Guideline-based Algorithm Research Articles

Stroke Risk Reduction in Atrial Fibrillation Through Pharmacist Prescribing

Major gaps in the delivery of appropriate oral anticoagulation therapy (OAC) exist, leaving a large proportion of persons with atrial fibrillation (AF) unnecessarily at risk for stroke and its sequalae. To investigate whether pharmacist-led OAC prescription can increase the delivery of stroke risk reduction therapy in individuals with AF. This prospective, open-label, patient-level randomized clinical trial of early vs delayed pharmacist intervention from January 1, 2019, to December 31, 2022, was performed in 27 community pharmacies in Alberta, Canada. Pharmacists identified patients 65 years or older with 1 additional stroke risk factor and known, untreated AF (OAC nonprescription or OAC suboptimal dosing) or performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. Patients with undertreated or newly diagnosed AF eligible for OAC therapy were considered to have actionable AF. Data were analyzed from April 3 to November 30, 2023. In the early intervention group, pharmacists prescribed OAC using guideline-based algorithms with follow-up visits at 1 and 3 months. In the delayed intervention group, which served as the usual care control, the primary care physician (PCP) was sent a notification of actionable AF along with a medication list (both enhancement over usual care). After 3 months, patients without OAC optimization in the control group underwent delayed pharmacist intervention. The primary outcome was the difference in the rate of guideline-concordant OAC use in the 2 groups at 3-month follow-up ascertained by a research pharmacist blinded to treatment allocation. Eighty patients were enrolled with actionable AF (9 [11.3%] newly diagnosed in 235 individuals screened). The mean (SD) age was 79.7 (7.4) years, and 45 patients (56.3%) were female. The median CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score was 2 (IQR, 2-3). Seventy patients completed follow-up. Guideline-concordant OAC use at 3 months occurred in 36 of 39 patients (92.3%) in the early intervention group vs 23 of 41 (56.1%) in the control group (P < .001), with an absolute increase of 34% and number needed to treat of 3. Of the 23 patients who received appropriate OAC prescription in the control group, the PCP called the pharmacist for prescribing advice in 6 patients. This randomized clinical trial found that pharmacist OAC prescription is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF. Scalability and sustainability of pharmacist OAC prescription will require larger trials demonstrating effectiveness and safety. ClinicalTrials.gov Identifier: NCT03126214.

Improving feasibility and timeliness of hereditary cancer risk assessment with a brief patient-administered digital tool and rapidly available telehealth genetic counseling.

10614 Background: Multiple guidelines recommend hereditary cancer risk assessment for all adults, yet it rarely is performed. This is largely due to the time-consuming nature of such assessments and difficulty with access to genetic counseling for those at high risk. We designed a care model to address these issues that is suitable for both oncology and non-oncology settings. It includes a brief patient-administered and clinically validated digital hereditary cancer risk assessment tool, followed by immediate online self-scheduling features for telehealth genetic counseling, with appointments available within 48 hours. The digital tool uses a guideline-based algorithm to assess whether genetic testing for hereditary cancer risk is indicated. Here we aim to evaluate the effectiveness and timeliness of this model. Methods: We conducted a retrospective chart review of consecutive patients that engaged with this model from May 2021 to August 2023 at 32 obstetrics and gynecology clinics. We also used nationwide data from the National Society of Genetic Counselor's (NSGC) Professional Status Survey. To assess timeliness of genetic counseling appointments in this care model, we compared the time from scheduling the appointment to the start of the appointment to wait times at health systems for comparable non-urgent cancer genetic counseling appointments, from the NSGC data. Effectiveness was assessed via rates of completion of the tool and scheduling of genetic counseling. Results: 2538 patients (98% female, mean age 37 years, 3.9% with a personal history of cancer) initiated the care model and 95% (2415/2538) completed the risk assessment tool. A quarter (26% (628/2415)) met criteria for germline genetic testing. The median time to complete the tool was 2.7 minutes (IQR 2.9). At the end of the tool, patients could click a button to schedule an appointment with a genetic counselor to discuss hereditary cancer risk and genetic testing. 44% (274/628) booked an appointment. The median time from scheduling to genetic counseling appointment was 2.8 days (IQR 4.9 days), which is shorter than the median wait time for comparable genetic counseling appointments at health systems in the nationwide NSGC dataset (21 days (IQR 53 days); p&lt;&lt; 0.01). Conclusions: The tool completion rate, rate of patients meeting criteria, and uptake of genetic counseling indicate the model is effective. Timeliness was improved by this model, with the digital tool assessing risk in ~3 minutes, compared to previous reports of ~30 minutes for manual hereditary cancer risk assessment. In addition, the timeliness of genetic counseling appointments was markedly better than the current standard of care. These findings suggest that this care model can support physicians in providing timely guideline-recommended hereditary cancer risk assessment to their patients.

