Interventions to prevent non-ventilator hospital-acquired pneumonia: A Making Healthcare Safer rapid review

Abstract

Background

Interventions to prevent non-ventilator hospital-acquired pneumonia (NV-HAP) was identified as a high priority patient safety practice (PSP) for inclusion in the Making Healthcare Safer IV review series by a multidisciplinary technical expert panel through the Agency for Healthcare Research and Quality (AHRQ) topic prioritization process.

Methods

We followed the AHRQ Evidence-based Practice Center Program's rapid review guidance. We searched PubMed, Embase, and the Cochrane Library to identify eligible systematic reviews from January 2019 to August 2024 and primary studies from January 2010 to August 2024. We included literature that addressed any PSPs intended to prevent NV-HAP among inpatients in U.S. hospitals. We registered the protocol in PROSPERO (CRD42024612917).

Results

We retrieved 4103 relevant citations. After title and abstract screening, 207 full-texts were assessed for eligibility, and 18 primary studies were included: six studies for oral care, seven studies for dysphagia screening and management, and five studies for prevention bundles (all five bundles included oral care as one component). Prevention bundle studies reporting NV-HAP incidence favored prevention bundles (Strength of Evidence: Low). For all other reported outcomes for each PSP, we rated the evidence as insufficient, mostly due to high study limitations and imprecision. Therefore, we were unable to draw conclusions about whether oral care, dysphagia screening and management are effective in preventing NV-HAP or other undesired outcomes.

Conclusion

The evidence supporting interventions for NV-HAP prevention is mostly limited and inconclusive. While prevention bundles showed potential benefits, further high-quality research is needed to improve patient outcomes through targeted, evidence-based interventions.

Keywords

Non-ventilator hospital-acquired pneumonia pneumonia prevention hospital acquired infection prevention patient safety practice infection prevention

Introduction

Pneumonia is the most frequent healthcare-associated infection (HAI), accounting for 27.9% of HAIs in the USA, with 64.5% of pneumonia cases not associated with ventilators, contributing to an overall non-ventilator hospital-acquired pneumonia (NV-HAP) incidence rate of 2.63 per 1000 patient stays in the USA.^1,2 An estimated 32.6–35.4 million hospitalized patients in the USA are at risk for NV-HAP.³ An analysis of over 6 million hospitalizations in the USA between 2015 and 2020 reported a mortality rate of 22% among those who experienced NV-HAP.⁴ NV-HAP is associated with substantially higher rates of intensive care unit (ICU) admissions and ventilator use, greater total hospital charges, and longer hospital length of stay (LOS) than those without NV-HAP.^4,5

Interventions to prevent NV-HAP include hand hygiene, oral care, diagnosis and management of dysphagia, early mobilization, multimodal interventions to prevent viral infection, head of bed elevation, education of patients and caregivers and staff, administration of prophylactic antibiotics, minimizing sedation, and breathing exercise.^6–8 Of these interventions, oral care, early assessment and management of aspiration, and early mobility—each targeting highly modifiable risk factors—have been most extensively studied.^9–13 The purpose of this rapid review was to evaluate and synthesize the evidence on benefits and harms of different patient safety practices (PSPs) used to prevent NV-HAP, as part of the Agency for Healthcare Research and Quality's (AHRQ) Making Healthcare Safer IV report series.¹⁴ The full report is available at: https://effectivehealthcare.ahrq.gov/products/nv-hap/rapid-research.

Methods

Interventions to prevent NV-HAP was identified as a high priority PSP for inclusion in the Making Healthcare Safer IV report series by a panel of multidisciplinary experts using a modified Delphi technique and selected for rapid review by an evidence-based practice center (EPC).¹⁵ A representative from AHRQ served as a Contracting Officer's Technical Representative and provided technical assistance during the conduct of the full rapid review. and provided comments on draft versions of the full evidence report.¹⁶ AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis or interpretation, or preparation, review, or approval of the manuscript for publication.

We followed the adjustments and streamlining processes proposed by the AHRQ EPC Program for conducting this rapid review.¹⁷ The protocol for this rapid review is available on the AHRQ website at: https://effectivehealthcare.ahrq.gov/products/nv-hap/protocol and was registered in PROSPERO (CRD42024612917).

