Comparative Effectiveness Of Interventions Research Articles

Comparative efficacy, safety and cost of oral Chinese patent medicines for rheumatoid arthritis: a Bayesian network meta-analysis

BackgroundRheumatoid arthritis (RA) is a common inflammatory disease with a substantial burden for society and economic worldwide. Chinese patent medicines (CPMs) have gained attention as alternative remedies due to they can exert the satisfactory therapeutic effects via holistic regulation. Currently, several oral Chinese patent medicines are routinely recommended for managing and treating RA. Therefore, a network meta-analysis (NMA), which tries to synthesize evidences for a decision making by evaluating the comparative effectiveness of multiple interventions against the same disease, was undertaken to identify the optimal intervention according to their efficacy in clinical treatment and symptom remission, safety profile and daily cost.MethodsRandomized controlled trials (RCTs) regarding CPMs to treat RA were comprehensive retrieved from 3 foreign databases and 4 Chinese databases, and the retrieved results were last updated on January 10, 2019. The bias of the selected trials was assessed by two individuals independently through RoB2. A random-effects model was adopted during the meta-analytic procedures, and outcomes concerning efficacy and safety were evaluated as odds ratios (OR), mean differences (MD) and 95% credible intervals (CI) utilizing Stata 14.1 and WinBUGS 1.4.3 software. Furthermore, the cluster analysis and comprehensive investigation were preformed concerning the comparative efficacy, safety and cost of oral CPMs.ResultsOne hundred sixteen RCTs involving 10,213 individuals met the inclusion criteria and were enrolled into current NMA. The results from existing evidence indicated that Biqi capsule and Yuxuebi capsule probably had a favorable balance in consideration of benefits, tolerability and daily cost. Furthermore, as the least expensive choice, glucosides of Tripterygium Wilfordii tablet was associated with displaying a trend of relieving joint tenderness, joint swelling, and morning stiffness for patients with RA.ConclusionBiqi capsule, Yuxuebi capsule and glucosides of Tripterygium Wilfordii tablet were recommended for treating RA based on the favorable benefits in both clinical efficacy and symptoms, and they, meanwhile, might be associated with the more tolerable and acceptable therapeutic alternative in terms of safety profile and daily cost. Nevertheless, the additional results from high-quality, multi-center and head-to-head trials would be pivotal for supporting our findings.

Abstract A030: Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects and cost effectiveness

Abstract Purpose: Latinas suffer disproportionately from breast cancer relative to non-Latina Whites, partially due to lower guideline-concordant screening. Multiple approaches are used to address this disparity including educational interventions and empowerment-related interventions, wherein a subset of the population is trained to share information with other members of the priority population. However, little is known about the relative effects of these different approaches. Objective: To analyze preliminary data regarding the effectiveness and cost-effectiveness of education and empowerment approaches. Methods: This ongoing, quasiexperimental trial is situated in two lower-income Latino communities in Chicago. Eligibility criteria include: 1) age of 52-74; 2) no mammography use within past 2 years; 3) no previous breast cancer diagnosis; and 4) no prior health volunteerism experience. Women are assigned to a cohort and participate in a three-week intervention (education: breast cancer, diet, physical activity; empowerment: breast cancer, sharing information with networks, health volunteerism). For women who wish to obtain mammography (from either arm), the study team provides navigation to free/low-cost services. Data collected at baseline, post-intervention, and six-month follow-up include standard demographics and self-reported mammography use, which are verified by study navigation records. The perspective for cost-effectiveness analyses was the community-based organization implementing the program. Cost data include overhead, non-personnel, and personnel costs (per task, per person encounter). Cost data were standardized to US dollars in 2018 and extrapolated to the duration of study implementation. Results: Our current sample is 97 women (51 education; 46 empowerment). Most women were 52-64 years old (70%), had insurance (58%), had less than a 9th grade education (60%), had an annual household income of <$15,000 (67%), and were born in Mexico (86%). More empowerment participants obtained a mammogram than education participants, after adjusting for age, education, income, insurance, mammography history, and mammography plans (47% vs. 74%; OR = 3.2, 95%CI [1.1, 9.00], p=.001). The empowerment intervention was also less expensive. The costs for education and empowerment interventions were $32,919 and $24,983 ($645 and $490 per person), respectively. Hence, empowerment appears to be a dominant strategy. Discussion: Empowerment approaches may be more effective and more cost effective in promoting mammography than education approaches among non-adherent Latinas. Limitations concern generalizability due a non-probability based sample, and limited ability for causal inferences due to a lack of randomization. Next steps include incorporating participants' costs and including unintended effects (e.g., number of non-participant women obtaining mammography). Citation Format: Yamile Molina, Liliana G. San Miguel, Catherine Pichardo, Genesis Rios, Leslie Diaz, Stephanie Cardenas, Esmeralda Cardoso-Mendoza, Juanita Arroyo, Maria Medina, Nora Coronado, Araceli Lucio, Olivia Hernandez, Surrey Walton. Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects and cost effectiveness [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A030.

