Cardiologists' practices compared with practice guidelines: use of beta-blockade after acute myocardial infarction

Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study

OBJECTIVES

To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission.

MEASUREMENTS

The outcome was beta-blocker initiation within 30 days of NH readmission.

RESULTS

Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership.

CONCLUSION

Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial

BACKGROUND

Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA.

QUESTIONS/PURPOSES

We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period.

METHODS

Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated.

RESULTS

Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years.

CONCLUSIONS

Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Lack of concordance between empirical scores and physician assessments of stroke and bleeding risk in atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

BACKGROUND

Physicians treating patients with atrial fibrillation (AF) must weigh the benefits of anticoagulation in preventing stroke versus the risk of bleeding. Although empirical models have been developed to predict such risks, the degree to which these coincide with clinicians' estimates is unclear.

METHODS AND RESULTS

We examined 10 094 AF patients enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) registry between June 2010 and August 2011. Empirical stroke and bleeding risks were assessed by using the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or transient ischemic attack (CHADS2) and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) scores, respectively. Separately, physicians were asked to categorize their patients' stroke and bleeding risks: low risk (<3%); intermediate risk (3%-6%); and high risk (>6%). Overall, 72% (n=7251) in ORBIT-AF had high-risk CHADS2 scores (≥2). However, only 16% were assessed as high stroke risk by physicians. Although 17% (n=1749) had high ATRIA bleeding risk (score ≥5), only 7% (n=719) were considered so by physicians. The associations between empirical and physician-estimated stroke and bleeding risks were low (weighted Kappa 0.1 and 0.11, respectively). Physicians weighed hypertension, heart failure, and diabetes mellitus less significantly than empirical models in estimating stroke risk; physicians weighted anemia and dialysis less significantly than empirical models when estimating bleeding risks. Anticoagulation use was highest among patients with high stroke risk, assessed by either empirical model or physician estimates. In contrast, physician and empirical estimates of bleeding had limited impact on treatment choice.

CONCLUSIONS

There is little agreement between provider-assessed risk and empirical scores in AF. These differences may explain, in part, the current divergence of anticoagulation treatment decisions from guideline recommendations.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01165710.

beta-Blocker use following myocardial infarction: low prevalence of evidence-based dosing

BACKGROUND

Quality improvement programs have shown increased use of beta-blockers post-myocardial infarction (MI), but there are no data on whether appropriate doses are administered.

METHODS

In a prospective registry that enrolled consecutive patients with MI, we evaluated beta-blocker dosing at discharge after MI and 3 weeks later and assessed clinical predictors for treatment with very low doses. We studied 1,971 patients (70.8% male) with a mean age of 63.9 +/- 13.7 years, of whom 48.2% had an ST-elevation MI.

RESULTS

beta-Blocker utilization rates following MI were 93.2% at discharge: 20.1% received <25% of target dose, 36.5% received 25% of target dose, 26.4% received 26% to 50% of target dose, and 17.0% received >50% of target dose. Between discharge and 3 weeks, 76.4% had no change in beta-blocker dose, with 11.9% and 11.6% having their dose reduced and increased, respectively. Absence of hypertension, acute percutaneous coronary intervention, older age, and no angiotensin-converting enzyme inhibitor therapy were consistent predictors of treatment with very low beta-blocker doses.

CONCLUSIONS

Underdosing of beta-blockers is highly prevalent among patients post-MI. This represents an important opportunity in quality improvement for the care of patients who have suffered an MI.

Intervention to improve adherence to ACC/AHA recommended adjunctive medications for the management of patients with an acute myocardial infarction

BACKGROUND

The most recent published guidelines regarding management of patients surviving an acute myocardial infarction (AMI) advocate the administration of aspirin (ASA), beta blockers (BB), and angiotensin-converting enzyme inhibitors (ACEi) and discourages the use of calcium-channel blockers (CCB). Previous data collected in our region from the National Registry (NR) showed a dismal compliance with these guidelines. In an attempt to increase physician awareness and to optimize implementation of recommended guidelines, a cardiac and pharmacy steering committee was created.

METHODS

The pharmacist assigned to the project identified all patients admitted with an AMI using troponin-I and creatine kinase-MB (CK-MB) reports. The pharmacist then contacted physicians to make recommendations if an adjunctive medication was not prescribed for a patient with no apparent contraindications. Administration rates for ASA, BB, ACEi, and CCB were then assessed and compared with the previously obtained baseline data from the NR.

RESULTS

At admission, the use of ASA increased from 70 to 72%, BB from 45 to 72%, and ACEi from 12 to 44%. In terms of medications at discharge, ASA use increased from 74 to 88%, BB from 55 to 76%, and ACEi from 30 to 40%. In addition, the prescription rates for CCB at discharge decreased from 36 to 21%.

CONCLUSIONS

An interdisciplinary approach for disease management is an effective method for improving adherence to treatment guidelines simply with pharmacy intervention. The percentage of patients receiving the recommended adjunctive medications increased significantly. We propose that these guidelines should be periodically inserviced to physicians. Furthermore, patient counseling sessions should also be instituted to help reinforce the importance of compliance with the medications after discharge, as well as lipid management and smoking cessation.

Use of evidence-based therapies after discharge among elderly patients with acute myocardial infarction

BACKGROUND

Postdischarge use of evidence-based drug therapies has been proposed as a measure of quality of care for myocardial infarction patients. We examined trends in the use of evidence-based drug therapies after discharge among elderly patients with myocardial infarction.

METHODS

We performed a cross-sectional study in a retrospective population-based cohort that was created using linked administrative databases. We included patients aged 65 years and older who were discharged from hospital with a diagnosis of myocardial infarction between Apr. 1, 1992, and Mar. 31, 2005. We determined the annual percentage of patients who filled a prescription for statins, beta-blockers and angiotensin-modifying drugs within 90 days after discharge.

