terms of global outcome measures. (3) Galantamine--one systematic review and three RCTs (plus three studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that galantamine is beneficial in terms of global, cognitive and functional scales. RESULTS - SUMMARY OF BENEFITS: It is difficult to quantify benefits from the evidence available in the literature. Statistically significant improvements in tests such as ADAS-cog (Alzheimer's Disease Assessment Scale cognitive subscale) may not be reflected in changes in daily life. (ABSTRACT TRUNCATED)     

Do HEDIS measures reflect cost-effective practices?

PURPOSE: Whether the Health Plan Employer Data and Information Set (HEDIS) performance measures for managed care plans encourage a cost-effective use of society's resources has not been quantified. Our study objectives were to examine the cost-effectiveness evidence for the clinical practices underlying HEDIS 2000 measures and to develop a list of practices not reflected in HEDIS that have evidence of cost effectiveness. DATA SOURCES: Two databases of economic evaluations (Harvard School of Public Health Cost-Utility Registry and the Health Economics Evaluation Database) and two published lists of cost-effectiveness ratios in health and medicine. STUDY SELECTION: For each of the 15 "effectiveness of care" measures in HEDIS 2000, we searched the data through 1998 for cost-effectiveness ratios of similar interventions and target populations. We also searched for important interventions with evidence of cost-effectiveness (<$20,000 per life-year [LY] or quality-adjusted life year [QALY] gained), which are not included in HEDIS. All ratios were standardized to 1998 dollars. The data were collected and analyzed during fall 2000 to summer 2001. DATA EXTRACTION: Cost-effectiveness ratios reporting outcomes in terms of cost/LY or cost/QALY gained were included if they matched the intervention and population covered by the HEDIS measure. DATA SYNTHESIS: Evidence was available for 11 of the 15 HEDIS measures. Cost-effectiveness ranges from cost saving to $660,000/LY gained. There are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors. CONCLUSIONS: HEDIS measures generally reflect cost-effective practices; however, in a number of cases, practices may not be cost effective for certain subgroups. Data quality and availability as well as study perspective remain key challenges in judging cost effectiveness. Opportunities exist to refine existing measures and to develop additional measures, which may promote a more efficient use of societal resources, although more research is needed on whether these measures would also satisfy other desirable attributes of HEDIS.     

Review of systematic reviews about the efficacy of non-pharmacological interventions to improve sleep quality in insomnia

Background Insomnia is a very common condition in various populations. Non-pharmacological interventions might offer (safe) alternatives for hypnotics. Aim To evaluate the evidence for efficacy from systematic reviews about non-pharmacological interventions to improve sleep quality in insomnia by a systematic review of systematic reviews and meta-analyses. Search strategy Search strategies were conducted in the Database of Abstracts of Reviews of Effects (2002-July 2008), The Cochrane Database of Systematic Reviews (2000-July 2008) and PubMed (1950-July 2008). Sleep quality was the outcome measure of interest. Selection criteria Systematic reviews about the efficacy of one or more non-pharmacological interventions for insomnia, concerning both adult and elderly populations, were included. Reviews that included studies performed among populations suffering with severe neurological or cognitive impairments or with addictive disorders were excluded. Data analysis Relevant data were extracted. The quality of the reviews found was appraised by using the Overview Quality Assessment Questionnaire. The evidence was appraised and divided into six classes. Results and conclusions Sixteen reviews about 17 interventions were included. Six reviews were of adequate methodological quality. Of these, only one provided an effect size: a moderate effect was found for music-assisted relaxation. Weak evidence indicating a large effect was found for multicomponent cognitive behavioural therapy, progressive muscle relaxation, stimulus control and 'behavioural only'. Weak evidence indicating a moderate effect was found for paradoxical intention. Finally, weak evidence indicating a moderate to large effect was found for relaxation training. Because of the lack of sufficient methodological quality and the lack of calculated effect sizes, most of the included reviews were not suitable for drawing rigorous conclusions about the effect of non-pharmacological interventions on sleep quality in insomniacs. The non-pharmacological treatment of insomnia would benefit from renewed reviews based on a rigorous methodological approach.     

Systematic Reviews in Occupational Health and Safety: where are we and where should we go?

