[Standards for the appropriate use of percutaneous transluminal coronary angioplasty and aortocoronary surgery]

Beyond visual acuity: Patient-relevant assessment measures of visual function in retinal diseases

PURPOSE

To identify patient-reported outcomes (PROs) and other clinical outcome measures (contrast sensitivity (CS), low-luminance visual acuity (LLVA) and reading acuity or reading speed (RA-RS)), relevant to patients with age-related macular degeneration (AMD) or diabetic retinopathy (DR), which would be recommended for use in clinical practice.

METHODS

The RAND/UCLA Appropriateness Method, based on the synthesis of the scientific evidence and the collective judgment of an expert panel using the two-round Delphi method, was applied. The evidence synthesis was performed by searching for articles on outcome measures for AMD and/or DR published between 2005 and 2018 in English or Spanish. The expert panel consisted of 14 Spanish ophthalmologists, who rated the recommendation degree for each outcome measure on a scale of 1 (extremely irrelevant) to 9 (maximum relevance). The recommended outcome measures were established according to the panel median score and the level of the panelists' agreement.

RESULTS

Through the evidence search, 33 PRO-specific questionnaires (21 for visual function, six for AMD, three for DR, one for AMD and DR) and two treatment satisfaction questionnaires (one on AMD and one on DR) were identified. In addition, 21 methods were found for measuring CS, five for LLVA, and nine for RA-RS. According to the panel ratings, 11 of the 64 outcome measures evaluated for AMD, and seven of the 61 evaluated for DR were recommended.

CONCLUSION

The AMD and DR outcome measures recommended will help ophthalmologists choose the outcome measure most appropriate for their patients. Furthermore, the use of PROs will contribute to shifting clinical practice towards patient-centered medicine.

Quality of care standards for nursing clinics in rheumatology

BACKGROUND

Nursing clinics in rheumatology (NCR) are organizational models in the field of nursing care. There are various NCR models, but there is no consensus on its operational definition. Our objective is to develop quality standards to define and characterize a NCR.

METHOD

Two-round Delphi method. The panel consisted of 67 experts: Rheumatologists and nurses of the nursing working group of the Spanish Society of Rheumatology (SSR). The Delphi questionnaire was developed after a literature and experience review from previous SSR projects. The questionnaire consists of 7 sections: general considerations, standards of structure, process, treatment and monitoring, health education, training and research and quality of care. Each item was scored from 1 (least important) to 9 (most important) or by assigning a number (e.g., waiting days). The degree of agreement among the experts was categorized according to the coefficient of variation (CoV) between very high (CoV≤25%) and very low (CoV>100%).

RESULTS

The second round questionnaire (182 items) was answered by 46 panelists (34 rheumatologists and 12 nurses). A very important agreement was reached on the general standards of structure, process, treatment and monitoring, health education and quality of care. Less agreement was observed on standards related to training time, number of recommended nurses' research projects and publications.

CONCLUSION

The standards developed in this study would be useful for establishing desirable quality standards of structure and process, and criteria for clinical work, research and teaching that can be used to develop and evaluate the NCRs.

In-hospital mortality and complications after coronary angioplasty, City of Rio de Janeiro, Southeastern Brazil

OBJECTIVE

To estimate in-hospital mortality and prevalence of complications of percutaneous transluminal coronary angioplasty (PTCA) in public hospitals.

METHODS

Data for 2,913 PTCA were obtained from the Brazilian National Health System (SUS) Hospital Authorization Database in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2003. After simple random sampling and data weighting, 529 medical records of patients undergoing PTCA, including all deaths, in four public hospitals (federal and state university, and federal and state reference hospitals) were studied. Comparison tests of mortality according to patient characteristics, comorbidities, complications, types of PTCA procedures, and indications for PTCA were performed using Poisson's regression models.

RESULTS

The overall in-hospital mortality was 1.6% (range: 0.9-6.8%). The age distribution of mortality was as follows: 0.2% in patients younger than 50; 1.6% in those 50-69; and 2.7% in those older than 69. High mortality was seen in primary and rescue PTCAs: 17.4% and 13.1%, respectively; and mortality in elective PTCA was 0.8%. The main complications during PTCA were dissection (5%; mortality: 11.5%) and artery occlusion (2.6%; mortality: 21.8%). Bleeding was seen in 5.9% of the patients (mortality: 5.6%) and 3.0% required blood transfusion (mortality: 12.0%). The complication of acute myocardial infarction was seen in 1.1% of patients (mortality: 38%) and stroke was associated with a mortality of 17.5%.

