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PubMed2005

Goal directed therapy: how long can we wait?

Intensive monitoring and aggressive management of perioperative haemodynamics (goal directed therapy) have repeatedly been reported to reduce the significant morbidity and mortality associated with high risk surgery. It may not matter what particular monitor is used to assess cardiac output but it is essential to ensure adequate oxygen delivery. If this management cannot begin preoperatively, it is still worth beginning goal directed therapy in the immediate postoperative period.

Clinical Protocols↗
PubMed2000

Clear goals, solid evidence, integrated systems, realistic roles.

To maximize the effectiveness of home care in improving or maintaining the health of Canadians, home-care programs must have clear goals, be founded firmly on evidence of effectiveness, form part of an integrated healthcare system and be grounded in constitutional and political reality. Goals should be client-centred and distinguish between curative, supportive and preventive care. Curative and supportive home care can be cost-effective if substitution for more costly institutional services can be achieved, but the cost-effectiveness of preventive home care and comprehensive care for the elderly has not been clearly demonstrated. Integrated delivery systems are a prerequisite for effective substitution of care at home for institutional care. Federal financing dedicated to a home-care program is unnecessary and is a political and constitutional non-starter. Federal leadership for a national home-care approach would be welcome. Canada Health Act protection for access to medically necessary home care is attractive, but such protection for pharmaceuticals is a higher need. Federal support for research and demonstration of new models of care is valuable.

Canada↗
PubMed2000

Correspondence between delusions and personal goals: a qualitative analysis.

OBJECTIVES: This pilot study describes a qualitative method for exploring delusions in terms of motivational themes. DESIGN: A semi-structured interview schedule was developed on the basis of an elementary conceptual frame specifying research questions. The analysis of each case uses a structured format. Triangulation was used to check: (i) reliability of motive categories; (ii) their consistent application to delusions. METHODS OF ANALYSIS: All patients had delusions and were diagnosed as having a psychotic disorder. Two types of analysis were used: (i) Interpretative phenomenological analysis with features of grounded analysis was used to classify motives. Data from 14 participants was used for this. (ii) The second phase was an examination of a possible correspondence of themes and involved: (a) a category-led thematic analysis of the delusion in terms of motivations; (b) a category-led thematic analysis of life goals and problems again in terms of motivations; and (c) an examination of correspondence between (a) and (b). RESULTS: The classification of goals and difficulties suggested six main categories: social connection; competence; experiential base (i.e. states of mind and body); material base (e.g. housing); direction; and evaluation (i.e. how a person evaluates himself or believes others evaluate him). Four cases are presented, each exploring the correspondence of themes. CONCLUSION: The methods of analysis seemed coherent and useful. In the cases presented, the delusions appeared to relate to fundamental concerns in a person's life.

Adult↗
PubMedDate not supplied

Balancing the goals of health care provision and financing.

A desirable system for providing and financing health care must balance three goals: (1) preventing the deprivation of care because of a patient's inability to pay; (2) avoiding wasteful spending; and (3) allowing care to reflect the different tastes of individual patients. This essay discusses the application of these goals and uses them to consider a reform of the system of health savings accounts (HSAs) that was enacted as part of the 2003 Medicare legislation and, separately, the challenge posed by the very expensive treatments for rare diseases that are becoming more frequently available.

Consumer Behavior↗
PubMed1992

Hemodynamic and oxygen transport patterns for outcome prediction, therapeutic goals, and clinical algorithms to improve outcome. Feasibility of artificial intelligence to customize algorithms.