RESULTS

The percentage of patients who filled a prescription for a beta-blocker increased from 42.6% in 1992 to 78.1% in 2005. The percentage of patients who filled a prescription for an angiotensin-modifying drug increased from 42.0% in 1992 to 78.4% in 2005. The percentage of patients who filled a prescription for a statin increased from 4.2% in 1992 to 79.2% in 2005. In 2005, about half of the hospitals had rates of use for each of these therapies that were less than 80%. The temporal rate of increase in statin use after discharge was slower among noncardiologists than among cardiologists (3.5%-2.8% slower). The rate of increase was 4.8% slower for among physicians with low volumes of myocardial infarction patients than among those with high volumes of such patients and was 5.7% greater at teaching hospitals compared with nonteaching hospitals.

INTERPRETATION

Use of statins, beta-blockers and angiotensin-modifying drugs increased from 1992 to 2005. The rate of increase in the use of these medications after discharge varied across physician and hospital characteristics.

Comparing clinical and administrative data for profiling hospitals on postdischarge medication use by patients with acute myocardial infarction

BACKGROUND

Postdischarge medication use is frequently used as a measure of hospital performance, with many reports produced using clinical data obtained from chart reviews. The introduction of a drug benefit program administered by the Centers for Medicare and Medicaid Services presents an opportunity to use administrative data for routine reporting on hospital performance. We determined the concordance between hospital-specific prescribing rates of evidence-based medical therapies obtained from clinical and administrative data in Ontario, Canada.

METHODS

This was a retrospective cohort study using data on patients discharged from 102 hospitals in Ontario, Canada with acute myocardial infarction (AMI) between April 1, 1999, and March 31, 2001. We compared hospital-specific rates of discharge prescribing in AMI patients, determined using clinical data obtained using retrospective chart review with hospital-specific rates of prescriptions filled within 30 days of hospital discharge in elderly patients using administrative data.

RESULTS

There was a moderate agreement between hospital-specific rates of discharge prescriptions written for AMI patients in clinical data with hospital-specific rates of prescriptions filled using administrative data. Although differences in rates were, on average, small between the 2 data sources, there was moderate variation in the differences between these 2 rates across hospitals. There was very strong agreement between rates of discharge prescribing in all patients and in ideal patients with no contraindications, both determined using clinical data.

CONCLUSIONS

Post-AMI discharge prescribing in all patients determined using clinical data is an excellent proxy for prescribing in ideal patients using clinical data. However, there is weaker agreement between administrative and clinical data.

Post-myocardial infarction beta-blocker therapy: the bradycardia conundrum. Rationale and design for the Pacemaker & beta-blocker therapy post-MI (PACE-MI) trial

Multiple clinical trials have demonstrated beta-blockers improving survival after myocardial infarction (MI). Patients with "bradycardia-related" contraindications to beta-blockers, such as those with asymptomatic bradycardia or AV conduction abnormalities, have been excluded from clinical trials of beta-blockers and continue to be excluded from post-MI beta-blocker therapy in routine clinical practice. These patients tend to be elderly and have a high 1-year mortality. If beta-blockers provide benefit to the post-MI patient independent of their heart rate-lowering effect, then these patients could benefit substantially from initiation of beta-blocker therapy. However, in this particular group of patients, beta-blockers can be safely initiated only if more severe or significant bradycardia can be prevented by pacemaker implantation. It is unclear whether adverse effects related to pacemaker implantation could also negate some or all of the hypothesized benefit of beta-blocker therapy. Although beta-blockers are particularly effective in the elderly, the benefit of beta-blocker therapy in patients with bradycardia-related contraindications to beta-blockers has not been established. The PACE-MI trial is a randomized controlled trial that will address whether beta-blocker therapy enabled by pacemaker implantation is superior to no beta-blocker and no pacemaker therapy after MI in patients with rhythm contraindications to beta-blockers or in those who have developed symptomatic bradycardia due to beta-blockers. The trial will randomize 1124 patients to standard therapy (not to include beta-blockers as patients must have a contraindication to be enrolled) or standard therapy plus pacemaker implantation and beta-blocker. The primary end point is the composite end point of total mortality plus nonfatal reinfarction.

How compliant are we with guidelines for coronary angiography in clinical practice?

BACKGROUND

The American College of Cardiology and American Heart Association have published guidelines for coronary angiography. We evaluated the compliance rate with these guidelines in clinical practice, its correlation to results of angiography and aimed to identify problem areas of non-compliance.

METHODS

We prospectively evaluated 802 consecutive referrals for coronary angiography over 5 months in 2002 in a tertiary referral hospital. These referrals were assessed by two independent reviewers blinded to the results of angiography.

RESULTS

Patient age was 62 +/- 11 years (522 men, 433 inpatients, 369 day-only patients). Referrals were outside published guidelines in 34.3 and 36.2% as evaluated by the two reviewers (concordance rate 88.2%, kappa = 0.74, p < 0.001). Intraobserver agreement was 97.5%. The rate of angiography showing either normal arteries or only minor diseases (<50%) was higher for referrals outside guidelines (68.4 vs 22.6%, P < 0.001). Compliance rate was high with indications of non-ST-elevation myocardial infarction (99.2%) and ST-elevation myocardial infarction (95.8%), valvular disease (80%) and arrhythmia (80%). Compliance rate was lower with assessment of dyspnoea or heart failure (74.3%) and before non-cardiac surgery (72.7%) and was particularly low with assessment of chest pain (53.2%). Younger age (odds ratio (OR) 1.04, P < 0.001), female sex (OR 2.67, P < 0.001), day-only procedure (OR 2.27, P < 0.001) and non-invasive cardiologist referrer (OR 1.41, P = 0.046) were independent predictors of non-compliance.

CONCLUSION

Referrals for coronary angiography were outside guidelines in a significant proportion of patients. Rate of negative angiography was higher when the referrals were outside guidelines. Problematic areas of non-compliance could be identified. Measures specifically targeting these areas may be more effective in improving the overall guideline compliance in clinical practice.

