AHRQ Report on Cancer Control Interventions

The Agency for Healthcare Research and Quality (AHRQ) has released a new evidence report on cancer control interventions. “Evidence Report/Technology Assessment: Number 79—Diffusion and Dissemination of Evidence-based Cancer Control Interventions” is available online atwww.ahrq.gov/clinic/epcsums/canconsum.htm.

The report evaluated the effectiveness of cancer control interventions. It found that passive approaches (diffusional techniques), such as mailing materials to targeted populations, are generally ineffective. Active approaches (dissemination methods), such as the train-the-trainer model, media campaigns, and educating opinion leaders, are more likely to be effective in promoting change in knowledge, attitudes, and behaviors when used alone or in combination.

For smoking cessation, effective interventions include brief advice by a health care professional, office prompts (e.g., reminder systems, telephone counseling as a single intervention or in combination with other interventions, individual smoking cessation counseling), and media campaigns.

For dietary changes, effective interventions include tailored and multiple contacts directed at high-risk patients. Adequate physician training also was noted as an effective intervention.

For breast cancer screening, effective strategies for increasing mammography include invitations or mailed reminders, office system interventions (i.e., prompts), and financial barrier interventions, especially when a multi-component strategy is undertaken that combines behavior and cognitive interventions.

For cervical cancer screening, effective interventions include office systems (computer or manual chart reminders) and invitations and reminders to patients. There is limited evidence of effectiveness for educational materials, telephone counseling, removal of financial barriers, media campaigns, and advice from health care professionals.

There are inadequate data regarding effective interventions for the control of cancer pain. Promising interventions include the transmission of patient's self-reported pain scales to oncologists, pain education for nursing staff, and the use of daily pain diaries.

Guidelines on Diagnosis and Management of ADHD

The Institute for Clinical Systems Improvement has released a new guideline on attention-deficit/hyperactivity disorder (ADHD). “Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care for School Age Children and Adolescents” is available online atwww.icsi.org.

The presentation of ADHD to the family physician may range from straightforward to quite complex. Many patients who present with learning or behavior problems and who are suspected of having ADHD can be adequately evaluated and managed in the primary care setting, allowing for subspecialty or multidisciplinary consultation in more complex cases.

The guidelines include the following key points:

• Evaluate children and adolescents suspected of having ADHD by using the criteria found in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or the primary care version (DSM-PC). Consistent and appropriate diagnostic tools should be used.

• Screen all patients for other primary conditions or comorbidities and appropriately refer to subspecialty consultation for further evaluation.

• Coordinate a simultaneous multimodal management plan that involves parent-, child-, and school-focused interventions.

• Establish communication and intervention links with related systems (e.g., schools, mental health professionals).

• Establish appropriate use of psychostimulants in initial and ongoing management of patients with ADHD.

• Provide consistent and comprehensive monitoring and care coordination for all patients with ADHD including pharmacologic and non-pharmacologic interventions, identification and management of emerging comorbidities, and the impact of ADHD on patients, their families, and schools.

Regarding pharmacotherapy, stimulant medications are considered first-line therapy because they are effective in 70 to 80 percent of children with ADHD. First-line agents include methylphenidate (Ritalin), dextro-amphetamines (Dexedrine), and amphetamine salts (Adderall), while second-line agents include bupropion (Wellbutrin), guanfacine (Tenex), imipramine (Toframil), desipramine (Norpramine), clonidine (Catapres), and pemoline (Cylert). There is no clear advantage of one first-line stimulant over another, although individual patients may respond differently.

Global Developmental Delay in Children

The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society have released a practice parameter on global developmental delay. “Evaluation of the Child with Global Developmental Delay” appears in the February 2003 issue of Neurology.

Global developmental delay is common and affects 1 to 3 percent of children. Included in the practice parameter are the following key points:

• Routine metabolic screening is not indicated in the initial evaluation of a child with global developmental delay.

• Even in the absence of dysmorphic features or features suggestive of a specific syndrome, routine cytogenetic studies and molecular testing for the fragile X mutation are recommended.

• The diagnosis of Rett syndrome should be considered in girls with unexplained moderate to severe developmental delay.

• Additional genetic studies (e.g., subtelomeric chromosomal rearrangements) also may be considered in selected children.

• Evaluation of serum lead levels should be restricted to those children with identifiable risk factors for excessive lead exposure.

• Thyroid studies need not be undertaken (unless clinically indicated) if the child underwent newborn screening.

• An electroencephalogram is not recommended as part of the initial evaluation unless there are historical features suggestive of epilepsy or a specific epileptic syndrome. Routine neuroimaging, with magnetic resonance imaging preferred to computed tomography, is recommended, particularly if abnormalities are found on physical examination.

• Because of the increased incidence of visual and auditory impairments, children with global developmental delay may undergo appropriate visual and audiometric assessment at the time of diagnosis.

AHRQ Review of Disability and Chronic Fatigue Syndrome

The Agency for Healthcare Research and Quality (AHRQ) has issued results of a systematic review that provides the Social Security Administration with information to evaluate disability in persons with chronic fatigue syndrome. The report is available online atwww.ahrq.gov/clinic/epcsums/cfsdissum.htm.

AHRQ reviewed 53 eligible studies of 4,558 adult patients with chronic fatigue syndrome. Quantitative syntheses were not possible because of insufficient and inconsistent reporting and results. The evidence supported the following conclusions:

• Some patients with chronic fatigue syndrome have discrete cognitive or affective impairments on neuropsychologic tests, but these results are not consistent, nor can causality associated with decreased employment rates be inferred.

• Depression was the only impairment that appeared to be consistently associated with disability or work outcomes.

• No specific interventions were proved effective in restoring a patient's ability to work.

• No specific patient characteristics have been defined that can predict positive employment outcomes in patients with chronic fatigue syndrome.

• It is important to compare the patient's level of functioning at the time of diagnosis with his or her level of functioning prior to the onset of illness, especially as it relates to work, school, social, and home activities.

The AHRQ concludes that more studies are needed to better assess and evaluate disability in patients with chronic fatigue syndrome.