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Engel J, van der Wulp I, de Bruijne M, Wagner C. A cross-sectional multicentre study of cardiac risk score use in the management of unstable angina and non-ST-elevation myocardial infarction. BMJ Open 2015; 5:e008523. [PMID: 26603242 PMCID: PMC4663402 DOI: 10.1136/bmjopen-2015-008523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Quantitative risk assessment in unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI), by using cardiac risk scores, is recommended in international guidelines. However, a gap between recommended care and actual practice exists, as these instruments seem underused in practice. The present study aimed to determine the extent of cardiac risk score use and to study factors associated with lower or higher cardiac risk score use. SETTING 13 hospitals throughout the Netherlands. PARTICIPANTS A retrospective chart review of 1788 charts of patients with UA and NSTEMI, discharged in 2012. PRIMARY AND SECONDARY OUTCOMES The extent of cardiac risk score use reflected in a documented risk score outcome in the patient's chart. Factors associated with cardiac risk score use determined by generalised linear mixed models. RESULTS In 57% (n=1019) of the charts, physicians documented the use of a cardiac risk score. Substantial variation between hospitals was observed (16.7-87%), although this variation could not be explained by the presence of on-site revascularisation facilities or a hospitals' teaching status. Obese patients (OR=1.49; CI 95%1.03 to 2.15) and former smokers (OR=1.56; CI 95%1.15 to 2.11) were more likely to have a cardiac risk score documented. Risk scores were less likely to be used among patients diagnosed with UA (OR=0.60; CI 95% 0.46 to 0.77), in-hospital resuscitation (OR=0.23; CI 95% 0.09 to 0.64), in-hospital heart failure (OR=0.46; CI 95% 0.27 to 0.76) or tachycardia (OR=0.45; CI 95% 0.26 to 0.75). CONCLUSIONS Despite recommendations in cardiac guidelines, the use of cardiac risk scores has not been fully implemented in Dutch practice. A substantial number of patients did not have a cardiac risk score documented in their chart. Strategies to improve cardiac risk score use should pay special attention to patient groups in which risk scores were less often documented, as these patients may currently be undertreated.
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Affiliation(s)
- Josien Engel
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Ineke van der Wulp
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martine de Bruijne
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Chew DP, Briffa TG. The Clinical Care Standards in ACS: Towards an Integrated Approach to Evidence Translation in ACS Care. Heart Lung Circ 2015; 24:213-5. [DOI: 10.1016/j.hlc.2014.12.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/28/2014] [Indexed: 11/24/2022]
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Lauzier F, Muscedere J, Deland E, Kutsogiannis DJ, Jacka M, Heels-Ansdell D, Crowther M, Cartin-Ceba R, Cox MJ, Zytaruk N, Foster D, Sinuff T, Clarke F, Thompson P, Hanna S, Cook D. Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit. Crit Care 2014; 18:R82. [PMID: 24766968 PMCID: PMC4057024 DOI: 10.1186/cc13844] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 02/25/2014] [Indexed: 11/22/2022] Open
Abstract
Introduction Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk. Methods We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. Results We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23). Conclusions Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.
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Muscedere J, Sinuff T, Heyland DK, Dodek PM, Keenan SP, Wood G, Jiang X, Day AG, Laporta D, Klompas M. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest 2014; 144:1453-1460. [PMID: 24030318 DOI: 10.1378/chest.13-0853] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Ventilator-associated conditions (VACs) and infection-related ventilator-associated complications (iVACs) are the Centers for Disease Control and Prevention's new surveillance paradigms for patients who are mechanically ventilated. Little is known regarding the clinical impact and preventability of VACs and iVACs and their relationship to ventilator-associated pneumonia (VAP). We evaluated these using data from a large, multicenter, quality-improvement initiative. METHODS We retrospectively applied definitions for VAC and iVAC to data from a prospective time series study in which VAP clinical practice guidelines were implemented in 11 North American ICUs. Each ICU enrolled 30 consecutive patients mechanically ventilated > 48 h during each of four study periods. Data on clinical outcomes and concordance with prevention recommendations were collected. VAC, iVAC, and VAP rates over time, the agreement (κ statistic) between definitions, associated morbidity/mortality, and independent risk factors for each were determined. RESULTS Of 1,320 patients, 139 (10.5%) developed a VAC, 65 (4.9%) developed an iVAC, and 148 (11.2%) developed VAP. The agreement between VAP and VAC was 0.18, and between VAP and iVAC it was 0.19. Patients who developed a VAC or iVAC had significantly more ventilator days, hospital days, and antibiotic days and higher hospital mortality than patients who had neither of these conditions. Increased concordance with VAP prevention guidelines during the study was associated with decreased VAP and VAC rates but no change in iVAC rates. CONCLUSIONS VACs and iVACs are associated with significant morbidity and mortality. Although the agreement between VAC, iVAC, and VAP is poor, a higher adoption of measures to prevent VAP was associated with lower VAP and VAC rates.
