Enhanced counseling for women undergoing BRCA1/2 testing : impact on subsequent decision making about risk reduction behaviours

The authors evaluated the impact of an enhanced counseling intervention, designed to promote well informed decision making for follow-up risk reduction options for ovarian cancer, among high-risk women undergoing BRCA1/2 testing (N = 77). Following standard genetic counseling, participants received either an enhanced counseling session—designed to help participants anticipate their reactions to possible test outcomes and plan for postresult consequences—or a general health information control session. One week after disclosure of test results, women in the enhanced counseling group experienced a greater reduction in avoidant ideation, suggesting more complete processing of risk feedback. At the 6-month follow-up, intervention respondents reported seeking out more information about prophylactic oophorectomy and were more likely to have actually undergone preventive surgery. The results indicate that the use of enhanced counseling can play an important role in decision making about risk reduction behaviours following BRCA1/2 testing.14 page(s

GRADE guidelines: 3. Rating the quality of evidence

This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

Study objectivePrevious reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events.MethodsWe identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate- to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations.ResultsWe evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations.ConclusionHigh-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation