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Field P, Franklin RC, Barker R, Ring I, Leggat P, Canuto K. Importance of cardiac rehabilitation in rural and remote areas of Australia. Aust J Rural Health 2021; 30:149-163. [PMID: 34932825 DOI: 10.1111/ajr.12818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/15/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses. DESIGN Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit. SETTING Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care. PARTICIPANTS (a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care. OUTCOME MEASURES Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits. RESULTS Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care. CONCLUSION Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease.
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Affiliation(s)
- Patricia Field
- College of Public Health, Medicine and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Richard C Franklin
- College of Public Health, Medicine and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Ruth Barker
- College of Healthcare Sciences, James Cook University, Cairns, QLD, Australia
| | - Ian Ring
- Division of Tropical Health & Medicine, James Cook University, Townsville, QLD, Australia
| | - Peter Leggat
- College of Public Health, Medicine and Veterinary Sciences, James Cook University, Townsville, QLD, Australia.,Faculty of Health Sciences, Flinders University, Adelaide, QLD, Australia
| | - Karla Canuto
- College of Public Health, Medicine and Veterinary Sciences, James Cook University, Townsville, QLD, Australia.,South Australian Health and Medical Research Institute, Wardliparingga Aboriginal Health Equity, Adelaide, SA, Australia
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Bahiru E, Agarwal A, Berendsen MA, Baldridge AS, Temu T, Rogers A, Farquhar C, Bukachi F, Huffman MD. Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review. Circ Cardiovasc Qual Outcomes 2019; 12:e005513. [PMID: 31525081 DOI: 10.1161/circoutcomes.118.005513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Quality improvement initiatives have been developed to improve acute coronary syndrome care largely in high-income country settings. We sought to synthesize the effect size and quality of evidence from randomized controlled trials (RCTs) and nonrandomized studies for hospital-based acute coronary syndrome quality improvement interventions on clinical outcomes and process of care measures for their potential implementation in low- and middle-income country settings. METHODS AND RESULTS We conducted a bibliometric search of databases and trial registers and a hand search in 2016 and performed an updated search in May 2018 and May 2019. We performed data extraction, risk of bias assessment, and quality of evidence assessments in duplicate. We assessed differences in outcomes by study design comparing RCTs to nonrandomized quasi-experimental studies and by country income status. A meta-analysis was not feasible due to substantial, unexplained heterogeneity among the included studies, and thus, we present a qualitative synthesis. We screened 5858 records and included 32 studies (14 RCTs [n=109 763] and 18 nonrandomized quasi-experimental studies [n=54-423]). In-hospital mortality ranged from 2.1% to 4.8% in the intervention groups versus 3.3% to 5.1% in the control groups in 5 RCTs (n=55 942). Five RCTs (n=64 313) reported 3.0% to 31.0% higher rates of reperfusion for patients with ST-segment-elevation myocardial infarction in the intervention groups. The effect sizes for in-hospital and discharge medical therapies in a majority of RCTs were 3.0% to 10.0% higher in the intervention groups. There was no significant difference in 30-day mortality evaluated by 4 RCTs (n=42 384), which reported 2.5% to 15.0% versus 5.9% to 22% 30-day mortality rates in the intervention versus control groups. In contrast, nonrandomized quasi-experimental studies reported larger effect sizes compared to RCTs. There were no significant consistent differences in outcomes between high-income and middle-income countries. Low-income countries were not represented in any of the included studies. CONCLUSIONS Hospital-based acute coronary syndrome quality improvement interventions have a modest effect on process of care measures but not on clinical outcomes with expected differences by study design. Although quality improvement programs have an ongoing and important role for acute coronary syndrome quality of care in high-income country settings, further research will help to identify key components for contextualizing and implementing such interventions to new settings to achieve their desired effects. Systematic Review Registration: URL: https://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42016047604.