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Affiliation(s)
- John Muscedere
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON.
| | - Tasnim Sinuff
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
| | - Daren K Heyland
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON
| | - Peter M Dodek
- Center for Health Evaluation and Outcome Sciences and Department of Medicine, Providence Health Care and University of British Columbia, Vancouver, BC
| | - Sean P Keenan
- Department of Critical Care Medicine, Fraser Health Authority, BC; Department of Medicine, University of British Columbia, Vancouver, BC
| | - Gordon Wood
- Vancouver Island Health Authority, Victoria, BC
| | - Xuran Jiang
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON
| | - Andrew G Day
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON
| | - Denny Laporta
- Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
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Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study. Crit Care Med 2013; 41:15-23. [PMID: 23222254 DOI: 10.1097/ccm.0b013e318265e874] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.
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Patkar V, Acosta D, Davidson T, Jones A, Fox J, Keshtgar M. Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance. BMJ Open 2012; 2:bmjopen-2011-000439. [PMID: 22734113 PMCID: PMC3383983 DOI: 10.1136/bmjopen-2011-000439] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES The cancer multidisciplinary team (MDT) meeting (MDM) is regarded as the best platform to reduce unwarranted variation in cancer care through evidence-compliant management. However, MDMs are often overburdened with many different agendas and hence struggle to achieve their full potential. The authors developed an interactive clinical decision support system called MATE (Multidisciplinary meeting Assistant and Treatment sElector) to facilitate explicit evidence-based decision making in the breast MDMs. DESIGN Audit study and a questionnaire survey. SETTING Breast multidisciplinary unit in a large secondary care teaching hospital. PARTICIPANTS All members of the breast MDT at the Royal Free Hospital, London, were consulted during the process of MATE development and implementation. The emphasis was on acknowledging the clinical needs and practical constraints of the MDT and fitting the system around the team's workflow rather than the other way around. Delegates, who attended MATE workshop at the England Cancer Networks' Development Programme conference in March 2010, participated in the questionnaire survey. OUTCOME MEASURES The measures included evidence-compliant care, measured by adherence to clinical practice guidelines, and promoting research, measured by the patient identification rate for ongoing clinical trials. RESULTS MATE identified 61% more patients who were potentially eligible for recruitment into clinical trials than the MDT, and MATE recommendations demonstrated better concordance with clinical practice guideline than MDT recommendations (97% of MATE vs 93.2% of MDT; N=984). MATE is in routine use in breast MDMs at the Royal Free Hospital, London, and wider evaluations are being considered. CONCLUSIONS Sophisticated decision support systems can enhance the conduct of MDMs in a way that is acceptable to and valued by the clinical team. Further rigorous evaluations are required to examine cost-effectiveness and measure the impact on patient outcomes. The decision support technology used in MATE is generic and if found useful can be applied across medicine.
