Trends in clinical indicators of care for adult peritoneal dialysis patients in the United States from 1995 to 1997. ESRD Core Indicators Workgroup.
(73/8935)
BACKGROUND: This article describes the changes in four core indicator variables: dialysis adequacy, hematocrit, serum albumin, and blood pressure in peritoneal dialysis CAPD and cycler patients over a three-year period. METHODS: A national random sample of adult peritoneal dialysis patients in the United States was drawn each study period. Clinical data abstraction forms were completed by facility staff for patients selected for the sample, returned to the respective network, then forwarded to the Health Care Financing Administration for analysis. RESULTS: The mean weekly Kt/V urea for CAPD patients increased from 1.91 in 1995 to 2.12 in 1997 (P < 0.001) and for cycler patients, from 2.12 in 1996 to 2.24 in 1997 (P < 0.05). The mean weekly creatinine clearance for CAPD patients increased from 61.48 liter/week/1.73 m2 in 1995 to 65.84 liter/week/1.73 m2 in 1997 (P < 0.05). For cycler patients, it increased from 63.37 liter/week/1.73 m2 in 1996 to 67.45 liter/week/1.73 m2 in 1997 (P < 0.05). Despite this increase in adequacy values, less than 40% of peritoneal dialysis patients in 1997 had weekly Kt/V urea or creatinine clearance values that met subsequently published National Kidney Foundation's Dialysis Outcomes Quality Initiative (DOQI) guidelines. These data suggest that the dialysis prescription may not be adequately modified to compensate for increased body weight and for decreased residual renal function as years on dialysis increase. The average hematocrit value increased modestly in both CAPD and cycler patients from 1995 to 1997, and the number of patients with a hematocrit of less than 25% decreased from 6% in 1995 to 1.4% in 1997 (P < 0.001). Both serum albumin values and systolic and diastolic blood pressure values were essentially unchanged during the three-year period of observation. CONCLUSIONS: Despite improvements in dialysis adequacy and hematocrit values, there remains much room for improvement in these core indicator values. (+info)
Cycler adequacy and prescription data in a national cohort sample: the 1997 core indicators report. Health Care Financing Administration Peritoneal Dialysis Core Indicators Study Group.
(74/8935)
BACKGROUND: The Health Care Financing Administration Peritoneal Dialysis Core Indicator Project obtains data yearly in four areas of patient care: dialysis adequacy, anemia, blood pressure, and nutrition. METHODS: Adequacy and dialysis prescription data were obtained using a standardized data abstraction form from a random sample of adult U.S. peritoneal dialysis patients who were alive on December 31, 1996. RESULTS: For the cohort receiving cycler dialysis, 22% were unable to meet the National Kidney Foundation Dialysis Outcome Quality Initiatives (NKF-DOQI) dialysis adequacy guidelines because they did not have at least one adequacy measure during the six-month period of observation. Thirty-six percent of patients met NKF-DOQI guidelines for weekly Kt/V urea, 33% met guidelines for weekly creatinine clearance (CCr), and 24% met guidelines for both urea and creatinine clearances. The mean weekly adequacy values were 2.24 +/- 0.56 for Kt/V urea and 67.5 +/- 24.4 liter/1.73 m2 for CCr, and the median values were 2.20 and 62.25 liter/1.73 m2, respectively. The mean prescribed 24-hour volume was 12,040 +/- 3255 ml, and the median prescribed volume was 11,783 ml. Only 60% of patients were prescribed at least one daytime dwell. By logistic regression analysis, risk factors for an inadequate dose of dialysis included being in the highest quartile of body surface area (odds ratio = 3.3 for CCr and 3.4 for Kt/V urea) and a duration of dialysis greater than two years (odds ratio = 4.2 for CCr and 2.1 for Kt/V urea). CONCLUSION: There is much room for improvement in providing an adequate dose of dialysis to cycler patients. Practitioners should be more aggressive in increasing dwell volumes, adding daytime dwells, and adjusting nighttime dwell times in order to compensate for the loss of residual renal function over time. These changes can only be accomplished if practitioners measure periodically the dose of dialysis as outlined in the NKF-DOQI guidelines. (+info)
Missed opportunities for prevention in general internal medicine.