A generalized decision tree or clinical algorithm for treatment of high-risk elective surgical patients was developed from a physiologic model based on empirical data. First, a large data bank was used to do the following: (1) describe temporal hemodynamic and oxygen transport patterns that interrelate cardiac, pulmonary, and tissue perfusion functions in survivors and nonsurvivors; (2) define optimal therapeutic goals based on the supranormal oxygen transport values of high-risk postoperative survivors; (3) compare the relative effectiveness of alternative therapies in a wide variety of clinical and physiologic conditions; and (4) to develop criteria for titration of therapy to the endpoints of the supranormal optimal goals using cardiac index (CI), oxygen delivery (DO2), and oxygen consumption (VO2) as proxy outcome measures. Second, a general purpose algorithm was generated from these data and tested in preoperatively randomized clinical trials of high-risk surgical patients. Improved outcome was demonstrated with this generalized algorithm. The concept that the supranormal values represent compensations that have survival value has been corroborated by several other groups. We now propose a unique approach to refine the generalized algorithm to develop customized algorithms and individualized decision analysis for each patient's unique problems. The present article describes a preliminary evaluation of the feasibility of artificial intelligence techniques to accomplish individualized algorithms that may further improve patient care and outcome.

Algorithms↗
PubMed2003

Setting your practice goals.

Goal setting is a powerful business technique. Far more than just a motivational concept, it is an outcome of strategic planning. Doctors who set goals are usually more clearly focused on where they want the practice to go and when they want to get there.

Humans↗
PubMed1999

Analytical quality specifications for serum lactate dehydrogenase isoenzyme 1 based on clinical goals.

The aim of the study was to deduce analytical quality specifications for the determination of catalytic concentration of serum lactate dehydrogenase isoenzyme 1 (S-LD-1) according to clinical goals (the clinical utility model). We defined clinical goals for false positive and false negative S-LD-1 measurements in the monitoring of patients with testicular germ cell tumors (TGCT), clinical stage I, on a surveillance only program. The absolute S-LD-1 catalytic concentrations were routinely corrected for contamination from preanalytical hemolysis. A reference group of 37 men had a near In-Gaussian distribution for the absolute S-LD-1 catalytic concentration. The geometric mean was 76 U/l and an S-LD-1 >128 U/l (99.72 percentile, the decision limit) indicated a high risk of a relapse of TGCT. We have previously shown that an S-LD-1 >160 U/l (treatment limit) was associated with a suboptimal outcome from the treatment of metastatic TGCT. The maximum allowable analytical positive bias was 5 U/l, and the maximum allowable analytical negative bias was -32 U/l. The maximum allowable analytical coefficient of variation, CV(A), was 11% (approximately 14 U/l) at a bias = -5 U/l. For S-LD-1 measurements not corrected for hemolysis, the decision limit was 145 U/l, the maximum allowable negative bias -19 U/l, and CV(A) 8%(approximately 12 U/l). A routine correction for hemolysis had a large impact on the analytical quality specifications.

Catalysis↗
PubMedDate not supplied

Nutritional rehabilitation of anorexia nervosa. Goals and dangers.

Nutritional rehabilitation of adolescents with anorexia nervosa is both a science and an art. The goals are to promote metabolic recovery; restore a healthy body weight; reverse the medical complications of the disorder and to improve eating behaviors and psychological functioning. Most, but not all of the medical complications are reversible with nutritional rehabilitation. Refeeding patients with anorexia nervosa results in deposition of lean body mass initially, followed by restoration of adipose tissue as treatment goal weight is approached. The major danger of nutritional rehabilitation is the refeeding syndrome, characterized by fluid and electrolyte, cardiac, hematological and neurological complications, the most serious of which is sudden unexpected death. The refeeding syndrome is most likely to occur in those who are severely malnourished. In such patients, this complication can be avoided by slow refeeding with careful monitoring of body weight, heart rate and rhythm and serum electrolytes, especially serum phosphorus. This paper reviews our clinical experience.

Adolescent↗
PubMed2006

Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal-directed therapy: still outcome markers?

PURPOSE: To compare the evolution of standard base excess and serum lactate level between surviving and non surviving patients with severe sepsis and septic shock resuscitated with early goal-directed therapy. METHODS: This is a retrospective study in an intensive care unit of a university tertiary hospital where 65 consecutive severe sepsis and septic shock patients were observed without any intervention in the treatment by the authors of this report. RESULTS: In our study, the mortality of severe sepsis and septic shock patients was 38%. The central venous oxygen saturation of both groups was above 70% after the resuscitative period, excluding the second day of the non survivors group (69.8%). After the second day, the central venous oxygen saturation was significantly higher in the survivors group (P < .001). Standard base excess was initially low in both groups, but from the second day on, the correction of standard base excess was significantly more successful and linear in the survivor group (P < .001). Lactate levels were similar during the evolution of both groups. CONCLUSIONS: Although evolutive standard base excess and serum lactate level are still outcome markers in severe sepsis and septic shock patients resuscitated with early goal-directed therapy, other studies must be performed to clarify if hemodynamic interventions based on standard base excess and serum lactate level could be reliable to improve clinical outcomes in severe sepsis and septic shock patients.

