Agency For Health Care Policy And Research Guidelines Research Articles

Effect of slow stroke back massage nursing (SSBMN) cutaneus stimulus on pain intensity on sweet food crawings (Arai Pinang) suffering low back pain (LBP)

Low back pain is the most common complaint. About 90% of the causes of LBP are mechanical factors. The normal anatomic structure of the body when used excessively or previously experienced trauma can cause stress or strain on muscles, tendons and ligaments. Actually the pain is minimized by using a back massage. AHCPR (Agency for Health Care Policy and Research) guidelines for non-pharmacological acute pain management are suitable interventions. Non-pharmacological interventions that can be done to treat pain are cutaneous stimulation, distraction, relaxation, guided imagination and hypnosis. This study aims to determine the effect of slow stroke back massage cutaneous stimulus on pain intensity in Ladu snack craftsmen (aria pinang) who suffer from low back pain in Pariaman City. The research design used is a quasi experiment. The number of samples is 14 respondents with purposive sampling technique. The independent variable was slow stroke back massage cutaneous stimulus while the dependent variable was pain intensity. This study used the Wilcoxon signed runk test.

Can Patient Expectations of Returning to Work Documented Before, During, or at the End of Treatment Predict Actual Return to Work Post-treatment? An Evidence-Based Structured Systematic Review.

There is significant evidence that patient expectations can impact their treatment outcomes. The hypothesis of this systematic review was then the following. There will be significant consistent evidence as specified by the Agency for Health Care Policy and Research (AHCPR) guidelines that chronic pain patient (CPP) expectations for returning to work documented before, during, or at the end of treatment will predict actual return to work post-treatment. Of 316 references, 12 studies fulfilled inclusion criteria. These studies analyzed expectations of returning to work documented before, during, or at the end of treatment and utilized these for predicting return to work post-treatment. Relevant aspects of these studies were abstracted into tabular form for numerical analysis. All studies were rated independently by two reviewers for quality. The percentage of the 12 studies supporting the hypothesis was determined. This was then utilized to determine an AHCPR guideline rating for consistency. No studies had a rejection quality score. All studies were type 4. The hypothesis was supported by 91.6% of the studies. According to the AHCPR guidelines, this translated into an A rating: consistent findings from multiple type 4 studies. CPP expectations of returning to work as documented before, during, or at the end of treatment may predict actual return to work post-treatment.

Should We Still Use Red Flags in the Diagnosis of Low Back Pain?