(75/8935)
BACKGROUND: According to the Canadian Society of Internal Medicine, the Canadian general internist is in the ideal position to promote patient health through disease prevention. To explore the general internist's contribution to disease prevention, the authors quantified the extent to which opportunities for prevention were addressed by the general internal medicine (GIM) service in an acute care teaching hospital in Calgary. METHODS: The authors interviewed 100 adult patients before discharge from the hospital's GIM service between May 14, 1997, and Dec. 2, 1997. The number of potential opportunities for preventive intervention were identified for each patient from 10 possible interventions recommended by the Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care): breast cancer screening, Papanicolaou smear for cervical cancer, counselling on menopausal hormone replacement therapy, digital rectal examination for prostate cancer, smoking cessation counselling, cholesterol measurement, therapy or monitoring for hypertension, influenza vaccination, pneumococcal vaccination and colorectal cancer screening. The authors determined which interventions the patient had undergone before the current admission to hospital and, using patient recall and postdischarge medical chart review, which opportunities for intervention were addressed by the GIM service during the current admission. An opportunity for preventive intervention was considered as addressed by the GIM service if it was performed during the current admission or if the general internist informed the patient or the patient's family physician of the need for such intervention in the near future. RESULTS: Among the 10 preventive interventions considered, a mean of 3.8 potential opportunities for prevention were identified for each patient. Of these, 46.5% had been addressed before the current admission, and 8.7% were addressed by the GIM service during the admission. Therefore, at the time of discharge, a mean of 55.2% of opportunities had been addressed. Among the opportunities not previously addressed, the GIM service most frequently addressed digital rectal examination for prostate cancer and cholesterol measurement. INTERPRETATION: General internists are discharging patients without sufficiently addressing opportunities for disease prevention. Preventive care protocols may be needed to limit the frequency of missed opportunities for prevention in patients admitted to tertiary care GIM services. (+info)
No impact from active dissemination of the Ottawa Ankle Rules: further evidence of the need for local implementation of practice guidelines.
(76/8935)
BACKGROUND: Local implementation strategies are often required to promote consistent adherence to clinical guidelines, but they are time consuming and expensive. The authors tested an educational intervention designed to increase use of the Ottawa Ankle Rules, a widely publicized set of clinical guidelines previously shown to reduce the use of radiography for diagnosis of acute ankle injuries. METHODS: The study consisted of a quasi-experimental, before-and-after comparative analysis. Trained experts provided 1-hour educational sessions and supplied resource materials on the Ottawa Ankle Rules to health care professionals from 63 Ontario hospitals. Participants were asked to evaluate the intervention. The authors then compared, for periods before and after the educational sessions, the use of ankle radiography for adults with acute ankle injury in 10 hospitals that received the educational intervention and reported no (n = 5) or some (n = 5) prior use of the rules and in 5 control hospitals, which declined the educational intervention because they were already implementing the rules. RESULTS: Although participants gave highly positive appraisals of the Ottawa Ankle Rules and the educational sessions, there was no reduction in the use of ankle radiography for the 10 hospitals that received the educational sessions (73% before and 78% after the intervention, p = 0.11). In contrast, use of radiography decreased significantly, from 75% to 65%, in the 5 control hospitals (p = 0.022). INTERPRETATION: Even when a dissemination strategy is well received and involves a widely accepted clinical guideline, the impact on behaviour in clinical practice may be small. In addition to broad dissemination, an active local implementation strategy is necessary to encourage physicians to adopt clinical guidelines. (+info)
MR contrast media in neuroimaging: a critical review of the literature.
