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Biomedical subjects

A G Ellrodt

Publications and source records attributed to A G Ellrodt.

At least 19 recordsLinked to original sources
PubMed1995

Measuring and improving physician compliance with clinical practice guidelines. A controlled interventional trial.

OBJECTIVE: To determine factors that may lead physicians not to comply with clinical practice guidelines. DESIGN: Retrospective analysis of patients whose physicians were not compliant with discharge recommendations from a prospective, controlled interventional trial of a guideline to reduce hospital length of stay for patients admitted for chest pain. SETTING: A large community teaching hospital. PARTICIPANTS: Patients admitted with chest pain who were not discharged according to a practice guideline. RESULTS: 79 (34%) of 230 patients with chest pain classified as being at low risk by concurrent or retrospective review were not discharged by day 3 (the guideline recommendation). Of these 79 patients, 33 (42%) were misclassified at concurrent review (10 were falsely classified as being at high risk and 23 were falsely classified as being at low risk). Of 46 correctly classified patients, 11 (14%) were classified as having noncompliant physicians because of health care system inefficiencies. The status of 7 (9%) patients was changed to high risk between initial classification and potential discharge. For 15 patients (19%), no obvious reason for delayed discharge was found, but they had a higher severity of illness than did low-risk patients discharged according to the guideline as measured by mean time-insensitive predictive instrument scores (41.3% +/- [SD] 14.1% compared with 31.5% +/- 14.3%; P = 0.017). In 13 patients (16%), physicians refused to follow the guideline recommendations. CONCLUSIONS: In measuring and attempting to improve physician compliance with a length-of-stay guideline, physician refusal accounts for a small percentage (16%) of noncompliance. Implementation issues, health care system inefficiency, and severity of illness were the predominant reasons why physicians did not comply with guidelines. Our study further supports the principle that clinical practice guidelines should complement rather than be a substitute for physician judgment.

Chest Pain↗
PubMed1995

Total knee replacement. A guideline to reduce postoperative length of stay.

In a retrospective study in an academic, acute-care community hospital, we studied the possible safety and effectiveness of a practice guideline recommending early discharge from the hospital for patients having uncomplicated total knee replacement. Of 206 patients receiving knee replacements, 162 (79%) were classified by the guideline as being at low risk for complications between the 4th and 7th postoperative days. Use of the guideline could have reduced the postoperative length of stay from 7.3 +/- 2.6 days to 4 days for the 112 patients (54%) who became low risk on the 4th postoperative day. Explicit and implicit review of the quality of care determined that 157 patients (96.9%; 95% confidence interval, (92.9%, 99.0%) could have been safely transferred from the acute-care hospital to an appropriate setting when they became classified at low risk between the 4th and 7th postoperative days. Clinical practice guidelines can possibly be used to reduce the postoperative length of acute-care hospital stay for patients having knee replacements. This guideline requires further study in a controlled clinical trial before it can be recommended for use.

Aged↗
PubMed1994

Reducing lengths of stay in the coronary care unit with a practice guideline for patients with congestive heart failure. Insights from a controlled clinical trial.