CONCLUSIONS

The cardiac in-hospital mortality was high when PTCA was performed for a patient with ST elevation acute myocardial infarction. Elective PTCA had mortality and complications levels above the expected in four public hospitals in the main city of Rio de Janeiro.

[Coronary angioplasty in diabetic patients. Current and future perspectives]

It has been estimated that 15-25% of patients who undergo percutaneous or surgical coronary angioplasty are diabetics. The indications for coronary revascularization and initial results of the procedure do not differ substantially between patients with diabetes mellitus and non-diabetics. However, the long-term results of both percutaneous and surgical coronary angioplasty are less favorable in diabetics in terms of mortality and the need for new revascularization procedures. The development and widespread use of stents and glycoprotein IIb/IIIa receptor inhibiting drugs have improved the clinical evolution of diabetics treated with angioplasty. Currently available data show that the administration of glycoprotein IIb/IIIa inhibitors to patients undergoing coronary angioplasty is especially useful in diabetics and improves short-term and long-term results, decreasing one-year mortality by 45%. There seem to be indications for the routine use of glycoprotein IIb/IIIa inhibitors in diabetics treated with angioplasty. While the use of stents has improved long-term and short-term results in diabetics, the success rates of angioplasty in diabetics are still lower than in non-diabetics. Diabetes is still an independent predictor of restenosis and long-term events after stenting interventions. Analysis of the studies comparing percutaneous and surgical revascularization in diabetic patients with multivessel disease shows that surgery is superior in terms of long-term mortality and need for new revascularization procedures. Stenting has improved, but not substantially, the results of multivessel angioplasty in diabetics. Therefore, the indications for angioplasty in multivessel diabetics should be evaluated individually. Factors that contribute to the less favorable post-angioplasty evolution of diabetic patients are more rapid progression of atherosclerosis and, especially, a higher rate of restenosis. New angioplasty techniques, such as brachytherapy and drug-eluting stents, are likely to significantly improve the results of percutaneous interventions in diabetics, thus allowing the indications for angioplasty in diabetics to be extended even further in the near future.

Gender differences in clinical status at time of coronary revascularisation in Spain

OBJECTIVE

To study gender differences in clinical status at the time of coronary revascularisation.

DESIGN

Retrospective study of clinical records. Two stage stratified cluster sampling was used to select a nationally representative sample of patients receiving a coronary revascularisation procedure in 1997.

SETTING

All of Spain.

MAIN OUTCOME MEASURES

Odds ratios (OR) in men and women for different clinical and diagnostic variables related with coronary disease. A logistic regression model was developed to estimate the association between coronary symptoms and gender.

RESULTS

In the univariate analysis the prevalence of the following risk factors for coronary heart disease was higher in women than in men: obesity (OR=1.8), hypertension (OR=2.9) and diabetes (OR=2.1). High surgical risk was also more prevalent among women (OR=2.6). In the logistic regression analysis women's risk of being symptomatic at the time of revascularisation was more than double that of men (OR=2.4).

CONCLUSIONS

Women have more severe coronary symptoms at the time of coronary revascularisation than do men. These results suggest that women receive revascularisation at a more advanced stage of coronary disease. Further research is needed to clarify what social, cultural or biological factors may be implicated in the gender differences observed.

The appropriateness of use of percutaneous transluminal coronary angioplasty in Spain

BACKGROUND

The rapid increase in the number of percutaneous transluminal coronary angioplasty (PTCA) procedures performed in Spain in recent years raises questions about how appropriately this procedure is being used. To examine this issue, we studied the appropriateness of use of PTCA in Spanish patients and factors associated with inappropriate use.

METHODS

We applied criteria for the appropriate use of PTCA developed by an expert panel of Spanish cardiologists and cardiovascular surgeons to a random sample of 1913 patients undergoing PTCA in Spain in 1997. The patients were selected through a two-step sampling process, stratifying by hospital type (public/private) and volume of procedures (low/medium/high). We examined the association between inappropriate use of PTCA and different clinical and sociodemographic factors.