The architecture of evidence-based gynaecology

Modern evidence-based medicine (EBM) and its predecessor 'Medecin d'Observation' both emphasise that potential advances in healthcare must be researched and proven to do more good than harm using the principles of clinical epidemiology before they are incorporated into medical practice. EBM is considered an important advance in improving clinical care in gynaecology but EBM skills have traditionally not been covered in undergraduate or postgraduate education. Therefore there is a perceived need to compile texts on various aspects of gynaecological practice using EBM principles. This is what these two issues of the Best Practice series hope to achieve. The various chapters will provide readers with clinical advice generated from critically appraised information that has been identified as addressing relevant questions.

A survey to determine the prevalence and characteristics of training in Evidence-Based Medicine in emergency medicine residency programs

We conducted a survey to determine the prevalence, training methods, and allotment of time for teaching evidence-based medicine (EBM) skills within accredited Emergency Medicine (EM) residency programs in the United States. A survey was mailed to program directors of all 122 accredited Emergency Medicine residency programs. The survey was also sent to program directors using an e-mail listserv. Responses were obtained from 53% of programs; 80% (95% CI: 68-89) of EM programs reported teaching some EBM. Although respondents believed a median of 10 hours were required to adequately cover this topic, only 22% provided more than 5 hours per year. Sixtey-three percent (95% CI: 50-75) of respondents reported using the JAMA Users' Guides series in journal club and 83% reported efforts to link journal clubs to patient care. Perceived barriers to integrating EBM into teaching and patient care included lack of trained faculty, lack of time, lack of familiarity with EBM resources, insufficient funding, and lack of interested faculty. In summary, academic EM programs are attempting to train residents in EBM, but perceive a lack of trained faculty, time, and funding as barriers. Desired resources include a defined curriculum, on-line training for faculty, and defined strategies for integration of EBM into training and patient care.

Evaluating the effect on patient outcomes of appropriate and inappropriate use of beta-blockers as secondary prevention after myocardial infarction in a medicaid population

BACKGROUND

Acute myocardial infarction (AMI) is associated with high mortality in the United States. Beta-blockers have been shown to reduce mortality and reinfarction rates when used for long-term prevention after an AMI. However, this therapy is both underused and misused. The effect of this practice on outcomes needs to be investigated.

OBJECTIVE

This study was undertaken to evaluate the effect on patient outcomes (ie, fatality, health care utilization, and costs) of appropriate and inappropriate prescribing of beta-blocker therapy after AMI in a Medicaid population aged <65 years.

METHODS

Data for 1 year before and after AMI were extracted from West Virginia Medicaid claims from January 1, 1996, to June 30, 2001. Information was obtained regarding prescriptions for beta-blockers for these patients within 90 days after discharge. Patients were divided into 2 groups: those who were prescribed therapy appropriately and those who were prescribed therapy inappropriately (underuse or misuse). Fatality rates during 1 year after discharge were compared using chi-square analysis. The study used regression analysis to model health care utilization and costs as a function of appropriately/inappropriately prescribed groups.

RESULTS

Data were assessed for 488 eligible patients (mean [SD] age, 53.70 [8.14] years; 246 men [50.4%], 242 women [49.6%]). Overall, 309 patients (63.3%) had appropriate prescribing of beta-blockers; at the end of 1 year, these patients had a significantly lower all-cause death rate compared with those who were prescribed therapy inappropriately (P = 0.030). Although the cardiac death rate was slightly lower for the appropriate group, the difference was not statistically significant. The appropriately prescribed group had significantly higher health care utilization in the follow-up period (P < 0.050 for hospital visits, emergency department visits, and length of stay). These groups demonstrated differences in a few variables at baseline (age, presence of absolute contraindications, presence of hypertension, number of noncardiac admissions before AMI, and use of beta-blockers before AMI: all, P < 0.050), implying different severity levels. Patient health status at the time of the incident AMI had a confounding effect on health care utilization, and there were indications that the appropriate group had greater severity compared with the inappropriate group.

CONCLUSIONS

Appropriate prescribing of beta-blockers for secondary prevention after an AMI was associated with better survival in this population. However, the effects of inappropriate and appropriate beta-blocker prescribing on health care utilization need to be evaluated prospectively so that all severity indicators can be properly adjusted.

Outcomes of inappropriate prescribing of beta-blockers after an acute myocardial infarction in a Medicaid population

BACKGROUND

Acute myocardial infarction (AMI) is associated with high mortality. beta-Blockers are known to reduce mortality and reinfarction rates when used for long-term prevention following an AMI.

OBJECTIVE

To assess the prescribing patterns of beta-blockers in patients after experiencing an AMI in the West Virginia Medicaid program and examine its impact on patient outcomes.

METHODS

One-year pre- and post-AMI data were extracted for 488 Medicaid patients. Prescribing of beta-blockers within 90 days after discharge was evaluated among these patients. Based on American Heart Association/American College of Cardiology guidelines, patients were divided into 2 groups: those prescribed therapy appropriately and those prescribed therapy inappropriately (underuse, misuse). One-year all-cause mortality, cardiac mortality, and cardiac morbidity were compared between the groups using survival analysis.

RESULTS

Approximately 64% of the patients were appropriately prescribed beta-blockers and illustrated significantly (p = 0.035) lower all-cause mortality rates compared with the inappropriately prescribed group at the one-year follow-up. Cardiac mortality evaluation showed no significant findings. The groups differed significantly in morbidity outcome (time to first cardiac hospitalization), with the inappropriate group exhibiting later hospitalization at the end of the year (p = 0.019). However, the appropriate group had a higher proportion of hypertensive patients, suggesting more severity compared with the inappropriate group.

CONCLUSIONS

Inappropriate prescribing of beta-blockers following AMI was observed in this Medicaid population. Data suggest that there were overall survival benefits associated with appropriate beta-blocker prescribing. However, cardiac morbidity associated with inappropriate prescribing needs to be evaluated after adjusting for disease severity between the 2 groups.

Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting

PURPOSE

To assess the adequacy of symptomatic treatment for chronic stable angina among primary care patients who receive care from the Department of Veterans Affairs (VA).

METHODS

We conducted a cross-sectional analysis involving 7038 veterans with self-reported coronary heart disease who completed the Seattle Angina Questionnaire and who had made a primary care visit to one of seven VA general internal medicine clinics between May 1997 and January 2000. The main outcome measures included the anginal frequency scale of the questionnaire and receipt of prescriptions for antianginal medication in three classes (beta-blockers, calcium antagonists, and long-acting nitrates).