Literature searches and screening

A medical librarian developed search strategies (Appendix A in the supplementary materials) and conducted searches in PubMed, Embase, and the Cochrane Library in August 2024 to identify primary studies and systematic reviews based on the inclusion and exclusion criteria presented in Appendix B in the supplementary materials. A single reviewer performed most of the title and abstract screening using DistillerSR's artificial intelligence (AI) prioritization process.^18,19 Once 70% of the abstracts were screened, we used DistillerSR's AI prioritization process to screen another 10% representing the remaining records with the highest likelihood of inclusion. We also used DistillerSR AI's audit tool to identify any relevant studies that may have been accidently excluded by the single reviewer.¹⁸ A single reviewer reviewed all full texts, and another reviewer checked a 10% sample of the excluded full texts to ensure accuracy and consistency.

Data extraction and risk of bias assessment

With the assistance of Claude,^20,21 software that uses a large language model, reviewers extracted available data, including author, year, study design, care setting, patient population, characteristics of the PSPs used to prevent NV-HAP, details about the outcomes, and unintended harms. We used the Cochrane Collaboration's Tool for Assessing the Risk of Bias Of Randomised Trials (ROB1)²² and the Risk Of Bias In Non-randomized Studies—of Interventions (ROBINS-I)²³ to assess the risk of bias in the randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs), respectively. We did not assess the risk of bias of the included pre–post studies, and instead deemed them all at critical risk of bias due to inherent limitations in the study design.

Data synthesis and strength of evidence assessment

We narratively summarized findings across primary studies for each PSP. PSP classification relied first on how the interventions were reported in the studies, and we verified against the details for each intervention. When a study tested only a single oral-hygiene component, we classified it as oral care. When oral care was one element of a broader multi-component program, we classified the study as a bundle to avoid misattribution of effects to oral care alone.

We assessed study limitations, directness, consistency, and precision to determine the strength of evidence (SOE) for each PSP outcome following the methods outlined in the AHRQ Effective Health Care Program Methods Guide for Effectiveness and Comparative Effectiveness Reviews.²⁴ See the detailed methods in Appendix D in the supplementary materials.

Results

Evidence base

Our searches retrieved 4103 relevant citations after deduplication (Figure 1). Following the title and abstract screening, 207 full texts were screened for eligibility. A total of 18 studies (19 publications)^25–43 were included with six studies^{30,35–37,40,41} on oral care, seven studies^{28,29,32–34,38,39} on dysphagia screening and management, and five studies from six publications^{25–27,31,42,43} on prevention bundles.

Figure 1.

PRISMA flow diagram.

The overall body of evidence is summarized in Table 1. Details for the SOE ratings for each PSP, study and patient characteristics and outcomes for each PSP are shown in Tables C-1 through C-11 in Appendix C in the supplementary materials. Risk of bias assessment ratings for the included RCTs and NRCSs are presented in Tables C-12 and C-13 in the supplementary materials, respectively.

Oral care

Six studies (1 cluster RCT,³⁰ 1 NRCS,³⁵ and 4 pre–post studies^36,37,40,41) focused on oral care, with five studies^{30,35–37,40} on oral care protocols and one study⁴¹ on an oral care documentation quality improvement (QI) initiative (Tables C-1 and C-2 in the supplementary materials). All oral care protocol studies^{30,35–37,40} enrolled patients who were not on ventilators or reported NV-HAP incidence rates. The oral care documentation QI study⁴¹ reported hospital-acquired pneumonia (HAP) incidence without explicitly stating whether ventilated patients were excluded or whether pneumonia outcomes excluded ventilator-acquired pneumonia (VAP).^30,44

Table 1.

Overview of body of evidence.

Patient safety practice	Outcome measure	Number and types of studies	Study findings	Strength of EVIDENCE
Oral care protocol	NV-HAP incidence	1 cluster RCT,³⁰ 1 NRCS,³⁵ and 3 pre–post studies^36,37,40	Mixed results	Insufficient
	Hospital length of stay	1 cluster RCT³⁰ and 1 NRCS³⁵	Mixed results	Insufficient
	Mortality	1 pre–post study⁴⁰	Favored oral care protocol	Insufficient
Oral care documentation QI initiative	NV-HAP incidence	1 pre–post study⁴¹	Inconclusive	Insufficient
Dysphagia screening and management	NV-HAP incidence	2 NRCSs^32,34 and 4 pre–post studies^28,29,38,39	Mixed results	Insufficient
Dysphagia screening and management	Mortality	1 NRCS³² and 2 pre–post studies^38,39	Mixed results	Insufficient
Dysphagia management with thick- vs. thin-liquid diets	NV-HAP incidence	1 NRCS³³	Favored thin-liquid diets	Insufficient
	Mortality	1 NRCS³³	Inconclusive	Insufficient
	Hospital length of stay	1 NRCS³³	Inconclusive	Insufficient
	30-day rehospitalization	1 NRCS³³	Inconclusive	Insufficient
Prevention bundle	NV-HAP incidence	5 pre–post studies^{25–27,31,42,43}	Favored prevention bundles	Low
	Mortality	1 pre–post study³¹	Favored prevention bundle	Insufficient
	Harm	1 pre–post study³¹	Inconclusive	Insufficient