Artificial Intelligence–Assisted Left Ventricular Diastolic Function Assessment and Grading: Multiview Versus Single View

Clinical assessment and grading of left ventricular diastolic function (LVDF) requires quantification of multiple echocardiographic parameters interpreted according to established guidelines, which depends on experienced clinicians and is time consuming. The aim of this study was to develop an artificial intelligence (AI)-assisted system to facilitate the clinical assessment of LVDF. In total, 1,304 studies (33,404 images) were used to develop a view classification model to select six specific views required for LVDF assessment. A total of 2,238 studies (16,794 two-dimensional [2D] images and 2,198 Doppler images) to develop 2D and Doppler segmentation models, respectively, to quantify key metrics of diastolic function. We used 2,150 studies with definite LVDF labels determined by two experts to train single-view classification models by AI interpretation of strain metrics or video. The accuracy and efficiency of these models were tested in an external data set of 388 prospective studies. The view classification model identified views required for LVDF assessment with good sensitivity (>0.9), and view segmentation models successfully outlined key regions of these views with intersection over union>0.8 in the internal validation data set. In the external test data set of 388 cases, AI quantification of 2D and Doppler images showed narrow limits of agreement compared with the two experts (e.g., left ventricular ejection fraction, -12.02% to 9.17%; E/e' ratio, -3.04 to 2.67). These metrics were used to detect LV diastolic dysfunction (DD) and grade DD with accuracy of 0.9 and 0.92, respectively. Concerning the single-view method, the overall accuracy of DD detection was 0.83 and 0.75 by strain-based and video-based models, and the accuracy of DD grading was 0.85 and 0.8, respectively. These models could achieve diagnosis and grading of LVDD in a few seconds, greatly saving time and labor. AI models successfully achieved LVDF assessment and grading that compared favorably with human experts reading according to guideline-based algorithms. Moreover, when Doppler variables were missing, AI models could provide assessment by interpreting 2D strain metrics or videos from a single view. These models have the potential to save labor and cost and to facilitate work flow of clinical LVDF assessment.

Clinical Decision Trees to Guide Physical Therapy Management of Persons with Huntington's Disease.

In 2020, our group published physical therapy clinical practice guidelines (CPG) for people with Huntington's disease (HD). The guideline recommendations were categorized according to six primary movement impairment classifications. To facilitate implementation of this CPG, we have developed guideline-based algorithms for physical therapy assessments and interventions and recommendations for therapists to overcome barriers to CPG implementation for people with HD. We conducted a literature review of papers that evaluated physical therapy interventions in individuals with HD (n = 26) to identify assessments for each of the primary movement impairment classifications, and then searched for papers (n = 28) that reported their clinometric/psychometric properties in HD. Assessments were evaluated using modified Movement Disorder Society Committee on Rating Scales criteria and other relevant criteria. We identified a "core set" of physical therapy assessments for persons with HD, including the Six Minute Walk Test, Timed Up and Go Test, Berg Balance Scale, and the Medical Outcomes Study Short Form 36 (SF-36). We then developed guideline-based decision trees to assist in decision making and implementation of the CPG into practice for persons with HD across the continuum of care. Finally, we developed strategies for overcoming barriers to implementation, such as seeking specialized training in HD, engaging caretakers or family members to help the person with HD to exercise, and establishing clinical pathways that support early physical therapy referrals. Knowledge translation documents such as this are essential to promoting implementation of the physical therapy CPGs into clinical practice.

