Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions.

BACKGROUND AND OBJECTIVE: Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population. METHODS: Structured literature review of PubMed and clinicaltrials.gov was conducted to identify relevant studies. Inclusion criteria were studies evaluating ED returns by identifying risk factors and interventions in the pediatric population. Emergency department return was defined as returning to the ED within 1 year after initial visit. Abstract and full text articles were reviewed, and data were abstracted by 2 independent authors. RESULTS: A total of 963 articles were screened and yielded 42 potential relevant articles involving pediatric population. After full text review, a total of 12 articles were included in the final analysis (6 on risk factors and 6 on interventions). Risk factors for pediatric ED return included behavioral/psychiatric problems, younger age, acuity of illness, medical history of asthma, and social factors. Interventions included computer-generated instructions, postdischarge telephone coaching, ED-made appointments, case management, and home environment intervention. Emergency department-made appointments and postdischarge telephone coaching plus monetary incentive improved outpatient follow-up rate but not ED return. Home environment assessment coupled with case management reduced ED returns specifically among asthma patients. CONCLUSIONS: Several patient and visit characteristics can help predict children at risk for ED return. Although some interventions are successful at improving postdischarge follow-up, most did not reduce ED returns.

Chronic venous leg ulcer treatment: future research needs.

The prevalence and costs of chronic venous ulcer care in the US are increasing. The Johns Hopkins University Evidence-Based Practice Center recently completed a systematic review of the comparative effectiveness of advanced wound dressings, antibiotics, and surgical management of chronic venous ulcers. Of 10,066 citations identified in the literature search, only 66 (0.06%) met our liberal inclusion criteria for providing evidence on the effectiveness of interventions for chronic venous ulcers. Based on review of those studies, members of our team and a panel of informed stakeholders identified important research gaps and methodological deficiencies and prioritized specific future research needs. Based on that review, we provide the results of our assessment of future research needs for chronic venous ulcer care. Advanced wound dressings were considered to have the highest priority for future research, followed by venous surgery and antibiotics. An imperative from our assessment is that future research evaluating interventions for chronic venous ulcers meet quality standards. In a time of increasing cost pressure, the wound care community needs to develop high-quality evidence to justify the use of present and future therapeutic modalities.

Setting an agenda for comparative effectiveness systematic reviews in CKD care.

Systematic reviews comparing the effectiveness of strategies to prevent, detect, and treat chronic kidney disease are needed to inform patient care. We engaged stakeholders in the chronic kidney disease community to prioritize topics for future comparative effectiveness research systematic reviews. We developed a preliminary list of suggested topics and stakeholders refined and ranked topics based on their importance. Among 46 topics identified, stakeholders nominated 18 as 'high' priority. Most pertained to strategies to slow disease progression, including: (a) treat proteinuria, (b) improve access to care, (c) treat hypertension, (d) use health information technology, and (e) implement dietary strategies. Most (15 of 18) topics had been previously studied with two or more randomized controlled trials, indicating feasibility of rigorous systematic reviews. Chronic kidney disease topics rated by stakeholders as 'high priority' are varied in scope and may lead to quality systematic reviews impacting practice and policy.

Treatment of degenerative lumbar spinal stenosis.

Spinal stenosis is a narrowing of the vertebral canal that compresses spinal nerves and may cause leg pain and difficulty walking. The symptoms of degenerative lumbar stenosis commonly occur in elderly adults and can be treated conservatively with pain-relieving agents or aggressively with decompressive surgery. Most studies of the effectiveness of treatments are poor in quality; however, there appear to be potential relationships between treatments, patient characteristics, and treatment outcomes. Studies indicate the following: (1) local anesthetic block can reduce symptoms on a short-term basis, while epidural steroids offer no additional benefit; (2) patients with moderate or severe symptoms benefit more from surgery than from conservative therapy; and (3) patients with leg pain and severely restricted walking ability regain mobility after surgery. Definitive evidence-based conclusions about the efficacy of conservative or surgical treatments await the results of well-designed clinical trials.

Recent developments in diagnosis and intervention for aspiration and dysphagia in stroke and other neuromuscular disorders.

This review discusses the impact of the evidence-based report on dysphagia diagnosis and treatment in stroke patients prepared in 1999 by ECRI under contract with the Agency for Healthcare Research and Quality (AHRQ). Subsequent research findings are highlighted and research design and reporting problems in the field are discussed. Progress has been made toward standardizing training and rating of videofluoroscopic studies of swallowing (VFSS); however, a consensus does not yet exist. A randomized, controlled trial demonstrated that treatment directed by fiber-optic endoscopic evaluation of swallowing with sensory testing (FEESST) or VFSS resulted in approximately equivalent pneumonia rates. These two different methods provide both overlapping and complementary information. There is discussion of the research design problems of mixed patients versus homogeneous populations, case-control diagnostic studies, inappropriate calculations of diagnostic sensitivity/specificity using imperfect "gold standards," the lack of concurrent control groups in treatment studies, and the misuse of statistical significance tests and P values in examining matching of patient characteristics in comparative studies and in identifying important variables in regression analysis.