APACHE↗
PubMed2006

Fertility regulation and reproductive health in the Millennium Development Goals: the search for a perfect indicator.

Although several key elements of sexual and reproductive health are included in the United Nations Millennium Development Goals, a measure of women's capacity to regulate their fertility safely and effectively is missing. We considered the usefulness of 3 pairs of indicators in monitoring this component of reproductive health: contraceptive prevalence and total fertility; unmet need for contraception and unplanned births; and unsafe abortion and abortion mortality. A single measure of contraceptive use is insufficient. The risks women face from unplanned births and unsafe abortion should also be incorporated into the monitoring process, either directly within the Millennium Development Goals framework or as a parallel effort by reporting governments and other agencies.

Abortion, Induced↗
PubMed1999

Can data-driven benchmarks be used to set the goals of healthy people 2010?

OBJECTIVES: Expert panels determined the public health goals of Healthy People 2000 subjectively. The present study examined whether data-driven benchmarks provide a better alternative. METHODS: We developed the "pared-mean" method to define from data the best achievable health care practices. We calculated the pared-mean benchmark for screening mammography from the 1994 National Health Interview Survey, using the metropolitan statistical area as the "provider" unit. Beginning with the best-performing provider and adding providers in descending sequence, we established the minimum provider subset that included at least 10% of all women surveyed on this question. The pared-mean benchmark is then the proportion of women in this subset who received mammography. RESULTS: The pared-mean benchmark for screening mammography was 71%, compared with the Healthy People 2000 goal of 60%. CONCLUSIONS: For Healthy People 2010, benchmarks derived from data reflecting the best available care provide viable alternatives to consensus-derived targets. We are currently pursuing additional refinements to the data-driven pared-mean benchmark approach.

Benchmarking↗
PubMed2006

Remission, a therapeutic goal in inflammatory arthropathies? Clinical data from adalimumab studies.

In recent years, there have been major advances in the management of rheumatoid arthritis (RA), leading to the development of tumour necrosis factor (TNF) antagonists. With these agents, it is possible to arrest joint damage and, by treating early in the disease course, to prevent joint damage. It is also now thought that early treatment can achieve clinical remission in a substantial proportion of patients. With these increased expectations, a change is required in the way clinical improvement and drug efficacy is measured. The existing standard endpoint commonly used in RA clinical trials, the American College of Rheumatology (ACR) 20% response measure, is inadequate for the new goals of therapy that should be based on clinical remission and radiographic assessment.Adalimumab, a fully human anti-TNF monoclonal antibody, has been shown to be effective in achieving remission and preventing radiographic progression of joint damage in patients with RA and other inflammatory arthropathies, including psoriatic arthritis and ankylosing spondylitis. In a placebo-controlled trial in patients with early RA, combination treatment with adalimumab plus methotrexate (MTX) has been shown to be superior to either treatment alone in inducing significant clinical remission while being generally well tolerated. Compared with monotherapy, combination therapy resulted in significantly more patients (49% vs 25%; p < 0.001) remaining in clinical remission after 2 years. Suppression of joint damage assessed by the degree of inhibition of radiographic progression was also significantly higher for patients treated with adalimumab plus MTX (and with adalimumab alone) at 6 months, 1 and 2 years than for those treated with MTX alone. These data support the notion that clinical remission is a realistic therapeutic goal in patients with RA.

Adalimumab↗
PubMed2006

Cost effectiveness of adding ezetimibe to atorvastatin therapy in patients not at cholesterol treatment goal in Canada.

