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Treatment Strategies for Women with Coronary Artery Disease

Treatment Strategies for Women with Coronary Artery Disease. Prepared for: Agency for Healthcare Research and Quality (AHRQ ). Accreditation Statement. Physician Credit Designation Statement

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Treatment Strategies for Women with Coronary Artery Disease

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  1. Treatment Strategies for Women with Coronary Artery Disease Prepared for: Agency for Healthcare Research and Quality (AHRQ)

  2. Accreditation Statement Physician Credit Designation Statement PRIME Education, Inc. (PRIME®) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. PRIME® designates this live activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only credit commensurate with the extent of their participation in the activity. Physician Assistant Accreditation Statement AAPA accepts AMA Category 1 CME Credit™ for the PRA from organizations accredited by ACCME. Nurse Practitioner Accreditation Statement PRIME Education, Inc (PRIME®) is approved as a provider of Nurse Practitioner Continuing Education by the American Academy of Nurse Practitioners. Provider number: 060815. This program is accredited for 0.50 contact hour. Program ID# CER23. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Nurse Accreditation Statement PRIME Education, Inc. (PRIME®) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. PRIME® designates this activity for 0.50 contact hour. California Nurse Accreditation Statement PRIME® designates this educational activity for .50 contact hour for California nurses. PRIME® is accredited as an approver of continuing education in nursing by the California Board of Registered Nursing.

  3. Disclosure Policy PRIME Education, Inc (PRIME®) endorses the standards of the ACCME, as well as those of the AANP, ANCC and ACPE, that require everyone in a position to control the content of a CME/CE activity to disclose all financial relationships with commercial interests that are related to the content of the CME/CE activity. CME/CE activities must be balanced, independent of commercial bias and promote improvements or quality in healthcare. All recommendations involving clinical medicine must be based on evidence accepted within the medical profession. A conflict of interest is created when individuals in a position to control the content of CME/CE have a relevant financial relationship with a commercial interest which therefore may bias his/her opinion and teaching. This may include receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, stocks or other financial benefits. PRIME® will identify, review and resolve all conflicts of interest that speakers, authors, course directors, planners, peer reviewers, or relevant staff disclose prior to an educational activity being delivered to learners. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Disclosure information for speakers, authors, course directors, planners, peer reviewers, and/or relevant staff are provided with this activity. Presentations that provide information in whole or in part related to non FDA approved uses of drugs and/or devices will disclose the unlabeled indications or the investigational nature of their proposed uses to the audience. Participants should refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. Participants should verify all information and data before treating patients or employing any therapies prescribed in this educational activity. The opinions expressed in the educational activity are those of the presenting faculty and do not necessarily represent the views of PRIME®, the ACCME, AANP, ACPE, ANCC and other relevant accreditation bodies. Disclosure Information

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  5. Learning Objectives Upon completion of this activity, the participant should be able to: Identify available treatment options for Coronary Artery Disease (CAD), specifically for women presenting with STEMI, UA/NSTEMI, or chronic angina Assess the benefits and harms of treatment strategies for CAD in women, including clinical outcomes, modifiers of effectiveness, and safety outcomes Apply the AHRQ findings of the systemic review to improve outcomes for women with CAD through patient centered care

  6. Coronary Artery Disease (CAD) in Women • Cardiovascular disease (CVD) is the leading cause of mortality for women in the U.S. • 500,000 women die of CVD each year (approx. one death every minute) • Mortality in women exceeds those in men • Mortality from CVD exceeds next seven causes of death in women combined • CAD includes coronary atherosclerotic disease, myocardial infarction (MI), acute coronary syndrome (ACS) and angina • Most prevalent form of CVD and is the largest subset of this mortality • Higher prevalence in men until reach 75 years of age (thus giving the perception CAD is a male-specific disease) Mieres JH, et al. Circulation. 2005;111(5):682-96. Lloyd-Jones D, et al. Circulation. 2010;121(7):e46-e215. Roger VL, et al. Circulation. 2012;125(1):e2-e220.

