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"effective health care"

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Rating the Strength of Evidence From the Comparative Effectiveness Review

Presentation: Antinuclear Antibody, Rheumatoid Factor, and Cyclic-Citrullinated Peptide Testing for the Evaluation of Musculoskeletal Complaints in Pediatric Populations

Keywords: comparative effectiveness review | strength of evidence | evidence grade | risk of bias | consistency | directness | precision | Quality Assessment of Diagnostic Accuracy Studies | QUADAS

Applicability Resources. Clinical experts and stakeholders can provide general information important to framing applicability issues. What does the population of interest looks like? What types of care or procedures are routine or represent standard of care? Are certain subpopulations characteristically different from others?

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Applicability Resources

Presentation: Assessing Applicability

Keywords: Effective Health Care Program | comparative effectiveness review | stakeholder | population

Judge Applicability and Strength of Evidence Separately. Applicability is best reported separately from quality or strength of evidence. Internal validity concerns are not altered by changes in perspective, but applicability is. Some evidence hierarchies (GRADE) consider applicability “or directness” when assessing the quality of evidence. For systematic reviews in which multiple perspectives (clinician, patient, policymaker) are considered, applicability should be assessed separately.

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Judge Applicability and Strength of Evidence Separately

Presentation: Assessing Applicability

Keywords: applicability | strength of evidence | internal validity | GRADE

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The Comparative Effectiveness Review Development Process

Presentation: Comparative Effectiveness and Safety of Radiotherapy Treatments for Head and Neck Cancer

Keywords: comparative effectiveness review

This slide set is based on a comparative effectiveness review (CER) titled, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin II-Receptor Blockers (ARBs) Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease (IHD), that was developed by the University of Connecticut/Hartford Hospital Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) and is available online at effectivehealthcare.ahrq.gov (Contract No. 290-2007-10067-I). CERs represent comprehensive systematic reviews of the literature usually comparing two or more types of treatment, such as different drugs, for the same disease. Primary clinical trials were identified from searches of MEDLINE (1966 to February 2009), Embase (1974 to February 2009), and the Cochrane Central Register of Controlled Trials (1966 to February 2009). The methods used to develop this CER followed version 1.0 of the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews published by AHRQ (draft available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf).

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Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II-Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Presentation: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: comparative effectiveness | effective health care | angiotensin-converting enzyme inhibitor | angiotensin II-receptor blocker | ischemic heart disease | left ventricular systolic function

This slide set is based on a comparative effectiveness review (CER) titled, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin II-Receptor Blockers (ARBs) Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease (IHD), that was developed by the University of Connecticut/Hartford Hospital Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) and is available online at effectivehealthcare.ahrq.gov (Contract No. 290-2007-10067-I). CERs represent comprehensive systematic reviews of the literature usually comparing two or more types of treatment, such as different drugs, for the same disease. Primary clinical trials were identified from searches of MEDLINE (1966 to February 2009), Embase (1974 to February 2009), and the Cochrane Central Register of Controlled Trials (1966 to February 2009). The methods used to develop this CER followed version 1.0 of the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews published by AHRQ (draft available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf). The talk will cover the current evidence on the burden of cardiovascular disease in the U.S. followed by the available statistics and characteristics of the target population, patients with stable ischemic heart disease (IHD) and preserved left ventricular systolic function (LVSF). We will briefly discuss the comparative effectiveness review process, including the specific questions addressed in this CER and the results from this research. Finally, the benefits and harms of each treatment modality are presented in such a way as to promote doctor-patient communication in order to facilitate an informed decisionmaking process.

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Outline of Material

Presentation: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: effective health care | informed decisionmaking | key questions | comparative effectiveness