RESULTS

Overall, 46% of the PTCA procedures were appropriate, 31% were uncertain and 22% were inappropriate. Two factors contributing to inappropriate use were patients' receipt of less than optimal medical therapy and their failure to undergo stress testing. Institutional type and volume of procedures were not significantly related with inappropriate use.

CONCLUSIONS

One of every five PTCA procedures in Spain is done for inappropriate reasons. Assuring that patients receive optimal medical therapy and undergo stress testing when indicated could contribute to more appropriate use of PTCA.

[Quality control and improvement of the care provided to the patient with acute myocardial infarction. Implementation of a quality assurance program]

INTRODUCTION AND OBJECTIVES

Hospital care of patients with acute myocardial infarction involves a series of therapeutic measures and risk stratification which are a must since their efficacy has been clearly demonstrated. The aim of this study was to develop an internal program to guarantee and improve the quality of hospital care to acute myocardial infarction patients.

METHODS

A medical audit was carried out for evaluation. Seven evaluation criteria considered as class I by the guidelines on the management of acute myocardial infarction patients were analyzed in the discharge report of 163 consecutive patients. Following analysis of the results corrective measures were implemented. In the second phase reevaluation of 40 patients was performed to determine the efficacy of the adopted measures.

RESULTS

Following the first evaluation the use of AAS, IECAS and the beta-blockers was found to be correctly indicated in 95, 80 and 72% of the patients, respectively. A strategy of the adequate stratification of risk was carried out and ventricular function was evaluated in 93 and 96% of the cases. Correct hypolipemia treatment was indicated in 54% of the cases with an adequate diet being prescribed in 100%. Three months after the intervention, 40 new patients were evaluated with all the criteria analyzed being fulfilled in 100% of the cases.

CONCLUSIONS

The use of evaluation techniques and improvement in the quality of health care provided to cases of acute myocardial infarction allows the determination of the care undertaken and its correction if necessary in order to follow the guidelines recommended for the care of these patients.

[Appropriate use of the mechanisms for the fixation of hip prostheses]

OBJECTIVE

To evaluate the appropriateness of the use of fixation mechanisms for hip replacement in patients with osteoarthritis or prosthesis revision, using explicit criteria.

METHODS

Following the RAND appropriateness method, it was carried out a revision of the bibliography and was created a list of 12 indications for osteoarthritis and 32 for the revision. A panel of 27 experts, all of them traumatologists, punctuated the degree of appropriateness for each indication in a scale of 1 (completely inappropriate) up to 9 (completely appropriate). According to the median of the punctuations and the agreement level, each indication was classified as appropriate, uncertain or inappropriate. The data of ten public hospitals of medium and big size of the Basque Service of Health-Osakidetza, were picked up and the developed criteria were applied to the evaluated interventions.

RESULTS

831 osteoarthritis interventions and 349 revisions were evaluated. Of the 136 interventions in which the prosthesis used was cemented, in two thirds its use was considered appropriate. The cementless prosthesis was used more frequently (77%) and in most of the cases (94%) it was considered appropriate according to the criteria of the panel. Of the 68 acetabular revisions in which cemented prosthesis was used, in 85% of them the use of cementless mechanism was recommended. However, of the 134 interventions that used cementless, the panel agreed on 94%. Similar results happened with the femoral revision.

CONCLUSIONS

The study offers some recommendations on the use of the cemented and cementless prosthesis, based on the work of a panel of experts. Once applied, the criteria of the panel a certain level of uncertain use is observed.

[The practical clinical guidelines of the Sociedad Española de Cardiología on interventional cardiology: coronary angioplasty and other technics]

Interventional cardiology has had an extraordinary expansion in last years. This clinical guideline is a review of the scientific evidence of the techniques in relation to clinical and anatomic findings. The review includes: 1. Coronary arteriography. 2. Coronary balloon angioplasty. 3. Coronary stents. 4. Other techniques: directional atherectomy, rotational atherectomy, transluminal extraction atherectomy, cutting balloon, laser angioplasty and transmyocardial laser and endovascular radiotherapy. 5. Platelet glycoprotein IIb/IIIa inhibitors. 6. New diagnostic techniques: intravascular ultrasound, coronary angioscopy, Doppler and pressure wire. For the recommendations we have used the classification system: class I, IIa, IIb, III like in the guidelines of the American College of Cardiology and the American Heart Association.

[The practical clinical guidelines of the Sociedad Española de Cardiología on coronary surgery]

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.