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Background & aimsRelative risk of colorectal cancer (CRC) decreases with age among individuals with a family history of CRC. However, no screening recommendations specify less frequent screening with increasing age. We aimed to determine whether such a refinement would be cost effective.MethodsWe determined the relative risk for CRC for individuals based on age and number of affected first-degree relatives (FDRs) using data from publications. For each number of affected FDRs, we used the Microsimulation Screening Analysis model to estimate costs and effects of colonoscopy screening strategies with different age ranges and intervals. Screening was then optimized sequentially, starting with the youngest age group, and allowing the interval of screening to change at certain ages. Strategies with an incremental cost effectiveness ratio below $100,000 per quality-adjusted life year were considered cost effective.ResultsFor people with 1 affected FDR (92% of those with a family history), screening every 3 years beginning at an age of 40 years is most cost effective. If no adenomas are found, the screening interval can gradually be extended to 5 and 7 years, at ages 45 and 55 years, respectively. From a cost-effectiveness perspective, individuals with more affected FDRs should start screening earlier and at shorter intervals. However, frequency can be reduced if no abnormalities are found.ConclusionsUsing a microsimulation model, we found that for individuals with a family history of CRC, it is cost effective to gradually increase the screening interval if several subsequent screening colonoscopies have negative results and no new cases of CRC are found in family members.

PurposeFamily history of colorectal cancer (CRC) is a known risk factor for CRC and encompasses both genetic and shared environmental risks.MethodsWe conducted a systematic review to estimate the impact of family history on the natural history of CRC and adherence to screening.ResultsWe found high heterogeneity in family-history definitions, the most common definition being one or more first-degree relatives. The prevalence of family history may be lower than the commonly cited 10%, and confirms evidence for increasing levels of risk associated with increasing family-history burden. There is evidence for higher prevalence of adenomas and of multiple adenomas in people with family history of CRC but no evidence for differential adenoma location or adenoma progression by family history. Limited data regarding the natural history of CRC by family history suggest a differential age or stage at cancer diagnosis and mixed evidence with respect to tumor location. Adherence to recommended colonoscopy screening was higher in people with a family history of CRC.ConclusionStratification based on polygenic and/or multifactorial risk assessment may mature to the point of displacing family history-based approaches, but for the foreseeable future, family history may remain a valuable clinical tool for identifying individuals at increased risk for CRC.

The Evaluation of Genomic Applications in Practice and Prevention Working Group was first convened in 2005 to develop and test evidence-based methods for the evaluation of genomic tests in transition from research to clinical and public health practice. Over the ensuing years, the Working Group has met 26 times, publishing eight recommendation statements, two methods papers, and one outcomes paper, as well as planning and serving as technical experts on numerous associated systematic reviews. Evaluation of Genomic Applications in Practice and Prevention methods have evolved to address implications of the proliferation of genome-wide association studies and are currently expanding to face challenges expected from clinical implementation of whole-genome sequencing tests. In this article, we review the work of the Evaluation of Genomic Applications in Practice and Prevention Working Group over the first 8 years of its existence with an emphasis on lessons learned throughout the process. It is hoped that in addition to the published methods of the Working Group, the lessons we have learned along the way will be informative to others who are producers and consumers of evidence-based guidelines in the field of genomic medicine.