  7. CAD in Women: Factors Contributing to Lower Use of Evidence-Based Medicine and Higher Complications • CVD affects women later in life than men – first MI 70.3 yrs. vs. 64.5 yrs. • At CAD diagnosis, women more likely to have comorbid factors • Women present different symptoms, more subtle • Smaller coronary vessels in women make revascularization difficult and microvascular disease more common than men • Women tend toward less extensive CAD and higher proportion of non-obstructive CAD • Women experience delays in diagnosis and effective treatment due to • Delays in hospitalization, symptom pattern and recognition, • Higher frequency of nonobstructive CAD • There are uncertainties with treatment options for women • Underrepresentation in RCT (lack of data = uncertain risk/benefit ratio of options) • Current treatment guidelines have insufficient recommendations based on gender Mieres JH, et al. Circulation. 2005;111(5):682-96. Alexander KP, et al. Circulation. 2006;114(13):1380-7. Pepine CJ. J Am Coll Cardiol. 2004;43(10):1727-30.

  8. Clinical Presentations of CAD • CAD is the presence of atherosclerosis in the epicardial coronary arteries • Atherosclerotic plaques may rupture or cause acute ischemia or progressively narrow the coronary artery lumen • A stable plaque progressively narrowing and hardening the coronary artery lumen, but not necessarily blocking completely the flow of blood, results in chronic stable angina • Stable angina is typically characterized by pain that typically occurs with moderate to severe exertion • Stable angina is usually mild in nature and can be relieved with rest or sublingual nitroglycerin • A plaque can become unstable by rupturing and exposing its content in the artery lumen activating platelets and the coagulation cascade and can become life threatening Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  9. Acute Coronary Syndromes • Acute ischemia can lead to: • Unstable angina: reversible ischemia • Non-ST elevation myocardial infarction (NSTEMI): partial obstruction and tissue damage • ST elevation myocardial infarction (STEMI): complete epicardial occlusions leading to possible transmural infarction of the heart • The constellation of clinical symptoms that are compatible with acute myocardial ischemia is usually referred to as acute coronary syndrome • When left untreated, CAD can lead to MI (heart attack or sudden cardiac arrest) • Significant CAD is defined angiographically as a stenosis (narrowing) with >70 percent diameter in at least one major epicardial artery segment or with greater >50 percent diameter in the left main coronary artery Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  10. Treatment Options for Patients with CAD • Optimal medical management • Manage risk factors • Pharmacological treatment • Patient adherence • Coronary Revascularization • Percutaneous Coronary Intervention (PCI) • Minimally invasive and preferred for patients with mild CAD (single/double vessel disease) • Reduces angina and myocardial ischemia • Coronary Artery Bypass Grafting (CABG) • Inpatient invasive surgery preferred for patients with significant CAD (left main or severe triple vessel disease with reduced left ventricular function Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  11. Comparing PCI and CABG • In patients with moderate CAD, uncertainty exists about which to use • Advantages of PCI over CABG • Relative ease of use • Avoidance of general anesthesia, thoracotomy, extracorporeal circulation, central nervous system complications, and prolonged convalescence • Repeat PCI can be performed easily • Quick revascularization in emergency situations • Disadvantages of PCI over CABG • Early restenosis • Inability to relieve many totally occluded arteries or vessels with extensive atherosclerotic disease • Advantages of CABG over PCI • Greater durability • More complete revascularization regardless of the morphology of the obstructing lesion Lansky AJ, et al. Circulation. 2005;111(7):940-53. Bravata DM, et al. Agency for Healthcare Research and Quality. 2012. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/15/55/CER_PCI_CABGMainReport.pdf.

  12. Comparison of Treatment Strategies for Women with CAD CABG = coronary artery bypass grafting; CAD = coronary artery disease; NSTEMI = non-ST elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  13. Effective Healthcare Program CER Number 66Treatment Strategies for Women with CAD:Objectives of This Systematic Review • To assess the comparative effectiveness of the major treatment options for CAD specifically in women, evaluating these comparisons: • PCI versus fibrinolysis or PCI versus conservative/ supportive medical management in women with STEMI • Early invasive versus initial conservative management in women with UA/NSTEMI • PCI versus CABG versus optimal medical therapy in women with stable or unstable angina • To assess these endpoints: • Clinical outcomes • Modifiers of effectiveness by demographic and clinical factors • Safety outcomes Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  14. Search/Inclusion Criteria Final Result: 72 articles representing 28 RCT studies passed full-text screening were included in review Strength of Evidence: Graded as High, Moderate, Low, or Insufficient Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  15. Management of STEMI • STEMI is caused by the complete occlusion of an epicardial artery, leading to possible transmural infarction of the heart muscle • Management of STEMI: Patients are candidates for pharmacological or catheter-based reperfusion therapy • Pharmacological therapy • Fibrinolysis • Conservative/supportive therapy with facilitated antithrombotic medications • PCI • Immediate revascularization • Data demonstrates benefit of PCI in reducing major cardiovascular adverse events when compared to fibrinolysis or conservative therapy • Preferred when have close access to a catheterization facility • In general • Not treated with CABG (unless emergent from PCI complications) • Receive optimal medical therapy in addition to treatment directed at removing the clot Kushner FG, et al. Circulation. 2009;120(22):2271-306.