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Affiliation(s)
- Ehete Bahiru
- Department of Medicine, University of California Los Angeles, CA (E.B.)
| | - Anubha Agarwal
- Department of Medicine (A.A., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark A Berendsen
- Galter Health Sciences Library (M.A.B.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abigail S Baldridge
- Department of Preventive Medicine (A.S.B., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tecla Temu
- Departments of Global Health (T.T.), University of Washington, Seattle
| | - Amy Rogers
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (A.R.)
| | - Carey Farquhar
- Departments of Epidemiology and Medicine (C.F.), University of Washington, Seattle
| | | | - Mark D Huffman
- Department of Medicine (A.A., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine (A.S.B., M.D.H.), Northwestern University Feinberg School of Medicine, Chicago, IL.,The George Institute for Global Health, Food Policy Division, Sydney, Australia (M.D.H.)
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Bjarnason-Wehrens B, Grande G, Loewel H, Völler H, Mittag O. Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes? ACTA ACUST UNITED AC 2016; 14:163-71. [PMID: 17446793 DOI: 10.1097/hjr.0b013e3280128bce] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.
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Affiliation(s)
- Birna Bjarnason-Wehrens
- Institute for Cardiology and Sports Medicine, German Sport University Cologne, 50933 Cologne, Germany.
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Goodney PP. Using risk models to improve patient selection for high-risk vascular surgery. SCIENTIFICA 2012; 2012:132370. [PMID: 24278669 PMCID: PMC3820539 DOI: 10.6064/2012/132370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 10/16/2012] [Indexed: 06/02/2023]
Abstract
Vascular surgeons frequently perform procedures aimed at limiting death, stroke, or amputation on patients who present with diseases such as aortic aneurysms, carotid atherosclerosis, and peripheral arterial occlusive disease. However, now more than ever surgeons must balance the potential benefits associated with these interventions with the risks of physiologic insult for these elderly patients, who often have significant comorbidity burdens and the potential for costly complications. In this paper, we highlight how regional and national datasets can help surgeons identify which patients are most likely to benefit from vascular operations and which patients are most likely to suffer complications in the postoperative period. By using these guidelines to improve patient selection, our risk models can help patients, physicians, and policymakers improve the clinical effectiveness of surgical and endovascular treatments for vascular disease.
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Affiliation(s)
- Philip P. Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766, USA
- Dartmouth-Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH 03765, USA
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Conry MC, Humphries N, Morgan K, McGowan Y, Montgomery A, Vedhara K, Panagopoulou E, Mc Gee H. A 10 year (2000-2010) systematic review of interventions to improve quality of care in hospitals. BMC Health Serv Res 2012; 12:275. [PMID: 22925835 PMCID: PMC3523986 DOI: 10.1186/1472-6963-12-275] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 07/14/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Against a backdrop of rising healthcare costs, variability in care provision and an increased emphasis on patient satisfaction, the need for effective interventions to improve quality of care has come to the fore. This is the first ten year (2000-2010) systematic review of interventions which sought to improve quality of care in a hospital setting. This review moves beyond a broad assessment of outcome significance levels and makes recommendations for future effective and accessible interventions. METHODS Two researchers independently screened a total of 13,195 English language articles from the databases PsychInfo, Medline, PubMed, EmBase and CinNahl. There were 120 potentially relevant full text articles examined and 20 of those articles met the inclusion criteria. RESULTS Included studies were heterogeneous in terms of approach and scientific rigour and varied in scope from small scale improvements for specific patient groups to large scale quality improvement programmes across multiple settings. Interventions were broadly categorised as either technical (n = 11) or interpersonal (n = 9). Technical interventions were in the main implemented by physicians and concentrated on improving care for patients with heart disease or pneumonia. Interpersonal interventions focused on patient satisfaction and tended to be implemented by nursing staff. Technical interventions had a tendency to achieve more substantial improvements in quality of care. CONCLUSIONS The rigorous application of inclusion criteria to studies established that despite the very large volume of literature on quality of care improvements, there is a paucity of hospital interventions with a theoretically based design or implementation. The screening process established that intervention studies to date have largely failed to identify their position along the quality of care spectrum. It is suggested that this lack of theoretical grounding may partly explain the minimal transfer of health research to date into policy. It is recommended that future interventions are established within a theoretical framework and that selected quality of care outcomes are assessed using this framework. Future interventions to improve quality of care will be most effective when they use a collaborative approach, involve multidisciplinary teams, utilise available resources, involve physicians and recognise the unique requirements of each patient group.
