The Effectiveness of Total Worker Health Interventions: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Background: The Total Worker Health (TWH) program of the National Institute for Occupational Safety and Health aims to advance worker well-being by integrating injury and illness prevention efforts with work-related safety and health hazard efforts. Purpose: To evaluate evidence on the benefits and harms of integrated TWH interventions. Data Sources: MEDLINE, Cochrane Library, and PsycINFO (January 1990 through September 2015); clinical trial registries; and reference lists. Study Selection: English-language studies that enrolled employed adults and compared integrated interventions with usual work practice, no intervention, or another intervention. Data Extraction: Dual abstraction and risk-of-bias (ROB) assessment. Data Synthesis: Ten of the 15 included studies had high ROB, primarily because of selection and attrition bias. Findings graded as having low strength of evidence (SOE) supported the effectiveness of TWH interventions for improving smoking cessation, as measured by self-reported 7-day abstinence over 22 to 26 weeks (2 randomized, controlled trials [RCTs]; n = 737), and increasing consumption of fruits and vegetables over 26 to 104 weeks (3 RCTs; n = 6056); results apply to populations of blue-collar manufacturing and construction workers. Findings graded as having low SOE supported the effectiveness of TWH interventions for reducing sedentary work behavior in office workers over 16 to 52 weeks (2 RCTs; n = 262). Evidence was insufficient or lacking for other outcomes of interest, such as rates of work injuries, quality of life, and harms. Limitation: Small, diverse body of evidence with many methodological limitations; possible publication bias. Conclusion: Integrated TWH interventions might improve health behaviors (for example, reduce tobacco use and sedentary behavior and improve diet) of workers, but effects of these interventions on injuries and overall quality of life are not known. Primary Funding Source: Agency for Healthcare Research and Quality.

PCSK9 Inhibitors: Lots of Work Done, Lots More to Do

Update in Hospital Medicine: Evidence Published in 2015

Readmission Rates After Passage of the Hospital Readmissions Reduction Program: A Pre–Post Analysis: Annals of Internal Medicine: Vol 166, No 5

Background: Whether hospitals with the highest risk-standardized readmission rates (RSRRs) subsequently experienced the greatest improvement after passage of the Medicare Hospital Readmissions Reduction Program (HRRP) is unknown. Objective: To evaluate whether passage of the HRRP was followed by acceleration in improvement in 30-day RSRRs after hospitalizations for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia and whether the lowest-performing hospitals had faster acceleration in improvement after passage of the law than hospitals that were already performing well. Design: Pre–post analysis stratified by hospital performance groups. Setting: U.S. acute care hospitals. Patients: 15 170 008 Medicare patients discharged alive from 2000 to 2013. Intervention: Passage of the HRRP. Measurements: 30-day readmission rates after hospitalization for AMI, CHF, or pneumonia for hospitals in the highest-performance (0% penalty), average-performance (>0% and <0.50% penalty), low-performance (≥0.50% and <0.99% penalty), and lowest-performance (≥0.99% penalty) groups. Results: Of 2868 hospitals serving 1 109 530 Medicare discharges annually, 30.1% were highest performers, 44.0% were average performers, 16.8% were low performers, and 9.0% were lowest performers. After controlling for prelaw trends, an additional 67.6 (95% CI, 66.6 to 68.4), 74.8 (CI, 74.0 to 75.4), 85.4 (CI, 84.0 to 86.8), and 95.1 (CI, 92.6 to 97.5) readmissions per 10 000 discharges were found to have been averted per year in the highest-, average-, low-, and lowest-performance groups, respectively, after passage of the law. Limitation: Inability to distinguish between improvement caused by the magnitude of the penalty or by different levels of health improvement in different patient populations. Conclusion: After passage of the HRRP, 30-day RSRRs for myocardial infarction, heart failure, and pneumonia decreased more rapidly than before the law's passage. Improvement was most marked for hospitals with the lowest prelaw performance. Primary Funding Source: National Institutes of Health.

Human Trafficking: The Role of Medicine in Interrupting the Cycle of Abuse and Violence

Human trafficking, a form of modern slavery, is an egregious violation of human rights with profound personal and public health implications. It includes forced labor and sexual exploitation of both U.S. and non-U.S. citizens and has been reported in all 50 states. Victims of human trafficking are currently among the most abused and disenfranchised persons in society, and they face a wide range of negative health outcomes resulting from their subjugation and exploitation. Medicine has an important role to play in mitigating the devastating effects of human trafficking on individuals and society. Victims are cared for in emergency departments, primary care offices, urgent care centers, community health clinics, and reproductive health clinics. In addition, they are unknowingly being treated in hospital inpatient units. Injuries and illnesses requiring medical attention thus represent unique windows of opportunity for trafficked persons to receive assistance from trusted health care professionals. With education and training, health care providers can recognize signs and symptoms of trafficking, provide trauma-informed care to this vulnerable population, and respond to exploited persons who are interested and ready to receive assistance. Multidisciplinary response protocols, research, and policy advocacy can enhance the impact of antitrafficking health care efforts to interrupt the cycle of abuse and violence for these victims.