Systematic Reviews have been introduced to improve the synthesis of available evidence and to reduce bias in the conclusions about a body of evidence. Nowadays, Systematic Review is an established method also in the Occupational Safety and Health (OSH) field. It is the Cochrane Work Review Group that facilitates authors to produce Cochrane reviews of intervention topics in this area. A variety of guidelines used Cochrane Work reviews for underpinning their recommendations. Due to the comprehensive search and reproducibility of the methods of a systematic review, it turned out that systematic reviews can be powerful in changing beliefs. For example, studies published in the eighties advocated the use of back schools. Nowadays, we know that the total body of evidence has changed the traditional view that training in lifting techniques could prevent back pain. ‘Sitting is the new smoking’ is an eye catching nicely alliterating motto, but it is of course highly overstated. The findings of a Cochrane review of the effects of interventions to decrease sitting at work showed that sitting time can be reduced by a bit less than two hours per day by providing sit-stand desks plus education. However, it is unclear if this is sufficient to counter the effects of sitting. A wealth of evidence on OSH interventions has been collected by international collaboration in the Cochrane Work Review Group. This can be extended to systematic reviews of the effects of exposure of workers to assess to which risks of adverse health effects they are exposed.Key words: Systematic reviews, effectiveness of interventions, effects of exposures     

Smoking-cessation interventions by type of provider: a meta-analysis

OBJECTIVE: To synthesize the evidence on the effectiveness of smoking-cessation interventions by type of provider. METHODS: A random effects meta-regression was estimated to examine the effect of provider and whether the intervention contained nicotine replacement therapy (NRT), on the intervention's relative risk of quitting as compared to placebo or usual care from studies published in databases from inception to 2000. Thirty additional studies not included in the previous 1996 and 2000 U.S. Public Health Service clinical practice guidelines were used to provide the most comprehensive analysis to date of the comparative effectiveness of different types of providers in interventions for smoking cessation that have been published. RESULTS: The effectiveness without NRT follows: psychologist (1.94, 95% confidence interval [CI]: 1.04-3.62); physician (1.87, CI=1.42-2.45); counselor (1.82, CI=0.84-3.96); nurse (1.76, CI=1.21-2.57); unknown (1.27, CI=0.57-2.82); other (1.18, CI=0.67-2.10); and self-help (1.28, CI=0.89-1.82). Effectiveness of most providers increased by almost twofold with the use of NRT. CONCLUSIONS: Smoking-cessation interventions without NRT delivered by psychologists, physicians, or nurses are all effective. NRT increases the effectiveness of most providers.     

Interventions to Reduce Anticholinergic Burden in Adults Aged 65 and Older: A Systematic Review

IntroductionOlder age is associated with multimorbidity and polypharmacy with high anticholinergic burden (ACB). High ACB is linked to adverse events such as poor physical functioning, dementia, cardiovascular disease, and falls. Interventions are needed to reduce this burden.Aims/ObjectivesThe aim was to systematically review the literature to identify and describe studies of clinical and cost-effectiveness of interventions designed to reduce ACB in adults (≥65 years) on polypharmacy regimes, compared with usual care. The objective was to answer the following questions: What are the contents of the interventions? Were these interventions clinically effective? Were these interventions cost effective?.Design, setting, and participantsSystematic review of interventions to reduce anticholinergic burden in adults aged 65 and older in any clinical setting.MethodsEligible papers reported primary or secondary research describing any type of intervention including systematic reviews, randomized controlled trials (RCTs), controlled clinical trials, or nonrandomized pre-post intervention studies (PPIs) published in English from January 2010 to February 2019. Databases searched included CINAHL, Ovid MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL).ResultsThe search yielded 5862 records. Eight studies (4 RCTs, 4 PPIs) conducted in hospital (4), community (2), nursing homes (1), and retirement villages (1) met the inclusion criteria. Pharmacists, either individually or as part of a team, provided the intervention in the majority of studies (6/8). Most (7/8) involved individual patient medication review followed by feedback to the prescriber. Two of the 4 RCTs and all non-RCTs reported a decrease in ACB following the intervention. No study reported cost outcome.Conclusions/ImplicationsPharmacists may be well placed to implement an ACB reduction intervention. This is the first systematic review of interventions to reduce ACB in older adults, and it highlights the need for development and testing of high-quality pragmatic clinical and cost-effectiveness trials in community and specific patient populations at high risk of harm from ACB.[PROSPERO registration: CRD42018089764].     