Note: The number of studies in this table does not total 18 included studies because some studies reported more than one outcome. Also, in three cases (e.g., oral care protocols, mortality outcome), the evidence statistically significantly favored an intervention, but other aspects of the evidence (typically risk of bias) resulting in a strength of evidence rating of insufficient, precluding conclusions.

Abbreviations: NV-HAP: nonventilator hospital-acquired pneumonia; NRCS: nonrandomized comparative study; QI: quality improvement; RCT: randomized controlled trial.

All oral care was delivered primarily by nursing staff, some with additional involvement of speech language pathologists³⁵ and support from interprofessional teams in others.^37,40 All protocols focused on toothbrushing (with soft-bristle or suction toothbrushes), toothpaste or antiseptic rinses, and, in some cases, denture cleaning^30,35 with a target frequency of 2–4 times per day. Two studies^37,40 implemented the oral care protocol hospital-wide for at-risk patients. The other studies^30,35,36,41 implemented their protocols or QI initiatives in two to four medical and/or surgical units, regardless of patient risk. The details of the oral care protocols are summarized in Table C-3 in the supplementary materials.

All five oral care protocol studies reported NV-HAP incidence, with two^30,35 reporting hospital LOS and one⁴⁰ reporting mortality. Studies reported mixed findings regarding the prevention of NV-HAP by oral care protocols. One cluster RCT³⁰ of 8709 patients in four medical and surgical units reported a difference in NV-HAP incidence rates favoring the oral care protocol over usual care, but the difference was statistically significant only in medical units (n = 4784) and not in surgical units (n = 3925). One NRCS (n = 2890)³⁵ found no statistically significant difference (adjusted odds ratio [aOR]: 1.42 [95% CI: 0.79, 2.53]). NV-HAP incidence decreased in all three pre–post studies,^36,37,40 but only one study⁴⁰ showed a statistically significant difference. We determined the SOE for NV-HAP with oral care protocols to be insufficient due to high study limitations, inconsistency, and imprecision, and we were unable to draw conclusions about whether oral care protocols are effective in preventing NV-HAP.

One cluster RCT³⁰ and one NRCS³⁵ reported mixed findings on hospital LOS. One cluster RCT (n = 8709)³⁰ showed a negligible, statistically nonsignificant difference between the oral care protocol and usual care groups in medical units (mean difference [MD] −0.10 days [95% CI: −0.48, 0.28]), but statistically significantly longer hospital LOS in surgical units (2.10 days [95% CI: 1.71, 2.49]). The NRCS (n = 2890)³⁵ found a small, but statistically significant difference (−0.70 days [95% CI: −1.05, −0.35]) favoring the oral care protocol. However, due to high study limitations, inconsistency, and imprecision, we determined the SOE for hospital LOS to be insufficient and were unable to draw conclusions about whether oral care protocols are effective in decreasing hospital LOS.

Mortality due to NV-HAP was reported in one pre–post study (n = 417)⁴⁰ with a statistically significant reduction from baseline favoring the oral care protocol (15.4% vs. 38.5% during post- and pre-intervention periods, respectively; p = .037). Due to high study limitations, inconsistency, and imprecision, we determined the SOE for mortality to be insufficient and were unable to draw conclusions about whether oral care protocol is effective in reducing mortality.

The QI initiative study on oral care documentation⁴¹ using Plan-Do-Study-Act cycles reported a statistically nonsignificant decrease in the NV-HAP incidence from baseline (rates per 1000 patient-days, 0.28 vs. 0.44 for the QI initiative vs. usual care, respectively; p = .167). Due to high study limitations and imprecision, we determined the SOE to be insufficient for the outcome of NV-HAP for the QI initiative and were unable to draw conclusions about whether oral care documentation QI initiative is effective in preventing NV-HAP.

