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Adherence to guidelines for atrial fibrillation management of patients referred to cardiology departments: Studio Italiano multicentrico sul Trattamento della Fibrillazione Atriale (SITAF).

Europace. 2010 May 28;

Authors: Bottoni N, Tritto M, Ricci R, Accogli M, Di Biase M, Iacopino S, Iori M, Themistoclakis S, Sitta N, Spadacini G, De Ponti R, Brignole M,

Aims The purpose of this study was to evaluate adherence to national guidelines on the non-pharmacologic (ablative) treatment of atrial fibrillation (AF). Methods and results This prospective, observational, transversal study enrolled 1256 consecutive in- and outpatients referred to 43 cardiology departments between 1 and 31 October 2008 for the management of AF as a primary diagnosis. A rhythm-control strategy (cardioversion, antiarrhythmic medication, pace-maker implantation, substrate ablation, alone or in combination) was prescribed in 865 (69%) of the patients and a rate-control strategy [drugs, atrioventricular junction ablation and pace-maker implantation (Ablate and Pace)] in 285 (23%). Specifically, substrate catheter ablation was indicated by the attending cardiologist in 187 (14.9%) patients and Ablate and Pace in 29 (2.3%). According to guideline indications, substrate catheter ablation would have been indicated in 183 (14.6%) patients, but only 105 (57%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.49). Atrioventricular junction ablation and pace-maker implantation would have been indicated in 108 (8.6%) patients, but only 29 (27%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.06). Conclusion About a quarter of patients referred to cardiology departments for AF management have potential indications for non-pharmacological treatment according to the guidelines. Substrate catheter ablation was offered by the attending cardiologist in a percentage similar to that expected, but concordance with guideline indications was moderate. Atrioventricular junction ablation and pace-maker implantation was largely underused.

PMID: 20511358 [PubMed - as supplied by publisher]

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Comparison of original (2003) and revised (2008) national guidelines for reporting of cerebrospinal fluid spectrophotometric scanning for suspected subarachnoid haemorrhage against patient outcome.

Ann Clin Biochem. 2010 May 28;

Authors: Griffiths MJ, Chow E, Panting MD, Ford C, Gama R

BACKGROUND: National guidelines for cerebrospinal fluid (CSF) analysis and its reporting in suspected subarachnoid haemorrhage (SAH) were published in 2003, but revised in 2008 to give greater clarity in interpretation. It is not known whether the less ambiguous reporting of 2008 guidelines may lead to a false assurance and adversely affect patient outcome. We, therefore, re-interpreted scans reported under the 2003 guidelines, using the 2008 guidelines and compared these reports against final diagnosis and patient outcome obtained from a retrospective case-note review audit. METHODS: We identified requests for CSF xanthochromia studies from the laboratory system between September 2006 and August 2007. Spectroscopy scans were then retrieved and re-interpreted using the 2008 guidelines. The original reports and re-interpreted scans were compared against diagnosis and patient outcome using case-note review. RESULTS: We received 93 requests for CSF spectroscopy on 90 patients. Fourteen requests were not processed due to insufficient sample, but of these three patients had a repeat lumbar puncture (LP). Two further requests were not processed at the request of the clinician as they were no longer clinically indicated. Therefore, 77 spectroscopic scans were re-interpreted. The revised guidelines re-classified 11 previously equivocal scans into the not supportive of SAH category. On case-note review, one patient had a subsequent fatal SAH. The remaining 10 were given non-SAH final diagnoses and none had similar further inpatient episodes for at least 12 months and up to 18 months following LP. CONCLUSIONS: The revised (2008) national guidelines for the analysis of CSF in suspected SAH offer greater clarity in reporting without adversely affecting patient outcome.

PMID: 20511372 [PubMed - as supplied by publisher]

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Association between adherence to evidence-based guidelines for the prescription of non-steroidal anti-inflammatory drugs and the incidence of gastric mucosal lesions in Japanese patients.