Abstract 11918: Improving Quality of Care for Patients With Valvular Heart Disease in a Learning Health System

Introduction: Delayed treatment of valvular heart disease (VHD) is associated with higher mortality and adverse event incidence. In a large, integrated health system, we developed and piloted a digital health solution embedded in the electronic health record (EHR) to identify, triage, and streamline evaluation of patients with VHD. Methods: The initiative began May 2021 with agreement of our team members and stakeholders for prioritization of the project and implementation. Structured echocardiographic data were made available in electronic data warehouse. SQL-based disease classification algorithms based on published guidelines were built for aortic stenosis (AS), mitral regurgitation (MR) and tricuspid regurgitation. Echocardiograms with suspected VHD were pushed daily into a reporting dashboard and smartform we built within the EHR. Nurse coordinators responsible for VHD patient care tested the platform, and we iteratively adapted components based on feedback. Performance of AS and MR classification algorithms against historical data were evaluated using kappa statistics. We launched the program in March 2022 and report the initial results. Results: Between August and October 2021, 650 echocardiograms were reviewed by a nurse coordinator. Agreement between the guideline-based algorithms and chart review was moderately high (0.64 for AS and 0.86 for MR). Between March and May 2022, 7180 echocardiograms with suspected VHD were surfaced in the EHR for 6588 patients. Among 1501 patients prioritized for review based on disease severity, 341 patients were referred to the valve clinic for procedural intervention, 783 patients are under watchful waiting, and 377 patients were determined to unlikely benefit from valve interventions. Conclusions: By leveraging data from echocardiogram repositories, it is feasible to implement a VHD quality improvement program within a learning health system. This requires a diverse and interdisciplinary team for development, implementation, governance, and continued iteration of EHR-embedded digital health tools to improve quality of care. While we focused on VHD, our methodology and infrastructure allow for expansion and leverage into other therapeutic domains within cardiovascular disease and beyond.

Animation and interactivity facilitate acquisition of pediatric life support skills: a randomized controlled trial using virtual patients versus video instruction

BackgroundSeveral promising studies suggest a positive impact of interactive and media-enriched e-learning resources such as virtual patients (VP) on skill acquisition in pediatric basic life support (PBLS). This study investigates which immanent VP components account for this effect.MethodsN = 103 medical students in their 5th year were assigned to one of three groups: a video group prepared with self-instructional videos on PBLS (N = 37); an animation-enriched VP group with VP containing interactive questions (N = 35), static and animated media, and a static VP group with VP containing interactive questions and only static media (N = 31). Subsequent PBLS demonstrations were video-documented and scored for adherence to guideline-based algorithm, temporal demands (such as correct pace of rescue breaths and chest compressions), and quality of procedural steps (e.g., correct head positioning), as well as overall competency by two group-blinded, independent pediatricians.ResultsGroups did not differ with regard to adherence to correct algorithm (88.7 ± 10.3, 93.3 ± 6.7 and 90.3 ± 10.5, respectively). Self-instruction with animated media – through videos or animation-enriched VP – resulted in a better adherence to temporal demands, as compared with training with static VP (64.5 ± 26.3 and 50.7 ± 25.7, respectively, vs. 23.8 ± 21.0). Procedural quality by the video group was slightly inferior compared with the animation-enriched VP group (79.5 ± 12.3 vs. 82.0 ± 11.9), and distinct inferior in overall ‘competent’ ratings (43.2% vs. 65.7%). The static VP group performed considerably most poorly of all three groups (temporal adherence 73.2 ± 11.9 and 19.4% ‘competent’ ratings).ConclusionsVP can feasibly enhance PBLS skill acquisition. Thoughtful design of animations and interactivity of the VP further improves such skill acquisition, both in quality of performance and in adherence to temporal demands.