Commentary The landmark clinical practice guideline on acute low back problems in adults published by the Agency for Health Care Policy and Research (AHCPR) in 1994 drew attention to the identification of red flags1. These refer to a group of clinical symptoms and signs that may indicate the potential presence of a serious underlying spine pathology like fracture, malignancy, infection, and cauda equina syndrome or a rapidly progressive neurologic deficit. In the absence of these signs and symptoms, diagnostic testing is not clinically helpful in the first 4 weeks of symptoms. Since then, the identification of red flags has become part of our clinical routine. It has also been adopted in many clinical practice guidelines for low back pain all over the world2. However, the utility of red flags in detecting serious spine pathologies has often been questioned, because of the high false-positive rates, the lack of standardization in the wide variety of red flags, and an overall lack of evidence for the diagnostic accuracy of recommended red flags2,3. The current study by Premkumar et al., “Red Flags for Low Back Pain Are Not Always Really Red. A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain,” provides further insight into the diagnostic accuracy of red flags in low back pain. This is possibly the largest single-center study on the utility of red flags in low back pain, with nearly 10,000 patients completing a standardized questionnaire of red flag questions before seeing their surgeon. The authors found that “while a positive response to a red flag question may indicate the presence of disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis.” They recommended that clinicians use caution when interpreting red flags as screening tools. Red flags are still red. This statement is supported by the increased likelihood of diagnoses of fracture, malignancy, infection, and cauda equina syndrome when there were positive responses to the red flag questions in this study, except for night pain. Combining 2 red flag symptoms increased the likelihood ratios further. Night pain as represented by the red flag question “Pain awakens from sleep” was nonspecific, with high false-positive rates of >85% for malignancy and >96% for infection when no other red flag symptom was present. It was not found to be a useful question to determine any diagnosis. However, it should be noted that night pain was not listed as a red flag in the 1994 AHCPR guideline. The medical history red flags that were related to pain for cancer detection in the AHCPR guideline were “Bed rest no relief” and “Duration of pain >1 month.”1 The clinical practice guideline published jointly by the American College of Physicians (ACP) and the American Pain Society (APS) in 2007 also did not include night pain as a key feature in the diagnostic workup for malignancy and infection, although “awakening due to back pain during the second part of the night…” was listed in the diagnostic workup for ankylosing spondylitis4. Interestingly, this 2007 guideline made no reference to “red flags,” but instead listed key features in the history and physical examination that were almost identical to red flags in the diagnostic workup for possible causes of low back pain. Both the AHCPR and the joint ACP/APS guidelines recommend performing a focused medical history and physical examination during which red flags or key features of serious underlying spine pathology are identified. These red flags or key features form part of the clinical assessment, quite unlike the current study design in which the red flag questions were in a self-administered questionnaire completed before the visit. The findings and recommendations of the current study should be interpreted in the context of its study design. Misinterpretation of the questions and incorrect filling out of the questionnaire could give rise to inaccurate data. The authors acknowledged that it is possible that patients may respond differently to the questions when asked verbally by their physician, who would be available for clarification of the question. It is also unrealistic to expect high sensitivity and specificity of diagnoses from just 2 to 4 questions in a self-administered questionnaire. This study clearly shows the inherent danger of identifying red flags using screening questionnaires alone, as a negative response to some of the red flag questions did not help to rule out red flag diagnoses. Clinical evaluation by medical history and physical examination is still mandatory.

Is Smoking Associated with Alcohol-Drug Dependence in Patients with Pain and Chronic Pain Patients? An Evidence-Based Structured Review

The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs). Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines. In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other. There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure.

Clinical Risk Stratification in the Emergency Department Predicts Long-Term Cardiovascular Outcomes in a Population-Based Cohort Presenting With Acute Chest Pain

The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all EDs in Olmsted County, Minnesota. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of noncardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and at a median follow-up of 7.3 years, and mortality through a median of 16.6 years.The 2271 patients were classified as follows: 436 (19.2%) as high risk, 1557 (68.6%) as intermediate risk, and 278 (12.2%) as low risk. Thirty-day MACCE occurred in 11.5% in the high-risk group, 6.2% in the intermediate-risk group, and 2.5% in the low-risk group (p < 0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate-risk (hazard ratio [HR], 1.91; 95% confidence intervals [CI], 1.33-2.75) and high-risk groups (HR, 2.45; 95% CI, 1.67-3.58). Intermediate- and high-risk patients demonstrated a 1.38-fold (95% CI, 0.95-2.01; p = 0.09) and a 1.68-fold (95% CI, 1.13-2.50; p = 0.011) higher mortality, respectively, compared to low-risk patients at 16.6 years. At 7.3 and at 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk.In conclusion, a widely applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from a more aggressive cardiovascular risk factor management strategy.

The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome

The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

Efficacy of a smoking cessation intervention using the AHCPR guideline tailored for Koreans: a randomized controlled trial

This study was undertaken to evaluate a tailored smoking cessation intervention, which is applicable to Korean culture, using the Agency for Health Care Policy and Research (AHCPR) guideline. On-site counselors provided brief nurse-assisted smoking cessation counseling, including follow-up telephone support, to prevent a relapse in 200 randomly assigned smoking patients. These patients were referred by their physicians regardless of their willingness in smoking cessation in the outpatient department at a university hospital. Nicotine replacement therapy was not provided. Another 201 patients served as a control. After 5 months, current smoking cessation was self-reported on the phone and validated later by a portable carbon monoxide analyzer. After 5 months, the participants in the intervention group were no more likely to quit smoking than the control group. A subgroup analysis by age showed that the intervention among 166 younger smokers (aged 49 or less) was significantly more likely to be effective {risk ratio = 5.76 [95% confidence interval (CI) 1.34-24.74]} than it was among 235 older smokers (aged 50 or more) [risk ratio = 1.03 (95% CI 0.53-1.99)]. This study suggests a smoking cessation intervention using the AHCPR guideline tailored for Koreans, is effective for assisting outpatients aged 49 or younger to quit smoking.