Although more than 1,000 medical practice guidelines have been developed, there have been few evaluations of their use in clinical practice or information to judge whether practice guidelines can be used to reduce health care costs. For this reason, the authors conducted a prospective controlled clinical trial with an alternating-month design at a large teaching community hospital to study the use of a practice guideline to promote early transfer of patients admitted to a hospital with congestive heart failure (CHF) from the coronary care unit (CCU) and intermediate care unit to unmonitored beds. The practice guideline was supported by locally derived risk information and recommended consideration of early "step-down" transfer of low-risk patients with CHF 24 hours after hospital admission. Physicians caring for patients identified as "low risk" received concurrent personalized written and verbal reminders concerning the guideline recommendation. Study subjects were patients admitted to a hospital CCU and intermediate care unit between November 1, 1991 and April 30, 1993 with a diagnosis of CHF or pulmonary edema. Ninety patients with CHF were identified as low risk according to the guideline during the study period. Feedback of the practice guideline recommendation was not associated with a significant increase in physician adoption of the guideline or shorter lengths of stay in the CCU or intermediate care unit. Physicians may have compensated for statistically insignificant reductions in monitored lengths of stay by increasing the length of stay in unmonitored beds (1.80 +/- 2.32 to 4.02 +/- 4.09 days, P = .002) and the total length of stay (4.73 +/- 2.43 to 6.71 +/- 5.44 days, P = .03). Quality of patient care, patient outcomes, and patient satisfaction were not affected by the guideline. Our study results suggest that implementation of a locally derived practice guideline for patients with CHF did not result in adoption of the guideline by physicians. The complexity of implementing the guideline, changes in physician practice before the study, and the failure of the guideline to address the continuum of patient care across monitored and unmonitored beds may have accounted for rejection of the guideline. Our experience demonstrates that practice guidelines, whenever possible, should be evaluated in prospective trials before they should be disseminated for widespread use.

Adult↗
PubMed1992

The case for intensive dissemination: adoption of practice guidelines in the coronary care unit.

Medical practice guidelines are being embraced enthusiastically by subspecialty and government organizations, but although hundreds have been developed at great public and private expense, there are few examples of how they have improved the quality of care or reduced health care costs. This article reports documented experience in changing physician behavior after implementing medical practice guidelines in the coronary care unit without altering physician incentives or imposing the threat of sanctions. Guideline adoption did require significant attention to the implementation process, including endorsement of guidelines by local "opinion leaders," validation by local data, and an intensive and concurrent implementation strategy.

Chest Pain↗
PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗
PubMed1992

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units.

OBJECTIVES: Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness. DESIGN: A prospective, observational study. SETTING: The coronary care and intermediate care unit in an 1,100-bed community hospital. PATIENTS: A total of 217 patients hospitalized for chest pain cared for by noncardiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer. CONCLUSIONS: There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.

Age Factors↗
PubMed1990

Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial.

OBJECTIVE: To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN: Prospective, controlled, interventional trial using an alternate month study design. SETTING: A large teaching community hospital. PATIENTS: Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS: During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS: Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS: The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Aged↗
PubMed1990

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients.

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Aged↗
PubMed1989

Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome?

The maternal death rate and rate of preterm delivery associated with pneumonia during pregnancy have not decreased since the introduction of antibiotics four decades ago. We retrospectively reviewed 25 cases of pneumonia during pregnancy; these cases occurred among 32,179 deliveries. Medical complications included: bacteremia, 16%; empyema, 8%; atrial fibrillation, 4%; respiratory failure necessitating mechanical ventilation, 20%. Obstetric complications occurring during the pneumonia episode included: preterm labor, 44%; preterm delivery, 36%. A patient with cystic fibrosis died; one stillbirth and two neonatal deaths occurred. Underlying maternal disease was significantly associated with maternal medical complications (p = 0.023) and preterm delivery (p = 0.012). Significant medical and obstetric complications continue to occur frequently despite modern antimicrobial, tocolytic, and supportive therapy. Underlying maternal disease, including acquired immunodeficiency syndrome and cystic fibrosis, was associated with preterm delivery and neonatal and maternal death.

Adolescent↗
PubMed1989

Selecting the best triage rule for patients hospitalized with chest pain.

PURPOSE: During an observational study, we investigated the potential benefits and risks of the use of admission and early transfer triage rules in 498 patients hospitalized with chest pain. PATIENTS AND METHODS: Appropriateness of triage decisions was measured using explicit and implicit judgments. RESULTS: Application of an admission triage rule (partially based on the Brush electrocardiographic criteria) would have increased coronary care unit (CCU) admissions by 3%, whereas application of a triage rule 24 hours after admission would have reduced bed utilization by 860 intermediate care and 82 CCU bed-days per year when compared with actual patient triage. Although 9.5% of patients who underwent triage according to the early transfer triage rule would have experienced a minor complication after transfer, the medical care of none would have been adversely affected. CONCLUSION: Our results show that application of a triage rule 24 hours after admission may have the potential to shorten length of stay in the CCU and intermediate care unit without significantly compromising patient care. However, use of the admission triage rule would have increased CCU bed utilization. The failure of the admission triage rule to improve bed utilization illustrates the potential hazards of ignoring patient complications, interventions, and co-morbidity when predicting the efficacy of a triage rule.

