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PubMed1987

[Reduction of ventricular tachycardia by programmed electric stimulation. Clinical implications].

The mode of termination by programmed electrical stimulation of sustained ventricular tachycardia (VT) (more than 30 seconds) and induced by stimulation was investigated in 33 patients. In 27 patients (82%) programmed stimulation was possible because VT did not require an immediate electric shock or did not terminate spontaneously, but constant reduction of VT was obtained with one extrasystole in only 1 patient (3%), with two extrasystoles in 5 patients (15%) and by overdrive stimulation in 12 patients (36%). The remaining 15 patients (45%) required an external electric shock either because VT was poorly tolerated clinically, or because stimulation had failed. In 8 of the 27 cases in whom stimulation was attempted (30%), acceleration of VT was observed. A significant correlation was found between the need for electrical shock and the VT cycle length. It is concluded that reduction of VT by programmed electrical stimulation can only be successful in a limited number of patients and carries a significant risk of acceleration. These data must be taken into account when temporary treatment of VT by stimulation is contemplated. They should incite to considerable caution in the use of implantable pacemakers for tachycardia termination.

Adult↗
PubMed2005

Overserving at licensed premises in Stockholm: effects of a community action program.

OBJECTIVE: The aim of this research was to study the sustainable effects of a community action program on alcohol service to intoxicated patrons at licensed premises. METHOD: Since 1996, the hospitality industry and authorities in Stockholm, Sweden, have been cooperating to reduce problems related to alcohol consumption at licensed premises. The intervention has included community mobilization, training in responsible beverage service (RBS) and enforcement. A pretest in 1996 and follow-ups in the 1999 and 2001 designs were used to study licensed premises in Stockholm. Male actors portraying intoxicated patrons visited the licensed premises and attempted to order beer. Observers were present at each visit. At the pretest, 92 licensed premises were visited, 47 in north central Stockholm and 45 in south central Stockholm. In 1999, 103 establishments were visited, 61 in north central Stockholm and 42 in south central Stockholm. At the latest follow-up in 2001, 100 licensed premises were visited, 56 in north central Stockholm and 44 in south central Stockholm. RESULTS: The results from the latest follow-up in 2001 showed a statistically significant improvement over those of earlier measures, with a refusal rate of 70% compared with 47% in 1999 and 5% in 1996. There were improvements in both study areas (i.e., north and south central Stockholm). CONCLUSIONS: There has been a significant improvement in the rate of refusal of alcohol service at licensed premises in Stockholm during the project period. The reason for this is probably a combination of the intervention efforts: community mobilization, RBS training and a more efficient monitoring of alcohol service by authorities.

Alcoholism↗
PubMed2006

A model for improving physician performance in developing countries: a three-year postgraduate training program in Laos.

The Faculty of Medical Sciences of the National University of Laos, in partnership with Health Frontiers, an American nonprofit organization, Case Western Reserve University of Cleveland, Ohio, and Khon Kaen University of Khon Kaen, Thailand, administer a postgraduate internal medicine training program for Lao physicians. Begun in 2001, the program admits six participants per year; participants complete clinical rotations in three hospitals in Vientiane, Laos, as well as one other clinical site. The goal of the program is to prepare a core group of local physicians to deliver healthcare, and train others according to an international standard of care. The program has two exceptional features. First, the vast majority of the training takes place in Laos. This avoids the "brain drain" that can occur when nationals of developing countries train abroad. In addition, because the training uses personnel, facilities, and technology available locally, graduates are better prepared to serve the needs of the Lao people. Second, the partnership is an all-volunteer model, committed to a long-term undertaking. American-trained specialists who live in Laos are available to work with the participants on a daily basis. Participants have a long period of time to acquire, reinforce, and be tested in new knowledge and benefit from learning from American colleagues who model an evidence-based approach to medical care, while still working in local conditions. As more Lao physicians receive this level of training, the program will become locally sustainable and help break a cycle of dependency on foreign expertise within the Lao health care sector. Preliminary results suggest that the program is succeeding, and could be replicated elsewhere.

Developing Countries↗
PubMed1994

Regional myocardial sympathetic dysinnervation in arrhythmogenic right ventricular cardiomyopathy. An analysis using 123I-meta-iodobenzylguanidine scintigraphy.