Despite research investment and a growing body of diverse evidence there has been no comprehensive review and grading of evidence for public health emergency preparedness and response practices comparable to those in medicine and other public health fields. The National Academies of Sciences, Engineering, and Medicine convened an ad hoc committee to develop and use methods for grading and synthesizing diverse types of evidence to create a single certainty of intervention‐related evidence to support recommendations for Public Health Emergency Preparedness and Response Research. A 13‐step consensus building method was used. Experts were first canvassed in public meetings, and a comprehensive review of existing methods was undertaken. Although aspects of existing review methodologies and evidence grading systems were relevant, none adequately covered all requirements for this specific context. Starting with a desire to synthesize diverse sources of evidence not usually included in systematic reviews and using GRADE for assessing certainty and confidence in quantitative and qualitative evidence as the foundation, we developed a mixed‐methods synthesis review and grading methodology that drew on (and in some cases adapted) those elements of existing frameworks and methods that were most applicable. Four topics were selected as test cases. The process was operationalized with a suite of method‐specific reviews of diverse evidence types for each topic. Further consensus building was undertaken through stakeholder engagement and feedback The NASEM committee's GRADE adaption for mixed‐methods reviews will further evolve over time and has yet to be endorsed by the GRADE working group. [ABSTRACT FROM AUTHOR]

To the Editor.-- In their recent Pediatrics article, Hauck et al (1) reported on the association between pacifier use at last sleep and sudden infant death syndrome (SIDS) and recommended [...]

Enrolling uninsured people into managed care plans may not increase costs substantially. Researchers analyzed various measures of health care utilization in 346 previously uninsured people who were enrolled into an HMO and 382 people already enrolled in one. There was no significant difference between the two groups in terms of number of hospital admissions, number of days in the hospital or the use of outpatient services. However, the odds of visiting a physician was 30% higher in the previously uninsured group. This was mostly due to their perception that they had health problems., Objective.--To investigate the utilization of health care services of previously uninsured low-income patients after becoming insured by a health maintenance organization (HMO). Design.--Retrospective study of utilization in a previously uninsured study group compared with an age- and sex-matched randomly selected control group of commercial HMO enrollees. Setting.--Group model HMO. Patients.--A study group of 346 previously uninsured low-income patients and 382 controls. Measures.--Outpatient visits for primary and specialty care, outpatient pharmacy, laboratory, and radiology use, and inpatient admissions and hospital days over a 2-year period. Self-reported health status measures were obtained to control for differences in health status. Principal Findings.--There were no differences between the study and control groups in hospital admissions, hospital days, and measures of outpatient laboratory, pharmacy, and radiology use. The odds of having an outpatient visit per patient per month was 30% higher for the study group. Approximately half the increase in the odds ratio for outpatient visits was related to the worse self-perceived health status of the study group. While both groups utilized more services in the early phase of their enrollment, the intensity of this start-up effect was similar for both groups. Conclusions.--Compared with a commercial group of the same age and sex, the patterns of utilization were similar and the financial costs of care were only moderately more for a previously uninsured group provided with comprehensive HMO insurance. With the growth of managed care, these data should be beneficial in the development of health care programs for the growing number of uninsured Americans. JAMA. 1997;277:1067-1072

Although studies of injury-related disability among children tend to focus on injuries requiring hospitalization or on brain injuries, most injuries suffered by children are treated in the doctor's office and do not require admission to the hospital. There is limited information about the degree of disability caused by injury among children who do not require hospitalization. The effects of injuries on long-term physical health of children not requiring hospitalization were assessed. In addition, the types of injuries that result in impairment of function were identified in an effort to develop methods to prevent those types of injuries. The study involved children and adolescents from newborn to 19 years old. The subjects were seen in either an emergency department or outpatient clinic. Their physical health was assessed using a test developed by the Rand Health Insurance Study. Injury restricted normal weekly activities for 55.1 percent of subjects. Complete resumption of ordinary activities had not been achieved one week after injury for 16.4 percent of subjects and one month after injury for 3.8 percent. Impairment of function was more severe for children aged 10 years or older as compared with younger children. The most severe disability resulted from injuries related to fractures and dislocations, sprains, activities involving sports, recreation, and falls. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods of Surveillance for HIV Infection in Primary Care Outpatients in the United States Synopsis Primary care outpatients provide a good sentinel population for monitoring levels and trends of HIV […]

To the Editor.-- Representing the Pediatric Orthopaedic Society of North America, we are writing in response to the special article by the US Preventive Services Task Force (USPSTF) "Screening for [...]