Randomized Controlled Trial of Technology-Assisted Case Management in Low Income Adults with Type 2 Diabetes.

To assess the efficacy of technology-assisted case management (TACM) with medication titration by nurses using guideline-based algorithms, under physician supervision in improving glycemic control in low-income rural adults with poorly controlled type 2 diabetes. Adults (aged ≥18 years) from the southeastern United States with hemoglobin A1c [HbA1c] ≥8% were randomized to TACM or usual care. Evidence-based guidelines were used to develop medication titration algorithms in conjunction with clinic physicians. Participants were given a telehealth device that uploaded blood glucose and blood pressure readings daily to a central server. A nurse case manager was trained on the algorithms and authorized to titrate medications every 2 weeks based on the algorithm under the supervision of an internist and an endocrinologist. Participants were assessed at baseline, 3 months, and 6 months. The primary outcome was HbA1c at 6-months postrandomization in the intent-to-treat (ITT) population. One hundred thirteen participants were randomized to either TACM intervention or usual care. Based on ITT population after multiple imputation, the analysis of covariance with baseline HbA1c as covariate showed that HbA1c at 6 months for TACM was significantly lower compared to the usual care group (-0. 99, P = 0.024). Moreover, longitudinal mixed effects analysis suggested that the rate of decline in HbA1c over time for TACM was significantly faster compared to the usual care group (-0.16, P = 0.038). Results based on per-protocol population were similar. Technology-assisted case management by a nurse with medication titration under physician supervision is efficacious in improving glycemic control in low-income rural adults with poorly controlled type 2 diabetes.

Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study.

The aim of this study was to determine the long-term effects and determinants of success of cardiac pacing in patients affected by reflex syncope enrolled in the Syncope Unit Project 2 (SUP 2) study. Initial results have validated the effectiveness of a standardized guideline-based algorithm which can be used in clinical practice in order to select suitable candidates for cardiac pacing. In this prospective, multicentre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncope, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker. Of 281 patients who met the inclusion criteria, 137 (49%) received a pacemaker and were followed up for a mean of 26 ± 11 months: syncope recurred in 25 (18%) of them. At 3 years, the actuarial syncope recurrence rate was 20% [95% confidence interval (CI) 12-30] and was significantly lower than in 142 patients who did not receive a pacemaker and were observed by means of an ILR [43% (95% CI 29-57), P = 0.01]. The 3-year recurrence rate was not different among 78 CSM+, 38 TT+, and 21 ILR+ patients, whereas it was lower in 20 patients with negative TT [5% (95% CI 0-15)] than in 61 patients with positive TT [24% (95% CI 10-38)]. The benefit of cardiac pacing is maintained at 3 years, irrespective of the index diagnostic test, and is maximum in patients with negative TT. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01509534.

The influence of asthma control on psychosocial outcomes for pregnant women with asthma

Objective: To investigate the relationship between asthma control and psychosocial outcomes in pregnant women with asthma. Methods: Secondary analysis (N = 221) of a randomized controlled trial of treatment adjustments, based on fractional exhaled nitric oxide versus clinical guideline-based algorithms. Psychosocial variables included generic and asthma-specific quality of life (SF12, AQLQ-M), illness perceptions (BIPQ), perceived control (PCAQ), perceived risk of side effects (PRSE) and anxiety (STAI-6). Asthma control was defined as controlled (Asthma Control Questionnaire (ACQ7) ≤1.5 at randomization and end of study), improved (ACQ7 > 1.5 at randomization and ≤1.5 at end of study) and unimproved (ACQ7 >1.5 at end of study). Regression models were fitted for each psychosocial measure at the end of the study, with adjustment for baseline values and smoking status, with predictor variable asthma control. Results: Women with unimproved asthma had poorer physical (SF12, p = 0.012) and asthma-specific quality of life across all domains (AQLQ-M, p ≤ 0.012) compared to women with controlled asthma. They believed that they had less control over their asthma (PCAQ total p = 0.014), had more symptoms and that their illness had a greater effect on their emotions and their lives in general (BIPQ identity, consequences, concern, emotional response p ≤ 0.015). Women with improved asthma control had significantly lower AQLQ-M breathlessness (p = 0.048) and lower total scores (p = 0.04) than women with controlled asthma. Conclusions: Pregnant women who are not able to get control of their asthma symptoms may experience worse quality of life and are likely to have more negative perceptions about their condition.