The comparative effectiveness review topic, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II-Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease, was nominated in a public process. Sufficient research into the current literature determined that there was a need for the available evidence on the addition of ACEIs and ARBs to standard medical therapy for patients with stable ischemic heart disease and preserved left ventricular systolic function (LVSF) and that there was an adequate number of clinical trials to be included in a comparative effectiveness review (CER). Based on this research, the Agency for Healthcare Research and Quality (AHRQ) commissioned the University of Connecticut/Hartford Hospital Evidence-Based Practice Center to prepare the CER with input from a Technical Expert Panel. This advisory panel was comprised of experts in different specialties, including cardiologists, a cardiovascular pharmacist/pharmacologist, and a health policy pharmacist. The panel identified important issues, reviewed proposed methods, defined parameters for the review of evidence, and helped to refine the key clinical questions that the research would subsequently address. Once formulated, the key clinical questions were published online and were made available for public commentary in order to refine the scope and focus of the research questions. A comprehensive systematic review of the literature was then conducted using several well-known databases, including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. All methods used in the review followed version 1.0 of AHRQ’s Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews (available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf) and the trial end points were determined a priori. Based on the findings of the review, a draft CER was prepared and published online for public comment, and the draft underwent rigorous peer review to improve the final product. After the CER was finalized, the complete report was published on the Internet (available at: http://effectivehealthcare.ahrq.gov/ehc/products/57/335/bodyfinal.pdf) and a condensed version was published in the Annals of Internal Medicine (available at: http://www.annals.org/content/early/2009/10/19/0003-4819-151-12-200912150-00162.full).

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The CER Development Process

Presentation: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: effective health care | peer-review process | systematic review | comparative effectiveness

To determine the strength of the evidence resulting from the systematic review, researchers used the methodology of the University of Connecticut/Hartford Hospital Evidence-Based Practice Center for grading, which is based on the GRADE (Grading of Recommendations, Assessment, DEvelopment) system of the Cochrane Collaboration. This system uses four required domains — risk of bias, consistency, directness, and precision — for assessments. All assessments were made by two investigators who resolved disagreements through discussion. The strength of evidence pertaining to each key question was classified into three broad categories or grades:
1. High means that there are consistent results from good quality clinical trials. Further research is very unlikely to change the conclusions.
2. Moderate means that findings are supported, but further research could change the conclusions.
3. Low means that there are very few clinical trials, or existing trials are flawed.

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Rating the Strength of Evidence From the CER: A Modification of the GRADE Methodology

Presentation: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: effective health care | GRADE | strength of evidence | comparative effectiveness

The CER Development Process (2)Utilization data for rFVIIa was taken from the Perspective Comparative Database of Premier, Inc., in Charlotte, NC (2000–2008). A comprehensive systematic review of the literature was conducted from 10 electronic databases, grey literature, trial registries, and reference lists. Studies on the spectrum of rFVIIa off-label use, effectiveness of rFVIIa for the five AHRQ-selected indications, and studies on the potential harms for the five indications were included. All methods used in the review followed version 1.0 of the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews published by AHRQ (draft available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf). The draft CER was prepared and published online and was subject to public comment and peer review. Once finalized, the complete report was published on the Effective Health Care Program Web site (available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=450).

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The CER Development Process (2)

Presentation: Comparative Effectiveness of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications vs. Usual Care

Keywords: comparative effectiveness | recombinant factor VIIa | off-label | methods | peer review | research process

The CER Development Process (2)A comprehensive systematic review of the literature was then conducted from 12 electronic databases (1990 to September 2009), grey literature, trial registries, and reference lists. Controlled and uncontrolled studies that assessed nonoperative or operative treatments or postoperative rehabilitation for adults with confirmed rotator cuff tears were included. All methods used in the review followed version 1.0 of the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews published by AHRQ (draft available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf). The draft CER was prepared and published online and was subject to public comment and peer review to improve the final product. Once finalized, the complete report was published on the Effective Health Care Program Web site (available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=467) and in the Annals of Internal Medicine (abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/20621893).

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The CER Development Process (2)

Presentation: Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears

Keywords: comparative effectiveness | methods | peer review | research process

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Evidence-Based Health Care

Presentation: Introduction to the User’s Guide for Developing a Protocol for Observational Comparative Effectiveness Research

Keywords: evidence-based health care | patient-centered outcomes research | informed treatment decisions

Patient Discussion: Treatment
You suggest to this patient that they discuss the possibility of adding an ACEI to his current medications. In order to do this, you review with him a patient guide titled, “ACE Inhibitors” and “ARBs” To Protect Your Heart? A Guide for Patients Being Treated for Stable Coronary Heart Disease, from the Effective Health Care Program website at: http://effectivehealthcare.ahrq.gov. You explain to him that the guide is based on a review of multiple studies about specific medications for patients with stable ischemic heart disease.

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Patient Discussion: Treatment

Presentation: Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

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