Dysphagia screening and management

Seven studies reported results for dysphagia screening and management, with six^{28,29,32,34,38,39} on dysphagia screening protocols and screening tools and one study³³ comparing thick-liquid diets with thin-liquid diets for dysphagia management (Tables C-4 to C-7 in the supplementary materials). Three studies^28,29,39 examined the effects of a standardized dysphagia screening protocol with and without dysphagia management procedures for patients who tested positive, whereas one study³⁸ focused on the effects of a dysphagia screening tool alone. Additionally, two studies^32,34 considered any dysphagia screening accepted by its institution³² or per the Get With The Guidelines (GWTG) Stroke registry standard.³⁴ Three studies^29,32,34 compared dysphagia screening with no screening, whereas the other four studies^28,29,38,39 compared their dysphagia screening protocol or a tool with usual care before its implementation. All studies reported pneumonia incidence, one study reported hospital LOS,³³ four reported mortality,^32,33,38,39 and one reported 30-day rehospitalization.³³

The included studies used different pneumonia definitions and terminologies (Table C-8 in the supplementary materials). None of the included studies reported NV-HAP outcomes specifically. Instead, one²⁹ reported hospital-acquired aspiration pneumonia without VAP, two studies did not explicitly state whether VAPs were excluded in the aspiration pneumonia²⁸ or HAP,³⁴ and one³⁹ noted that VAPs were included in their HAP outcome.

There were mixed findings regarding the effects of dysphagia screening on NV-HAP prevention among stroke patients in two NRCSs^32,34 and two pre–post studies.^38,39 Dysphagia screening protocols or tools statistically significantly reduced NV-HAP incidence from baseline in two pre–post studies.^38,39 One study (n = 2372)³⁸ using the MetroHealth Dysphagia Screen⁴⁵ in all patients with stroke presenting to an ED showed statistically significantly lower HAP rates after its implementation in patients with ischemic stroke (n = 1441; 8.0% vs. 13.8% for screening vs. usual care; p = .007) and hemorrhagic stroke (n = 931; 13% vs. 19%; p < .001). A standardized dysphagia screening protocol with an expedited speech pathology swallow evaluation following a positive test³⁸ showed a statistically significant reduction in HAP from baseline (aOR: 0.43 [95% CI: 0.25, 0.71]). Of the two NRCSs^32,34 involving 332,021 patients with stroke, one NRCS reported a statistically significant association between dysphagia screening and HAP compared with no screening, favoring no dysphagia screening (aOR: 1.4 [95% CI: 1.32, 1.47]; controlled for age, sex, race, and diagnosis). In contrast, the other NRCS³² showed no statistically significant difference in NV-HAP incidence between the two groups (3.9% vs. 4.2% for screening vs. no screening; RR 0.91 [95% CI: 0.77, 1.07]).

Two pre–post studies^28,29 in patients without stroke reported mixed findings of dysphagia screening in preventing NV-HAP. One pre–post study (n = 54,902 admissions)²⁸ comparing a standardized dysphagia screening protocol with usual care in all adult inpatients reported a statistically significant decrease in aspiration pneumonia from baseline (rate per 1000 admissions, 1.31 vs. 2.17 for screening vs. usual care; p < .018). However, a dysphagia screening program developed for acute care oncology inpatients²⁹ did not show any benefits in preventing NV-HAP (incidence rate per 1000 admissions, 8.78 vs. 7.36; RR 1.22 [95% CI: 0.82, 1.83]). Due to high study limitations, inconsistency, and imprecision, we determined the SOE for NV-HAP incidence with dysphagia screening to be insufficient and were unable to conclusions about whether dysphagia screening is effective in preventing NV-HAP.

Three studies^32,38,39 reported mixed results on mortality with dysphagia screening in patients with stroke. One NRCS (n = 18,017)³² comparing standardized dysphagia screenings with no screening in patients with ischemic and hemorrhagic stroke reported a lower mortality rate with screening compared with no screening, but the difference was not statistically significant (2.3% vs. 2.8%; p = .07). One pre–post study (n = 2334)³⁹ reported a statistically significant increase in mortality from baseline (20.2% vs. 14.3%; RR 1.47 [95% CI: 1.20, 1.79]), favoring usual care. Another study (n = 2372)³⁸ reported a statistically nonsignificant increase in mortality among ischemic stroke, favoring usual care, but a statistically nonsignificant decrease in mortality from baseline in patients with hemorrhagic stroke, favoring dysphagia screening. Due to concerns about high study limitations, inconsistency, and imprecision, we determined the SOE for mortality to be insufficient and were unable to draw conclusions about whether dysphagia screening is effective in reducing mortality.