RESULTS

Seventy percent of the patients experienced angina or took sublingual nitroglycerin preparations two or fewer times per week. Of the 30% of patients with more frequent symptoms, 22% were receiving no antianginal medications and 33% were receiving only one class of antianginal medication. Of the patients with frequent angina who were prescribed medications, 18% were taking no medications at the recommended therapeutic dose and 50% were receiving only one class of antianginal medication at the recommended therapeutic dose.

CONCLUSION

A substantial proportion of patients with frequent episodes of chronic stable angina appeared to be receiving an inadequate antianginal regimen in terms of number of agents and dosages. While numerous studies have described inadequate treatment of asymptomatic conditions and risk factors, our results suggest similar deficiencies in addressing a serious and eminently treatable symptomatic problem.

Hospital-level performance improvement: beta-blocker use after acute myocardial infarction

BACKGROUND

National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics.

METHODS AND RESULTS

We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of -50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest.

CONCLUSIONS

The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.

Use of β-Blockers in Patients with COPD

OBJECTIVE:

To evaluate the safety and cardiovascular benefits of β-blocker therapy in patients with chronic obstructive pulmonary disease (COPD).

DATA SOURCES:

Clinical literature was accessed through MEDLINE (1966–February 2003). Key search terms included chronic obstructive pulmonary disease and adrenergic β-antagonists.

DATA SYNTHESIS:

β-Blockers are often avoided in patients with COPD because of fear of bronchoconstriction, despite the known cardiovascular mortality benefits. A review of studies evaluating the use of β-blockers in COPD was undertaken.

CONCLUSIONS:

The literature supports the safety and mortality benefits of using β-blockers in COPD. Patients with mild to moderate COPD should receive cardioselective β-blocker therapy when a strong indication exists.

Effects of computerized guidelines for managing heart disease in primary care

BACKGROUND

Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).

OBJECTIVE

To assess the effects of computer-based cardiac care suggestions.

DESIGN

A randomized, controlled trial targeting primary care physicians and pharmacists.

SUBJECTS

A total of 706 outpatients with heart failure and/or ischemic heart disease.

INTERVENTIONS

Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.

MEASUREMENTS

Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines.

RESULTS

Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.

CONCLUSIONS

Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

Medical myths involving diabetes

Medical myths occur for many different reasons. Myths surrounding diabetes are common and are usually attributable to practices that have not been evaluated rigorously (sliding-scale insulin use), concerns related to pathophysiology (beta-blocker use), or extrapolation from small studies or case series (niacin use in patients with diabetes). Myths often are passed on from generation of house staff to students by word of mouth. It is often difficult to determine the origins of some myths, as is the case with sliding-scale insulin use. Other myths may have grown from the inclusion of information from a small case series in an authoritative text [1]. Understanding the myths and misconceptions about the care of patients with diabetes is important in providing excellent care to the patient with diabetes.

A new framework for describing and quantifying the gap between proof and practice

BACKGROUND

Substantial gaps often exist between every day practice and best practice as defined by research evidence. We present a framework for defining, analyzing, and quantifying such proof-to-practice gaps.

METHOD

An intervention's use can be plotted over time as ideal and actual uptake curves among candidates and noncandidates. Gaps of underuse are deviations from ideal uptake among candidates and can be quantified as underuse NNPs (Number Not Prevented): the number of disease events each year that would have been prevented, but were not, because of underuse among candidates of the intervention. Gaps of overuse are deviations from ideal uptake among non candidates and can be similarly quantified as overuse NNPs.

RESULTS

Applying our method to the underuse of beta-blockers at hospital discharge postmyocardial infarction (MI) in the United States demonstrates an annual NNP of 2995 first-year post-MI deaths not prevented (sensitivity analysis range 455-20,409). Our NNP analysis framework highlights challenges to the determination of efficacy and efficiency, the definition of what constitutes proof, rapid recognition of proof when it does occur, the definition of eligible candidates, and the definition of the proportion of candidates treated.

CONCLUSION

League tables of NNPs can help policy makers compare the clinical consequences of underuse and overuse of diverse interventions, while the NNP framework provides a systematic approach for describing and analyzing the components of proof-to-practice gaps. Such gap analyses can help organizations direct their resources to reducing gaps of greatest clinical consequence.

[Methods of reporting research-results and their influence on decision-making by cardiologists prescribing drugs for primary and secondary prevention]

OBJECTIVES

To assess the influence of the form of presentation of the results of clinical trials on the quantitative perceptions of cardiologists regarding the efficacy of drugs for the primary and secondary prevention of coronary heart disease and their likelihood of prescribing them.

METHOD

We conducted a survey of 1,408 cardiologists in Spain who were randomly allocated of three questionnaires that used different measurements to evaluate the impact of published clinical trials.

RESULTS

Five-hundred and fifty-nine questionnaires (40%) were suitable for analysis. On a scale of 0 to 10, the following mean efficacy estimates were obtained from questionnaire items that focused, respectively, on the results of clinical trials in terms of relative risk reduction, absolute risk reduction, and number needed to treat: primary prevention with statins: 6.79, 6.38 and 5.43; primary prevention with aspirin: 6.84, 5.06 and 4.25; secondary prevention with statins: 8.16, 7.76 and 7.54; secondary prevention with ACE inhibitors: 7.11, 7.81 and 7.19, and secondary prevention with beta-blockers: 7.22, 7.43 and 6.98. The likelihood that a drug treatment would be prescribed was not influenced very much by the form of presentation of the trial results.

CONCLUSIONS

Presenting the results of clinical trials in the form of relative risk reduction, as compared with presenting results in terms of absolute risk reduction or number needed to treat, led to overestimation of the efficacy of interventions without influencing the likelihood of prescribing a given drug therapy.

