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PubMedDate not supplied

Management of acute asthma in Canada: an assessment of emergency physician behaviour.

The study objective was to assess Canadian emergency physicians for their management preferences and their compliance with recently developed guidelines for treatment of acute asthma in adults. The design was a cross-sectional survey sent to members of the Canadian Association of Emergency Physicians (CAEP) and to the emergency department (ED) directors of all Canadian hospitals with more than 25 beds in November 1992. ED directors who had not responded were sent a second survey in January 1993. The response rates for the survey were 60.1% (362/602) for ED directors and 53.4% (302/586) for CAEP members. Respondents were more likely to be from larger hospitals and to have completed some training beyond general practice level (CCFP, CCFP-EM, ABEM, FRCPC). There were wide variations among respondents in the use of objective measurements of asthma severity (forced expiratory volume in 1 s [FEV1] and peak expiratory flow rates [PEFR]), dosing of bronchodilators, and utilization of systemic corticosteroids. Forty-six percent of respondents used the FEV1 "occasionally" (22.3%) or "never" (23.8%), and 26.7% used PEFR "occasionally" (15.8%) or "never" (10.9%) in asthma management. Ninety-seven percent used nebulized beta agonist "always" (71.3%) or "often" (25.6%), but only 48.5% used the metered dose inhaler (MDI) "always" (11%) or "often" (37.5%). More than a quarter of respondents (27.2%) used doses of beta agonists that were less than those recommended (> every 30-60 min). Oral corticosteroids were prescribed at discharge only "occasionally" (51.1%), "seldom" (18.9%), or "never" (6.5%) in 76.6% of physicians. Physicians with more training were more likely to assess and treat patients according to current asthma treatment guidelines. The survey shows that many Canadian emergency physicians did not follow published recommendations for the care of patients with acute asthma. This finding was especially so with regard to objective evaluation of airflow, aggressive use of beta-agonists, the use of corticosteroids, and in making appropriate arrangements for patient discharge and follow-up.

Acute Disease↗
PubMed2001

The management of hypertension in Canada: a review of current guidelines, their shortcomings and implications for the future.

Clinicians are exposed to numerous hypertension guidelines. However, their enthusiasm for these guidelines, and the impact of the guidelines, appears modest at best. Barriers to the successful implementation of a guideline can be identified at the level of the clinician, the patient or the practice setting; however, the shortcomings of the guidelines themselves have received little attention. In this paper, we review the hypertension guidelines that are most commonly encountered by Canadian clinicians: the "1999 Canadian Recommendations for the Management of Hypertension," "The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" in the United States and the "1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension." The key points of these guidelines are compared and the shortcomings that may impede their ability to influence practice are discussed. The main implications for future guideline developers are outlined.

Antihypertensive Agents↗
PubMed2006

[Rehabilitation of children and adolescents].

In recent years a significant increase in most chronic mental and physical illnesses among children and adolescents was reported. Thus, medical child and adolescent rehabilitation plays a major role. Therefore, early diagnosis and multimodal intervention in childhood and adolescence is necessary, to prevent a chronic course of disease. Patient education programs have been shown to be effective in the treatment of chronic illnesses. Those programs are mostly aimed to improve the compliant behavior and disease management. Consecutively, the health status and quality of life should be improved. Due to the implementation of guidelines and evaluation studies the quality of rehabilitation programs was ameliorated during the past 15 years. However, future research should develop flexible rehabilitation programs in particular (rehabilitation duration, rehabilitation near or far from place of residence, rehabilitation chain with in-patient, partially out-patient, and out-patient programs), whose effectiveness has to be proven.

Adolescent↗
PubMed1997

Asthma in the managed care setting.

The quality improvement techniques of managed care are dramatically upgrading the delivery of asthma education and therapy, yielding cost-effective outcomes through a variety of approaches. Guidelines have been available in national and international references, but successful implementation outside of managed care has been poor. The complex components known to produce success in asthma care have not been properly reimbursed in the fee-for-service tradition. Even within managed care settings, attention to cost-effectiveness varies widely, and creative new approaches promise better returns than early asthma programs. Tools that managed care can offer for improved asthma outcomes and cost-effective options are presented.

Adolescent↗
PubMed2002

[Educational programs and self-management in bronchial asthma].

Bronchial asthma is one of the most common chronic diseases in the world and can affect people of all ages. In the last few years there has been a considerable improvement in the etiopathogenetic knowledge of the disease and extremely effective anti-asthmatic drugs are available. However, asthma-related morbidity and mortality are increased, especially in Western countries. In an attempt to reverse this negative trend, for a number of years national and international guidelines on asthma have been published all over the world. These guidelines have the aim of improving asthma diagnosis and treatment and of conveying a fundamental educational message both to health workers and to patients and their families. From the data in the literature it can be clearly seen that only through the application of valid educational programs is it possible for asthmatics to improve their knowledge of the disease and to understand how they can look after themselves by a careful evaluation of their own symptoms and respiratory function. They should also be aware of the drugs available for the treatment of both acute asthmatic crises and chronic asthma, but especially of the fact that this chronic inflammatory affection can be fully treated. In particular, an educational program organized with groups of maximum 10-12 people attending 2 lessons and with helpful training tools, can increase significantly asthma knowledge, treatment compliance and patient self-management. The aim of this review is to highlight the importance of educational programs and those obscure areas which slow down their large scale application and universal acceptance.