Aged↗
PubMed1988

Felodipine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in hypertension.

Felodipine is a dihydropyridine calcium antagonist which selectively relaxes vascular smooth muscle. By acting at peripheral arterioles, it lowers systemic vascular resistance and thereby produces substantial decreases in blood pressure and increases in cardiac output. Felodipine is indicated for the management of hypertension, and in patients with mild to moderate disease felodipine monotherapy markedly lowers blood pressure. It proved as effective as atenolol, and equivalent to hydrochlorothiazide, either with or without amiloride, in terms of antihypertensive activity. Comparative studies also demonstrated that once daily administration with an extended-release formulation provides equivalent antihypertensive efficacy to the same amount of drug administered twice daily as the standard tablets. As a second- or third-line treatment for patients with moderate to severe hypertension refractory to standard drug combinations, felodipine produced considerable reductions in blood pressure when added to beta-blockers and diuretics, either alone or in combination, in studies lasting up to 48 weeks. In comparative studies of multiple-drug treatments felodipine was found to have superior efficacy to hydralazine and prazosin, and was at least as effective as nifedipine, minoxidil and propranolol, when used with diuretics and/or beta-blockers. As an alternative to hydrochlorothiazide, in combination with beta-blockers, felodipine consistently controlled blood pressure in a greater percentage of patients and usually provided greater decreases in blood pressure. The main side effects with felodipine are ankle oedema, headache and flushing. Although the overall incidence of effects is quite high, they are usually mild in nature. Nevertheless, withdrawal due to side effects has been necessary in about 7% of patients overall. Thus, the efficacy of felodipine has been demonstrated in mild, moderate and severe hypertension. At the present time it seems particularly suitable as a second- or third-line treatment in refractory hypertension, but it also can be used as monotherapy for mild to moderate disease.

Felodipine↗
PubMed1986

Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction.

To determine the spectrum and prognostic implications of left and right ventricular (LV and RV) ejection fractions (EFs) in acute myocardial infarction (AMI), radionuclide ventriculography was performed in 114 consecutive patients, admitted without (Killip class I, 78 patients) or with (killip class II, 36 patients) clinical signs of pulmonary congestion within 24 hours of onset of symptoms of a transmural AMI. Mean LVEF was significantly lower in patients in Killip class II than in those in class I (0.32 +/- 0.11 vs 0.46 +/- 0.15, p less than 0.001) and in patients with anterior than inferior AMI (0.34 +/- 0.11 vs 0.52 +/- 0.14, p less than 0.001). Of the 36 patients with a severely depressed (0.30 or less) LVEF, 15 (42%) were in Killip class I. Mean RVEF did not differ significantly between Killip class I and II patients (0.42 +/- 0.11 vs 0.40 +/- 0.12, difference not significant) but was significantly lower in patients with inferior than anterior AMI (0.38 +/- 0.09 vs 0.44 +/- 0.11, p = 0.005). In patients with inferior AMI, a depressed RVEF (0.38 or less) was associated with a normal LVEF in 30% and a depressed LVEF in 20%, whereas in those with anterior AMI, a depressed RVEF, observed in 25% of patients, occurred only in association with a depressed LVEF.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1986

Sepsis and septic shock.

Sepsis and septic shock remain all too frequent syndromes in modern medicine with unacceptably high mortality rates. Physicians must be aware of the many ways in which sepsis and septic shock may present and the multiple differential diagnoses. Early recognition and prompt institution of empiric therapy are of utmost importance. Our current limited understanding of the pathophysiology of sepsis and septic shock significantly limits our ability to treat this syndrome effectively and thus substantively alter mortality. New developments in immunology and metabolism seem promising in furthering our understanding and improving our therapy of this complex multisystem disorder.