Medical treatment of patients with stable angina pectoris referred for coronary angiography: failure of treatment or failure to treat

BACKGROUND

Patients referred for elective coronary arteriography because of stable angina pectoris frequently do not receive appropriate medical therapy prior to arteriography. Persistence of symptoms due to lack of appropriate therapy may influence the decision to catheterize and the treatment chosen following catheterization.

HYPOTHESIS

The present study evaluates whether patients with stable angina pectoris referred for cardiac catheterization received optimal therapy prior to the procedure. We also evaluated whether medical therapy was optimized as a result of the hospitalization for catheterization.

METHODS

We evaluated prospectively the adequacy of medical therapy in 333 consecutive patients undergoing elective coronary arteriography. Of these, 160 had stable angina pectoris as their main problem and constituted the study group.

RESULTS

Mean duration of angina was 7.5 +/- 6.3 months. Canadian Cardiovascular Society angina grade 1 was present in 20, grade 2 in 77, grade 3 or 4 in 63 patients. Arteriography showed a > or = 50% coronary stenosis in 141 of 160 patients. Aspirin was used by 96%, and 86% received at least one drug aimed at relieving anginal symptoms: beta blockers in 69%, calcium blockers in 30%, and long-acting nitrates in 29%. Antianginal drugs and drugs aimed at treating risk factors were usually taken at a low, subtherapeutic dosage. Only 35 of 110 patients taking beta blockers had a resting heart rate of <60/min. Following catheterization, 88 of 141 patients with coronary stenosis of > or = 50% underwent percutanous intervention and 5 had urgent surgery. Optimization of treatment was advised in only 7 of 48 patients for whom medical therapy or elective surgery was recommended.

CONCLUSION

Patients with stable angina pectoris are frequently referred for cardiac catheterization without making a serious attempt to control their symptoms by medical therapy. Risk factors are undertreated. With proper pharmacotherapy, many patients might have become asymptomatic and have chosen not to undergo catheterization and subsequent percutaneous interventions.

The gap between knowledge and practice in the treatment and prevention of cardiovascular disease

There is a gap between the current knowledge of the treatment of cardiac conditions derived from evidence-based medicine and the widespread application of this knowledge. The use of ACE inhibitors for patients with congestive heart failure, beta blockers in postmyocardial infarction patients, anticoagulation in patients with chronic atrial fibrillation, cholesterol medications for either primary or secondary prevention of coronary artery disease, and antihypertensive treatment, are of proven benefit, yet all are underutilized by cardiologists, as well as other medical practitioners. There is evidence that there are methods to improve the prescribing of medication, but further studies are required to identify the best ways of doing this. A challenge for the future will be to identify and apply the best educational programs to improve the quality and efficiency of medical care. (c) 2000 by CHF, Inc.

Modulation of beta-adrenergic receptor subtype activities in perioperative medicine: mechanisms and sites of action

This review focuses on the mechanisms and sites of action underlying beta-adrenergic antagonism in perioperative medicine. A large body of knowledge has recently emerged from basic and clinical research concerning the mechanisms of the life-saving effects of beta-adrenergic antagonists (beta-AAs) in high-risk cardiac patients. This article re-emphasizes the mechanisms underlying beta-adrenergic antagonism and also illuminates novel rationales behind the use of perioperative beta-AAs from a biological point of view. Particularly, it delineates new concepts of beta-adrenergic signal transduction emerging from transgenic animal models. The role of the different characteristics of various beta-AAs is discussed, and evidence will be presented for the selection of one specific agent over another on the basis of individual drug profiles in defined clinical situations. The salutary effects of beta-AAs on the cardiovascular system will be described at the cellular and molecular levels. Beta-AAs exhibit many effects beyond a reduction in heart rate, which are less known by perioperative physicians but equally desirable in the perioperative care of high-risk cardiac patients. These include effects on core components of an anaesthetic regimen, such as analgesia, hypnosis, and memory function. Despite overwhelming evidence of benefit, beta-AAs are currently under-utilized in the perioperative period because of concerns of potential adverse effects and toxicity. The effects of acute administration of beta-AAs on cardiac function in the compromised patient and strategies to counteract potential adverse effects will be discussed in detail. This may help to overcome barriers to the initiation of perioperative treatment with beta-AAs in a larger number of high-risk cardiac patients undergoing surgery.

Beta blocker prescribing differences in patients with and without diabetes following a first myocardial infarction

AIMS

To document the prescribed usage of beta blockers in patients with and without diabetes mellitus discharged from hospital following a first myocardial infarction.

METHODS

All patients with diabetes and a group of patients matched for age and sex without diabetes, admitted with a documented first myocardial infarction during the period 1995-1999 at the Royal Liverpool University Hospital, Liverpool, UK were audited.

RESULTS

Data were available on 201 patients with diabetes and 199 patients without diabetes. No significant differences existed between the diabetic and non-diabetic groups for age and sex. Twenty-three per cent of patients with diabetes were prescribed a beta blocker compared to 52% of non-diabetic patients (P < 0.01). Patients with diabetes had a higher frequency of perceived contraindications than patients without diabetes (36 vs. 27%, P < 0.001). Thirty-five per cent of patients with diabetes and 18% of non-diabetic patients had no contraindication to the use of beta blocker but were not prescribed one (P < 0.001).

CONCLUSIONS

Although beta blockers can provide useful benefits in patients with diabetes following a myocardial infarction, this study suggests that a significant proportion of patients with diabetes and without a contraindication to treatment are still not receiving beta blockers after myocardial infarction.

Electronic trial banks: a complementary method for reporting randomized trials

BACKGROUND

Randomized clinical trial (RCT) results are often difficult to find, interpret, or apply to clinical care. The authors propose that RCTs be reported into electronic knowledge bases-trial banks-in addition to being reported in text. What information should these trial-bank reports contain?

METHODS

Using the competency decomposition method, the authors specified the ideal trial-bank contents as the information necessary and sufficient for completing the task of systematic reviewing.

RESULTS

They decomposed the systematic reviewing task into four top-level tasks and 62 subtasks. 162 types of trial information were necessary and sufficient for completing these subtasks. These items relate to a trial's design, execution, administration, and results.