Do The Second-Generation “Atypical Neuroleptics” Have Analgesic Properties? A Structured Evidence-Based Review: Table 1

This is a structured, evidence-based review of all available studies on the potential effectiveness of the atypical neuroleptics for the treatment of pain (analgesia). To determine what evidence, if any, exists for, or against, the effectiveness of the atypical neuroleptics for analgesia. There has been significant controversy over whether the conventional neuroleptics (non-atypicals) have analgesic properties. A recent review (Patt et al. 1994) did conclude that the evidence for effectiveness was sparse, except for methotrimeprazine. However, that review did not include a new class of neuroleptics: the atypicals such as olazapine, risperidone, quetiapine, etc. A computer and manual search for studies relating to the atypicals and their analgesic effectiveness produced 10 studies/reports. These were reviewed in detail, and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized by the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). The strength and consistency of the evidence represented by the 10 studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. Of the 10 studies/reports, four were characterized by AHCPR guidelines as Type II (experimental), two were Type III (quasiexperimental), two were Type IV (nonexperimental), and two were Type V (case reports). Of these studies/reports, 90% indicated that the atypicals did have an analgesic effect. The overall strength and consistency of this evidence using the AHCPR guidelines was, therefore, categorized as B (generally consistent from Type II, Type III, and Type IV studies). Based on the above results, it was concluded that the reviewed data were generally consistent, suggesting that some of the atypicals may have an analgesic effect. There were, however, few double-blind, placebo-controlled studies, and many of the reports/studies had less than 50 patients. As such, this question requires further research.

The incremental value of troponin‐I testing in patients with intermediate risk unstable angina

Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk. The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA. In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification. Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p < 0.001 by chi-square for trend). High troponin-I (> or =2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (> or =0.4 < 2 ng/dl). Of those with high troponin-I, a primary event occurred in 36, 42, and 0% in the respective high-, intermediate-, and low-risk groups (p < 0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p < 0.001. The AHCPR guidelines risk stratify patients with UA. High troponin-I adds significant (p < 0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

Novel therapeutic agents: Do the second generation “atypical neuroleptics” have antinociceptive properties? A structured evidence base review

The objective of this study was to determine if the “atypical neuroleptic” have antinociceptive efficacy. There has been significant controversy over whether the conventional neuroleptics (non-atypicals) have antinociceptive efficacy. A recent reviewer did conclude that the evidence for efficacy was sparse, except for methotrimeprazine. However, this review did not include a new class of neuroleptics: the atypicals such as olazapine, risperidone, quetiapine, etc. A computer and manual search for studies relating to the atypicals and antinociception produced 10 studies. These studies were reviewed in detail, and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized for the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). The strength and consistency of the evidence represented by the 10 studies was then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. Of the 10 studies, four were characterized by AHCPR guidelines as Type II (experimental), two as Type III (quasi-experimental), two as Type IV (non-experimental), and two as Type V (case reports). Of these studies, 90% indicated that the atypicals did have an antinociceptive effect. The overall strength and consistency of this evidence utilizing the AHCPR guidelines was therefore categorized as B (generally consistent from Type II, Type III and Type IV studies). Based on the above results, it was concluded that the reviewed data was generally consistent in indicating that the atypicals may have an antinociceptive effect.

Health care practitioners' motivation for tobacco-dependence counseling.