Assessment of a standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncopes.

Opinions differ regarding the effectiveness of cardiac pacing in patients affected by reflex syncope. We assessed a standardized guideline-based algorithm in different forms of reflex syncope. In this prospective, multi-centre, observational study, patients aged >40 years, affected by severe unpredictable recurrent reflex syncopes, underwent carotid sinus massage (CSM), followed by tilt testing (TT) if CSM was negative, followed by implantation of an implantable loop recorder (ILR) if TT was negative. Those who had an asystolic response to one of these tests received a dual-chamber pacemaker. 253 patients, mean age 70 ± 12 years, median 4 (3-6) syncopes, 89% without or with short prodromes. Of these patients, 120 (47%) received a pacemaker and 106 were followed up for a mean of 13 ± 7 months: syncope recurred in 10 (9%). The recurrence rate was similar in 61 CSM+ (11%), 30 TT+ (7%), and 15 ILR+ (7%) patients. The actuarial total syncope recurrence rate was 9% (95% confidence interval (CI), 6-12) at 1 year and 15% (95% CI, 10-20) at 2 years and was significantly lower than that observed in the group of 124 patients with non-diagnostic tests who had received an ILR: i.e. 22% (95% CI, 18-26) at 1 year and 37% (95% CI, 30-43) at 2 years (P = 0.004). About half of older patients with severe recurrent syncopes without prodromes have an asystolic reflex for which cardiac pacing goes along with a low recurrence rate. The study supports the clinical utility of the algorithm for the selection of candidates to cardiac pacing in everyday clinical practice. http://www.clinicaltrials.gov. Unique identifier: NCT01509534.

Interventions for managing asthma in pregnancy.

Interventions for managing asthma in pregnancy.

Myokardinfarkt

The third version of the Universal Definition of Myocardial Infarction (MI) was published in 2012. The diagnosis of acute myocardial infarction (AMI) should only be made in a clinical setting consistent with acute myocardial ischaemia when evidence of myocardial necrosis is present. The diagnostic criteria for MI are fulfilled when a rise and/or fall of cardiac biomarkers (preferentially troponins) occurs with at least one value above the 99th percentile of the upper reference limit. In addition, there should be symptoms of ischaemia, new changes in electrocardiogram (ECG), imaging evidence of a new loss of viable myocardium or new regional wall motion abnormality, or the identification of an intracoronary thrombus by angiography or autopsy. This revised definition updates previous versions by including changes to diagnostic ECG criteria, placing a higher emphasis on cardiac imaging, modifying the criteria for subtypes of MI and implementing high sensitivity cardiac troponin (cTn) assays. A guideline-based algorithm for management of patients with suspected acute coronary syndrome allowing "early rule-in" and "rule-out" of non-STEMI with high sensitivity cTn assays is also presented.

Guideline-Recommended Fractional Exhaled Nitric Oxide Is a Poor Predictor of Health-care Use Among Inner-city Children and Adolescents Receiving Usual Asthma Care