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Affiliation(s)
- Mary C Conry
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Division of Population Health Sciences, Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niamh Humphries
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Karen Morgan
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Yvonne McGowan
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Kavita Vedhara
- Institute of Work, Health and Organisations (I-WHO), University of Nottingham, Nottingham, United Kingdom
| | | | - Hannah Mc Gee
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Sun H, Liu M, Hou S. Quality indicators for acute myocardial infarction care in China. Int J Qual Health Care 2011; 23:365-74. [PMID: 21561980 DOI: 10.1093/intqhc/mzr020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Although quality indicators for the care of patients having acute myocardial infarction have been described for other countries, there are none specifically tailored to the Chinese health-care system. The study objective was to develop quality indicators for acute myocardial infarction in China, which measure and improve the quality of care for this patient population, and which could be reported on performance reports. DESIGN A modified Delphi process regarding association with seven dimensions (evidence-based, usefulness, interpretable, validity, prevention, feasibility and overall assessment) on a 5-point scale. PARTICIPANTS A 17-member multidisciplinary expert panel was assembled, including 6 thoracic and cardiovascular surgeons and 11 cardiovascular internists. MAIN OUTCOME MEASURE Indicators with an arithmetic mean score of >4 in the overall assessment group were considered for the discussion round with the panelists. RESULTS A total of 60 quality indicators were examined. There were 33 quality indicators with scores >4. This list was distilled to 23 indicators related to quality of care. These selected indicators consisted of 5 outcome variables, 15 process of care variables and 3 structure variables. CONCLUSIONS This set of consensus quality indicators can be used as a standard list to be monitored by providers of acute myocardial infarction care in an effort to continuously evaluate and improve their performance.
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Affiliation(s)
- Hongpeng Sun
- Public Health College, Harbin Medical University, 157 Baojian Road, Haerbin City, Heilongjiang Province, 150081, P.R. China
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Goodney PP, Eldrup-Jorgensen J, Nolan BW, Bertges DJ, Likosky DS, Cronenwett JL. A regional quality improvement effort to increase beta blocker administration before vascular surgery. J Vasc Surg 2011; 53:1316-1328.e1; discussion 1327-8. [PMID: 21334166 DOI: 10.1016/j.jvs.2010.10.131] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/13/2010] [Accepted: 10/13/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine if a regional quality improvement effort can increase beta-blocker utilization prior to vascular surgery and decrease the incidence of postoperative myocardial infarction (POMI). METHODS A quality improvement effort to increase perioperative beta blocker utilization was implemented in 2003 at centers participating in the Vascular Study Group of New England (VSGNE). A 90% target was set and feedback given at biannual meetings. Beta blocker utilization (<1 month preoperative versus chronic) and POMI rates were prospectively collected for patients undergoing open abdominal aortic aneurysm (AAA) repair (n = 926) and lower extremity bypass (LEB; n = 2,123) from 2003 through 2008. Predictors of POMI were determined using multivariate logistic regression. Rates of beta blocker administration and POMI were analyzed over time, and across strata of patient risk based on a multivariate model. RESULTS Perioperative beta blocker treatment increased from 68% of patients in the first 3 months of 2005 to 88% by the last 3 months of 2008 (P < .001). In 2003, 44% of patients not on chronic beta blockers were treated with preoperative beta blockers; by 2008, 78% of patients not on chronic beta blockers were started perioperatively on these medications (P < .001). Beta blocker utilization increased across all centers and surgeons participating during the study period, and increased in patients of low, medium, and high cardiac risk. However, the rate of POMI did not change over time (5.2% in 2003, 5.5% in 2008; P = .876), although a trend towards lower POMI rate was seen in patients on preoperative beta blockers (4.4% in 2003-2005, 2.6% in 2006-2008; P = .43). In multivariable modeling we found that age >70 (odds ratio [OR], 2.1), positive stress test (OR, 2.2), congestive heart failure (CHF; OR, 1.7), chronic beta blocker administration (OR, 1.7), resting heart rate <70 (OR, 1.8), and diabetes (OR, 1.6) were associated with POMI. Resting heart rate was similar for patients on chronic (67), preoperative (70), and no beta blockers (70; P = .521). CONCLUSIONS Our regional quality improvement effort successfully increased perioperative beta blocker utilization. However, this was not associated with reduced rates of POMI or resting heart rate. While this demonstrates the effectiveness of regional quality improvement efforts in changing practice patterns, further work is necessary to more precisely identify those patients who will benefit from beta blockade at the time of vascular surgery.