INTRODUCTION: This analysis compared the cost effectiveness of adding ezetimibe to atorvastatin therapy versus atorvastatin titration or adding cholestyramine (a resin) for patients at high risk of a coronary artery disease (CAD) event who did not reach target cholesterol levels on their current atorvastatin dosage. The primary analysis focused on 65-year-old patients with low-density lipoprotein cholesterol (LDL-C) levels of 3.1 or 3.6 mmol/L with a treatment goal of <2.5 mmol/L, classified as very high risk according to the 2000 Canadian Guidelines for Management and Treatment of Hyperlipidaemia. METHODS: A previously developed Markov model was utilised to capture the cost and clinical consequences of lipid-lowering therapy in primary and secondary prevention of CAD. Comparisons between treatment strategies were made using ICERs (cost per QALY) from a Canadian Ministry of Health perspective. The effects of lipid-lowering therapies were based on clinical trial data. The risks of CAD events were estimated using Framingham Heart Study risk equations. Treatment costs and the costs of acute and long-term care for CAD events were included in the analysis. Costs (Canadian dollar, 2002 values) and outcomes were discounted at 5% per annum. RESULTS: Ezetimibe added to atorvastatin therapy compared with treatment with the most common fixed atorvastatin daily dosage (10 mg) or with common atorvastatin titration strategies (up to 20 mg daily; up to 40 mg daily) resulted in cost per QALY estimates ranging from 25,344 to 44,332 Canadian dollars. The addition of ezetimibe to atorvastatin therapy was less costly and more effective than the addition of cholestyramine (dominant). CONCLUSION: Our analysis suggests that adding ezetimibe to atorvastatin for patients not achieving treatment goals with their current atorvastatin dose produces greater clinical benefits than treatment with a fixed-dose atorvastatin or atorvastatin titration at an increased overall cost. The cost-effectiveness ratios provide strong evidence for the adoption of ezetimibe within the Canadian healthcare system.

Adult↗
PubMed1997

Model of complications of NIDDM. II. Analysis of the health benefits and cost-effectiveness of treating NIDDM with the goal of normoglycemia.

OBJECTIVE: To analyze the health benefits and economics of treating NIDDM with the goal of normoglycemia. RESEARCH DESIGN AND METHODS: Incidence-based simulation model of NIDDM was used. Hazard rates for complications were adjusted for glycemia using risk gradients from the Diabetes Control and Complications Trial. Treatment costs were estimated from national survey data and clinical trials. Incremental costs and benefits were expressed in present value dollars (3% discount rate). Life-years were adjusted for quality of life, yielding quality-adjusted life-years (QALYs). RESULTS: Comprehensive treatment of NIDDM that maintains an HbA1c value of 7.2% is predicted to reduce the cumulative incidence of blindness, end-stage renal disease, and lower-extremity amputation by 72, 87, and 67%, respectively. Cardiovascular disease risk increased by 3% (no effect of treating glycemia is assumed). Life expectancy increased 1.39 years. The cost of treating hyperglycemia increased by almost twofold, which is partially offset by reductions in the cost of complications. The estimated incremental cost/QALY gained is $16,002. Treatment is more cost-effective for those with longer glycemic exposure (earlier onset of diabetes), minorities, and those with higher HbA1c under standard care. CONCLUSIONS: The incremental effectiveness of treating NIDDM with the goal of normoglycemia is estimated to be approximately $16,000/QALY gained, which is in the range of interventions that are generally considered cost-effective.

Adult↗
PubMed1999

Functional roles of the proprioceptive system in the control of goal-directed movement.

This article explored functional roles of the proprioceptive system during the control of goal-directed movements. Proprioceptive information contributes to the control of movement through both reflex and central connections. Spinal and transcortical reflex loops establish a servomechanism which provides automatic corrections of unexpected changes in muscle length and allows compensation for undesirable irregularities in the mechanical properties of muscles by modulating limb stiffness at the subconscious level. Central connections provide the control system with information about peripheral states which is used in voluntary components of movement control. Before the initiation of movement, proprioceptive information about initial limb orientation becomes a basis for the programming of motor commands. During a movement, proprioceptive input about velocities and angular displacements of a limb is used to regulate movement by triggering planned sequences of muscle activation and modulating motor commands. After movement, feedback produced by responses is compared with previously stored information, verifying the quality of the movement. Considering potential roles of the reflex and central connections, the proprioceptive system seems to constitute an important aspect of motor control mechanisms, providing the control system with efficiency and flexibility in the regulation of goal-directed movements.

