28th Bethesda Conference. Task Force 2: Guideline implementation

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic.

METHODS

The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic.

RESULTS

Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p<0.001) and hospital length of stay (6.5 days before, 5.6 days after; p=0.055). beta-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p<0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p<0.001).

CONCLUSIONS

Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and beta-blocker therapy while preserving a low rate of cardiac complications.

Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: randomised controlled study

OBJECTIVE

To study the efficacy of case method learning, for general practitioners, on patients' lipid concentrations in the secondary prevention of coronary artery disease.

DESIGN

Prospective controlled trial.

SETTING

Södertälje, Stockholm County, Sweden.

PARTICIPANTS

255 consecutive patients with coronary artery disease.

INTERVENTION

Guidelines were mailed to all general practitioners (n=54) and presented at a common lecture. General practitioners who were randomised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period. A locally well known cardiologist served as a facilitator.

MAIN OUTCOME MEASURE

Concentration of low density lipoprotein cholesterol at baseline and after two years. Analysis according to intention to treat (intervention and control groups (n=88)) was based on group affiliation at baseline.

RESULTS

Low density lipoprotein cholesterol was reduced by 0.5 mmol/l (95% confidence interval 0.2 to 0.8 mmol/l) (9.3% (2.9% to 15.8%)) from baseline in patients in the intervention group and by 0.5 (0.1 to 0.9) mmol/l compared with controls (P<0.05). No change occurred in the control group (0.0 (-0.2 to 0.2) mmol/l). Low density lipoprotein cholesterol decreased by 0.6 (0.4 to 0.8) mmol/l in a group of patients who received specialist care.

CONCLUSION

Case method learning resulted in a lowering of low density lipoprotein cholesterol in the primary care patients with coronary artery disease comparable to that achieved at a specialist clinic. Conventional presentation of practice guidelines had no effect.