Comparative effectiveness of revascularization strategies for early coronary artery disease: A multicenter analysis

ObjectivesThe goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years. MethodsWe performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups. ResultsAfter adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001). ConclusionsAmong patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization.

Determining optimal strategies for primary prevention of cardiovascular disease: systematic review, cost-effectiveness review and network meta-analysis protocol

BackgroundDespite recent improvements in the burden of cardiovascular disease (CVD) in the UK, deaths from CVD are relatively high compared with other high-income countries. An estimated 7 million people in the UK are living with CVD, and the healthcare cost is approximately £11 billion annually. In more than 90% of cases, the risk of a first heart attack is thought to be related to modifiable risk factors including smoking, poor diet, lipidemia, high blood pressure, inactivity, obesity and excess alcohol consumption. The aim of the study is to synthesise evidence for the comparative effectiveness and cost-effectiveness of different interventions for the primary prevention of CVD.MethodsWe will systematically search databases (for example, MEDLINE (Ovid), Embase (Ovid), Cochrane Library) and the reference lists of previous systematic reviews for randomised controlled trials that assess the effectiveness and cost-effectiveness of any form of intervention aimed at adult populations for the primary prevention of CVD, including but not limited to lipid lowering medications, blood pressure lowering medications, antiplatelet agents, nutritional supplements, dietary interventions, health promotion programmes, physical activity interventions or structural and policy interventions. Interventions may or may not be targeted at high-risk groups. Publications from any year will be considered for inclusion. The primary outcome will be all cause mortality. Secondary outcomes will be cardiovascular diseases related mortality, major cardiovascular events, coronary heart disease, incremental costs per quality-adjusted life years gained. If data permits, we will use network meta-analysis to compare and rank effectiveness of different interventions, and test effect modification of intervention effectiveness using subgroup analyses and meta-regression analyses.DiscussionThe results will be important for policymakers when making decisions between multiple possible alternative strategies to prevent CVD. Compared to results from existing multiple separate pairwise meta-analyses, this overarching synthesis of all relevant work will enhance decision-making. The findings will be crucial to inform evidence-based priorities and guidelines for policies and planning prevention strategies of CVD.Systematic review registrationPROSPERO CRD42019123940.

The comparative effectiveness of physical exercise interventions in individuals with chronic non-specific neck pain: protocol for a network meta-analysis

IntroductionNeck pain is a global burdensome problem, with a large proportion of neck pain cases becoming chronic. Although physical exercise is a commonly prescribed treatment, the evidence on the effectiveness...

Discussion: Comparative Effectiveness of Different Interventions of Perivascular Hyaluronidase.

Discussion: Comparative Effectiveness of Different Interventions of Perivascular Hyaluronidase.

Abstract MP12: Lay- vs Professional-led Weight Loss Interventions for Overweight and Obese Youth: A Systematic Review and Network Meta-analysis

Context: In this network meta analysis, we examine the short and long-term effects of professional and lay-led behavioural interventions for obese youth. Objective: The appropriate approach for weight loss among overweight and obese youth remains unclear. We evaluated the comparative effectiveness of behavioural pediatric weight loss interventions led by lay persons and professionals. Data Sources: MEDLINE, Embase, the Cochrane Library, and CINAHL between January 1996 and June 2019. Study Selection: Randomized controlled trials of behavioural lifestyle interventions that enrolled overweight and obese children and adolescents (5-18 years old) administered for at least 12 weeks. Data Extraction: A network meta-analyses using a Bayesian framework and Markov-chain Monte-Carlo simulation methods were used to combine direct and indirect evidence. The immediate and sustained change from baseline in weight (kg) and body mass index (BMI; kg/m2) were primary outcomes. Results: Of 34,384 citations retrieved, we included 78 RCTs (4,556 participants), delivered for 12 to 104 weeks. Compared to standard care, professional-led weight loss interventions were associated with a significant reduction in body weight [-1.6 kg, 95% credible interval (CrI) -2.3, -0.99, 64 trials] that was not sustained long-term [-1.02 kg, 95% CrI -2.2, +0.34, 21 trials]. There was no evidence of a meaningful weight loss for lay-led interventions in the short-term [-1.4 kg; 95% CrI -3.0, +0.26; 5 trials], or long-term [-0.98 kg, 95% CrI -3.6, +1.8, 1 trial] compared to standard care. Direct comparisons revealed expert and lay-led interventions yield similar effects (-0.25 kg, 95%CrI -1.9, +1.3, 5 trials). Conclusions: Professional-led weight loss interventions are the most effective for achieving and sustaining weight reduction among overweight and obese youth. There is a need for high quality trials of lay-led weight loss interventions for obese youth.

Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis.

Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations. To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD. English-language searches of several bibliographic sources from database inception to 2 January 2019. 68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions. Two reviewers independently extracted data and rated study quality and strength of evidence (SOE). Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function. Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs. Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD. Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609).

Future research prioritization in cardiac resynchronization therapy

Although cardiac resynchronization therapy (CRT) is effective for some patients with heart failure and a reduced left ventricular ejection fraction (HFrEF), evidence gaps remain for key clinical and policy areas. The objective of the study was to review the data on the effects of CRT for patients with HFrEF receiving pharmacological therapy alone or pharmacological therapy and an implantable cardioverter-defibrillator (ICD) and then, informed by a diverse group of stakeholders, to identify evidence gaps, prioritize them, and develop a research plan. Relevant studies were identified using PubMed and EMBASE and ongoing trials using clinicaltrials.gov. Forced-ranking prioritization method was applied by stakeholders to reach a consensus on the most important questions. Twenty-six stakeholders contributed to the expanded list of evidence gaps, including key investigators from existing randomized controlled trials and others representing different perspectives, including patients, the public, device manufacturers, and policymakers. Of the 18 top-tier evidence gaps, 8 were related to specific populations or subgroups of interest. Seven were related to the comparative effectiveness and safety of CRT interventions or comparators, and 3 were related to the association of CRT treatment with specific outcomes. The association of comorbidities with CRT effectiveness ranked highest, followed by questions about the effectiveness of CRT among patients with atrial fibrillation and the relationship between gender, QRS morphology and duration, and outcomes for patients either with CRT plus ICD or with ICD. Evidence gaps presented in this article highlight numerous, important clinical and policy questions for which there is inconclusive evidence on the role of CRT and provide a framework for future collaborative research.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Glucosylsphingosine as a biomarker of disease burden in Gaucher disease

Poor medication adherence is associated with adverse health outcomes and higher costs of care. However, inconsistencies in the assessment of adherence are found in the literature.To evaluate the effect of different measures of adherence in the comparative effectiveness of complex interventions to enhance patients' adherence to prescribed medications.A systematic review with network meta-analysis was performed. Electronic searches for relevant pairwise meta-analysis including trials of interventions that aimed to improve medication adherence were performed in PubMed. Data extraction was conducted with eligible trials evaluating short-period adherence follow-up (until 3 months) using any measure of adherence: self-report, pill count, or MEMS (medication event monitoring system). To standardize the results obtained with these different measures, an overall composite measure and an objective composite measure were also calculated. Network meta-analyses for each measure of adherence were built. Rank order and surface under the cumulative ranking curve analyses (SUCRA) were performed.Ninety-one trials were included in the network meta-analyses. The five network meta-analyses demonstrated robustness and reliability. Results obtained for all measures of adherence were similar across them and to both composite measures. For both composite measures, interventions comprising economic + technical components were the best option (90% of probability in SUCRA analysis) with statistical superiority against almost all other interventions and against standard care (odds ratio with 95% credibility interval ranging from 0.09 to 0.25 [0.02, 0.98]).The use of network meta-analysis was reliable to compare different measures of adherence of complex interventions in short-periods follow-up. Analyses with longer follow-up periods are needed to confirm these results. Different measures of adherence produced similar results. The use of composite measures revealed reliable alternatives to establish a broader and more detailed picture of adherence.

Development and application of multiscale models of acute viral infections in intervention research

The objective of this study is to advance two frontiers in multiscale modelling of acute viral infections, which are (a) the mathematical technology or technical frontier, where we present a new method for development of multiscale models of acute viral infections using influenza A virus (IAV) as a paradigm in which a new set of metrics to measure both individual level and community level infectiousness are introduced, and (b) the scientific applications frontier, where we demonstrate the implementation of multiscale modelling in evaluating the comparative effectiveness of IAV health interventions from efficacy data. The multiscale model is developed by integrating the within‐host scale and the between‐host scale. Using the example of IAV as a paradigm, we demonstrate the utility and process by which multiscale modelling can be used to evaluate the comparative effectiveness of health interventions that operate at different scale domains. The multiscale modelling is general enough to be applicable to other acute viral infections.