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Goodney PP, Nolan BW, Schanzer A, Eldrup-Jorgensen J, Stanley AC, Stone DH, Likosky DS, Cronenwett JL. Factors associated with death 1 year after lower extremity bypass in Northern New England. J Vasc Surg 2009; 51:71-8. [PMID: 19939615 DOI: 10.1016/j.jvs.2009.07.123] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 07/24/2009] [Accepted: 07/24/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Using 30-day operative mortality reported with lower extremity bypass (LEB) in preoperative decision making may underestimate the actual death rate encountered before patients have truly recovered from surgery, especially in elderly, debilitated patients with significant tissue loss. Therefore, we examined preoperative, patient-level risk factors that predict survival within the first year following LEB. METHODS Using our regional quality improvement initiative in 11 hospitals in Northern New England, we studied 2306 LEB procedures performed in 2031 patients between January 2003 and December 2007. Sixty surgeons contributed to our database, and over 100 demographic and clinical variables were abstracted by trained researchers. Cox proportional hazards models were used to generate hazard ratios (HR) and surrounding 95% confidence intervals (CI) for our combined outcome measure of death occurring within the first year postoperatively. RESULTS We found that within our cohort of 2306 bypass procedures, 11% of patients died within 1 year of surgery (2% prior to discharge, 9% prior to 1-year follow-up). We identified six preoperative patient characteristics associated with higher risk of death in multivariate analysis: congestive heart failure (HR 1.3, 95% CI 1.0-1.8), diabetes (HR 1.5, 95% CI 1.1-2.1), critical limb ischemia (CLI) (HR 1.7, 95% CI 1.3-2.4), lack of single-segment saphenous vein (HR 1.9, 95% CI 1.5-2/5), age over 80 (HR 2.0, 95% CI 1.5-2.7), dialysis dependence (HR 2.7, 95% CI 1.9-3.6), and emergent nature of the procedure (HR 3.4, 95% CI 1.7-6.8). While patients with no risk factors had 1-year death rates that were less than 5%: patients with three or more risk factors had a 28% chance of dying before 1 year postoperatively. When we compared risk-adjusted survival across centers, we found that one center in our region performed significantly better than expected (observed-to-expected outcome ratio 0.7, 95% CI 0.6-0.9, P = .04). CONCLUSIONS Preoperative risk factors allow surgeons to predict survival in the first year following LEB, and to more precisely inform patients about their operative risk with LEB. Additionally, our model facilitates benchmarking comparison of risk-adjusted outcomes across our region. We believe quality improvement measures such as these will allow surgeons to identify best practices and thereby improve outcomes with LEB across centers.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebano, NH 03765, USA
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Schanzer A, Goodney PP, Li Y, Eslami M, Cronenwett J, Messina L, Conte MS. Validation of the PIII CLI risk score for the prediction of amputation-free survival in patients undergoing infrainguinal autogenous vein bypass for critical limb ischemia. J Vasc Surg 2009; 50:769-75; discussion 775. [DOI: 10.1016/j.jvs.2009.05.055] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 05/27/2009] [Accepted: 05/28/2009] [Indexed: 10/20/2022]
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Goodney PP, Nolan BW, Schanzer A, Eldrup-Jorgensen J, Bertges DJ, Stanley AC, Stone DH, Walsh DB, Powell RJ, Likosky DS, Cronenwett JL. Factors associated with amputation or graft occlusion one year after lower extremity bypass in northern New England. Ann Vasc Surg 2009; 24:57-68. [PMID: 19748222 DOI: 10.1016/j.avsg.2009.06.