Cost‐effectiveness of Occupational Therapy in Older People: Systematic Review of Randomized Controlled Trials

A systematic review of the cost‐effectiveness of occupational therapy for older people was conducted. MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library, OT seeker and unpublished trials registers were searched. Reference lists of all potentially eligible studies were searched with no language restrictions. We included trial‐based full economic evaluations that considered both costs and outcomes in occupational therapy for older people compared with standard care (i.e. other therapy) or no intervention. We reviewed each trial for methodological quality using the Cochrane risk of bias tool and assessed the quality of economic evaluations using a Drummond checklist. In the results of this review, we included five eligible studies (1–5) that were randomized controlled trials with high‐quality economic evaluation. Two studies were full economic evaluations of interventions for fall prevention (1 and 2); two studies were full economic evaluations of preventive occupational therapy interventions (3 and 4; one was a comparison of an occupational therapy group with a social work group); one study was a full economic evaluation of occupational therapy for individuals with dementia (5). Two of the studies (one was preventive occupational therapy [3] and the other was occupational therapy for dementia [5]) found a significant effect and confirmed the cost‐effectiveness of occupational therapy for older people compared with the control group. These studies found that occupational therapy for older people was clinically effective and cost‐effective in comparison with standard care or other therapies. With reference to their clinical implication, these intervention studies (using a client‐centred approach) suggested potentially cost‐effective means to motivate clients to maintain their own health. However, this review has limitations because of the high heterogeneity of the reviewed studies on full economic evaluations of occupational therapy for older people. Future studies on the cost‐effectiveness of occupational therapy in older people are strongly warranted. Copyright © 2015 John Wiley & Sons, Ltd.     

Telerehabilitation in stroke care--a systematic review

We conducted a systematic review of telerehabilitation interventions in stroke care. The following databases were searched: Medline, Embase, DARE-NHSEED-HTA (INAHTA) and the Cochrane Library. Nine studies, all published after 2000, were included in the review. A wide variety of telemedicine interventions in post-stroke rehabilitation care was identified. Four studies had been carried out in the USA, two in the Netherlands, two in Italy and one in China. There were four randomized controlled trials and one qualitative analysis. Four studies used an observational study design/case series. Home-based telerehabilitation interventions showed promising results in improving the health of stroke patients and in supporting caregivers. Telemedicine systems based on a virtual environment for upper extremity exercise can improve the physical health of stroke patients. Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions. There was no evidence regarding the effects on resource utilization or cost-effectiveness. Most studies showed promising results, although overall, the quality of the evidence on telerehabilitation in post-stroke care was low.     

Effectiveness of Dietary Interventions in Prevention and Treatment of Iron-Deficiency Anemia in Pregnant Women: A Systematic Review of Randomized Controlled Trials

Pregnant women are among the population groups most vulnerable to the development of anemia, as the overall iron requirement during pregnancy is significantly higher than in non-pregnant women. The aim of the systematic review was to assess the effectiveness of dietary interventions in the prevention and treatment of iron-deficiency anemia in pregnant women based on randomized-controlled trials. The systematic review was based on the PRISMA guidelines and is registered in the PROSPERO database (CRD42021261235). The search was conducted within PubMed and Web of Science databases for the period until June 2021. The included randomized controlled trials presented effectiveness of dietary interventions in prevention and treatment of iron-deficiency anemia in pregnant women. From the total number of 7825 screened records, the final number of seven studies were included in the systematic review. The procedure of screening, inclusion, reporting, and assessment of the risk of bias while using the revised Cochrane risk of bias tool for randomized trials was conducted by two independent researchers. The studies included in the systematic review were conducted in populations of anemic pregnant women, or mixed populations of anemic and non-anemic pregnant women. The interventions described within the studies were associated with including fortified products, regular products, or dietary counselling. They were based on providing an increased amount of iron, providing an increased amount of multiple nutrients, or general counselling only, while effectiveness was compared with effectiveness of the placebo, supplementation, or control group. The study duration was diversified from a few weeks to half a year or longer. The major biochemical measure assessed within the included studies was hemoglobin. All applied dietary interventions, based on providing increased amount of iron, providing increased amount of multiple nutrients, or general counselling only, were effective. The majority of included studies were assessed as ones of a medium risk of bias. For some studies a high risk of bias was indicated, which resulted from a risk of bias arising from the randomization process, due to deviations from the intended interventions, and in selection of the reported result. Considering this fact, more randomized controlled trials should be planned and conducted in a rigorous manner to confirm the formulated observations of effectiveness of the studied interventions based on providing an increased amount of iron, providing an increased amount of multiple nutrients, or general counselling only.     