BACKGROUND: In patients with arrhythmogenic right ventricular cardiomyopathy (ARVC), the frequent provocation of ventricular tachycardia during exercise, the sensitivity toward catecholamines, and the response toward antiarrhythmic drug regimen with antiadrenergic properties suggest an involvement of the sympathetic nervous system in arrhythmogenesis. METHODS AND RESULTS: To analyze the presence, extent, and location of impaired myocardial sympathetic innervation in ARVC, 123I-meta-iodobenzylguanidine (123I-MIBG) scintigraphy was performed in 48 patients with ARVC. For comparison, 9 patients with idiopathic ventricular tachycardia and a control group of 7 patients without heart disease were investigated. In patients with ARVC, the clinical sustained (n = 25; 52%) or nonsustained (n = 23; 48%) ventricular tachycardia originated in the right ventricular outflow tract in 38 patients (79%), whereas in the remaining 10 patients (21%), the site of origin was the apical (n = 5) or inferior (n = 5) right ventricle. In 33 patients (69%), nonsustained or sustained ventricular tachycardia was provocable by exercise (n = 28 of 48; 58%) and/or by isoproterenol infusion (n = 16 of 37; 43%), whereas programmed ventricular stimulation induced sustained or nonsustained ventricular tachycardia in 16 patients each (33% each). With 123I-MIBG scintigraphy, the right ventricle was not visible in any patient. No areas of intense 123I-MIBG uptake ("hot spots") were observed. All patients of the control group and 7 of 9 patients (78%) with idiopathic ventricular tachycardia showed a uniform tracer uptake in the left ventricle. In contrast, only 8 of 48 ARVC patients (17%) showed a homogeneous distribution of 123I-MIBG uptake, whereas 40 patients (83%) demonstrated regional reductions or defects of tracer uptake. In 3 of 48 patients (6%), the defect area was < 15%; in 21 patients (44%), it was 15% to 30%; and in 16 patients (33%), it was > 30% of the polar map area of the left ventricle (mean, 23 +/- 15%; range, 0% to 57%). In 38 of 40 patients (95%) with an abnormal 123I-MIBG scan, reduced tracer uptake was located in the basal posteroseptal left ventricle, involving the adjacent lateral wall in 10, the anterior wall in 2, and the apex in 12 patients. Only 2 patients demonstrated isolated defects of the anterior or lateral wall; one involved the apex. Perfusion abnormalities in the areas of 123I-MIBG defects were excluded by stress/redistribution 201T1 single-photon emission computed tomography scintigraphy and by normal coronary angiograms in all patients. Abnormalities in 123I-MIBG scintigraphy in patients with ARVC correlated with the site of origin of ventricular tachycardia, demonstrating a regionally reduced tracer uptake in 36 of 38 patients (95%) with right ventricular outflow tract tachycardia compared with only 4 of 10 patients (40%) with other right ventricular origins of tachycardia. There was no correlation between the results of 123I-MIBG scintigraphy and the extent of right ventricular contraction abnormalities, right ventricular ejection fraction, biopsy results, coronary anatomy, or left ventricular involvement in ARVC. CONCLUSIONS: In patients with ARVC, regional abnormalities of sympathetic innervation are frequent and can be demonstrated by 123I-MIBG scintigraphy. Sympathetic denervation appears to be the underlying mechanism of reduced 123I-MIBG uptake and may be related to frequent provocation of ventricular arrhythmias by exercise or catecholamine exposure in ARVC. Therefore, in patients with ARVC, the noninvasive detection of localized sympathetic denervation by 123I-MIBG imaging may have implications for the early diagnosis and for the choice of antiarrhythmic drugs in the treatment of arrhythmias.

3-Iodobenzylguanidine↗
PubMedDate not supplied

The development and evaluation of lighten up, an Australian community-based weight management program.