Smoking cessation counseling by practitioners occurs at low rates in spite of strong evidence that counseling increases quit rates and reduces patient mortality. In a preliminary study, 1060 New York State physicians completed a survey concerning use of the Agency for Health Care Policy and Research (AHCPR) Guidelines, perceived autonomy and perceived competence for counseling, perceived autonomy support from insurers, and barriers to counseling. Considered together, perceived autonomy, perceived competence and perceived autonomy support predicted time devoted to counseling and use of the AHCPR guidelines. The primary, longitudinal study of 220 health care practitioners who attended a smoking cessation workshop predicted change in the practitioners' perceived autonomy and perceived competence for counseling as a function of the degree to which they experienced the workshop instructor as autonomy-supportive. In turn, change in perceived autonomy predicted change in time spent counseling and change in use of the AHCPR guidelines.

A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs.

This is a structured, evidence-based review of all available studies addressing the concept of nonorganic findings: Waddell signs (WSs). To determine what evidence, if any, exists for the various interpretations for the presence of WSs on physical examination. WSs are a group of eight physical findings divided into five categories, the presence of which has been alleged at times to have the following interpretations: Malingering/secondary gain, hysteria, psychological distress, magnified presentation, abnormal illness behavior, abnormal pain behavior, and somatic amplification. At the present time, there is, therefore, significant confusion as to what these findings mean. A computer and manual literature search produced 61 studies and case series reports relating to WSs. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: 1) Reliability (test-retest); 2) Reliability (inter-rater); 3) Reliability (factor analysis); 4) Validity, psychological distress; 5) Validity, correlation Minnesota Multiphasic Pain Inventory (MMPI); 6) Validity, correlation abnormal illness behavior; 7) Validity, other behaviors; 8) Validity, as a nonorganic phenomenon; 9) Validity, correlation pain drawing; 10) Validity, functional performance; 11) Validity, treatment outcome; 12) Validity, predicting surgical treatment outcome; 13) Validity, return to work outcome; 14) Validity, secondary gain correlation; and 15) Validity, pain correlation. Each study in each topic area was classified according to the type of study it represented according to the type of evidence guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 14 study quality criteria was used to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 14 minus the total number of not applicables, and multiplying by 100. Only studies having a quality score of 75% or greater were used to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies in each topic area (above) was then categorized according to the strength and consistency AHCPR guidelines. Conclusions of this review for each topic area are based on these results. Of the 61 studies, four had quality scores below 75% and were not used to generate the results of this review. According to the AHCPR guidelines for strength and consistency of the reviewed data, the following results were obtained: 1) There was consistent evidence for WSs being associated with decreased functional performance, poor nonsurgical treatment outcome, and greater levels of pain; 2) There was generally consistent evidence for WSs not being associated with psychological distress, abnormal illness behavior, or secondary gain; 3) There was also generally consistent evidence that WSs are an organic phenomenon and that they cannot be used to discriminate organic from nonorganic problems; 4) There was inconsistent evidence that WSs do demonstrate inter-rater reliability, do not correlate with the neurotic triad of the MMPI, are associated with poorer surgical treatment outcome, and are associated with nonreturn to work; 5) There was little or no evidence that WSs demonstrate test-retest reliability, or reliable factors, and are associated with self-esteem problems, catastrophizing, or the nonorganic pain drawing. Based on the above results, the following conclusions were made: 1) WSs do not correlate with psychological distress; 2) WSs do not discriminate organic from nonorganic problems; 3) WSs may represent an organic phenomenon; 4) WSs are associated with poorer treatment outcome; 5) WSs are associated with greater pain levels; 6) WSs are not associated with secondary gain; and 7) As a group, WS studies demonstrate some methodological problems.

Is pain fatiguing? A structured evidence-based review.