American Thoracic Society guidelines support using fractional exhaled nitric oxide (FENO) measurements in patients with asthma and highlight gaps in the evidence base. Little is known about the use of FENO levels to predict asthma exacerbations among high-risk, urban, minority populations receiving usual care. Children with persistent asthma (n = 138) were enrolled in a prospective, observational cohort study and skin tested at baseline (a wheal ≥ 3 mm indicated a positive skin-prick test). FENO levels, lung function, and asthma-related health-care use were assessed at baseline and every 3 months thereafter for 1 year. Relationships between FENO levels and health-care use in the subsequent 3 months were examined. Final models accounted for repeated outcome measures and were adjusted for age, sex, and lung function. The mean age of the children was 11 years (range, 5-17 years), and most were male (57%), black (91%), and atopic (90%). At baseline, the median FENO level was 31.5 parts per billion (interquartile range, 16-61 ppb) and mean FEV1/FVC was 80.7% (SD, ± 9.6%). There were 237 acute asthma-related health-care visits, 105 unscheduled doctor visits, 125 ED visits, and seven hospitalizations during the follow-up period. FENO level was not a significant predictor of acute visits, ED visits, unscheduled doctor visits, or hospitalization in either unadjusted or adjusted analyses. Use of recommended cut points did not improve the predictive value of the FENO level (positive predictive value, 0.6%-32.8%) nor did application of the guideline-based algorithm to assess change over time. FENO level may not be a clinically useful predictor of health-care use for asthma exacerbations in urban minority children with asthma.

An Opportunity to Ensure High-Quality Melanoma Care Through the Use of a Preoperative Treatment Algorithm

Studies have demonstrated variable adherence to published melanoma treatment guidelines. Payers have used algorithms to preapprove certain tests and treatments. Our objective was to develop a preoperative treatment assessment algorithm to ensure patients with melanoma receive recommended care. A treatment algorithm was developed using existing guidelines. Records of patients presenting with melanoma between September 2010 and May 2012 were reviewed. Surgical care was classified as having been adherent or nonadherent with the guideline-based algorithm. The algorithm was incorporated into a Web site for preoperative treatment verification. A treatment algorithm was developed on the basis of three critical pieces of preoperative data: Breslow thickness, presence of adverse primary tumor prognostic factors, and regional lymph node metastases. Treatment options included wide local excision (WLE), sentinel lymph node biopsy (SLNB), and completion/formal lymph node dissection. Of 328 patients evaluated, 316 (96%) were treated according to the guideline-based algorithm. Causes of variation from predicted treatment included patient preference, severe comorbidities, difficult tumor location, and uncertain depth. All departures (n = 12) were in clinically node-negative patients: six patients did not undergo SLNB as indicated, and six underwent SLNB that was not concordant with the algorithm. An algorithm-embedded Web site was designed for preoperative verification of planned procedures. As a proof of principle, an algorithm was developed to preoperatively verify that proposed melanoma treatments are concordant with established guidelines. These three pieces of information could be required during precertification, and nonconcordant treatment plans could prompt a peer-to-peer discussion. After additional pilot testing, the algorithm could offer a novel approach for quality improvement and provide a preoperative, prospective safeguard to ensure high-quality care for melanoma patients.

Treatment patterns and healthcare system burden of managed care patients with suspected pulmonary arterial hypertension in the United States

Objectives:To describe treatment patterns and healthcare burden among individuals with suspected pulmonary arterial hypertension (PAH), as identified through a practice guideline-based healthcare claims algorithm.Methods:Adults with evidence of PAH from 1 January 2004 (commercial and Medicaid) or 1 July 2006 (Medicare Advantage) through 30 June 2008 were identified. Given the lack of an ICD-9 code for PAH, an algorithm was developed requiring: (1) ≥1 claim for PAH medication (index date); (2) ≥1 claim with a pulmonary hypertension diagnosis code in the 6-month pre-index period (baseline) or within 90 days post-index; (3) a right heart catheterization or pulmonary hypertension-related inpatient stay during baseline or within 90 days post-index; and (4) continuous health plan enrollment for 6 months pre-index and ≥6 months post-index. Patients with PAH-specific medications during baseline were excluded. Treatment patterns, healthcare utilization, and costs were assessed during the period ending with the earlier of health plan disenrollment or 31 December 2008.Results:Among the 521 included patients, 69% were female. Most patients (94%) initiated treatment with monotherapy (most commonly sildenafil or bosentan), and 12.7% of all patients augmented their therapy by the end of the observation period. The medication possession ratio was 0.96 each for ambrisentan (SD = 0.04), bosentan (SD = 0.04), and sildenafil (SD = 0.05). Overall, 72.6% of patients discontinued therapy with a mean of 149 (SD = 170) days until discontinuation. A mean (SD) of 2.14 (1.82) all-cause office and 1.64 (1.98) outpatient visits occurred per patient per month. Mean PAH-related healthcare costs were $6617 per patient per month, comprising 71% of all-cause costs. The guideline-based algorithm may not have perfectly captured patients with PAH.Conclusions:Patients with suspected PAH were likely to initiate treatment with oral monotherapy, had high compliance rates, and received close ambulatory follow-up. PAH-related costs constituted the majority of all-cause healthcare costs.