UNLABELLED: Programs of widely ranging size were conducted successfully in seven localities and thus the program was considered an operational success. The reductions in weight, blood pressure, and waist and hip measurements observed at the 3-month follow-up compared well with reports of other community-based programs. Almost all participants evaluated the program highly and reported positive changes in behaviors related to food and exercise. Qualitative data indicate that the coordinators developed a sense of ownership of the program--which will be vital to its sustainability. Rapport between coordinators and participants was more easily established in smaller programs than in larger ones and was an important underlying determinant of retention rates. SIGNIFICANCE: The Lighten Up program integrates environmental and individual strategies to facilitate changes towards a positive, lifestyle approach to long-term weight management. The program aims to establish sustainable social support networks with effective links to health services. This study has demonstrated that, with appropriate training and resources, existing public sector, primary health care personnel with no previous experience in health promotion can implement the program successfully in several communities concurrently. In the Australian context, this program can play an important role as one strategy in a range of interventions required to address the issue of obesity. The stepped-care model described by Brownell proposes that program options of varying intensity, and thus cost, be available to meet the variety of needs of overweight people who wish to lose weight. The Lighten Up program was close to the midpoint of that range in that it combined population strategies with one-on-one contact with health care personnel. LIMITATIONS: Participants in the study were self-selected people who had acted quickly to enroll in the program, and it is therefore likely that the sample was overrepresented with early adopters who may have been more successful than others would have been. We cannot tell from this developmental study whether or not the program will appeal to population groups known to be at high risk for obesity. This is an important question that needs to be addressed in future research. No control group was included in the design and thus we cannot be sure the benefits experienced by the participants resulted from the program. However, process evaluation data indicate that nothing that might explain the findings, other than the program, occurred in the communities during the time of the study. Further important issues to be evaluated include: the long-term maintenance of weight loss; whether or not the program will reach targeted populations, particularly groups of low socioeconomic status; and the extent to which the public health staff will maintain enthusiasm for the training and the programs.

Adult↗
PubMed1999

United Nations Development Program solicits funds from corporations.

The Global Sustainable Development Facility (GSDF) project, a collaboration between the U.N. Development Program and a variety of global corporate sponsors, some with poor human rights, labor, and environmental records, has come under criticism from prestigious nongovernmental organizations around the world. A letter to James Gustave Speth, Administrator of the U.N. Development Program, expresses concern about the threat posed by the GSDF project to the independence and credibility of the U.N. Development Program.

Advertising↗
PubMed1991

Immediate reproducibility of electrically induced sustained monomorphic ventricular tachycardia before and during antiarrhythmic therapy.

The immediate reproducibility of sustained ventricular tachycardia induction was evaluated prospectively during 106 studies performed in 53 patients with clinical sustained monomorphic ventricular tachycardia. Programmed electrical stimulation was performed twice, using the same protocol during 53 drug-free studies and 53 subsequent studies on antiarrhythmic therapy. Sustained monomorphic ventricular tachycardia was reproduced in 104 (98%) of the 106 studies. There was no significant difference in the incidence of reproducible tachycardia in the drug-free state compared with that observed during treatment with different classes of antiarrhythmic drugs. An increase in the number of extrastimuli was required to reinitiate the tachycardia in 9 (11%) of 83 studies in which single or double extrastimuli were initially required to induce the tachycardia. In 39 (37%) of 104 studies with reproducible tachycardia induction, the two tachycardias significantly differed in electrocardiographic (ECG) configuration and cycle length. These observations suggest that the overall reproducibility of ventricular tachycardia induction is sufficiently high to provide a reliable marker for evaluating the efficacy of therapeutic interventions. However, specific tachycardia characteristics such as cycle length and ECG configuration are more variable even within the same study and may be less useful in assessing the effects of subsequent interventions.

Anti-Arrhythmia Agents↗
PubMed2000

Past and present national tick control programs. Why they succeed or fail.

The historical reasons for the introduction of tick control during the nineteenth century are reviewed. Background and concepts for the choice between long-term tick control and tick eradication are compared. Case studies of large-scale tick control or eradication programs in Africa, Australia, the United States, and the Caribbean are used to highlight successes and failures. The main reasons for lack of sustainability, or failure, of programs are discussed. These include the economic constraints that were faced in several African countries, or technical shortcomings such as were perceived as a major problem in Puerto Rico. The successes are generally associated with enforcement of appropriate legislation and good management, such as occurred in Zimbabwe. These case studies are analyzed to identify features that may assist in the implementation of the ongoing tropical bont tick eradication program in the Caribbean. The paper concludes with some practical suggestions for the future, and the need to reassess the economics of control and the potential additional animal health benefits derived from tick control programs.

Animal Husbandry↗
PubMed2005

Logic model use for breast health in rural communities.

PURPOSE/OBJECTIVES: To describe the use of a logic model methodology in the development, implementation, and evaluation of a regionally based cancer health network. DATA SOURCES: Published articles; online references; published reports from government, state, and private organizations; and regional breast health project results. DATA SYNTHESIS: Through the use of the logic model, the program objectives and outcomes were identified and actualized. CONCLUSIONS: The logic model served as a framework for developing the key components of the program: infrastructure, implementation, and sustainability. Supportive structures, such as the timeline, process evaluation, and outcome evaluation plan, enhanced the use of the logic model by adding clarity to program development and program evaluation. IMPLICATIONS FOR NURSING: Nurses, particularly advanced practice nurses and nurse managers, play a key role in leading program development. A logic model can be used to guide program development, implementation, and evaluation. It serves as an excellent framework for developing a program that integrates service, practice, and research.