This is a structured, evidence-based review of all available studies on the coexistence of fatigue and pain. To determine what evidence, if any, exists for or against the existence of an association between fatigue and pain and a potential etiological relationship between pain and fatigue. Pain physicians have noted fatigue as a frequent complaint in chronic pain patients (CPPs), and previous studies have reported the association of fatigue and pain. Computer and manual literature searches for studies relating to fatigue and pain produced 23 reports. These references were reviewed in detail, and information relating to the above problems was abstracted and placed into tabular form. Each report was also categorized for the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 15 quality criteria was utilized in order to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 15 minus the total number of not applicable, and multiplying by 100. Only studies having a quality score of 75% or greater were utilized to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies was then categorized according to the AHCPR guidelines. Conclusions of this review were based on those results. Of the 23 reports, 17 had quality scores of 75% or greater. Of these 17 reports, 94.1% indicated that there was an association between fatigue and pain. In addition, 100% of a subgroup of 13 reports (all with quality scores of 75% or greater) indicated that there may be an etiological relationship between pain and fatigue. The overall strength and consistency of this evidence according to AHCPR guidelines was therefore categorized as A (highly consistent findings from multiple studies). Based on the above results, it was concluded that there is an association between fatigue and pain and that there may be an etiological relationship between pain and fatigue. Pain physicians and other pain treatment professionals should be aware of the high prevalence of fatigue in pain patients. In addition, future research might investigate possible mechanisms for the relationship between pain and fatigue.

Cancer breakthrough pain characteristics and responses to treatment at a VA medical center

The purpose of this study is to analyze cancer breakthrough pain (BP) characteristics and how BP responds to conventional cancer pain management. Seventy-four cancer pain patients with worst pain severity ≥4 out of 10 completed the Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale-Short Form, Functional Assessment Cancer Therapy and Breakthrough Pain Questionnaires (BPQ) at an initial interview. Agency for Health Care Policy and Research (AHCPR) cancer pain management guidelines were followed. Pain syndromes and morphine equivalent daily dose (MEDD) orally were determined. One-week follow-up assessments were obtained in 66 patients with BPI and BPQ. The BP characteristics were similar at both time points. On day 1, 52 patients (70%) had BP, and the BP was unpredictable in 30 patients (58%). The median time to worst BP severity was 3 min. Patients with BP had significantly higher worst pain ( P<0.001). At week 1, the median MEDD doubled from 60 to 120 mg orally, and the number of patients who received adjuvant analgesics doubled from 31.1% (23 patients) on day 1 to 62.2% (41 patients). At week 1, 21 patients (32%) remained without BP, 21 patients (32%) were classified as BP responders and 24 patients (36%) were BP non-responders. The mean pain relief was similar for all three subgroups, i.e. around 80%. Compared to BP responders, BP non-responders had significantly higher worst pain ( P<0.0001), average pain ( P<0.004), and higher BPI interference parameters and shorter time to worst pain severity. The study confirmed the applicability of the BPQ to an US veteran population, and that pain management following the AHCPR guidelines is effective for a group of patients with cancer related BP. Underlying pain syndromes and the BP location may influence the response of BP to treatment. Patients with bone pain located in the spine, back, and pelvis may be at risk for resistant BP.

Continence Care Options for the Long-Term Care Resident: A Supplement to the Journal of the American Medical Directors Association