Comparative Effectiveness of Different Interventions of Perivascular Hyaluronidase.

Soft-tissue necrosis caused by vascular compromise is a frequent and troublesome complication of hyaluronic acid filler injection. Hyaluronidase has been proposed as a treatment for this condition. This study aimed to determine the effective dose and administration interval of hyaluronidase injection in a skin necrosis animal model. New Zealand rabbits were used to simulate the hyaluronic acid-associated vascular occlusion model. Hyaluronic acid filler (0.1 ml) was injected into the central auricular artery to create an occlusion. Three rabbit auricular flaps were injected with 500 IU of hyaluronidase once (group A) and three flaps each were injected at 15-minute intervals with 250 IU of hyaluronidase twice (group B), 125 IU of hyaluronidase four times (group C), 100 IU of hyaluronidase five times (group D), and 75 IU of hyaluronidase seven times (group E), all at 24 hours after occlusion. No intervention was administered after occlusion in the control group. Flap fluorescence angiography was performed immediately after hyaluronidase injection and on postoperative days 2, 4, and 7. Flap necrotic areas were analyzed. All control and experimental flaps demonstrated total occlusion after hyaluronic acid injection. The average total survival rate (positive area/total area ×100 percent) of control flaps was 37.61 percent. For experimental groups, the average total survival rates were 74.83 percent, 81.49 percent, 88.26 percent, 56.48 percent, and 60.69 percent in groups A through E, respectively. A better prognosis can be obtained by administering repeated doses rather than a single high dose of hyaluronidase.

Small Interventions for Big Change: Brief Strategies for Distress and Self-Management Amongst Youth with Type 1 Diabetes.

Diabetes self-management and diabetes distress are complex processes implicated in glycemic control and other health outcomes for youth with type 1 diabetes. Growing integration of medical and behavioral care provides opportunities for brief psychosocial interventions during routine diabetes care. This review focuses on interventions for self-management and diabetes distress that can be delivered alongside usual medical care or via a single-patient encounter. Recent research underscores the potential of brief interventions delivered by both medical providers and integrated behavioral health professionals, but little is known regarding the comparative effectiveness of different interventions or the factors that impact dissemination and implementation. This article asserts that brevity is critical to maximizing the reach, scalability, and impact of psychosocial interventions for youth with type 1 diabetes. The authors review existing evidence for brief interventions, describe several untested clinical strategies, and make recommendations for accelerating the translational study of brief interventions.

Comparative Effectiveness of Behavioral Interventions to Prevent or Delay Dementia: One-Year Partner Outcomes

Various behavioral interventions are recommended to combat the distress experienced by caregivers of those with cognitive decline, but their comparative effectiveness is poorly understood. Caregivers in a comparative intervention study randomly had 1 of 5 possible interventions suppressed while receiving the other four. Caregivers in a full clinical program received all 5 intervention components. Care partner outcomes in the study group were compared to participants enrolled in a full clinical program. Two hundred and seventy-two dyads of persons with amnestic mild cognitive impairment (pwMCI) and care partners enrolled in the comparative intervention study. 265 dyads participated in the full clinical program. Behavioral intervention components included: memory compensation training, computerized cognitive training, yoga, support group, and wellness education. Each was administered for 10 sessions over 2 weeks. A longitudinal mixed-effect regression model was used to analyze the effects of the interventions on partner burden, quality of life (QoL), mood, anxiety, and self-efficacy at 12 months follow-up. At 12 months, withholding wellness education or yoga had a significantly negative impact on partner anxiety compared to partners in the clinical program (ES=0.55 and 0.44, respectively). Although not statistically significant, withholding yoga had a negative impact on partner burden and mood compared to partners in the full clinical program (ES=0.32 and 0.36, respectively). Our results support the benefits of wellness education and yoga for improving partner's burden, mood, and anxiety at one year. Our findings are the first to provide an exploration of the impact of multicomponent interventions in care partners of pwMCI.

Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis.

Background and study aims While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. Methods A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringerʼs (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = – 0.69, 95 % CI [–1.18; – 0.21]), pancreatic stent (B = – 1.25, 95 % CI [–1.81 to –0.69]), LR (B = – 0.67, 95 % CI [–1.20 to –0.13]), and combination of LR plus rectal NSAIDs (B = – 1.58; 95 % CI [–3.0 to –0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment. Conclusions Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.