A standardized guideline-based algorithm coupled with online decision-making tool: the new frontier for efficient management of syncope?

Despite significant progress in the past three decades including the publication of guidelines, the development of several emergency room syncope decision rules and more generic risk scores, and the institution of formal dedicated syncope facilities, the management (diagnosis and therapy) of syncope is still largely unsatisfactory. A Position Paper commissioned by the Canadian Cardiovascular Society1 addresses the quality of evidence of the standardized methods of management of syncope proposed in recent years and gave pragmatic interpretation of strong vs. weak recommendations based on the GRADE system.2 In brief, there is little persuasive evidence that emergency room syncope rules and diagnostic syncope units provide efficient care and improved outcomes. While we congratulate the Canadian colleagues for their objective comprehensive evaluation, we think their conclusions reflect some major pitfalls that persist in the approach to patients with syncope: 1. Difficulty identifying patients at high risk (in particular those at short-term risk). This problem inevitably leads to an increase in the number of inappropriate hospitalizations, tests utilization, and eventually higher costs. 2. High rate of unexplained diagnosis. It seems that the most complex (i.e. with competing possible causes) and potentially severe syncope cases that require specialized treatment remain undiagnosed.3 Indeed, patients with unexplained syncope tend to be older and more frequently have structural heart disease or electrocardiographic abnormalities. Conversely, a diagnosis is more easily obtained in healthy young patients without structural heart disease, who are known to have a favourable outcome. The paradox is that the more we need a precise diagnosis, the more difficult it is to obtain one. 3. High rate of misdiagnosis. Typically patients are asymptomatic at the time of evaluation and the opportunity to capture a …

Evaluation of Patients with “Faint” in an American Teaching Hospital: A Dire Need for a Standardized Approach

Fainting is a major healthcare problem with significant morbidity, mortality, and healthcare cost. We sought to assess the appropriateness of current clinical practice when compared to a guideline-based algorithm. The records of 100 consecutive patients who presented with faint and were referred to the University of Utah for further evaluation by specialists were reviewed. We analyzed the clinical characteristics, tests performed, diagnosis made, and number of admissions. In addition, we applied a guideline-based algorithm to assess the appropriateness of these evaluations. The mean age was 49 ± 21 years with 57% being female. One-third presented with their first event. Structural heart disease was present in 22% of the cases. Twelve (36%) of 32 admissions were inappropriate. There was an underutilization of orthostatic testing, carotid sinus massage, and implantable loop recorder and overutilization of imaging studies and neurologic consultation. Specifically, active standing and tilt-table testing were performed in only 24% and 7% of the cases, respectively, none of the patients had carotid sinus massage despite 26% of them being ≥65 years old, and only 3% of the patients received an implantable loop recorder. With the current practice, a final diagnosis was made in 45 cases with 17 (38%) of the 45 final diagnoses not being sufficiently supported by the completeness of the evaluation. With the current practice at a major university hospital, the cause of faint was unexplained in a high number of cases. Our findings highlight the need for a standardized approach to patients presenting with faint.