  16. Key Question 1: Women with STEMI (PCI vs. Fibrinolysis/supportive therapy) • What is the effectiveness of PCI vs. fibrinolysis/supportive therapy on clinical outcomes? • Nonfatal MI, death, stroke, repeat revascularization, recurrent unstable angina, heart failure, repeat hospitalization, length of hospital stay, angina relief, quality of life, or cognitive effects • Is there evidence that the comparative effectiveness of PCI vs. fibrinolysis/supportive therapy varies based on characteristics, such as: • Age, race, or other demographic and socioeconomic risk factors? • Coronary disease risk factors such as diabetes, chronic kidney disease, or other comorbid disease? • Angiographic-specific factors? • Hospital characteristics? • What are the significant safety concerns associated with each treatment strategy? Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  17. KQ1 Findingsin STEMIThe Studies: • 7 studies (6 good quality, 1 fair) compared PCI with or without supportive therapy with fibrinolysis or other routine medical care for women with STEMI and contributed evidence about • the comparative effectiveness • modifiers of effectiveness • safety for these interventions • These studies included a total of 4,527 patients, of which 1,174 (26%) were women Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  18. KQ1 Findings in STEMI:Effectiveness of Intervention Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  19. KQ1 Findings in STEMI: Modifiers of Effectiveness Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  20. KQ1 Findings in STEMI: Safety Concerns Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  21. Management of UA/NSTEMI • Goals of therapy • Immediate relief of ischemia • Prevention of serious adverse outcomes (i.e., death or MI) • Patients with UA/NSTEMI are not candidates for immediate pharmacological reperfusion • Optimal management • Aggressive medical therapy • Anti-ischemic therapy • Antithrombotic therapy • Ongoing risk stratification • Invasive procedures (in some cases) • Two emerging management pathways: • Initial conservative • Early invasive strategy Anderson JL, et al. Circulation. 2007;116(7):e148-304.

  22. Initial Conservative vs. Early Invasive Strategy in UA/NSTEMI • Initial conservative (selective invasive management) only in patients whom: • Medical therapy fails • Objective evidence of ischemia identified • Early invasive strategy (PCI or CABG) • No initial noninvasive stress test or medical treatment failure needed • Coronary angiography within 4 to 24 hours of admission • Continue optimal medical therapy • Evidence demonstrates improved clinical outcomes in patients with an invasive strategy • Guidelines recommend invasive approaches to treat patients with NSTEMI and high-risk acute coronary syndrome Anderson JL, et al. Circulation. 2007;116(7):e148-304.

  23. Key Question 2: Women with UA/NSTEMI (Early Invasive vs. Initial Conservative) What is the effectiveness of early invasive (PCI or CABG) versus initial conservative therapy on clinical outcomes? Is there evidence that the comparative effectiveness of early invasive vs. initial conservative therapy varies based on characteristics? What are the significant safety concerns associated with each treatment strategy? Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  24. KQ2 Key Findings in UA/NSTEMIThe Studies: • 7 studies (6 good quality, 1 fair) compared early invasive (revascularization via PCI or CABG) with initial conservative therapy for women with UA/NSTEMI and contributed evidence about • comparative effectiveness • modifiers of effectiveness • safety for these interventions • These studies included a total of 17,930 patients, of which 6,084 (34%) were women Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  25. KQ2 Findings in UA/NSTEMI: Effectiveness of Interventions Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  26. KQ2 Findings in UA/NSTEMI: Modifiers of Effectiveness Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  27. KQ2 Findings in UA/NSTEMI: Safety Concerns Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  28. Chronic Stable Angina • Treatment goals • Prevent MI and death • Reduce symptoms of angina and occurrence of ischemia • Improve quality of life for both of the above • All patients with stable angina are candidates for: • Optimal medical therapy • PCI or CABG based on findings from coronary angiography and if symptoms persist despite optimal medical therapy Gibbons RJ, et al. Circulation. 2003;107(1):149-58.