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Affiliation(s)
- Vivek Patkar
- The Breast Unit, Department of Surgery, Royal Free Hospital, London, UK
- Cancer Institute, University College London, London, UK
- Department of Oncology, Royal Free Hospital Hampstead NHS Trust, London, UK
| | - Dionisio Acosta
- Cancer Institute, University College London, London, UK
- Centre for Health Informatics and Multiprofessional Education (CHIME), University College London, London, UK
| | - Tim Davidson
- The Breast Unit, Department of Surgery, Royal Free Hospital, London, UK
| | - Alison Jones
- The Breast Unit, Department of Surgery, Royal Free Hospital, London, UK
- Department of Oncology, Royal Free Hospital Hampstead NHS Trust, London, UK
| | - John Fox
- Department of Engineering Science, Oxford University, Oxford, UK
| | - Mohammed Keshtgar
- The Breast Unit, Department of Surgery, Royal Free Hospital, London, UK
- Cancer Institute, University College London, London, UK
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Fox J, Patkar V, Chronakis I, Begent R. From practice guidelines to clinical decision support: closing the loop. J R Soc Med 2010; 102:464-73. [PMID: 19875535 DOI: 10.1258/jrsm.2009.090010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- John Fox
- Department of Engineering Science, University of Oxford, UK
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Huynh LT, Chew DPB, Sladek RM, Phillips PA, Brieger DB, Zeitz CJ. Unperceived treatment gaps in acute coronary syndromes. Int J Clin Pract 2009; 63:1456-64. [PMID: 19769702 DOI: 10.1111/j.1742-1241.2009.02182.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite a strong evidence-base for several therapies recommended in the management of acute coronary syndromes (ACS), many patients do not receive these therapies. The barriers preventing translation of evidence into practice are incompletely understood. The aim of this study was to survey clinicians regarding barriers to implementing recommendations of recently published national clinical guidelines and to determine the extent to which these impact clinical practice. METHODS A survey of clinicians at hospitals included in Australian Collaborative Acute Coronary Syndromes Prospective Audit (ACACIA, n = 3402, PML0051) was conducted, measuring self-stated knowledge, beliefs and guideline-concordant behaviours in relation to their care of ACS patients. Correlations between individual respondents' self-estimated rates and clinician's institutional rates of guideline-concordant behaviours were performed. RESULTS Most respondents (n = 50/86, 58%) were aware of current guidelines and their scope, achieving 7/10 (Interquartile Range (IQR) = 2) median score on knowledge questions. Belief in benefits and agreement with guideline-recommended therapy was high. However, none of these factors correlated with increased use of guideline therapies. Apart from clopidogrel (r(s) = 0.28, p < 0.01) and early interventional therapy for high-risk non-ST elevation myocardial infarction (r(s) = 0.31, p < 0.01), there were no significant correlations between individual clinicians' self-estimated rates of guideline-concordant practice and rates recorded in ACACIA data for their respective institution. CONCLUSION Beliefs about practice do not match actual practice. False beliefs regarding levels of evidence-based practice may contribute to inadequate implementation of evidence-based guidelines. Strategies such as continuous real-time audit and feedback of information for the delivery of care may help clinicians understand their levels of practice better and improve care.
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Affiliation(s)
- L T Huynh
- Department of Cardiovascular Medicine, Flinders University & Flinders Medical Centre, Bedford Park, SA, Australia
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Brieger D, Kelly A, Aroney C, Tideman P, Freedman SB, Chew D, Ilton M, Carroll G, Jacobs I, Huang NP. Acute coronary syndromes: consensus recommendations for translating knowledge into action. Med J Aust 2009; 191:334-8. [DOI: 10.5694/j.1326-5377.2009.tb02818.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 07/23/2009] [Indexed: 11/17/2022]
Affiliation(s)
| | - Anne‐Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, VIC
| | | | - Philip Tideman
- Flinders Medical Centre, Adelaide, SA
- Integrated Cardiovascular Clinical Network SA, Adelaide, SA
| | - Saul B Freedman
- Concord Repatriation General Hospital, Sydney, NSW
- Faculty of Medicine, University of Sydney, Sydney, NSW
| | - Derek Chew
- Flinders Medical Centre, Adelaide, SA
- Flinders Centre for Clinical Change and Health Care Research, Flinders University, Adelaide, SA
| | | | | | - Ian Jacobs
- Department of Emergency Medicine, University of Western Australia, Perth, WA
- Western Australian Branch, Australian Resuscitation Council, Perth, WA
- Western Australian Prehospital Care Research Unit, Perth, WA
| | - Nancy P Huang
- National Heart Foundation of Australia, Melbourne, VIC
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Abstract
Modern management of acute myocardial infarction is built on a clinical evidence base drawn from many studies undertaken over the past three decades. The evolution in clinical practice has substantially reduced mortality and morbidity associated with the condition. Key to this success is the effective integration of antithrombotic therapy combined with timely reperfusion, either primary percutaneous coronary intervention or fibrinolysis for ST-elevation myocardial infarction, and invasive investigation and revascularisation for non-ST-elevation myocardial infarction, underpinned by risk stratification and optimised systems of care. After the development of troponin assays for the detection of myonecrosis, the universal definition and classification of myocardial infarction now indicates the underlying pathophysiology. Additionally, an increasing appreciation of the importance of adverse events, such as bleeding, has emerged. Remaining challenges include the effective translation of this evidence to all patients with myocardial infarction, especially to those not well represented in clinical trials who remain at increased risk of adverse events, such as elderly patients and those with renal failure. On a global level, the epidemic of diabetes and obesity in the developed world and the transition from infectious diseases to cardiovascular disease in the developing world will place an increasing demand on health-care infrastructures required to deliver time-dependent and resource-intensive care. This Seminar discusses the underlying pathophysiology, evolving perspectives on diagnosis, risk stratification, and the invasive and pharmacological management of myocardial infarction.