Adult↗
PubMed2004

Critique of the American Cancer Society Guidelines for Breast Cancer Screening: Update 2003.

The American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 was obtained through the National Guideline Clearinghouse Web site and was critiqued for potential incorporation into practice. The updated guidelines address screening mammography, physical examination, and new technologies and describe how these may be applied to women at average risk, women at high risk, and older women. The new guidelines emphasize educating women and having them take a more active role in decision making.

Adult↗
PubMed2004

Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF): rationale and design.

Heart failure (HF) affects >5 million patients in the United States, and its prevalence is increasing every year. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors and beta-blockers reduce hospitalizations and mortality rates in patients with HF, these lifesaving therapies continue to be underused. Several studies in a variety of clinical settings have documented that a significant proportion of eligible patients with HF are not receiving treatment with these guideline-recommended, evidence-based therapies. In patients hospitalized with HF, who are at particularly high risk for re-hospitalization and death, the initiation of beta-blockers is often delayed because of concern that early initiation of these agents may exacerbate HF. Recent studies suggest that beta-blockers can be safely and effectively initiated in patients with HF before hospital discharge and that clinical outcomes are improved. The Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial demonstrated that pre-discharge initiation of carvedilol was associated with a higher rate of beta-blocker use after hospital discharge, with no increase in hospital length of stay. In addition, there was no increase in the risk of worsening of HF. Studies of hospital-based management systems that rely on early (pre-discharge) initiation of evidence-based therapies for patients with cardiovascular disease have also found increases in post-discharge use of therapy and a reduction in the rates of mortality and hospitalization. On the basis of these pivotal studies, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) program is designed to improve medical care and education of hospitalized patients with HF and accelerate the initiation of evidence-based HF guideline recommended therapies by administering them before hospital discharge. A registry component, planned as the most comprehensive database of the hospitalized HF population focusing on admission to discharge and 60- to 90-day follow-up, is designed to evaluate the demographic, pathophysiologic, clinical, treatment, and outcome characteristics of patients hospitalized with HF. The ultimate aim of this program is to improve the standard of HF care in the hospital and outpatient settings and increase the use of evidence-based therapeutic strategies to save lives.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Asthma management at discharge from the emergency department: a descriptive study.

BACKGROUND: The management of asthma remains suboptimal despite the publication of Canadian asthma guidelines in 1999. OBJECTIVES AND METHODS: A descriptive study was conducted to estimate the proportion of patients admitted to the emergency department (ED) for an asthma exacerbation who received a management plan at discharge that was in accordance with seven criteria stated in the Canadian asthma guidelines. The present study took place in two tertiary care hospitals in Montreal, Quebec. RESULTS: A total of 37 patients were enrolled. Three (8%) patients received a management plan at discharge that was in accordance with all seven criteria. Inhaled corticosteroids and oral corticosteroids were prescribed at discharge for 29 (78%) and 35 (95%) patients, respectively. Minimal asthma education was provided for 29 (78%) patients and a medical follow-up was recommended to 22 (60%) patients. Airflow obstruction was evaluated at discharge for only 20 (54%) patients. CONCLUSION: Overall, asthma management at discharge from the ED was generally not in accordance with the 1999 Canadian asthma guidelines. A standardized management plan should be implemented in the ED to improve the care of patients with asthma exacerbations.

Adult↗
PubMed2005

Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition.

BACKGROUND AND PURPOSE: To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. SUMMARY OF REVIEW: A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. CONCLUSIONS: There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Academic Medical Centers↗
PubMed1999

Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group.

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are major complications for hospital patients in developed countries. In 1995, the Scottish Intercollegiate Guidelines Network (SIGN) published an evidence-based guideline to encourage the appropriate use of prophylaxis for DVT among hospitalised patients at risk. The guideline was widely distributed within the NHS in Scotland; however, it is not clear what actions trusts have taken to implement it. OBJECTIVE: To investigate the type and extent of DVT guideline implementation activities in acute trusts in Scotland. METHOD: A semi-structured telephone interview with senior clinical audit staff in those trusts with acute services in Scotland. RESULTS: Twenty-nine of the 30 trusts approached participated in the survey (97%). A range of responses to the guideline were reported, including development of local protocols (n = 20), audit of DVT prophylaxis (n = 19), patient specific reminders (n = 13) and provision of a specialist DVT adviser (n = 3). Overall, 25 of the trusts had undertaken guideline development and dissemination activities, and 17 were involved in more active guideline implementation strategies. CONCLUSIONS: The majority of acute trusts in Scotland have responded to the SIGN guideline, usually through the development of local protocols. Strategies to implement the guideline or local protocol are less common. Further guidance is needed on this in the next edition of the guideline.

Clinical Protocols↗