Urinary incontinence is a common and important clinical problem in long-term care. The subject deserves treatment as a supplement to the Journal of the American Medical Directors Association, the flagship journal for our organization. It is important to primary care physicians involved in long-term care geriatrics as a part of continuity of primary care and for what may be an emerging medical specialty in long-term care geriatrics. In developing this supplement, I have been joined by Karen Prochoda, MD, CMD, an experienced medical director, to discuss the scope of the problem, costs of urinary incontinence, and the impact on residents’ quality of life and to elaborate on regulatory issues. I will provide a basic science foundation of relevant issues in anatomy, physiology, and pharmacology on which the reader may build an understanding of the rationale for the diagnostic process and for treatment. Thomas Lackner, PharmD, CGP, FASCP, will review available data from refereed sources regarding pharmacotherapy for various subtypes of urinary incontinence. Finally, Theodore Johnson, MD, MPH, CMD, will discuss behavioral treatment of urinary incontinence, surgical approaches, incontinence devices, and incontinence garments. He will also enlighten us on appropriate and inappropriate use of urinary catheters and on the assessment of patient preferences in developing a plan for treatment of urinary incontinence. I have recently publicly been somewhat critical of other industry-sponsored journal supplements for continuing medical education. Therefore, I have been specially attuned to avoiding unidentified bias within this supplement. The reader will, however, be aware that the authors of this supplement admit to a slightly more aggressive approach to the management of urinary incontinence with pharmacotherapy or for combined therapy in the long-term care resident than is implied in Agency for Health Care Policy and Research (AHCPR) or American Medical Directors Association (AMDA) clinical practice guidelines. Although this might be attributed to our relationships with the pharmaceutical industry, our clinical reasoning to the contrary is included in the text. The purpose of this supplement is not to replace AHCPR guidelines or AMDA clinical practice guidelines for urinary incontinence but instead to build on these to broaden the reader’s understanding of the subject in light of recent developments in both science and regulation. At times the authors will depart from the aforementioned guidelines, explaining reasons and circumstances for those departures. This is a clear example why guidelines should not be considered as dogmatic, authoritative statements for purposes of survey or litigation. Guidelines are general standards to consider during the process of development of an individualized plan of care for an individual patient/resident. In fact, AMDA guidelines purport to significantly depart from AHCPR guidelines for these same reasons, because care of urinary incontinence in the long-term care setting is significantly different from that in the overall population. The authors offer these potential departures from other guidelines for consideration in appropriate clinical circumstances and caregiving settings. I wish to thank the other authors for their skill and cooperation and the editorial board of Journal of the American Medical Directors Association for the opportunity to coordinate this supplement. I also wish to thank Ortho McNeill for their support through an unrestricted educational grant and the readership for your interest and commitment to the quality of care for the frail elderly.

Using a computerized patient database to evaluate guideline adherence and measure patterns of care for major depression.

This study examined the translation of recommendations from the Agency for Health Care Policy and Research (AHCPR) guidelines for major depression into measures derived from a computerized database to assess guideline conformance and patterns of care for major depression. Patients (n = 208) were identified who were hospitalized for major depression and had two or more outpatient mental health appointments within 6 months of discharge from an academically affiliated Veterans Affairs Medical Center. Measures were based on AHCPR guideline recommendations or developed independently. Conformance could be measured for three guideline recommendations. Of patients on single-agent antidepressant therapy, 87% received dosages within the recommended range. Sixty-nine percent received the recommended number of follow-up visits. Specific condition-related treatment interventions were identified in 32% of patients with concurrent alcoholism. Dual diagnoses of depression and drug or alcohol abuse were not deterrents to prescribing benzodiazepines. Despite its limitations, computerized database analyses provided efficient measures of guideline adherence.

High-risk management guidelines for elderly suicidal patients in primary care settings.

Older adults, especially older white men, are more likely to commit suicide than other age-groups. The assessment and management of suicide ideation and behavior for the elderly is especially relevant for primary care physicians because many patients visit their physician shortly before committing suicide. In 1993, the Agency for Health Care Policy and Research (AHCPR) released clinical practice guidelines for the treatment of depression in primary care settings. The AHCPR guidelines offered some assistance with respect to detecting and treating patients who are suicidal. However, these guidelines lacked detailed and specific instructions for managing high-risk patients within the context of intervention research. The current set of guidelines builds upon this previous work by describing (1) a general approach for interacting with suicidal patients; (2) structured assessments for determining the degree of risk for suicide; (3) crisis intervention strategies; and (4) ongoing management procedures for working with suicidal patients in primary care settings.

Quality indicators for prevention and management of pressure ulcers in vulnerable elders.

Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia, and are stro...