CONCLUSION

Trial-bank publishing of these 162 items would capture into computer-understandable form all the trial information needed for critically appraising and synthesizing trial results. Decision-support systems that access shared, up-to-date trial banks could help clinicians manage, synthesize, and apply RCT evidence more effectively.

Cardioprotective effect of prior beta-blocker therapy in reducing creatine kinase-MB elevation after coronary intervention: benefit is extended to improvement in intermediate-term survival

BACKGROUND

Both retrospective studies and prospective randomized trials have shown that beta-blockers improve survival and reduce the risk of reinfarction in patients with myocardial infarction. To evaluate whether beta-blockers exert similar protective benefits during and after coronary intervention, we studied the incidence of postprocedure creatine kinase (CK)-MB elevation in patients with or without prior beta-blocker therapy and its effect on intermediate-term ( approximately 1 year) survival.

METHODS AND RESULTS

We prospectively analyzed 1675 consecutive patients undergoing coronary intervention; of these patients, 643 (38.4%) were on beta-blocker therapy before the intervention. The incidence of CK-MB elevation after coronary intervention was 13.2% in patients on beta-blocker therapy before intervention and 22.1% in patients who were not on beta-blockers (P<0.001). Patients with prior beta-blocker therapy had lower persistent/recurrent postprocedure chest pain and lower preprocedure and postprocedure heart rates and mean blood pressures compared with patients who were not on beta-blockers (P<0.001). Multiple linear regression analysis revealed prior beta-blocker therapy as the sole independent factor for lower CK-MB release after coronary intervention. During intermediate-term follow-up at 15+/-3 months, patients on beta-blocker therapy before intervention had lower mortality rates compared with those not on beta-blockers (0.78% versus 1.96%; P=0. 04), although the benefit was independent of the reduction in CK-MB release.

CONCLUSIONS

Our nonrandomized, prospective analysis suggests that prior beta-blocker therapy has a cardioprotective effect in limiting CK-MB release after coronary intervention and that it is associated with a lower mortality at intermediate-term follow-up.

Impact of a clinical pathway on the care and costs of myocardial infarction

A time series of 110 patients with acute myocardial infarction admitted between January 1992 and June 1997 examined the effects of a clinical pathway. The pathway reduced length of hospital stay by 2.2 days and hospital charges by $1,008 without compromising care quality and outcomes.

Changes in the management of acute myocardial infarction in Southern Tasmania

BACKGROUND

In recent years, the management of acute myocardial infarction (AMI) has been the subject of many clinical trials. These studies have clearly established the value of using pharmacological agents, including aspirin, beta-blockers, thrombolytics and angiotensin converting enzyme (ACE) inhibitors. There have been suggestions, however, that practice has been slow to change in light of the findings of these trials.

AIM

To review cases of AMI at the major teaching hospital in Tasmania, Australia, to determine whether the recommendations from the results of the trials had been translated into local clinical practice, and to examine temporal changes in drug usage and clinical outcomes.

METHODS

A retrospective review of the medical records of patients admitted to the hospital with an AMI during 1996 and for the first four months of 1998 was performed. An extensive range of demographic and clinical variables was recorded, and differences between the 1996 and 1998 patients and between recipients and non-recipients of the different pharmacological agents were statistically evaluated.

RESULTS

The patients had a mean age of 65.9 +/- 12.3 years in 1996 (n = 205) and 66.8 +/- 12.3 years in 1998 (n = 71), with males accounting for 64.4% of cases in 1996 and 64.8% of cases in 1998. There were no significant demographic or medical history differences between the two groups. The median time of presentation after the onset of chest pain was 3.5 h in 1996 and 4 h in 1998. The rates of use of major therapeutic interventions post-AMI for 1996 and 1998, respectively, were: aspirin (89.1%, 90.3%), streptokinase (18.5%, 9. 9%), r-tPA (14.1%, 21.1%), intravenous beta-blockers (11.2%, 7.0%), oral beta-blockers (67.2%, 49.3%; P < 0.01), ACE inhibitors (44.4%, 59.2%; P < 0.05), intravenous nitrate (94.1%, 91.6%), oral nitrate (22.9%, 26.8%), calcium channel antagonists (19.5%, 35.2%; P < 0.05), cholesterol lowering agents (26.3%, 40.9%; P < 0.05), antiarrhythmics (21.5%, 25.4%) and warfarin (8.3%, 9.9%). Patients who received therapy with each of aspirin, r-tPA, intravenous beta-blockers, oral beta-blockers, intravenous nitrate and cholesterol lowering agents were significantly younger than the non-recipients (all P < 0.01), while patients treated with ACE inhibitors and antiarrhythmics were significantly older than the non-recipients (both P < 0.001). Non-recipients of thrombolytics presented to hospital significantly later, on average, than recipients. The hospital mortality rate was 15.1% in 1996 and 12.7% in 1998, and adverse drug reactions occurred in 21.5% of patients in 1996 and 15.5% in 1998.

CONCLUSION

Although there have been substantial increases in the use of ACE inhibitors and cholesterol lowering agents post-AMI in recent years, reductions in the use of thrombolytics and beta-blockers and their possible underuse in the elderly are of concern and warrant intervention.

Walking the tightrope on Medicare reform

A central controversy in the debate about Medicare is whether the program spends too much money or whether instead it should be expanded to cover more. I consider the value of increased Medicare spending. I argue that on average Medicare spending is worth it: the health gains brought by medicare have been greater than their cost. At the margin, however, services are overused and have low value. Medicare reforms need to promote the high average value of care while eliminating care of low value. Many of the proposed reforms fall short of this goal.

Treatment guideline for nursing home-acquired pneumonia based on community practice

OBJECTIVES

To describe the findings of a retrospective study of the treatment of nursing home-acquired pneumonia (NHAP) in 11 nursing homes in one community and the development of a treatment guideline for NHAP using data from the retrospective study.

DESIGN

A retrospective chart review of 239 episodes of NHAP occurring between November 1, 1997, and April 30, 1998, was performed. Data regarding antibiotic treatment of NHAP were used to revise a treatment guideline developed by the authors. Further refinements of the guideline were made based on small group discussions with physicians and nurse practitioners caring for the study population.