Let's Not SPRINT to Judgment About New Blood Pressure Goals

Update on Novel Drugs for Primary Care Practice: Drugs Approved by the U.S. Food and Drug Administration in 2015

Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Description: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents. Methods: The USPSTF reviewed the evidence on the benefits and harms of screening; the accuracy of primary care–feasible screening tests; and the benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years. Population: This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD. Recommendation: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I statement)

Genotyping for Human Papillomavirus Types 16 and 18 in Women With Minor Cervical Lesions: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 166, No 2

Background: High-risk human papillomavirus (hrHPV) testing to triage women with minor cervical lesions generates many referrals. Purpose: To evaluate the accuracy of genotyping for HPV types 16 and 18 and its utility as a second triage step after hrHPV testing in women with minor cervical lesions. Data Sources: Searches of 4 bibliographic databases, without language restrictions, from 1 January 1999 to 1 February 2016. Study Selection: Studies involving women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) who were triaged with tests for hrHPV and HPV 16/18 to find cervical intraepithelial neoplasia (grade ≥2 [CIN2+] or grade ≥3 [CIN3+]). Data Extraction: Independent study selection, extraction of data, and quality assessment by 2 reviewers. Data Synthesis: Twenty-four moderate- to good-quality studies involving 8587 women with ASC-US and 5284 with LSIL were found. The pooled sensitivity of HPV 16/18 genotyping for CIN3+ was about 70% for women with either ASC-US or LSIL. The pooled specificity (with a threshold of grade <2 CIN) was 83% (95% CI, 80% to 86%) for women with ASC-US and 76% (CI, 74% to 79%) for those with LSIL. The average risk for CIN3+ was 17% and 19% in HPV 16/18–positive women with ASC-US and LSIL, respectively, and was 5% in hrHPV-positive but HPV 16/18–negative women with either ASC-US or LSIL. Limitation: Methodological and technical heterogeneity among studies; insufficient data to assess accuracy of separate assays. Conclusion: Testing for HPV 16/18 to triage women with minor abnormal cytology is poorly sensitive but may be useful as a second triage test after hrHPV testing, with direct referral if the woman is positive for HPV 16/18. Whether colposcopy or repeated testing is recommended for hrHPV-positive but HPV 16/18–negative women depends on local decision thresholds that can be derived from pretest–posttest probability plots. Primary Funding Source: 7th Framework Programme of the European Commission.

Long-Term Risk for Device-Related Complications and Reoperations After Implantable Cardioverter-Defibrillator Implantation: An Observational Cohort Study: Annals of Internal Medicine: Vol 165, No 1

Background: Long-term nonfatal outcomes after implantable cardioverter-defibrillator (ICD) placement are poorly defined. Objective: To determine the long-term risk for ICD-related complications requiring reoperation or hospitalization and reoperation for reasons other than complications, and to assess associated patient and device characteristics. Design: Observational cohort study of ICD implantations from the National Cardiovascular Data Registry ICD registry linked with Medicare fee-for-service claims data. Setting: 1437 U.S. hospitals. Patients: 114 484 patients aged 65 years or older (mean, 74.8 years [SD, 6.2]; 72.4% male) receiving an ICD for the first time from 2006 to 2010 (single-chamber, 19.8%; dual-chamber, 41.3%; cardiac resynchronization therapy with a defibrillator [CRT-D], 38.9%). Measurements: Rate and cumulative incidence of ICD-related complications requiring reoperation or hospitalization and reoperation for reasons other than complications. Results: During a median follow-up of 2.7 years (interquartile range, 1.8 to 3.9 years), 40 072 patients died, representing 12.6 (95% CI, 12.5 to 12.7) deaths per 100 patient-years of follow-up. When the risk for death was accounted for, there were 6.1 (CI, 6.0 to 6.2) ICD-related complications per 100 patient-years that required reoperation or hospitalization and 3.9 (CI, 3.8 to 4.0) reoperations per 100 patient-years for reasons other than complications. Overall, 10 patients had complications or reoperation per 100 patient-years of follow-up. Younger age at implantation (65 to 69 vs. >85 years) (hazard ratio [HR], 1.55 [CI, 1.43 to 1.69]), receipt of a CRT-D device (HR, 1.38 [CI, 1.31 to 1.45]) versus a single-chamber device, female sex (HR, 1.16 [CI, 1.12 to 1.21]), and black race (HR, 1.14 [CI, 1.05 to 1.23]) were associated with the greatest increased risks for ICD-related complications. Limitation: The analysis was limited to Medicare fee-for-service patients aged 65 years or older. Conclusion: Patients have a high rate of device-related complications and reoperation for other causes after ICD implantation. Risks of ICD implantation and strategies to reduce them should be actively considered before implantation. Primary Funding Source: American College of Cardiology Foundation's National Cardiovascular Data Registry.