(77/8935)
BACKGROUND AND PURPOSE: MR contrast media are commonly used but do not have evidence-based guidelines for their application. This investigation seeks to define specific methodological problems in the MR contrast media literature and to suggest guidelines for an improved study design. METHODS: To evaluate the reported clinical efficacy of MR contrast media in neuroimaging, we performed a critical review of the literature. From 728 clinical studies retrieved via MEDLINE, we identified 108 articles that evaluated contrast media efficacy for a minimum of 20 patients per study. The articles were randomly assigned to four readers (a fifth reader reviewed all of the articles) who were blinded to article titles, authors, institutions, and journals of publication. The readers applied objective, well-established methodological criteria to assign each article a rating of A, B, C, or D. RESULTS: One hundred one of 108 articles received a D rating, six received a C rating, and one received a B rating. In general, the Methods sections of the evaluated articles did not contain details that would allow the reader to calculate reliable measures of diagnostic accuracy, such as sensitivity and specificity. Specifically, a common problem was failure to establish and uniformly apply an acceptable standard of reference. In addition, images were not always interpreted independently from the reference standard. Radiologists and clinicians need to determine the applicability of any published study to their own practices. Unfortunately, the studies we reviewed commonly lacked clear descriptions of patient demographics, the spectrum of symptomatology, and the procedure for assembling the study cohort. Finally, small sample sizes with inadequate controls were presented in almost all of the articles. CONCLUSION: Although MR contrast media are widely used and play an essential role in lesion detection and confidence of interpretation, no rigorous studies exist to establish valid sensitivity and specificity estimates for their application. On the basis of this review, we herein describe basic methods to document improvements in technology. Such studies are essential to devise measures of diagnostic accuracy, which can form the basis for further studies that will assess diagnostic and therapeutic impact and, ultimately, patient outcomes. (+info)
The assessment of genetic risk of breast cancer: a set of GP guidelines.
(78/8935)
BACKGROUND: Assessing a genetic risk for developing breast cancer is not an easy task for a GP. Current expert guidelines for referring and counselling women with a family history positive for breast cancer are complex and difficult to apply in general practice, and have only two strategies (to refer or not to refer for genetic counselling), giving no guidance for the GP on the management of women with a moderately increased risk of familial breast cancer. OBJECTIVES: We aimed to develop a set of simple practical guidelines for use in primary care for assessing risk and advising women with a positive family history in general practice and aimed to explore its performance. METHODS: Based on a consensus meeting of the Leiden working party of hereditary tumours, the GPs of a university-related health care centre developed a set of GP guidelines to assess risk and advise women with a family history positive for breast cancer in general practice. The GP guidelines include four therapeutic strategies (reassuring, starting surveillance, starting surveillance and contacting a family cancer clinic, referring to a family cancer clinic). Its performance was tested in 67 patients whose pedigrees were available together with the risk assessment of a clinical geneticist using Claus' tables as a gold standard. The gold standard was dichotomized regarding (i) referral to a family cancer clinic and (ii) surveillance. Two existing expert guidelines were similarly compared. RESULTS: Regarding referral to a family cancer clinic, the GP guidelines were very specific, whereas the expert guidelines were more sensitive. Regarding surveillance, the GP guidelines were very sensitive, whereas the expert guidelines were very specific. The total number of misclassified patients was lowest when using the GP guidelines, and higher when using the expert guidelines. CONCLUSIONS: The GP guidelines provide a simplification of current guidelines. Before using them on a larger scale, more testing and refining are needed to increase their sensitivity regarding a referral to a family cancer clinic and their specificity regarding surveillance. They incorporate a role for the GP in the care for women with a family history positive for breast cancer with a moderately increased risk. (+info)
Translating research into practice: a personal case study.
(79/8935)
Although much will change in the National Health Service as a result of the publication of the new White Paper, The new NHS: modern, dependable, the challenges of translating research into practice and ensuring evidence-based policy and practice will remain. This case study demonstrates some of the challenges and has important lessons for the future practice of public health medicine. (+info)
A review of shared care protocols for the treatment of problem drug use in England, Scotland, and Wales.
(80/8935)
In 1995, the Department of Health instructed health authorities to establish protocols for the shared care of problem drug users. Response to this has been disappointing: 26 out of 120 health authorities have shared care arrangements in place, with the content of these differing widely. (+info)