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Affiliation(s)
- Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
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Thinking styles and doctors' knowledge and behaviours relating to acute coronary syndromes guidelines. Implement Sci 2008; 3:23. [PMID: 18439250 PMCID: PMC2386502 DOI: 10.1186/1748-5908-3-23] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 04/25/2008] [Indexed: 11/28/2022] Open
Abstract
Background How humans think and make decisions is important in understanding behaviour. Hence an understanding of cognitive processes among physicians may inform our understanding of behaviour in relation to evidence implementation strategies. A personality theory, Cognitive-Experiential Self Theory (CEST) proposes a relationship between different ways of thinking and behaviour, and articulates pathways for behaviour change. However prior to the empirical testing of interventions based on CEST, it is first necessary to demonstrate its suitability among a sample of healthcare workers. Objectives To investigate the relationship between thinking styles and the knowledge and clinical practices of doctors directly involved in the management of acute coronary syndromes. Methods Self-reported doctors' thinking styles (N = 74) were correlated with results from a survey investigating knowledge, attitudes, and clinical practice, and evaluated against recently published acute coronary syndrome clinical guidelines. Results Guideline-discordant practice was associated with an experiential style of thinking. Conversely, guideline-concordant practice was associated with a higher preference for a rational style of reasoning. Conclusion Findings support that while guidelines might be necessary to communicate evidence, other strategies may be necessary to target discordant behaviours. Further research designed to examine the relationships found in the current study is required.
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Huynh LT, Phillips PA, Chew DP. Improving the management of acute coronary syndromes in Australia: translating evidence to outcomes. Intern Med J 2007; 37:412-5. [PMID: 17535387 DOI: 10.1111/j.1445-5994.2007.01373.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cardiovascular disease imposes a heavy burden of morbidity and mortality on the Australian community. This situation is likely to exacerbate as the number of elderly Australians increase. Management of acute coronary syndromes (ACS) is underpinned by a robust evidence base, which is outlined in clinical practice guidelines. Yet, despite wide diffusion of guidelines, many Australians who experience acute coronary syndromes do not receive optimal care. This article reviews what we have learnt from previous quality improvement initiatives and discusses what we need to know to improve acute coronary syndromes management in Australia.
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Affiliation(s)
- L T Huynh
- Department of Medicine, Cardiovascular Outcomes Research Group and Flinders Centre for Clinical Change and Healthcare Research, Flinders University, Adelaide, South Australia.
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Scott IA, Duke AB, Darwin IC, Harvey KH, Jones MA. Variations in indicated care of patients with acute coronary syndromes in Queensland hospitals. Med J Aust 2005; 182:325-30. [PMID: 15804222 DOI: 10.5694/j.1326-5377.2005.tb06729.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Accepted: 02/07/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify variation in the rates of use of key evidence-based therapies and in clinical outcomes among patients hospitalised with acute coronary syndromes (ACS). DESIGN Retrospective analysis of data on care processes and clinical outcomes of representative patient samples recorded by the Queensland Health Cardiac Collaborative registry. SETTING 18 public hospitals (3 tertiary, 15 non-tertiary) in Queensland, August 2001 to December 2003. STUDY POPULATION 2156 patients who died or were discharged after troponin-positive ACS. MAIN OUTCOME MEASURES Comparison of proportions of highly eligible patients receiving indicated care and in-hospital mortality between subgroups categorised by age, sex, comorbidities (diabetes, renal failure, chronic obstructive pulmonary disease and mental disorder), type of admitting hospital (tertiary or non-tertiary), and cardiologist involvement (transfer or non-transfer to cardiology unit). RESULTS Patients aged > or = 65 years were less likely than younger patients to receive heparin (79% v 87%), beta-blockers (79% v 87%), lipid-lowering agents (78% v 87%), coronary angiography (51% v 66%), and referral to cardiac rehabilitation (17% v 33%). Patients with diabetes were less likely than others to receive coronary angiography (50% v 63%), while those with moderate to severe renal failure were less likely to receive thrombolysis (52% v 84%), heparin (71% v 83%), beta-blockers (69% v 84%), lipid-lowering agents (61% v 84%), in-hospital cardiac counselling (46% v 64%) and referral to cardiac rehabilitation (9% v 25%). Patients admitted to tertiary hospitals were more likely than those admitted to non-tertiary hospitals to receive coronary angiography (85% v 55%) and referral to cardiac rehabilitation (36% v 21%). Risk-adjusted mortality was highest in patients with moderate to severe renal failure (15% v 3%) and older patients (6% v 2%). CONCLUSIONS Variations exist in the provision of indicated care to patients with ACS according to age, diabetic status, renal function and type of admitting hospital. Excess mortality in elderly patients and in those with advanced renal disease may be partially attributable to failure to use key therapies.