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 05/26/2009] [Accepted: 06/23/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal patient selection for lower extremity bypass surgery requires surgeons to predict which patients will have durable functional outcomes following revascularization. Therefore, we examined risk factors that predict amputation or graft occlusion within the first year following lower extremity bypass. METHODS Using our regional quality-improvement initiative in 11 hospitals in northern New England, we studied 2,306 lower extremity bypass procedures performed in 2,031 patients between January 2003 and December 2007. Sixty surgeons contributed to our database, and over 100 demographic and clinical variables were abstracted by trained researchers. Cox proportional hazards models were used to generate hazard ratios and surrounding 95% confidence intervals (CIs) for our combined outcome measure of major amputation (above-knee or below-knee) or permanent graft occlusion (loss of secondary patency) occurring within the first year postoperatively. RESULTS We found that within our cohort of 2,306 bypass procedures 17% resulted in an amputation or graft occlusion within 1 year of surgery. Of the 143 amputations performed (8% of all limbs undergoing bypasses), 17% occurred in the setting of a patent graft. Similarly, of the 277 graft occlusions (12% of all bypasses), 42% resulted in a major amputation. We identified eight preoperative patient characteristics associated with amputation or graft occlusion in multivariate analysis: age <50, nonambulatory status preoperatively, dialysis dependence, diabetes, critical limb ischemia, need for venovenostomy, tarsal target, and living preoperatively in a nursing home. While patients with no risk factors had 1-year amputation/occlusion rates that were <1%, patients with three or more risk factors had a nearly 30% chance of suffering amputation or graft occlusion by 1 year postoperatively. When we compared risk-adjusted rates of amputation/occlusion across centers, we found that one center in our region performed significantly better than expected (observed/expected ratio 0.7, 95% CI 0.6-0.9, p < 0.04). CONCLUSION Preoperative risk factors allow surgeons to predict the risk of amputation or graft occlusion following lower extremity bypass and to more precisely inform patients about their operative risk and functional outcomes. Additionally, our model facilitates comparison of risk-adjusted outcomes across our region. We believe quality-improvement measures such as these will allow surgeons to identify best practices and thereby improve outcomes across centers.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03765, USA.
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Gregory AT, Armstrong RM, Grassi TD, Van Der Weyden MB. Sharing the secrets of success: conversations with the Medical Journal of Australia / Wyeth Research Award winners, 1995–2006. Med J Aust 2007; 187:637-44. [DOI: 10.5694/j.1326-5377.2007.tb01455.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 10/31/2007] [Indexed: 11/17/2022]
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Chew DP, Amerena J, Coverdale S, Rankin J, Astley C, Brieger D. Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit. Intern Med J 2007; 37:741-8. [PMID: 17645500 DOI: 10.1111/j.1445-5994.2007.01435.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia. METHODS The Acute Coronary Syndrome Prospective Audit study is a prospective multi-centre registry of ST-segment elevation myocardial infarction (STEMI), high-risk non-ST-segment elevation ACS (NSTEACS-HR) and intermediate-risk non-ST-segment elevation ACS (NSTEACS-IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in-hospital management including invasive services, and clinical outcomes. RESULTS A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non-metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high-risk NSTEACS patients and 698 (20.5%) were intermediate-risk NSTEACS patients. Evidence-based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS-HR 54%, NSTEACS-IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS-HR 22.2%, NSTEACS-IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS-HR 1.8%, NSTEACS-IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS-HR: 2.8%, NSTEACS-IR 1.2%, P = 0.052). CONCLUSION There appears to be an 'evidence-practice gap' in the management of ACS, but this is not matched by an increased risk of in-hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.
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Affiliation(s)
- D P Chew
- Department of Cardiology, Flinders University, Flinders Medical Centre, Adelaide, South Australia.