J Gastroenterol. 2010 May 25;

Authors: Tsumura H, Fujita T, Tamura I, Morita Y, Yoshida M, Toyonaga T, Mukai H, Inokuchi H, Kutsumi H, Azuma T

OBJECTIVE: Recently, guidelines for the treatment and prevention of ulcers induced by non-steroidal anti-inflammatory drugs (NSAIDs) were established. This study investigated the association between the current adherence to the guidelines and the incidence of gastric mucosal lesions caused by NSAIDs. METHODS: This study included 254 NSAIDs users (128 regular and 126 on-demand users) who had undergone upper gastrointestinal endoscopy. The patients were characterized as high risk based on the following: age 65 years or older, history of peptic ulcers, concurrent use of corticosteroids or anticoagulants, and high-dose NSAIDs use. Adherence was defined as the prescription of NSAIDs with proton pump inhibitors, prostaglandin analogues, or high-dose histamine 2 receptor antagonists in high-risk NSAIDs user. The severity of gastric mucosal lesions was evaluated using the modified LANZA score (MLS). RESULTS: Seventy-nine (61.7%) of the regular NSAIDs users and 65 (51.6%) of the on-demand NSAIDs users met our definition of high-risk patients. Adherence in the regular NSAIDs users and on-demand NSAIDs users was 25 (31.7%) and 16 (24.6%), respectively. The incidence of gastric mucosal lesions (MLS >== 1) was significantly higher in the nonadherence group than in the adherence group for both regular NSAIDs users (59.3 vs. 28.0%, P = 0.01) and on-demand NSAIDs users (63.3 vs. 25.0%, P = 0.01). Gastric ulcers in the regular NSAIDs users were more frequently observed in the nonadherence group than in the adherence group (29.6 vs. 4.0%, P < 0.01). CONCLUSION: Nonadherence was associated with a high prevalence of NSAIDs-induced gastric mucosal lesions.

PMID: 20499110 [PubMed - as supplied by publisher]

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Evaluating the Performance of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) Bleeding Score in a Contemporary Spanish Cohort of Patients With Non-ST-Segment Elevation Acute Myocardial Infarction.

Circulation. 2010 May 24;

Authors: Abu-Assi E, Gracía-Acuña JM, Ferreira-González I, Peña-Gil C, Gayoso-Diz P, González-Juanatey JR

BACKGROUND: -The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) model provides a risk score that predicts the likelihood of major bleeding in patients hospitalized for non-ST-elevation acute myocardial infarction. The aim of the present work was to evaluate the performance of this model in a contemporary cohort of patients hospitalized for non-ST-elevation acute myocardial infarction in Spain. Methods and Results-The study subjects were 782 consecutive patients admitted to our center between February 2004 and June 2009 with non-ST-elevation acute myocardial infarction. For each patient, we calculated the CRUSADE risk score and evaluated its discrimination and calibration by the C statistic and the Hosmer-Lemeshow goodness-of-fit test, respectively. The performance of the CRUSADE risk score was evaluated for the patient population as a whole and for groups of patients treated with or without >/=2 antithrombotic medications and who underwent cardiac catheterization or not. The median CRUSADE score was 30 points (range, 18 to 45). A total of 657 patients (84%) were treated with >/=2 antithrombotic, of whom 609 (92.7%) underwent cardiac catheterization. The overall incidence of major bleeding was 9.5%. This incidence increased with the risk category: very low, 1.5%; low, 4.3%; moderate, 7.8%; high, 11.8%; and very high, 28.9% (P<0.001). For the patients as a whole, for the groups treated with or without >/=2 antithrombotics, and for the subgroup treated with >/=2 antithrombotics who did or did not undergo cardiac catheterization, the CRUSADE score showed adequate calibration and excellent discriminatory capacity (Hosmer-Lemeshow P>0.3 and C values of 0.82, 0.80, 0.70, and 0.80, respectively). However, it showed little capacity to discriminate bleeding risk in patients treated with >/=2 antithrombotics who did not undergo cardiac catheterization (C=0.56). Conclusions-The CRUSADE risk score was generally validated and found to be useful in a Spanish cohort of patients treated with or without >/=2 antithrombotics and in those treated with or without >/=2 antithrombotics who underwent cardiac catheterization. More studies are needed to clarify the validity of the CRUSADE score in the subgroup treated with >/=2 antithrombotics who do not undergo cardiac catheterization.