Power Analysis and Sample Size Planning in ANCOVA Designs

The analysis of covariance (ANCOVA) has notably proven to be an effective tool in a broad range of scientific applications. Despite the well-documented literature about its principal uses and statistical properties, the corresponding power analysis for the general linear hypothesis tests of treatment differences remains a less discussed issue. The frequently recommended procedure is a direct application of the ANOVA formula in combination with a reduced degrees of freedom and a correlation-adjusted variance. This article aims to explicate the conceptual problems and practical limitations of the common method. An exact approach is proposed for power and sample size calculations in ANCOVA with random assignment and multinormal covariates. Both theoretical examination and numerical simulation are presented to justify the advantages of the suggested technique over the current formula. The improved solution is illustrated with an example regarding the comparative effectiveness of interventions. In order to facilitate the application of the described power and sample size calculations, accompanying computer programs are also presented.

Health economic evaluations of interventions to increase physical activity and decrease sedentary behavior at the workplace: a systematic review.

Objective The workplace is an ideal setting to implement public health strategies, but economic justification for such interventions is needed. Therefore, we performed a critical appraisal and synthesis of health economic evaluations (HEE) of workplace interventions aiming to increase physical activity (PA) and/or decrease sedentary behavior (SB). Methods A comprehensive search filter was developed using appropriate guidelines, such as the Peer Review of Electronic Search Strategies (PRESS) checklist, and published search algorithms. Six databases and hand searches were used to identify eligible studies. Full HEE of workplace interventions targeting PA/SB were included. Methodological quality was assessed using the Consensus Health Economic Criteria (CHEC) list. Two researchers independently performed all procedures. Hedges' g was calculated to compare intervention effects. Outcomes from HEE were recalculated in 2017 euros and benefit-standardized. Results Eighteen HEE were identified that fulfilled on average 68% of the CHEC list criteria. Most studies showed improvements in PA/SB, but effects were small and thus, their relevance is questionable. Interventions were heterogeneous, no particular intervention type was found to be more effective. HEE were heterogeneous regarding methodological approaches and the selection of cost categories was inconsistent. Indirect costs were the main cost driver. In all studies, effects on costs were subject to substantial uncertainty. Conclusions Due to small effects and uncertain impact on costs, the economic evidence of worksite PA/SB-interventions remains unclear. Future studies are needed to determine effective strategies. The HEE of such interventions should be developed using guidelines and validated measures for productivity costs. Additionally, studies should model the long-term costs and effects because of the long pay-back time of PA/SB interventions.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BackgroundThis review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.MethodsMEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.ResultsA total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.ConclusionsAssuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.Systematic review registrationPROSPERO CRD42017072527.

Interventions to improve birth outcomes of pregnant women living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Improving the health of pregnant women is important to prevent adverse birth outcomes, such as preterm birth and low birthweight. We evaluated the comparative effectiveness of interventions under the domains of micronutrient, balanced energy protein, deworming, maternal education, and water sanitation and hygiene (WASH) for their effects on these adverse birth outcomes. Methods: For this network meta-analysis, we searched for randomized clinical trials (RCTs) of interventions provided to pregnant women in low- and middle-income countries (LMICs). We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We extracted data from eligible studies for study characteristics, interventions, participants' characteristics at baseline, and birth outcomes. We compared effects on preterm birth (<37 gestational week), low birthweight (LBW; <2500g), and birthweight (continuous) using studies conducted in LMICs. Results: Our network meta-analyses were based on 101 RCTs (132 papers) pertaining to 206,531 participants. Several micronutrients and balanced energy food supplement interventions demonstrated effectiveness over standard-of-care. For instance, versus standard-of-care, micronutrient supplements for pregnant women, such as iron and calcium, decreased risks of preterm birth (iron: RR=0.70, 95% credible interval [Crl] 0.47, 1.01; calcium: RR=0.76, 95%Crl 0.56, 0.99). Daily intake of 1500kcal of local food decreased the risks of preterm birth (RR=0.36, 95%Crl 0.16, 0.77) and LBW (RR=0.17, 95%Crl 0.09, 0.29), respectively when compared to standard-of-care. Educational and deworming interventions did not show improvements in birth outcomes, and no WASH intervention trials reported on these adverse birth outcomes. Conclusion: We found several pregnancy interventions that improve birth outcomes. However, most clinical trials have only evaluated interventions under a single domain (e.g. micronutrients) even though the causes of adverse birth outcomes are multi-faceted. There is a need to combine interventions that of different domains as packages and test for their effectiveness. Registration: PROSPERO CRD42018110446; registered on 17 October 2018.