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Escosteguy CC, Portela MC, Medronho RDA, Vasconcellos MTLD. AIH versus prontuário médico no estudo do risco de óbito hospitalar no infarto agudo do miocárdio no Município do Rio de Janeiro, Brasil. CAD SAUDE PUBLICA 2005; 21:1065-76. [PMID: 16021244 DOI: 10.1590/s0102-311x2005000400009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste estudo é avaliar o desempenho do Sistema de Informações Hospitalares (SIH) em relação ao prontuário médico na análise dos fatores associados à variação do risco de óbito hospitalar no infarto agudo do miocárdio. O estudo envolveu uma amostra aleatória, estratificada por hospital, de 391 prontuários médicos sorteados com base nos 1.936 formulários de Autorização de Internação Hospitalar (AIH) registrados com o diagnóstico principal de infarto agudo do miocárdio no Município do Rio de Janeiro, Brasil, em 1997. Para estudo dos fatores associados à variação do risco de óbito hospitalar foram usados modelos logísticos a partir do SIH e do prontuário, com construção de curvas ROC para comparar desempenho relativo entre eles. O diagnóstico foi confirmado em 91,7% dos casos; a letalidade foi 20,6%. O modelo desenvolvido a partir do prontuário apresentou o melhor ajuste por incluir variáveis de gravidade e processo não disponíveis no SIH (concordância = 90,1%). O modelo derivado do SIH teve um menor poder explicativo (concordância = 70,6%), mas a correção de erros de digitação e informação através do prontuário não modificou significativamente seu desempenho. A maior limitação do SIH foi o elevado sub-registro do diagnóstico secundário.
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Beswick AD, Rees K, West RR, Taylor FC, Burke M, Griebsch I, Taylor RS, Victory J, Brown J, Ebrahim S. Improving uptake and adherence in cardiac rehabilitation: literature review. J Adv Nurs 2005; 49:538-55. [PMID: 15713186 DOI: 10.1111/j.1365-2648.2004.03327.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS This paper presents a comprehensive systematic review of literature carried out to identify studies of interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation. BACKGROUND Guidelines recommend that cardiac rehabilitation should be offered to patients following acute myocardial infarction and revascularization. Uptake and adherence are low, particularly in women, older people, and socially deprived and ethnic minority patients. Although patient, service and professional barriers to rehabilitation uptake have been described, no attempt has been made to evaluate systematically interventions aimed at improving uptake and adherence in cardiac rehabilitation. METHODS A comprehensive search strategy identified studies of cardiac rehabilitation, using the terms uptake, adherence and compliance. The search included grey literature, hand searching of specialist journals and conference abstracts. No language restriction was applied. Studies were summarized in three qualitative overviews and assessed by quality of evidence. RESULTS From 3261 publications identified, 957 were acquired on the basis of title or abstract. Few studies were of sufficient quality to make specific recommendations. Six, 12 and five studies, respectively, provided adequate information on methods to improve uptake, adherence or professional compliance. A minority of studies were randomized controlled trials. Studies of motivational and self-management strategies and use of lay volunteers showed some promise in improving rehabilitation uptake or lifestyle change. Nurse-led coordination of care after hospital discharge may have a role in improving rehabilitation uptake. Limited information was provided on resource implications, and there was a lack of studies with under-represented groups. The literature contained numerous suggested interventions which merit evaluation in appropriately designed studies. CONCLUSIONS Little research has been reported evaluating interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation. A wide range of possible interventions was identified and further evaluations of methods are indicated.
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Affiliation(s)
- Andrew D Beswick
- Department of Social Medicine, University of Bristol, Bristol, UK.
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Tran CTT, Laupacis A, Mamdani MM, Tu JV. Effect of age on the use of evidence-based therapies for acute myocardial infarction. Am Heart J 2004; 148:834-41. [PMID: 15523314 DOI: 10.1016/j.ahj.2003.11.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have documented an underuse of evidence-based therapies in patients with acute myocardial infarction (AMI). However, many of these studies failed to consider contraindications to therapy, the effect of age (ie, elderly vs non-elderly patients) on use, or both. The objective of this study was to determine whether elderly patients are less likely than non-elderly patients to receive evidence-based AMI treatments, both before and after the consideration of contraindications to therapy. METHODS A retrospective chart review of a random sample of 5131 patients with AMI who were admitted to 1 of 44 hospitals in Ontario was conducted for the fiscal years 1994 to 1996. Using the Canadian Cardiovascular Research Team (CCORT)/Canadian Cardiovascular Society (CCS) Quality Indicators for AMI Care, we classified patients as being eligible or ideal (ie, no contraindications to treatment) candidates to receive aspirin, beta-blockers, thrombolysis, angiotensin-converting enzyme inhibitors (ACEIs), or statins or to undergo lipid profiling. The proportions of eligible and ideal patients who received treatment were calculated, and the latter were compared with benchmarks. RESULTS The median age of the cohort was 69 years; 63% were of the patients were aged > or =65 years. There was underperformance of prescribing treatments in ideal candidates relative to benchmarks (eg, aspirin at discharge: 78.6% vs 90% benchmark). The odds of ideal (ie, no contraindications) elderly candidates receiving various evidence-based AMI treatments were consistently less than that of non-elderly patients with AMI, with the exception of ACEIs at discharge (odds ratio, 1.46; 95% CI, 1.22-1.74). CONCLUSIONS Despite adjustments for contraindications to therapy, the underuse of AMI treatments, particularly in elderly patients, was found.