SETTING

Residents with NHAP were identified among the populations of 11 nursing homes in the metropolitan Buffalo, New York area (Erie county). These 11 nursing homes had a total of 2375 beds, comprising nearly one-third of all nursing home beds in the county.

PARTICIPANTS

Nursing home residents with chest X-rays showing infiltrates and signs and symptoms of pneumonia.

MEASUREMENTS

Antibiotic treatment (drug used, route of administration, and duration of treatment), location of initial treatment (nursing home or hospital), and status (alive or dead) of each resident were recorded 30 days after diagnosis of NHAP.

RESULTS

Of the 239 episodes of NHAP, 171 (72%) were initially treated in nursing homes. Of these 171 patients, 105 (61%) were treated only with an oral regimen, whereas 66 (39%) were treated initially with an intramuscular antibiotic and subsequently with an oral regimen. There was no significant difference in 30-day mortality rates between those initially treated in nursing homes (22%) and those initially treated in hospitals (31%; P = .15) or between those initially treated with an oral regimen in nursing homes (21%) and those initially treated with an intramuscular antibiotic in nursing homes (25%; P = .56). There was no consistency in how physicians made the choice to use intramuscular antibiotics in nursing homes, and a logistic model for predicting this approach could explain very little. The frequency of the prescription of various antibiotic agents in nursing homes and in hospitals was tabulated as well as the duration of treatment; specific attention was paid to the timing of the switch to an oral agent among episodes initially treated with a parenteral agent. These data were used in the guideline to make specific recommendations regarding which agent to prescribe, the duration of parenteral therapy, the timing of the switch to an oral regimen, and the duration of treatment. In the setting of informal small groups, the guideline was discussed with physicians who cared for residents with NHAP in the study nursing homes. Revisions made to the guideline were based on these discussions.

CONCLUSIONS

A treatment guideline for NHAP was developed primarily on the basis of the practices of geriatricians in one community. These treatment practices were similar to those reported in the literature in terms of the proportion of patients treated in nursing homes and the antibiotics prescribed. The guideline also provided specific recommendations for timing of the switch to an oral agent after parenteral therapy and for duration of treatment. Studies are in progress to determine if use of this guideline will reduce some of the variation observed in the treatment of NHAP.

Prevention of suboptimal beta-blocker treatment in patients with myocardial infarction

OBJECTIVE

To review the published data and clinical guidelines on the use of beta-blockers in myocardial infarctions (MIs) and contrast that with actual clinical practice.

DATA SOURCES

A MEDLINE search (January 1970-June 1999) was performed to identify all relevant articles. References from these articles were also evaluated for review if deemed important.

DATA SYNTHESIS

Intravenous and oral beta-blockers have been proven to improve outcomes in patients with MIs in numerous clinical trials. In current clinical practice, only 15% of MI patients receive intravenous beta-blockers and long-term beta-blocker therapy is used in <40% of patients without contraindications. However, they could be safely administered to 40% and 70% of these patients, respectively. Furthermore, most of these patients are receiving doses far below those found beneficial in clinical trials. Many of the real and perceived contraindications to beta-blockers are reviewed to allow the practitioner to identify patients who are incorrectly excluded from beta-blocker therapy. Also discussed are special clinical situations in which the benefits observed during clinical trials may not apply.

CONCLUSIONS

Beta-blockers are valuable drugs in the treatment of peri- and post-MI. In clinical practice, most patients are not treated or are inadequately treated with beta-blockers. Pharmacists should ensure that such patients actually have an absolute contraindication or unusual situation where therapy is not firmly indicated. Patients without absolute contraindications warrant titration to specific target doses or a target heart rate of 55-60 beats/min.

Differences in discharge medication after acute myocardial infarction in patients with HMO and fee-for-service medical insurance

OBJECTIVE

To assess the impact of fee-for-service (FFS) versus HMO medical insurance coverage on receipt of aspirin, beta-blockers, and calcium channel blockers at the time of hospital discharge following an acute myocardial infarction.

DESIGN

Prospective, population-based study.

SETTING

All 16 community and tertiary care hospitals in the metropolitan area of Worcester, Massachusetts.

PATIENTS

The study population consisted of patients under 65 years of age hospitalized with a validated acute myocardial infarction in all hospitals in the Worcester (Massachusetts) Standard Metropolitan Statistical Area (1990 census estimate, 437,000) during 1986, 1988, 1990, 1991, and 1993.

MEASUREMENTS AND MAIN RESULTS

After adjustment for demographic and clinical variables as well as study year, the odds ratios for receipt of each medication for patients with HMO insurance compared with FFS were 1.05 (95% confidence interval [CI] 0.77, 1.44) for aspirin, 1.32 (95% CI 0.98, 1.76) for beta-blockers, and 0.72 (95% CI 0.54, 0.96) for calcium channel blockers. Examination of temporal trends in utilization of these agents suggests that observed decreases in use of calcium channel blockers and increases in use of beta-blockers over the period under study occurred more rapidly for HMO than for FFS patients.

CONCLUSIONS

Overall, use of aspirin and beta-blockers was comparable among HMO and FFS patients and use of calcium channel blockers (deemed less effective or ineffective for secondary prevention) was lower among HMO patients. Differential adoption, over time, of evidence-based prescribing practices for medications between HMO and FFS patients who have had a myocardial infarction warrants further study.

beta blocker treatment and other prognostic variables in patients with clinical evidence of heart failure after acute myocardial infarction: evidence from the AIRE study

OBJECTIVES

To examine clinical outcomes associated with optional beta blockade in a population of patients with evidence of heart failure after myocardial infarction.

DESIGN AND PATIENTS

Data from the acute infarction ramipril efficacy (AIRE) study were analysed retrospectively. At baseline 22.3% of the patients were receiving a beta blocker. To minimise confounding, beta blocker and diuretic treatments, presence of clinical signs of heart failure, left ventricular ejection fraction, and 16 other baseline clinical variables were simultaneously entered in a multivariate Cox regression model. In addition, the same analysis was repeated separately within a high and a low risk group of patients, as defined according to the need for diuretic treatment.