One large NRCS³³ (n = 8916) retrospectively compared thick-liquid diets with thin-liquid diets in propensity score-matched hospitalized patients with Alzheimer disease or related dementias who had clinical suspicion of dysphagia. Thick-liquid diets showed a statistically significant higher association with respiratory complications (pneumonia, aspiration, and choking) than thin-liquid diets (odds ratio [OR] 1.73 [95% CI: 1.56, 1.91]). However, no statistically significant differences were reported for mortality (hazard ratio 0.92 [95% CI: 0.75, 1.14]), hospital LOS (MD, log days 0.02 [95% CI: −0.01, 0.04]), and 30-day rehospitalizations (OR 1.05 [95% CI: 0.93, 1.19]) between the two diets. Due to high study limitation, indirectness, and imprecision, we determined the SOE for all outcomes with thick-liquid diets as insufficient. Therefore, we did not draw conclusions about whether thick-liquid diets are effective in reducing the rate of NV-HAP incidence, mortality, hospital LOS, and 30-day rehospitalization.

Prevention bundles

Five pre–post studies from six publications of prevention bundles^{25–27,31,42,43} were included (Tables C-9 and C-10 in the supplementary materials). Three studies^26,27,31 included exclusively nonventilated patients, and the other two^25,42 also included ventilated patients, with only one study⁴² reporting NV-HAP incidence rates at 5 years for a nonventilated subgroup. All five prevention bundles included oral care. However, there was considerable variation in the other interventions included and in how they were implemented at each study location. Mobilization was included in four studies,^25,27,31,42 head elevation in three studies,^25,27,31,42 incentive spirometry with or without breathing exercise in three studies,^25,27,42 tube care (oropharyngeal and feeding tubes) in two studies,^26,31 dysphagia screening in one study,³¹ and a sedation protocol in two studies.^25,31 The bundles were integrated into the electronic health record in four studies.^26,27,31,42 Three studies^27,31,42 implemented all components simultaneously, while the others^25,26 introduced one or more interventions as a pilot, then gradually expanded the bundle based on needs and progress. Table C-11 in the supplementary materials provides details on each bundle's rationale, individual components, and implementation timelines.

All five studies^{25–27,31,42} reported unadjusted pneumonia incidence rates. Two studies^25,27 also reported American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk-adjusted observed/expected metrics, and one study³¹ reported mortality and harms. All five studies showed a statistically significant decrease in NV-HAP^26,27,31,42 and postoperative pneumonia²⁵ from baseline, favoring prevention bundles. Given high study limitations, we determined the SOE for NV-HAP outcome for prevention bundle to be low.

Only one study³¹ reported mortality due to NV-HAP, showing a statistically significant reduction in mortality due to NV-HAP across 21 hospitals, favoring prevention bundles (mortality rate per 1000 admissions: 0.34 vs. 1.05 [p = .006]; mortality rate per 100,000 members 1.24 vs. 4.37 [p = .003] for post- and pre-intervention periods, respectively). This study reported only NV-HAP-attributable mortality and did not provide mortality data for all hospitalized patients or for all patients at risk of NV-HAP. Given high study limitations, we determined the SOE to be insufficient for the outcome of mortality.

The same study³¹ examined potential harms associated with prevention bundle interventions and reported no risks of adverse events. Given the high study limitation, we determined the SOE to be insufficient for the outcome of harms.

Discussion and conclusions

Our rapid review identified three PSPs to prevent NV-HAP. Evidence for oral care protocols, based on one cluster RCT,³⁰ one NRCS,³⁵ and four pre–post studies,^36,37,40,41 showed mixed results for NV-HAP prevention and hospital LOS and favored oral care in terms of mortality. An oral care documentation QI study⁴¹ showed inconclusive findings on NV-HAP incidence. Dysphagia screening, examined in two NRCSs^32,34 and four pre–post studies,^28,29,38,39 demonstrated mixed results for both NV-HAP incidence and mortality. A dysphagia management NRCS³³ showed higher rates of respiratory complications with thick-liquid diets than with thin-liquid diets, favoring thin-liquid diets, but inconclusive findings for mortality, hospital LOS, and 30-day rehospitalizations. Prevention bundles, evaluated in five pre–post studies,^{25–27,31,42} showed statistically significant reductions in NV-HAP incidence and mortality, favoring prevention bundle, but inconclusive findings for harm. Although mortality rates for oral care and prevention bundle PSPs and respiratory complications reported for thin-liquid diets favored a specific PSP, the high study limitations (risk of bias) resulted in insufficient SOE, precluding conclusions. Therefore, we were able to conclude that only prevention bundles may reduce the risk of developing NV-HAP (SOE: Low).