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Affiliation(s)
- Chau T T Tran
- University of Toronto, Institute of Medical Sciences, Toronto, Ontario, Canada
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Schünemann HJ, Cook D, Grimshaw J, Liberati A, Heffner J, Tapson V, Guyatt G. Antithrombotic and Thrombolytic Therapy: From Evidence to Application. Chest 2004; 126:688S-696S. [PMID: 15383490 DOI: 10.1378/chest.126.3_suppl.688s] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about implementation strategies for practice guidelines is part of the 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that feasibility, acceptability and cost related to implementation strategies may lead to different choices depending on the practice setting (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). To encourage uptake of guidelines to reduce thrombosis, we recommend that appreciable resources be devoted to distribution of educational material (Grade 2B). We suggest that few resources be devoted to educational meetings (Grade 2B), to audit and feedback (Grade 2B), or to educational outreach visits (Grade 2B) to encourage uptake of the guidelines. We suggest that appreciable resources be devoted to computer reminders (Grade 2A) and to patient-mediated interventions (Grade 2B) to encourage uptake of the guidelines. This review suggests that there are few implementation strategies that are of unequivocal, consistent benefit, and that are clearly and consistently worth resource investment. Fully informed decisions will require additional research to identify effective guideline implementation strategies to optimize antithrombotic and thrombolytic therapy.
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Affiliation(s)
- Holger J Schünemann
- Department of Medicine, University at Buffalo, ECMC-CC142, 462 Grider St, Buffalo, NY 14215, USA.
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Scott IA, Harper CM. Guideline-discordant care in acute myocardial infarction: predictors and outcomes. Med J Aust 2002; 177:26-31. [PMID: 12088475 DOI: 10.5694/j.1326-5377.2002.tb04627.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2001] [Accepted: 03/18/2002] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. DESIGN Retrospective cohort study. SETTING Two community general hospitals. PARTICIPANTS 607 consecutive patients admitted with AMI between July 1997 and December 2000. MAIN OUTCOME MEASURES Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. RESULTS At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7-3.6), silent infarction (OR, 2.7; 95% CI, 1.6-4.6), anterior infarction (OR, 2.5; 95% CI, 1.7-3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5-6.4); and heart rate >/= 100 beats/min (OR, 2.1; 95% CI, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90-7.1). CONCLUSIONS Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.
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Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia.
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Scott IA, Coory MD, Harper CM. The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction. Med J Aust 2001; 175:465-70. [PMID: 11758074 DOI: 10.5694/j.1326-5377.2001.tb143678.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI). DESIGN Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database. SETTING All Queensland public hospitals, July 1991 - June 1999. STUDY POPULATION Patients with AMI admitted through the emergency department. INTERVENTION Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995. MAIN OUTCOME MEASURES Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions. RESULTS Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97). CONCLUSIONS Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.
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Affiliation(s)
- I A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD.