Breast Neoplasms↗
PubMed2005

Models of research-operational collaboration for behavioral health in space.

Addressing the behavioral health needs of astronauts clearly requires collaborations involving researchers, clinicians and operational support personnel, program administrators, and the astronauts themselves. However, such collaborations are often compromised by a failure to understand the needs, priorities, constraints, and preferences of potential collaborators. This failure, in turn, can lead to research of poor quality, implementation of programs and procedures that are not evidence-based, and an increased risk of morbidity and mission failure. The experiences of social marketing strategies in health promotion and disease prevention, cultural exchange between developers of evidence-based treatments and consumers, and dissemination and implementation of evidence-based practices in mental health services offer three different models of research-operational collaboration with relevance to behavioral health in space. Central to each of these models are the patterns of interpersonal relations and the individual, social, and organizational characteristics that influence these patterns. Any program or countermeasure for behavioral health in space must be both needs-based and evidence-based. The successful development, dissemination, implementation, and sustainability of such a program require communication, collaboration, and consensus among all key stakeholders. To accomplish this, all stakeholders must participate in creating a culture of operational research.

Aerospace Medicine↗
PubMed2006

Targeting Bid to prevent programmed cell death in neurons.

Sustained progression of neuronal cell death causes brain tissue loss and subsequent functional deficits following stroke or central nervous system trauma and in neurodegenerative diseases. Despite obvious differences in the pathology of these neurological disorders, the underlying delayed neuronal demise is carried out by a common biochemical cell death programme. Mitochondrial membrane permeabilization and subsequent release of apoptotic factors are key mechanisms during this process. Bcl-2 family proteins, e.g. the pro-apoptotic Bid, Bax or Bad and the antiapoptotic Bcl-2, Bcl-X(L), play a crucial role in the regulation of this mitochondrial checkpoint in neurons. In particular, cleavage of cytosolic Bid and subsequent mitochondrial translocation have been detected in many paradigms of neuronal cell death related to acute or chronic neurodegeneration. The current review focuses on the emerging role of Bid as an integrating key regulator of the intrinsic death pathway that amplifies caspase-dependent and caspase-independent execution of neuronal apoptosis. Therefore pharmacological inhibition of Bid provides a promising therapeutic strategy in neurological diseases where programmed cell death is prominent.

Apoptosis↗
PubMed1993

[Correlation between parameters measured by high amplification ECG and results of programmed ventricular stimulation after myocardial infarct].

The presence of late ventricular potentials and the induction of sustained ventricular tachycardia (SVT) by programmed ventricular stimulation (PVS) after myocardial infarction are markers of the risk of serious ventricular arrhythmias. The authors studied the value of signal averaged electrocardiography (SAECG) compared with induction of SVT by PVS in 118 consecutive patients 4 to 8 weeks after myocardial infarction. In addition to this study population, a control group of 22 patients with spontaneous SVT after myocardial infarction was also considered. Three parameters were measured after averaging 200 QRS complexes: the duration of the filtered QRS complex (QRSd), the duration of signals not exceeding 40 microV (LAS) and the root mean square of the voltage of the last 40 milliseconds (RMS). Abnormal values were defined as: QRSd > or = 120 ms, LAS > or = 39 ms, RMS < or = 20 microV. Patients in the study population were subdivided into 3 groups: Group I (n = 17) inducible SVT; Group II (n = 72) no inducible arrhythmias; Group III (n = 29) induction of sustained ventricular flutter or primary ventricular fibrillation requiring immediate cardioversion. The results showed a good correlation between SAECG and induction of SVT. The sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) were as follows: 1) QRSd > 120 ms: Se = 82%, Sp = 80%, PPV = 41%, NPV = 96%; 2) LAS > 39 ms: Se = 59%, Sp = 85%, PPV = 38%, NPV = 92%; 3) RMS < 20 V: Se = 59%, Sp = 88%, PPV = 43%, NPV = 93%.(ABSTRACT TRUNCATED AT 250 WORDS)

Action Potentials↗
PubMed2000

[Epidemiological surveillance of Chagas disease].

