EVIDENCE REPORT AND EVIDENCE-BASED RECOMMENDATIONS: INTERVENTIONS THAT PREPARED FOR: DEPARTMENT OF HEALTH AND U.S. HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION 7500 Security Blvd. MD Baltimore, 21244-1850 PREPARED BY: RAND REPORTS RA CONTRACT NUMBER: 500-98-0281 564 .85 CONTRACT PERIOD: September 30, 1998 to September 29, 2003 . E95 1999 Project Staff Evidence Report Task Order Director Paul Shekelle, M.D., Ph.D. Evidence Report Task Order Co-Director Erin Stone, M.D. Project Manager Margaret Maglione, M.P.P. Article Screening/Review Michael Hirt, M.D. Walter Mojica, M.D. Preethi Srikanthan, M.D. Tommy Tomizawa, M.D. Senior Statistician Sally Morton, Ph.D. Senior Programmer/Analyst Elizabeth A. Roth, M.A. Research Assistant Brian Chao, B.S. Editor Tamara Breuder, B.A. Staff Assistants Jeri Jackson, B.A. Shannon Rhodes, M.F.A. Technical Experts Brian Mittman, Ph.D. Jeremy Grimshaw, M.D. Lisa Rubenstein, M.D. Principal Investigator, Healthy Aging Project Laurence Rubenstein, M.D. c -X Preface The Health Care Financing Administration (HCFA), in consultation with other Agencies in the Department of Health and Human Services, initiated the Healthy Aging Project to enhance and promote the health of older people. A major objective ofthe Healthy Aging Project is to identify, synthesize and disseminate evidence HCFA and expert opinion on health promotion and disease prevention interventions that are evidence-based. is sponsoring reports that present evidence and expert opinion to assist public and private sector organizations in their efforts to improve the delivery of Medicare-covered preventive benefits and promote behavioral risk factor reduction. These reports provide comprehensive, science-based information on effective and cost- RAND HCFA effective interventions targeting the senior population. is producing these reports under a contract. HCFA expects that these evidence reports will inform peer review organizations, individual health plans, providers and purchasers, including Medicare and Medicaid, as well as the health care system as a whole by providing important information to help improve the delivery and quality of preventive health care for older people. We welcome written comments on this evidence report. They may be sent to: Healthy Aging Project Officer Division of Health Promotion and Disease Prevention Quality Measurement and Health Assessment Group Office of Clinical Standards and Quality Health Care Financing Administration 7500 Security Blvd. MS3-02-01 MD Baltimore. 21244-1850 Jeffrey Kang, MD, MPH Chief Clinical Officer Health Care Financing Administration The Southern California Evidence-Based Practice Center The Southern California Evidence-Based Practice Center is part of the Evidence-Based Practice Program sponsored by the Agency for Health Care Policy and Research. One of 12 such Centers nationwide, the Center conducts systematic reviews and technology assessments of all aspects ofhealth care; performs research on improving the methods of synthesizing the scientific evidence and developing evidence reports and technology assessments; and provides technical assistance to other organizations in their efforts to translate evidence reports and technology assessments into guidelines, performance measures, and other quality-improvement tools. RAND The Center combines the talents of and its five affiliated regional health care institutions: the University of California, Los Angeles; the University of California, San Diego; Cedars-Sinai Medical Center; the University of Southern California; and Value Health Sciences. In addition, through the VA/RAND/ University of California Field Program "Center for the Study of Health Care Provider Behavior," four Department of Veterans Affairs facilities collaborate with the Center. The Center is also affiliated with five health services research training programs. RAND The Southern California Center is the natural outcome of more than 20 years ofwork by and its affiliated institutions in reviewing the biomedical literature for evidence of benefits, harms, and costs; using meta-analysis, decision analysis, and cost-effectiveness analysis to synthesize the literature; developing measures ofclinical appropriateness and practice guidelines; developing and assessing