Biomechanical Phenomena↗
PubMed2006

Tracking progress towards the Millennium Development Goals: reaching consensus on child mortality levels and trends.

The increased attention to tracking progress towards the Millennium Development Goals (MDG), including Goal 4 of reducing child mortality, has drawn attention to a number of interrelated technical, operational and political challenges and to the underlying weaknesses of country health information systems upon which reliable monitoring depends. Assessments of child mortality published in 2005, for almost all low-income countries, are based on an extrapolation of the trends observed during the 1990s, rather than on the empirical data for more recent years. The validity of the extrapolation depends on the quality and quantity of the data used, and many countries lack suitable data. In the long run, it is hoped that vital registration or sample registration systems will be established to monitor vital events in a sustainable way. However, in the short run, tracking child mortality in high-mortality countries will continue to rely on household surveys and extrapolations of historical trends. This will require more collaborative efforts both to collect data through initiatives to strengthen health information systems at the country level, and to harmonize the estimation process. The latter objective requires the continued activity of a coordinating group of international agencies and academics that aims to produce transparent estimates -- through the consistent application of an agreed-upon methodology --for monitoring at the international level.

Child Mortality↗
PubMed2001

Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery.

STUDY DESIGN: Retrospective, cross-sectional regression modeling. OBJECTIVE: To predict physical therapy visits following arthroscopic knee surgery. BACKGROUND: The number of physical therapy visits required to achieve a set of specific minimal-level goals (full knee extension, straight leg raise, normalized gait pattern, bicycle pedaling, and independent home exercises) that are related to decreased complication rates has not previously been modeled. METHODS AND MEASURES: A multiple regression model to predict postoperative physical therapy visits was developed using subject demographics and 2 simple clinical measures, degree of straight leg raise lag and total range of motion. All data were collected from 148 patient charts. Model validity was examined by the predicted residual sum of squares technique and a second independent sample of 157 charts. RESULTS: Diagnosis group, surgery group, and range of motion were the significant variables predicting visits in the final model (R2 = 0.384). Results of model validation analyses using predicted residual sum of squares technique (R2 = 0.346) and the second set of data (R2 = 0.282) were satisfactory. Analysis of residuals (difference of observed and predicted visits) showed prediction of the number of physical therapy visits within 3 visits for approximately 75% of the cases in both sets of data. CONCLUSIONS: Using the model to predict physical therapy visits following arthroscopic knee surgery was more accurate than using diagnosis alone, except for lateral retinacular release. This study demonstrates how regression models could be used to explain variance in physical therapy visits for a given set of minimal functional goals.

Activities of Daily Living↗
PubMed1987

Genetic parameters of milk yield and composition and their relationships with alternative breeding goals.

Milk records on 32,077 Holstein cows in first lactation from 1116 herds on the Quebec Dairy Herd Analysis Service between 1973 and 1983 were used to estimate heritabilities of and genetic correlations between milk, fat, protein, and carrier (water, lactose, ash) yields; fat, protein, and carrier percentages; and ratios of protein to fat and protein plus fat to carrier. The cows were daughters of 451 sires; each sire was represented by five or more daughters. Heritabilities were from .20 to .31 for yields, .59 to .61 for percentages, and .58 to .61 for ratio measures. The heritability of protein yield was considerably lower than other yield traits (.20 vs. .28 to .31). The expected effects of multiple trait selection under 10 alternative breeding goals, using different sets of relative economic values, were considered using the genetic parameter estimates. Selection under the existing pricing system (milk yield plus fat percentage differential) had similar expected genetic gains for fat and protein yields as would be achieved under goals that either gave weight to milk yield and fat yield or to milk yield and the ratio of protein plus fat to carrier. Inclusion of information on protein percentage in an index gave relative little additional genetic progress in most traits, except some increases in protein yield and protein percentage were expected to be greater.

Animals↗