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000–2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to ‘over’ nutrition versus ‘under’ nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.     

Effectiveness of Dietary Interventions to Treat Iron-Deficiency Anemia in Women: A Systematic Review of Randomized Controlled Trials

Iron-deficiency anemia is the most frequent nutritional deficiency, with women of reproductive age being particularly at risk of its development. The aim of the systematic review was to assess the effectiveness of dietary interventions to treat iron-deficiency anemia in women based on the randomized controlled trials. The systematic review was conducted according to the PRISMA guidelines and registered in the PROSPERO database (CRD42021261235). The searching procedure was based on PubMed and Web of Science databases, while it covered records published until June 2021. It included all randomized controlled trials assessing effectiveness of various dietary interventions on treatment of iron-deficiency anemia in women of childbearing age. The total number of 7825 records were screened, while 14 of them were finally included in the systematic review. The studies were screened, included, and reported, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials by two independent researchers. The included studies compared the effectiveness of various dietary interventions with supplementation, placebo, control, or any other dietary intervention, while the assessed dietary interventions were based either on increasing iron supply and/or on increasing its absorption (by increasing vitamin C or vitamin D or decreasing phytate intake). The duration of applied intervention was diversified from 3 months or less, through 4 or 5 months, to half of a year or more. Among the assessed biochemical measures, the following were analyzed in majority of studies: hemoglobin, ferritin, transferrin receptor, hematocrit, and transferrin. The majority of included studies supported the influence of dietary interventions on the treatment of iron-deficiency anemia, as the applied dietary intervention was not effective in only three studies. The majority of included studies were assessed as characterized by medium risk of bias, while the overall risk was high for only four studies, which resulted from the randomization process, deviations from the intended interventions, and selection of the reported result. The majority of included studies were conducted for increasing iron supply and/or increasing vitamin C supply; however, only for the interventions including increasing iron supply and simultaneously increasing its absorption by vitamin C supply were all results confirmed effective. Vitamin D also seems to be an effective dietary treatment, but further studies are necessary to confirm the observations. Considering this fact, dietary interventions recommended for anemic female patients should include increased intake of iron and vitamin C.     

Cost-Effectiveness Analyses of Lung Cancer Screening Strategies Using Low-Dose Computed Tomography: a Systematic Review

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.

Objective

The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.

Methods

We searched MEDLINE, EMBASE, EBM Reviews—Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).

Results

The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.

Conclusions

The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.

     

Effectiveness and cost-effectiveness of initial combination therapy with interferon/peginterferon plus ribavirin in patients with chronic hepatitis C in Germany: a health technology assessment commissioned by the German Federal Ministry of Health and Social Security