medical review criteria; and developing and assessing performance measures and other tools for translating evidence-based RAND knowledge into clinical practice. The hallmark of this work has been (a) its multi-disciplinary nature: and its affiliated institutions combine the talents ofclinicians, health services researchers, epidemiologists, statisticians, economists, and advanced methods experts in meta-analysis and decision analysis; (b) the advancement of knowledge about the methods for performing literature reviews, synthesizing evidence, and developing practice guidelines or review criteria; and (c) the emphasis on developing and evaluating products for use in the real world of health care delivery. CONTENTS EXECUTIVE SUMMARY AND EVIDENCE-BASED RECOMMENDATIONS 4 EVIDENCE REPORT 14 INTRODUCTION 14 InfluenzaImmunization 14 PneumococcalVaccination 14 Mammography 15 : Cervical SmearCytology 15 Colon Cancer Screening 16 METHODS 17 DevelopmentofConceptual Model 17 Identification ofLiterature Sources 26 CochraneEffectivePractice and Organization ofCare (EPOC) Data Base 26 Previous Systematic Reviews 30 Center for Quality ofCare Research, Netherlands 32 Centers for Disease Control and Prevention (CDC) 33 Health Care Quality ImprovementProjects (HCQIP) 34 Evaluation ofPotentialEvidence 34 Extraction ofStudy-Level Variables and Results 38 ExpertPanelReview ofEvidence Report 49 Statistical Methods 51 Meta-regression analysis 51 Question Absolute effectiveness ofeach intervention 52 1: Question 2: Relative effectiveness ofeach intervention 53 Question 3: Importantcovariates 55 Question 4: Costeffectiveness 56 Question 5: Elements instrumentalto the success ofeach intervention 56 RESULTS 58 Identification ofEvidence 58 Distribution ofEvidence 58 Description ofEvidence 63 Quality ofEvidence 63 Description ofResults 64 Question Absolute effectiveness ofeach intervention 64 1 : Meta-regression 64 OrganizationalChange 68 Special Interventions: StandingOrders 75 Mass Mailings by Peer Review Organizations 77 Sigmoidoscopy Studies 79 Massmediastudies 82 RegulatoryChange Studies 82 Miscellaneous Studies 83 Question 2: Relative effectiveness ofeach intervention 85 Effectiveness ofmultiple interventions 86 Question 3: Importantcovariates 92 VulnerablePopulations 93 African-Americans 94 Hispanicpopulations 96 NativeAmericans 97 Ruralpopulations 98 i ReimbursementSystems 99 HMO versus Feefor Service 99 Question4: Costeffectiveness 100 Influenzaandpneumococcalvaccinations 100 Mammography 101 CervicalSmearCytology 102 ColonCancer Screening 104 Conclusions fromcost-effectweness studies 104 Question 5: Elements instrumentalto the success ofeach intervention 1 10 Educationalinterventions effectiveness by year 112 LIMITATIONS 117 CONCLUSIONS 119 REFERENCES CITED 121 APPENDICES 131 REFERENCE LIST: JOURNAL ARTICLES ACCEPTED 132 REFERENCE LIST: NARRATIVE PROJECT DOCUMENTS ACCEPTED 150 REFERENCE LIST: JOURNAL ARTICLES NOT ACCEPTED 155 REFERENCE LIST: NARRATIVE PROJECT DOCUMENTS NOT ACCEPTED ..182 GLOSSARY OF TERMS 200 EVIDENCE TABLES 202 n 11 TABLES Table 1. Classification for Interventions That Change Behavior 19 Table 2. EPOC Literature Search Strategy 27 Table 3. Review Articles 30 Table 4. Expert Panel 50 Table 5. Interventions by Service 62 Table 6. Effectiveness of Interventions 65 Table 7. Post-Intervention Rate 67 Table 8. Evidence Table - Studies that included Organizational Change 69 Table 9. Effect of Mass Mailings by Peer Review Organizations on Flu Vaccinations 78 Table 10. Sigmoidoscopy Studies 81 Table 11. Effectiveness of Single versus Multiple Interventions 88 Table 12. Marginal Effectiveness of Specific Interventions 90 Table 13. Important Covariates 93 Table 14. Evidence Table - Studies that included Cost Effectiveness 106 Table 15. Effectiveness of Specific Factors 1 1 Table 16. Expert Reviewers 199 FIGURES Figure 1. Conceptual Model 25 Figure 2. Screening Form 37 Figure 3. Abstraction Form 39 Figure 4. Literature Sources 60 Figure 5. Number of Retrieved Articles by Source 6 Figure 6. Immunizations - Study Effectiveness by Year 1 13 Figure 7. Mammography - Study Effectiveness by Year 1 14 Figure 8. Cervical Smear Cytology - Study Effectiveness by Year 115 Figure 9. Colon Cancer Screening - Study Effectiveness by Year 1 16 iii I