PMID: 20497978 [PubMed - as supplied by publisher]

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Guidelines for Assessment of Work Disability: An International Survey.

Gesundheitswesen. 2010 May 21;

Authors: Boer WE, Rijkenberg AM, Donceel P

BACKGROUND: Assessments of long-term work disability are carried out by social insurance physicians (SIPs) and are little supported with evidence or instruments. Guidelines are hardly ever used in social insurance medicine. Developments in social insurance medicine might be slow as insurance is different from clinical medicine. AIMS: We explored the comparability of assessments in social insurance medicine in different countries and asked what guidelines were in official use. METHODS: Eighteen European countries were invited. A questionnaire on assessments practices was sent to national experts. A comparative table was presented to all contributors. Countries with guidelines were visited. Guidelines were categorised according to their purpose and their contents were compared. The results were presented to experts of the participating countries for validation. RESULTS: Fourteen countries participated. Functional capacity assessment was common. Guidelines for SIPs were reported to be officially in use in Germany, Ireland, the Netherlands and Switzerland. Twenty-two guidelines were medical and eleven were procedural. Medical guidelines mainly treated the same topics. Procedural guidelines were more variable. CONCLUSION: Assessment of work disability is comparable between countries. Medical and procedural guidelines should be further developed and tested on their value in practice. The procedural guidelines need to be published in a clear and comparable manner. The legal security of claimants would be endorsed by this. Germany and the Netherlands are most experienced and could take the lead in international development.

PMID: 20496319 [PubMed - as supplied by publisher]

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Effect of the Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery Clinical Practice Guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon Clinical Practices.

Anesth Analg. 2010 May 20;

Authors: Likosky DS, Fitzgerald DC, Groom RC, Jones DK, Baker RA, Shann KG, Mazer CD, Spiess BD, Body SC

Background: The 2007 Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Clinical Practice Guideline for Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery was recently promulgated and has received much attention. Using a survey of cardiac anesthesiologists and perfusionists' clinical practice, we aimed to assess the current practices of perfusion, anesthesia, and surgery, as recommended by the Guidelines, and to also determine the role the Guidelines had in changing these practices. Methods: Nontrainee members of the Society of Cardiovascular Anesthesiologists, the American Academy of Cardiovascular Perfusion, the Canadian Society of Clinical Perfusion, and the American Society of ExtraCorporeal Technology were surveyed using a standardized survey instrument that examined clinical practices and responses to the Guidelines. Results: A total of 1402 surveys from 1061 institutions principally in the United States (677 institutions) and Canada (34 institutions) were returned, a 32% response rate. There was wide distribution of the Guidelines with 78% of anesthesiologists and 67% of perfusionists reporting having read all, part, or a summary of the Guidelines. However, only 20% of respondents reported that an institutional discussion had taken place as a result of the Guidelines, and only 14% of respondents reported that an institutional monitoring group had been formed. There was wide variability in current preoperative testing, perfusion, surgical, and pharmacological practices reported by respondents. Twenty-six percent of respondents reported 1 or more practice changes in response to the Guidelines. The changes made were reported to be highly (9%) or somewhat (31%) effective in reducing overall transfusion rates. Only 4 of 38 Guideline recommendations were reported by >5% of respondents to have been changed in response to the Guidelines. Conclusions: Wide variation in clinical practices of cardiac surgery was reported. Little change in clinical practices was attributed to the Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists Guidelines.

PMID: 20488928 [PubMed - as supplied by publisher]

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Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit?