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Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, Australia.
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Goldney RD. Audit of clinical practice guidelines in suicide prevention: who is the auditor? CRISIS 2004; 25:141-2. [PMID: 15387242 DOI: 10.1027/0227-5910.25.3.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Scott IA, Denaro CP, Bennett CJ, Mudge AM. Towards more effective use of decision support in clinical practice: what the guidelines for guidelines don’t tell you. Intern Med J 2004; 34:492-500. [PMID: 15317548 DOI: 10.1111/j.1445-5994.2004.00604.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Brisbane Cardiac Consortium Clinical Support Systems Program used multiple strategies in optimising quality of care of patients with either of two cardiac conditions. One of these strategies was the development and active implementation of decision support systems centred on evidence-based, locally agreed clinical practice guidelines. Our experience in undertaking this task highlighted numerous operational challenges for which solutions were difficult to extract from existing published literature. In the present article we provide a methodology grounded in both theory and real-world experience that may assist others in developing and implementing systems of guideline-based decision support.
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Affiliation(s)
- I A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Scott I, Youlden D, Coory M. Are diagnosis specific outcome indicators based on administrative data useful in assessing quality of hospital care? Qual Saf Health Care 2004; 13:32-9. [PMID: 14757797 PMCID: PMC1758063 DOI: 10.1136/qshc.2002.003996] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospital performance reports based on administrative data should distinguish differences in quality of care between hospitals from case mix related variation and random error effects. A study was undertaken to determine which of 12 diagnosis-outcome indicators measured across all hospitals in one state had significant risk adjusted systematic (or special cause) variation (SV) suggesting differences in quality of care. For those that did, we determined whether SV persists within hospital peer groups, whether indicator results correlate at the individual hospital level, and how many adverse outcomes would be avoided if all hospitals achieved indicator values equal to the best performing 20% of hospitals. METHODS All patients admitted during a 12 month period to 180 acute care hospitals in Queensland, Australia with heart failure (n = 5745), acute myocardial infarction (AMI) (n = 3427), or stroke (n = 2955) were entered into the study. Outcomes comprised in-hospital deaths, long hospital stays, and 30 day readmissions. Regression models produced standardised, risk adjusted diagnosis specific outcome event ratios for each hospital. Systematic and random variation in ratio distributions for each indicator were then apportioned using hierarchical statistical models. RESULTS Only five of 12 (42%) diagnosis-outcome indicators showed significant SV across all hospitals (long stays and same diagnosis readmissions for heart failure; in-hospital deaths and same diagnosis readmissions for AMI; and in-hospital deaths for stroke). Significant SV was only seen for two indicators within hospital peer groups (same diagnosis readmissions for heart failure in tertiary hospitals and inhospital mortality for AMI in community hospitals). Only two pairs of indicators showed significant correlation. If all hospitals emulated the best performers, at least 20% of AMI and stroke deaths, heart failure long stays, and heart failure and AMI readmissions could be avoided. CONCLUSIONS Diagnosis-outcome indicators based on administrative data require validation as markers of significant risk adjusted SV. Validated indicators allow quantification of realisable outcome benefits if all hospitals achieved best performer levels. The overall level of quality of care within single institutions cannot be inferred from the results of one or a few indicators.
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Affiliation(s)
- I Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia 4102.
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Pearson KJ. Guideline-discordant care in acute myocardial infarction: predictors and outcomes. Med J Aust 2002; 177:573-4; author reply 574. [PMID: 12429012 DOI: 10.5694/j.1326-5377.2002.tb04962.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2002] [Accepted: 09/04/2002] [Indexed: 11/17/2022]
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Scott IA, Harper CM. In reply: Guideline‐discordant care in acute myocardial infarction: predictors and outcomes. Med J Aust 2002. [DOI: 10.5694/j.1326-5377.2002.tb04963.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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