OBJECTIVES: The purpose of this health technology assessment (HTA), commissioned by the German Federal Ministry of Health and Social Security, was to systematically review the evidence for the effectiveness and cost-effectiveness of antiviral treatment (AVT) with interferon (INF) or peginterferon (PegIFN) in combination with ribavirin (RBV) in treatment-na?ve patients with chronic hepatitis C (CHC) and to apply these data in the context of the German health-care system. METHODS: We performed a systematic literature search on effectiveness and cost-effectiveness of AVT and summarized results using meta-analysis and evidence tables. We applied the German Hepatitis C Model (GEHMO), a decision-analytic Markov model, to determine long-term clinical effectiveness, costs, and incremental cost-effectiveness ratios (ICER) of the examined treatment strategies. Model parameters were derived from German databases, published international randomized clinical trials (RCT), and a Cochrane Review. RESULTS: Overall, nine RCTs, two HTA reports, one Cochrane review, two meta-analyses, and seven economic evaluations met the inclusion criteria. These studies indicate that PegIFN + RBV achieved the highest sustained virological response rates (SVR) (54-61 percent), followed by IFN + RBV (38-54 percent) and IFN monotherapy (11-21 percent). Based on our meta-analysis, PegIFN + RBV reduced cases without SVR by 17 percent compared with INF + RBV. International cost-effectiveness studies indicate that INF+ RBV is cost-effective when compared with INF monotherapy. For PegIFN + RBV, our decision analysis yielded an ICER of 9,800 Euros per quality-adjusted life-year gained. CONCLUSIONS: This HTA suggests that initial combination therapy prolongs life, improves quality of life, and is cost-effective in patients with CHC. Peginterferon plus ribavirin is the most effective and efficient treatment among the examined options. However, because not all chronic hepatitis C patients will develop progressive liver disease, a thorough assessment of the eligibility and appropriateness of treatment with combination therapy must be performed in each individual patient.     

A review of eHealth interventions for physical activity and dietary behavior change

OBJECTIVE: To review eHealth intervention studies for adults and children that targeted behavior change for physical activity, healthy eating, or both behaviors. DATA SOURCES: Systematic literature searches were performed using five databases: MEDLINE, PsychInfo, CINAHL, ERIC, and the Cochrane Library to retrieve articles. STUDY INCLUSION AND EXCLUSION CRITERIA: Articles published in scientific journals were included if they evaluated an intervention for physical activity and/or dietary behaviors, or focused on weight loss, used randomized or quasi-experimental designs, measured outcomes at baseline and a follow-up period, and included an intervention where participants interacted with some type of electronic technology either as the main intervention or an adjunct component. All studies were published between 2000 and 2005. RESULTS: Eighty-six publications were initially identified, of which 49 met the inclusion criteria (13 physical activity publications, 16 dietary behaviors publications, and 20 weight loss or both physical activity and diet publications), and represented 47 different studies. Studies were described on multiple dimensions, including sample characteristics, design, intervention, measures, and results. eHealth interventions were superior to comparison groups for 21 of 41 (51%) studies (3 physical activity, 7 diet, 11 weight loss/physical activity and diet). Twenty-four studies had indeterminate results, and in four studies the comparison conditions outperformed eHealth interventions. CONCLUSIONS: Published studies of eHealth interventions for physical activity and dietary behavior change are in their infancy. Results indicated mixed findings related to the effectiveness of eHealth interventions. Interventions that feature interactive technologies need to be refined and more rigorously evaluated to fully determine their potential as tools to facilitate health behavior change.     

Publication bias in meta‐analyses from the Cochrane Database of Systematic Reviews

We used a Bayesian hierarchical selection model to study publication bias in 1106 meta‐analyses from the Cochrane Database of Systematic Reviews comparing treatment with either placebo or no treatment. For meta‐analyses of efficacy, we estimated the ratio of the probability of including statistically significant outcomes favoring treatment to the probability of including other outcomes. For meta‐analyses of safety, we estimated the ratio of the probability of including results showing no evidence of adverse effects to the probability of including results demonstrating the presence of adverse effects. Results: In the meta‐analyses of efficacy, outcomes favoring treatment had on average a 27% (95% Credible Interval (CI): 18% to 36%) higher probability to be included than other outcomes. In the meta‐analyses of safety, results showing no evidence of adverse effects were on average 78% (95% CI: 51% to 113%) more likely to be included than results demonstrating that adverse effects existed. In general, the amount of over‐representation of findings favorable to treatment was larger in meta‐analyses including older studies. Conclusions: In the largest study on publication bias in meta‐analyses to date, we found evidence of publication bias in Cochrane systematic reviews. In general, publication bias is smaller in meta‐analyses of more recent studies, indicating their better reliability and supporting the effectiveness of the measures used to reduce publication bias in clinical trials. Our results indicate the need to apply currently underutilized meta‐analysis tools handling publication bias based on the statistical significance, especially when studies included in a meta‐analysis are not recent. Copyright © 2015 John Wiley & Sons, Ltd.     