Editorial comment

The issue of either spontaneous bleeding due to BPH or intraoperative and perioperative bleeding, occasionally requiring blood transfusions, has been an integral part of virtually all surgical series for this condition whether they describe open prostatectomy by the suprapubic or retropubic route or TURP. The 1994 Agency for Health Care Policy and Research (AHCPR) “Clinical Practice Guidelines for the Diagnosis and Treatment of Benign Prostatic Hyperplasia” established weighted averages for the need for intervention for bleeding (irrigation, return to operating room for exploration or cystoscopy) and for the need of blood transfusion based on an exhaustive literature review performed in the early 1990s (Table III). It is quite clear that the incidence of intraoperative and perioperative bleeding and the need for blood transfusion are significantly reduced since the publication of most of the series included in the analysis. However, intraoperative bleeding still constitutes a major problem for residents-in-training who have fewer and fewer opportunities to refine their technique of TURP. Postoperative bleeding and need for either catheterization, clot evacuation, or return to the operating room remains a problem, and the estimate made by the AHCPR Guidelines panel of 2.2% is most likely not too far off. Even in the hands of experienced resectionists, it is likely that 1 of every 50 patients will have a problem with postoperative bleeding and/or clots, requiring either a visit to the emergency room or a return to the operating room. TABLE IIIBleeding complications after surgery legend Key: TUIP = transurethral incision of the prostate; TURP = transurethral resection of the prostate. Intervention Bleeding Intervention Blood Transfusion n Weighted Average (%) n Weighted Average (%) Open prostatectomy 7761 1.5 6989 35.1 TUIP 1226 0.5 1243 1.2 TURP 7184 2.2 7603 12.5 legend Key: TUIP = transurethral incision of the prostate; TURP = transurethral resection of the prostate. Open table in a new tab

Chronic pain disability exaggeration/malingering and submaximal effort research.

This is the first review of chronic pain (CP) malingering/disease simulation research. The purpose of this review was to determine the prevalence of malingering within CP patients (CPPs), whether evidence exists that malingering can be detected within CPPs, and to suggest some avenues of research for this topic. A computer and manual literature search produced 328 references related to malingering, disease simulation, dissimulation, symptom magnification syndrome, and submaximal effort. Of these, 68 related to one of these topics and to pain. The references were reviewed in detail, sorted into 12 topic areas, and placed into tabular form. These 12 topic areas addressed the following: existence of malingering within the CP setting; dissimulation, identification simulated (faked) facial expressions of pain; identification of malingering by questionnaire; identification of malingered sensory impairment; identification of malingered loss of hand grip strength; identification of submaximal effort by isometric strength testing; identification of submaximal or malingered effort by isokinetic strength testing; identification of submaximal or malingered effort by the method of coefficient of variation; self-deception; symptom magnification syndrome; and miscellaneous malingering identification studies. Each report, in each topic area, was rated for scientific quality according to guidelines developed by the Agency for Health Care, Policy and Research (AHCPR) for rating the level of evidence presented in the reviewed study. The AHCPR guidelines were then used to rate the strength and consistency of the research evidence in each topic area based on the type of evidence the reports represented. All review conclusions were based on the results of these ratings. Any medical setting reporting on either malingering or disease simulation, or dissimulation, or submaximal effort and pain. Normal volunteers, CPPs, or any group asked to produce a submaximal or malingered effort or a malingered test profile. The reviewed studies indicated that malingering and dissimulation do occur within the CP setting. Malingering may be present in 1.25-10.4% of CPPs. However, because of poor study quality, these prevalence percentages are not reliable. The study evidence also indicated that malingering cannot be reliably identified by facial expression testing, questionnaire, sensory testing, or clinical examination. There was no acceptable scientific information on symptom magnification syndrome. Hand grip testing using the Jamar dynamometer and other types of isometric strength testing did not reliably discriminate between a submaximal/malingering effort and a maximal/best effort. However, isokinetic strength testing appeared to have potential for discriminating between maximal and submaximal effort and between best and malingered efforts. Repetitive testing with the coefficient of variation was not a reliable method for discriminating a real/best effort from a malingered effort. Current data on the prevalence of malingering within CPPs is not consistent, and no conclusions can be drawn from these data. As yet, there is no reliable method for detecting malingering within CPPs, although isokinetic testing shows promise. Claims by professionals that such a determination can be made should be viewed with caution.