Phys Ther. 2010 May 20;

Authors: Rutten GM, Degen S, Hendriks EJ, Braspenning JC, Harting J, Oostendorp RA

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005-2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. METHODS:/b> Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. RESULTS: /b> Higher percentages of adherence were associated with fewer functional limitations (beta=-0.21, P=.023) and fewer treatment sessions (beta=-0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. CONCLUSIONS:/b> The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

PMID: 20488978 [PubMed - as supplied by publisher]

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[Perspectives in guideline development and implementation in Germany.]

Z Rheumatol. 2010 May 20;

Authors: Kopp IB

Guidelines are important tools for improving knowledge management, processes and outcomes in health care. They aim to assisst both the clinical and the patient decision-making process, particularly in those areas of health care where considerable variation or potential for improvement exist. However, guidelines are often subject to substantial criticism by practicing clinicians. A prerequisite to improving the acceptance of guidelines is a systematic and methodically sound approach in guideline development. The German instrument for methodological guideline appraisal, DELBI, is intended to assist both guideline developers and users. However, this alone is insufficient. Implementation is a process requiring multifaceted strategies to promote behavior change. These include the provision of assistance for local adaptation and well-defined quality indicators for monitoring guideline adherence and quality of care. Additionally, possible links to existing quality management activities should be taken into account to avoid duplication of efforts.

PMID: 20490515 [PubMed - as supplied by publisher]

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[Towards an implementation of guidelines for the therapy of systemic sclerosis (scleroderma) : Between desire and reality.]

Z Rheumatol. 2010 May 20;

Authors: Becker MO, Müller-Ladner U, Riemekasten G

The clinical manifestations of systemic sclerosis (scleroderma, SSc) are characterized by three prominent features: autoimmunity/inflammation, vascular lesions (vasculopathy) and (organ) fibrosis. Drugs and other therapies are now available for each of these features. However, due to the low prevalence and high variation in clinical signs and symptoms of the disease, there are only few high quality clinical trials. The EULAR Scleroderma Trials and Research Group (EUSTAR, a subgroup of the European League Against Rheumatism, EULAR) has therefore started to assess the therapies available today and make recommendations. The present article discusses treatment options in systemic sclerosis beyond these recommendations. It is to be expected that the establishment of national and international networks for systemic sclerosis research (e.g. the German Network for Systemic Sclerosis, DNSS, and EUSTAR) will raise the standards of evidence-based therapy for systemic sclerosis in the future by analyzing large data sets and performing clinical trials.

PMID: 20490516 [PubMed - as supplied by publisher]

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[How closely does rheumatology treatment follow the guidelines? : Ambition and reality.]

Z Rheumatol. 2010 May 20;

Authors: Zink A, Huscher D, Schneider M

In 2005, the first evidence-based German guideline on the management of early rheumatoid arthritis (RA) was published. With data from the national database of the German Collaborative Arthritis Centres and other health care studies we evaluated to what extent current health care is in accordance with the guideline’s recommendations.A total of 66% of all newly referred RA patients seen at the national database centers in 2008 achieved the goal of seeing a rheumatologist within 3 months of symptom onset, while 75% were seen within 6 months. Before referral, 25% of the patients had DMARD therapy and 19% glucocorticoids. Of the patients in rheumatological care, 90% received DMARDs. The availability of early arthritis clinics determines the promptness of access to a rheumatologist.After 6 years of rheumatological care, around 80% of patients continuously seen were still under treatment with a conventional or biological DMARD. The highest continuation rates were seen for methotrexate monotherapy. Biologic agents were given in 2008 to 20% of patients. Of those with “severe” or “very severe” disease, 42% received biologics and 21% DMARD combination therapy. Low-dose glucocorticoids are the standard of care; of patients in rheumatological care, 88% received dosages up to 7.5 mg/d and 74% of up to 5 mg/d.

PMID: 20490517 [PubMed - as supplied by publisher]

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