Animals↗
PubMed1985

Efficacy and safety of sublingual nifedipine in hypertensive emergencies.

Hypertensive emergencies are a diverse group of disorders characterized by a marked elevation of systemic arterial pressure that is associated with acute end-organ dysfunction. The efficacy and safety of sublingual nifedipine were evaluated in 16 men and 14 women (mean age 65 +/- 14 years) who had hypertensive emergencies. Before treatment, mean systolic blood pressure was 224 +/- 23 mm Hg, mean diastolic blood pressure was 125 +/- 18 mm Hg, and the average mean arterial pressure was 158 +/- 16 mm Hg. Administration of 10 or 20 mg of sublingual nifedipine initiated a smooth and predictable decline in blood pressure values within five minutes and produced a peak effect between 30 and 60 minutes. At 30 minutes, the decreases in the systolic blood pressure, diastolic blood pressure, and mean arterial pressure for the group were 49 +/- 24 mm Hg, 31 +/- 17 mm Hg, and 39 +/- 20 mm Hg, respectively, all of which were highly significant (p less than 0.001). By 60 minutes, nifedipine had decreased the diastolic blood pressure to less than 120 mm Hg in 97 percent of patients, less than 110 mm Hg in 93 percent, and less than 100 mm Hg in 67 percent. Fourteen patients required other antihypertensive medications within the first 12 hours for the antihypertensive effect to be maintained. In this group, the systolic, diastolic, and mean arterial pressures were significantly lower than baseline values (p less than 0.001) at the time that the other drugs were started (which occurred at a mean of 4.3 +/- 3.2 hours after entry into the study). The response to nifedipine correlated with the blood pressure value prior to treatment, but did not correlate with age, gender, value prior to treatment, but did not correlate with age, gender, or the type of hypertensive emergency. Twenty mg of nifedipine produced a significantly greater antihypertensive effect than did 10 mg during the first 20 minutes (176 +/- 15 mm Hg versus 201 +/- 18 mm Hg systolic; p = 0.009) and appeared to be more efficacious clinically. In only two of 30 patients (7 percent) was the blood pressure response considered inadequate, and all 10 patients with pulmonary edema or myocardial ischemia showed clinical improvement within 60 minutes of treatment. In one patient, flushing and another symptom suggestive of transient symptomatic hypotension developed after treatment with nifedipine. These results suggest that sublingual nifedipine is a safe, effective, and practical agent for treating patients with hypertensive emergencies.

Administration, Oral↗
PubMed1985

Left ventricular performance in septic shock: reversible segmental and global abnormalities.

Left ventricular dysfunction has been implicated in the pathogenesis of septic shock, but little is known about its natural history, cause, and prognostic significance. Left ventricular performance was assessed by serial radionuclide and hemodynamic studies in 35 patients with culture-proven septic shock. The mean age (+/- S.D.) of the group was 64 +/- 18 years; 16 of the subjects were women, and 15 had antecedent heart disease. On the first study, the left ventricular stroke work index was depressed in 33 (94%) patients, and nineteen (54%) had a left ventricular ejection fraction less than 0.48. Twenty-two (63%) of the patients had segmental and four had generalized wall motion abnormalities. Conventional hemodynamic parameters were of no value in predicting the patients who had a depressed left ventricular ejection fraction or segmental abnormalities. Patients with underlying heart disease had a much higher frequency (87%) of segmental dysfunction than those without underlying heart disease (45%; p = 0.016), but no differences were noted in the left ventricular ejection fraction or left ventricular stroke work index of these two groups. Segmental abnormalities and low ejection fractions were seen more often in patients with a large left ventricular end-diastolic volume index. Only five subjects had a systemic vascular resistance index greater than 2580 dynes X sec X cm-5 per m2, and the correlation between systemic vascular resistance index and left ventricular ejection fraction was poor. No difference was found in the mean coronary perfusion pressure of those with segmental abnormalities and those with normal wall motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