RESULTS

beta Blocker treatment was an independent predictor of reduced risk of total mortality (hazard ratio 0.66, 95% confidence interval (CI) 0. 48 to 0.90) and progression to severe heart failure (0.58, 95% CI 0.40 to 0.83) for the entire study population. There were similar findings in high risk patients requiring diuretics (0.59, 95% CI 0.40 to 0.86; and 0.58, 95% CI 0.38 to 0.89).

CONCLUSIONS

beta Blocker treatment is associated with improved outcomes in patients with clinical evidence of mild to moderate heart failure after myocardial infarction. Most importantly, high risk patients with persistent heart failure appear to benefit at least as much as lower risk patients with transient heart failure.

Trends in the use of pharmacotherapies for acute myocardial infarction among physicians who design and/or implement randomized trials versus physicians in routine clinical practice: the MILIS-TIMI experience. Multicenter Investigation on Limitation of Infarct Size. Thrombolysis in Myocardial Infarction

BACKGROUND

Although studies have documented that randomized, controlled trials (RCTs) have a measurable influence on clinical practice, investigators have uncovered important deficiencies in the application of RCT findings to the management of acute myocardial infarction (AMI). Little is known about the extent to which physicians who design and/or implement clinical trials differ from physicians in routine practice in their translation of the literature.

METHODS

Our aims were to (1) evaluate recent trends in selected treatments of AMI in relation to the publication of RCTs, statistical overviews, and task-force guidelines, and (2) compare prescribing practices in AMI management between physicians in routine clinical practice and physicians who design and/or implement RCTs. We reviewed the use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers on entry and at discharge in patients enrolled in the MILIS, TIMI 1, 2, 4, 5, 6, and 9B trials with ST-elevation (and depression in MILIS) myocardial infarction for a period approaching 2 decades (August 1978 to September 1995). We hypothesized that physicians who participate in RCTs apply the findings of the published literature more promptly and thoroughly than physicians in routine practice.

RESULTS

Use of aspirin, beta-blockers, and angiotensin converting enzyme inhibitors exhibited a statistically significant time-related increase at discharge and, excepting beta-blockers, at enrollment across the trials. Prescription of calcium channel blockers showed a statistically significant decrease at discharge only. For all medications under study, increases and decreases in use associated with publication of clinical data occurred earlier and more steeply for the discharge cohort (prescriptions by physicians participating in RCTs) than for the enrollment cohort (prescriptions by physicians in routine practice). Recent prescribing practices (1994 to 1995) among RCT investigators and their colleagues have higher concordance with published findings than those of physicians in routine practice.

CONCLUSIONS

Physicians who design and/or implement RCTs translate the results of the medical literature more promptly and to a greater extent than physicians in routine clinical practice. Differences between different physician classes need to be studied further amid efforts to reconfigure health care delivery that currently favor more dominant roles for primary care physicians.

Potential impact of evidence-based medicine in acute coronary syndromes: insights from GUSTO-IIb. Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes trial

OBJECTIVES

The purpose of this study to determine whether use of cardiac medications reflects evidence-based recommendations for patients with non-ST elevation acute coronary syndromes.

BACKGROUND

Agency for Health Care Policy and Research practice guidelines for unstable angina recommend the use of cardiac medications based on evidence from randomized trials. It is unknown whether practitioners in the U.S., Canada and Europe follow these recommendations in patients with non-ST elevation acute coronary syndromes.

METHODS

We studied 7,743 patients with non-ST elevation acute coronary syndromes enrolled in the international Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes trial. The use of aspirin, beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors and calcium channel blocking agents was determined at discharge for all patients and "ideal" patients (those with indications and no contraindications). Using published estimates of relative mortality reductions with these drugs, we calculated the lives that could have been saved at 1 year if discharge medication use had better matched guideline recommendations.

RESULTS

Overall, guideline adherence at discharge in "ideal" patients was 85.6% for aspirin, 59.1% for beta-blockers and 51.7% for angiotensin-converting enzyme inhibitors. Calcium channel blockers were given to 26.7% of patients with a contraindication to these drugs. These rates were similar across locations of enrollment. Women and older patients less often received aspirin when "ideal," and younger patients more often received calcium channel blockers when they were contraindicated. If medication use had been more evidence-based, 1-year mortality might have been reduced by a relative 22%.

CONCLUSIONS

There is significant room for improvement in the use of recommended drugs in patients with non-ST elevation acute coronary syndromes. Medication use that more closely follows recommendations could reduce mortality in this population.

Effect of local standards on the implementation of national guidelines for asthma: primary care agreement with national asthma guidelines

OBJECTIVE

To assess the level of modification by local primary care doctors of key aspects of the National Asthma Education Program (NAEP) Guidelines for the Diagnosis and Management of Asthma.

DESIGN

A random sample of primary care physicians participating in local asthma guideline development.

SETTING

Two hospital systems, one based in an urban environment, and a second in a community and rural environment.

PARTICIPANTS

Primary care physicians.

INTERVENTION

Design of consensus-based local asthma guidelines using a modified Delphi approach.

MEASUREMENTS AND MAIN RESULTS

A total of 42 physicians participated in the local guideline development. With few exceptions, the primary care physicians modified in major ways the NAEP Guidelines regarding the role of pulmonary function testing and spirometry. Specifically, the local guidelines did not require peak flow and spirometry measurements as the basis for initiating inhaled steroids as did the national guidelines. All 42 physicians emphasized a clinical diagnosis versus one based on a pulmonary function. Peak flow monitoring was recommended by 35 (83%) of physicians in selected patients only, in contrast to the national guidelines, which emphasized monitoring for all patients routinely and during exacerbations. There was strong agreement with the national guidelines on the role and importance of patient education, and on the indications for the use of inhaled steroids.

CONCLUSIONS

Disagreement by primary care doctors with parts of the NAEP guideline is a potential cause for poor compliance and lack of influence on patient care. Recognizing the need to modify or customize guidelines through field testing with local primary care physicians will improve acceptance of national guidelines.