  29. Unstable Angina • Unstable angina (UA) is defined as angina with at least one of three features: • It occurs at rest or with minimal exertion • It is severe and of recent onset (within the past 4 to 6 weeks) • It occurs in a crescendo pattern (i.e., more severe, more prolonged, or more frequent than previously experienced) • UA and NSTEMI • Fairly similar pathophysiology, mortality rate, and management strategy • Often grouped together as UA/NSTEMI in clinical guidelines and trial populations Anderson JL, et al. Circulation. 2007;116(7):e148-304.

  30. Key Question 3: Strategy 1—Women with Stable Angina (Revascularization vs. Optimal Medical Therapy) • What is the effectiveness of the following treatment strategies on clinical outcomes? • Revascularization (PCI or CABG) vs. optimal medical therapy in women with stable angina • PCI vs. CABG in women with stable or unstable angina • Is there evidence that the comparative effectiveness of revascularization versus optimal medical therapy varies based on characteristics? • What are the significant safety concerns associated with each treatment strategy? Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  31. KQ3 Findings in Stable AnginaThe Studies: • 5 studies (all good quality) compared revascularization (PCI or CABG) with optimal medical therapy for women with stable angina and contributed evidence about • comparative effectiveness • modifiers of effectiveness • safety for these interventions • These studies included a total of 6,851 patients, of which 1,285 (19%) were women Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  32. KQ3 Findings in Stable Angina: Effectiveness of Interventions Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  33. KQ3 Findings in Stable/Unstable AnginaThe Studies: 10 studies (8 good quality, 2 fair) compared PCI with CABG in women with stable/unstable angina and contributed evidence about the comparative effectiveness, modifiers of effectiveness, or safety for these interventions. These studies included a total of 6,289 patients, of which 1,583 (25%) were women Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  34. KQ3 Findings in Stable/Unstable Angina: Effectiveness of Interventions Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  35. KQ3 Findings in Stable/Unstable Angina: Modifiers of Effectiveness Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  36. KQ3 Findings in Stable/Unstable Angina: Safety Concerns Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  37. Conclusions This review confirms current practice and evidence for care in one of the three areas evaluated, from studies reporting results specifically in women Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  38. Study Limitations • Focus on RCTS only • Only few studies reporting on: • Subgroup analyses by demographic or clinical characteristics • Harms or risks of therapy • Most studies applicable to modifiers of effectiveness or safety report data for overall population, not separated by sex • Not included observational and noncomparator studies in women • Sample size and low representation of women affect the ability to analyze results by sex • Exclusion of many articles due to lack of sex-specific reporting • Low numbers of studies available for analysis for each clinical presentation • On average, 17 percent of the articles comparing treatment strategies for CAD reported sex-specific outcomes • Reporting bias in publications resulted in selection bias in review Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  39. Study Limitations (cont.) • Strength of meta-analysis limited by: • Different definitions of primary composite outcome • Different timing of clinical endpoints • Change in PCI techniques and definition of optimal medical therapy over time • Most studies involved older therapies (balloon angioplasty or bare-metal stents) • Under-representation of current era of therapies • Drug-eluting stents and use of dual antiplatelet therapy • Variable reporting on the implementation of optimal medical therapy • Many multicenter, international RCTs • Generalizability to the United States may be of concern, although revascularization and prescription of medical therapies not very different • Not reported: • Medication adherence • Adverse effects and safety concerns other than bleeding Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  40. Directions for Future Research • Studies with sufficient representation of women • Women-only enrollment, or • Large sample size with stratification of randomization by sex • Patient-level meta-analysis • Comparing similar interventions for the same CAD presentation • Reporting sex by treatment results separately • Reporting demographic and clinical factors that influence cardiovascular outcomes • Reporting of safety concerns and risks by sex Dolor RJ, et al. Treatment strategies for women with CAD. Agency for Healthcare Research and Quality. 2012. Rockville, MD. Available at: http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1227.

  41. Effective Healthcare Program CER Number 43Treatment Strategies for Women with CAD:Thank you for your time • For CE/CME: • www.ce.effectivehealthcare.ahrq.gov/credit • Use code: CER23 • Visit AHRQ’s continuing education Web site regularly to participate in future programs • For electronic copies of the clinician guide, the consumer guide, and the full systematic review • http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1227&pageaction=displayproduct • Free print copies • AHRQ Publications Clearinghouse: (800) 358-9295

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