Reporting of adverse events in systematic reviews can be improved: survey results

OBJECTIVE: To assess how information about adverse events is included in systematic reviews. STUDY DESIGN AND SETTING: We included all new Cochrane reviews published in the Cochrane Database of Systematic Reviews (CDSRs) and all new reviews (2003--2004) in the Database of Abstracts of Reviews of Effects (DAREs) in Issue 1 2005 of The Cochrane Library. RESULTS: More than half of Cochrane (44/78) and DARE (46/79) reviews assessed drug interventions. The rest assessed surgery (Cochrane [12]; DARE [10]), psychosocial, educational, or physiotherapy interventions (22; 23). Seventy-six percent (59/78) of Cochrane reviews mentioned adverse events as an outcome compared with 48% (38/79) of DARE reviews. Most reviews mentioning adverse events were of drug interventions (Cochrane [41/59]; DARE reviews [29/38]). Considering reviews that mentioned adverse events, 95% (56/59) of Cochrane reviews included only randomized trials and 73% (43/59) included an analysis of adverse events. For 10 Cochrane reviews, adverse events had not been reported by the included trials. In contrast, 58% (22/38) of DARE reviews mentioning adverse events included only randomized trials, the rest included both randomized and nonrandomized studies. CONCLUSIONS: Most Cochrane reviews of drug interventions considered adverse events. This was not the case for DARE reviews and for Cochrane reviews of nondrug interventions. This could be improved.     

The effectiveness of workplace dietary modification interventions: A systematic review

Objective

To evaluate the effectiveness of workplace dietary modification interventions alone or in combination with nutrition education on employees' dietary behaviour, health status, self-efficacy, perceived health, determinants of food choice, nutrition knowledge, co-worker support, job satisfaction, economic cost and food-purchasing patterns.

Method

Data sources included PubMed, Medline, Embase, Psych Info., Web of Knowledge and Cochrane Library (November 2011). This review was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies were randomised controlled trials and controlled studies. Interventions were implemented for at least three months. Cochrane Collaboration's risk of bias tool measured potential biases. Heterogeneity precluded meta-analysis. Results were presented in a narrative summary.

Results

Six studies conducted in Brazil, the USA, Netherlands and Belgium met the inclusion criteria. Four studies reported small increases in fruit and vegetable consumption (≤ half serving/day). These studies involved workplace dietary modifications and three incorporated nutrition education. Other outcomes reported included health status, co-worker support, job satisfaction, perceived health, self-efficacy and food-purchasing patterns. All studies had methodological limitations that weakened confidence in the results.

Conclusion

Limited evidence suggests that workplace dietary modification interventions alone and in combination with nutrition education increase fruit and vegetable intakes. These interventions should be developed with recommended guidelines, workplace characteristics, long-term follow-up and objective outcomes for diet, health and cost.     

eLearning: a review of Internet-based continuing medical education

INTRODUCTION: The objective was to review the effect of Internet-based continuing medical education (CME) interventions on physician performance and health care outcomes. METHODS: Data sources included searches of MEDLINE (1966 to January 2004), CINAHL (1982 to December 2003), ACP Journal Club (1991 to July/August 2003), and the Cochrane Database of Systematic Reviews (third quarter, 2003). Studies were included in the analyses if they were randomized controlled trials of Internet-based education in which participants were practicing health care professionals or health professionals in training. CME interventions were categorized according to the nature of the intervention, sample size, and other information about educational content and format. RESULTS: Sixteen studies met the eligibility criteria. Six studies generated positive changes in participant knowledge over traditional formats; only three studies showed a positive change in practices. The remainder of the studies showed no difference in knowledge levels between Internet-based interventions and traditional formats for CME. DISCUSSION: The results demonstrate that Internet-based CME programs are just as effective in imparting knowledge as traditional formats of CME. Little is known as to whether these positive changes in knowledge are translated into changes in practice. Subjective reports of change in physician behavior should be confirmed through chart review or other objective measures. Additional studies need to be performed to assess how long these new learned behaviors could be sustained. eLearning will continue to evolve as new innovations and more interactive modes are incorporated into learning.