Chagas disease still constitutes an important medical problem in affected countries. In some, the extent of the disease is still unknown and control programs have not been implemented. In others the disease has been reduced due to regular control programs and other economic and social factors. Epidemiological surveillance with community participation to guard against disease transmission is now the basic challenge. Applied research and in-depth reformulation of health systems are required to establish efficient and sustainable Chagas disease surveillance programs, considering low density of peridomiciliary vectors as the most relevant factor. In addition, a large population of already infected, poor individuals require specific medical attention and social security. As a consequence of health care decentralization, Federal institutions such as the Brazilian National Health Foundation (FNS) are being progressively decommissioned, and new participants must be engaged in the process. Communities themselves, together with regional and local institutions, must take charge of surveillance in order to guarantee its efficiency and sustainability.

Animals↗
PubMed1986

Impact of organ transplant program on the Clinical Chemistry Laboratory at the University of Pittsburgh.

The success of cyclosporine in immunosuppressive therapy in organ transplantation suggests that such existing programs may expand in scope, and new programs may be initiated at institutions that currently do not have them. Significant clinical laboratory support and the allocation of laboratory resources are necessary to sustain an organ transplant program. At the University of Pittsburgh, the number of transplant-related clinical chemistry procedures (primarily cyclosporine and liver and renal function tests) increased from 1.4% of the total chemistry tests in 1979-1980 to 21% of the total in 1983-1984. There was a concomitant increase in cost for transplant chemistry tests as follows: $47,000 in the fiscal year 1979-1980 to $1,250,000 in the fiscal year 1983-1984. Measurement of blood cyclosporine levels alone can consume a large fraction of a total laboratory budget; from being a negligible expense at the end of March 1983, it escalated to almost $300,000 by October 1984. Our experience in this regard indicates that it is difficult to gauge the magnitude of necessary laboratory resource commitment to such a program a priori with any degree of certainty. In this context, the capacity to be flexible in assigning laboratory resources appears critical.

Chemistry, Clinical↗
PubMedDate not supplied

Program planning for a community pharmacy residency support service using the nominal group technique.

OBJECTIVE: To define programmatic objectives and initial operational priorities for CommuniRes, a university-based education and support service designed to help community pharmacists successfully implement and sustain community pharmacy residency programs (CPRPs). SETTING: Advisory committee of nationally recognized experts in CPRPs in a small-group planning session. PRACTICE DESCRIPTION: CPRPs are postgraduate clinical training experiences conducted in chain and independent community pharmacies. PRACTICE INNOVATION: The nominal group technique (NGT), a structured approach to group planning and decision making, was used to identify and prioritize the needs of CPRPs. INTERVENTIONS: Results of the NGT exercise were used as input to a brainstorming session that defined specific CommuniRes services and resources that must be developed to meet high priority needs of CPRPs. MAIN OUTCOME MEASURE: Group consensus on the priority needs of CPRPs was determined through rank order voting. RESULTS: The advisory committee identified 20 separate CPRP needs that it believed must be met to ensure that CPRPs will be successful and sustainable. Group voting resulted in the selection of six needs that were considered to be consensus priorities for services and resources provided through CommuniRes: image parity for CPRPs; CPRP marketing materials; attractive postresidency employment opportunities; well-defined goals, objectives, and residency job descriptions; return on investment and sources of ongoing funding for the residency; and opportunities and mechanisms for communicating/networking with other residents and preceptors. CONCLUSION: The needs-based programmatic priorities defined by the advisory committee are now being implemented through a tripartite program consisting of live training seminars for CPRP preceptors and directors, an Internet site (www.communires.com), and a host of continuing support services available to affiliated CPRP sites. Future programmatic planning will increasingly involve CPRP preceptors, directors, and former residents to determine the ongoing needs of CPRPs.

Education, Pharmacy, Continuing↗
PubMed2001

[Predictive value of frequency, duration and rate of ventricular salvos in ambulatory ECG for inducibility of sustained ventricular tachycardia].