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Escosteguy CC, Portela MC, Leite de Vasconcellos MT, de Andrade Medronho R. Pharmacological management of acute myocardial infarction in the municipal district of Rio de Janeiro. SAO PAULO MED J 2001; 119:193-9. [PMID: 11723533 DOI: 10.1590/s1516-31802001000600003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
CONTEXT International studies have shown a large variation in the utilization patterns of interventions, in acute myocardial infarction. OBJECTIVE To analyze utilization patterns of pharmacological interventions in acute myocardial infarction and their corresponding effects on hospital mortality. DESIGN Cross-sectional study. LOCAL: Hospitals of the Brazilian National Health System (SUS) in the municipal district of Rio de Janeiro. SAMPLE A stratified hospital sample of 391 medical records selected from the 1,936 admissions registered in the SUS Hospital Information System (SIH/SUS) with a main diagnosis of acute myocardial infarction, in the studied district in 1997. MAIN MEASUREMENTS Sex, age, time to treatment, risk factors, severity factors, diagnosis confirmation, use of pharmacological interventions, hospital death, contraindication of the use of thrombolytic therapy, contraindication of aspirin use. RESULTS We reviewed 98.2% of the sampled medical records. Acute myocardial infarction diagnosis was confirmed in 91.7% (95% CI 88.3 to 94.2). 61.5% were men and 38.5% women, with an average age of 60.2 years (SD 2.4). The median time interval between symptom onset and hospital admission was 11 hours. Hospital mortality was 20.6% (95% CI 16.7 to 25.0). Intravenous thrombolytic therapy was used in 19.5% (95% CI 15.8 to 23.9) of the cases; aspirin in 86.5% (95% CI 82.5 to 89.6); beta-blockers in 49.0% (95% CI 43.8 to 54.1); angiotensin-converting enzyme (ACE) inhibitors in 63.3% (95% CI 58.2 to 68.1); nitrates in 82.0% (95% CI 82.4 to 89.6); heparin in 81.3% (95% CI 76.9 to 85.0); calcium antagonists in 30.5% (95% CI 26.0 to 35.4). There was a significant variation in the use of thrombolytic therapy, beta-blockers, ACE inhibitors, calcium antagonists and heparin among hospitals of different juridical nature. CONCLUSIONS There was underutilization of some interventions with well-established efficacy (thrombolytic therapy, aspirin, beta-blockers and intravenous nitrates). The use of calcium antagonists, not supported by scientific evidence in acute myocardial infarction, was quite frequent. A logistic model documented the benefit of aspirin, beta-blockers and ACE inhibitor use in reducing the chance of hospital death.
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Affiliation(s)
- C C Escosteguy
- Epidemiology Service, Hospital dos Servidores do Estado, Ministry of Health, Rio de Janeiro, Brazil.
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Mudge AM, Brockett R, Foxcroft KF, Denaro CP. Lipid-lowering therapy following major cardiac events: progress and deficits. Med J Aust 2001; 175:138-40. [PMID: 11548079 DOI: 10.5694/j.1326-5377.2001.tb143061.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess hospital prescribing of lipid-lowering agents in a tertiary hospital, and examine continuation of, or changes to, such therapy in the 6-18 months following discharge. DESIGN Retrospective data extraction from the hospital records of patients admitted from October 1998 to April 1999. These patients and their general practitioners were then contacted to obtain information about ongoing management after discharge. SETTING Tertiary public hospital and community. PARTICIPANTS 352 patients admitted to hospital with acute myocardial infarction or unstable angina, and their GPs. MAIN OUTCOME MEASURES Percentage of eligible patients discharged on lipid-lowering therapy and percentage of patients continuing or starting such therapy 6-18 months after discharge. RESULTS 10% of inpatients with acute coronary syndromes did not have lipid-level estimations performed or arranged during admission. Documentation of lipid levels in discharge summaries was poor. Eighteen per cent of patients with a total serum cholesterol level greater than 5.5 mmol/L did not receive a discharge prescription for a cholesterol-lowering agent. Compliance with treatment on follow-up was 88% in the group discharged on treatment. However, at follow-up, 70% of patients discharged without therapy had not been commenced on lipid-lowering treatment by their GPs. CONCLUSIONS Prescribing of lipid-lowering therapy for secondary prevention following acute coronary syndromes remains suboptimal. Commencing treatment in hospital is likely to result in continuing therapy in the community. Better communication of lipid-level results, treatment and treatment aims between hospitals and GPs might encourage optimal treatment practices.
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Affiliation(s)
- A M Mudge
- Division of Medicine, Royal Brisbane Hospital, Brisbane, QLD
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