There are several limitations to consider in this review. First, because we adopted a rapid review approach guided by the methodology used in previous AHRQ Making Healthcare Safer reports, we focused only on studies conducted in the USA. Additionally, the included studies used different pneumonia terminologies and definitions. Variation also exists in the inclusion of ventilated patients and differences in reported pneumonia incidence, including whether VAP was explicitly excluded. This variability complicates the applicability of the findings, as results may not apply to all inpatient settings or patient demographics. Furthermore, key outcomes such as rehospitalizations, LOS, and potential harms were poorly reported, and many studies were underpowered to detect differences in NV-HAP incidence. The bundled interventions included different combinations of intervention components, making it difficult to identify the contributions of individual components. Finally, most studies did not adequately adjust for NV-HAP risk factors, such as season, admission type, chronic lung diseases, and ICU visits, highlighting the need for high-quality research to provide more reliable evidence for NV-HAP prevention strategies.

While prevention bundles have shown favorable effects in preventing NV-HAP, the components of these interventions may differ, and what works in one facility may not be effective in another. Tailoring these interventions to each facility's specific needs and capabilities is essential for achieving the best outcomes in NV-HAP prevention. Factors such as staff training and compliance, resource availability, facility size, unit type, and patient demographics should be considered when selecting the most appropriate bundled intervention.

Future research should address several gaps in the current understanding of NV-HAP. First, the lack of a standardized pneumonia definition in NV-HAP research complicates comparisons and limits generalizability. Establishing standardized pneumonia definitions is needed for more consistent and reliable research. Additionally, further studies should focus on optimizing oral care practices by examining the most effective frequencies, techniques, and materials (such as toothpaste and mouthwash composition). Research should compare existing dysphagia screening tools to identify the most reliable, accurate, and user-friendly options for different healthcare professionals. Finally, it is important to estimate the effectiveness of specific components in NV-HAP prevention bundles to help the U.S. healthcare system design bundled interventions suitable for various facilities and populations.

Supplemental Material

sj-doc-1-cri-10.1177_25160435251383320 - Supplemental material for Interventions to prevent non-ventilator hospital-acquired pneumonia: A making healthcare safer rapid review

Supplemental material, sj-doc-1-cri-10.1177_25160435251383320 for Interventions to prevent non-ventilator hospital-acquired pneumonia: A making healthcare safer rapid review by Jung Min Han, Jesse Wagner, Allison Hedden-Gross, James Davis, Ericka Kalp and Jonathan R Treadwell in Journal of Patient Safety and Risk Management

Footnotes

Acknowledgments

The authors gratefully acknowledge the following individuals for their contributions to this project: Eileen Cornish, B.A., and Evan LeGault, B.A., for their project management support, Laura Koepfler, M.L.S., for peer-reviewing the search strategies, Nikhil K. Mull, M.D., for providing subject matter expertise and reviewing the report, and Michael Phillips, MA, and Britney Hall, B.A., for their work in copy-editing, formatting, and ensuring 508 compliance. The authors also acknowledge David P. Calfee, M.D., M.S., M. Hassan Murad, M.D., and Eric B. Bass, M.D., M.P.H., for their valuable feedback on the protocol and/or report. Additionally, the authors acknowledge Ritu Sharma, B.Sc., for her administrative support.

ORCID iDs

Jung Min Han

Jesse Wagner

Allison Hedden-Gross

Ericka Kalp

Jonathan R Treadwell

Ethical considerations

This study is a rapid review of existing literature and does not involve human or animal participants. Therefore, ethical approval was not required.

Consent to participate

This study is a rapid review of existing literature and does not involve human or animal participants. Therefore, consent to participate was not required.

Consent to publication

All authors have reviewed and approved the final version of this manuscript for publication. This manuscript is being submitted as part of a co-publication agreement with the Agency for Healthcare Research and Quality (AHRQ), under which the journal and AHRQ will coordinate the release of this manuscript and the corresponding report.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded under Contract No. 75Q80120D00002 Task Order 75Q80124F32009 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors of this manuscript are responsible for its content. Statements in the manuscript do not necessarily reflect the official views of or imply endorsement by AHRQ or the HHS.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

Data are publicly available in AHRQ's Systematic Review Data Repository (SRDR Plus): https://srdrplus.ahrq.gov/public_data?id=6666&type=project

Supplemental material

Supplemental material for this article is available online.

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