Identification of high risk patients with coronary artery disease (CAD) prone to sudden cardiac death still remains a difficult issue. In 211 patients with CAD diagnosed by coronary angiography and documented non-sustained ventricular tachycardia (NSVT), programmed ventricular stimulation (PVS) was performed. NSVTs documented during Holter monitoring were analysed concerning frequency, duration and rate. To relate those parameters to the inducibility of sustained monomorphic ventricular tachycardias (MVT) during PVS, the total population was divided in different groups; patients with 1, 2-5 or > 5 salvos within 24 h; patients having salvos with a rate of > or = 150/min or < 150/min; patients with 3-5, 6-10 or > 10 consecutive extra beats. It could be demonstrated that in patients with CAD and NSVTs, induction of MVTs during PVS is more likely if the rate of the spontaneously occurring NSVT is > or = 150/min (22.1 vs 8.9%; p = 0.042). In contrast, there is apparently no correlation between the duration and incidence of NSVTs and the prevalence of MVTs during PVS. Multivariate analysis revealed the rate of documented NSVTs (odds ratio 2.98, p = 0.0314) and a decrease of left ventricular ejection fraction (odds ratio 1.69; p = 0.0013) as independent risk factors for the inducibility of MVTs. Conclusions CAD patients with fast salvos (> or = 150 beats/min) and reduced left ventricular ejection fraction are more likely to reveal inducible MVT during PVS and should, therefore, preferably be subjected to invasive risk stratification. The number of salvos per day and the number of consecutive beats, on the other hand, do not seem to be of relevant predictive value.

Aged↗
PubMed2004

Clinical education of ethicists: the role of a clinical ethics fellowship.

BACKGROUND: Although clinical ethicists are becoming more prevalent in healthcare settings, their required training and education have not been clearly delineated. Most agree that training and education are important, but their nature and delivery remain topics of debate. One option is through completion of a clinical ethics fellowship. METHOD: In this paper, the first four fellows to complete a newly developed fellowship program discuss their experiences. They describe the goals, structure, participants and activities of the fellowship. They identify key elements for succeeding as a clinical ethicist and sustaining a clinical ethics program. They critically reflect upon the challenges faced in the program. RESULTS: The one-year fellowship provided real-time clinical opportunities that helped them to develop the necessary knowledge and skills, gain insight into the role and scope of practice of clinical ethicists and hone valuable character traits. CONCLUSION: The fellowship enabled each of the fellows to assume confidently and competently a position as a clinical ethicist upon completion.

Bioethics↗
PubMed2000

Cost analysis of a provincial drug program to guide the treatment of upper gastrointestinal disorders.

BACKGROUND: Concerned with the rising costs of its drug programs for seniors and social-assistance recipients, the government of Newfoundland and Labrador requested physicians and pharmacists at the Memorial University of Newfoundland, and members of the Newfoundland and Labrador Medical Association and the Newfoundland Pharmaceutical Association to provide guidance to the health care community for the use of drugs to treat upper gastrointestinal disorders. METHODS: Algorithms for the management of dyspepsia and gastrointestinal reflux disease were created and distributed to all physicians and pharmacists in the province in June 1996. On July 1, 1996, the provincial government implemented a program to restrict payment for proton-pump inhibitors through its drug programs to situations defined by the algorithms. Restrictions were not applied to the prescribing of cimetidine, ranitidine and prokinetic agents. The status of famotidine and nizatidine was changed from "open benefit" to "special consideration," which requires prescribers to request authorization of their use on a case-by-case basis. RESULTS: Between July 1 and Dec. 31, 1996, 973 of 1078 requests for a proton-pump inhibitor were approved (679 for gastroesophageal reflux, 186 for Helicobacter pylori eradication, 55 for ulcer treatment and 53 for other reasons). The program resulted in a sustained reduction in drug expenditures. Total drug expenditures, which had risen from $39.0 million in 1992/93 to $50.8 million in 1995/96, fell after implementation of the program to $46.4 million in 1996/97 because of a decrease of more than 80% in the use of proton-pump inhibitors. Expenditures on proton-pump inhibitors, which had increased from $0.7 million for the 6 months ending March 1993 to $1.6 million for the 6 months ending March 1996, decreased to $0.3 million for the 6 months ending March 1997. The use of H2-antagonists, but not prokinetic agents, increased concomitantly with the decline in proton-pump inhibitor use. Compared with the year preceding implementation of the program, annual combined expenditures in the subsequent 3 years for H2-antagonists, prokinetic drugs and proton-pump inhibitors were reduced by $1.6 million, $1.7 million and $1.0 million, respectively. Feedback from physicians and pharmacists was supportive for the clinical information and prescribing guidelines. Concerns were mostly limited to process issues. INTERPRETATION: The program, designed by health care professionals, approved by health care associations and implemented by the province of Newfoundland and Labrador to guide the treatment of upper gastrointestinal disorders, has achieved a substantial reduction in drug expenditures.

Algorithms↗