The Impact of Uncontrolled Asthma on Absenteeism and Health-Related Quality of Life

Objective. To evaluate the impact of uncontrolled asthma on the absenteeism and health-related quality of life (HRQOL) of adults and children with asthma and the caregivers of pediatric patients. Patients and methods. Patient information was obtained from datasets maintained by National Jewish Health for this cross-sectional study. Participants in the study were 12 years of age or older. Participants younger than 18 years had their information provided by caregivers. Caregivers also provided 6 months of absenteeism and QOL data. Participants were classified as having uncontrolled asthma based on a treatment and symptom guideline-based algorithm. Absenteeism was assessed from the self-reported number of work or school days missed due to asthma during the previous 6 months. HRQOL among adults was measured using the validated Marks Asthma Quality of Life Questionnaire (Marks-AQLQ) and among caregivers using the validated Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ). To account for the positive skew in absenteeism data, a zero-inflated Poisson regression model was used to compare group differences. HRQOL was analyzed for adults and caregivers using the Wilcoxon-Mann-Whitney test. Results. A total of 15,149 patients met the inclusion criteria for the study and were included in the analysis. Adults with uncontrolled asthma and caregivers of children with uncontrolled asthma reported significantly higher absenteeism than their controlled counterparts: 43% vs 24% adults reported missing days of work, with a median 6 days vs 3 days missed; 31% vs 16% of caregivers reported missing days of work, with 4 days vs 2 days missed; and caregivers reported that more than 70% vs 45% pediatric patients missed school, with a median of 6 days vs 4 days missed (uncontrolled vs controlled asthma, respectively). Adult uncontrolled asthmatics and caregivers of uncontrolled pediatric patients had significantly lower HRQOL as indicated by the Marks-AQLQ (scores 1.5 points higher, p < 0.001) and PACQLQ (scores < 0.5 points lower, p < 0.001), respectively. Conclusions. Uncontrolled asthma has far-reaching impact on the productivity and quality of life of asthma patients and their caregivers. Proper assessment, treatment, and disease management to improve asthma control may reduce the impact of uncontrolled asthma on asthmatic adults, children, and the caretakers of pediatric asthmatic patients.

Optimizing Screening and Management of Asymptomatic Coronary Artery Disease in Patients With Stroke and Patients With Transient Ischemic Attack

The feasibility of implementing an expert consensus guideline recommending use of a stroke patient's profile to manage undiagnosed coronary artery disease remains unclear. Following a guideline-based algorithm, we screened consecutive patients with ischemic stroke and patients with transient ischemic attack for asymptomatic coronary artery disease using the Framingham Heart Study Coronary Risk Score (FCRS) cutoff of high risk (> or = 20%) for experiencing a hard coronary artery disease event over a 10-year period. Patients with high FCRS received dobutamine stress echocardiogram outpatient screening, additional treatment (beta-blocker), or further management (cardiologist referral). From July 2004 to September 2007, among 693 patients, 501 (72%) met study criteria, of which 80 (16%) had FCRS > or = 20%. Elevated serum glucose, nonhigh-density lipoprotein, triglycerides, homocysteine, glycosylated hemoglobin as well as large vessel atherosclerotic stroke mechanism were more frequent in high versus low FCRS patients (P<0.05). Among high FCRS patients, 35 (44%) had dobutamine stress echocardiogram performed. Leading reasons for dobutamine stress echocardiogram nonperformance were patient noncompliance (42%) and primary care physician refusal (33%). Screening for coronary artery disease risk using FCRS is feasible in hospitalized patients with stroke, but outpatient adherence to stress testing is challenging largely due to patient and primary care physician-related factors.

Improving outpatient treatment in schizophrenia: effects of computerized guideline implementation—results of a multicenter-study within the German Research Network on Schizophrenia

Schizophrenia clinical practice guidelines are developed to provide expert- and evidence-based advice to practicing psychiatrists in order to improve the management of this disorder. However, the application of these guidelines in everyday health care can still be described as nonsatisfying. Within the project "Guideline-supported quality management in outpatient treatment", we investigated whether guideline adherence and quality of outcome can be improved by implementing a computer-based, guideline-oriented decision-support system. Therefore, a disease-specific decision-support system was developed interactively presenting guidelines to support the physicians decision-making process during the treatment of schizophrenia patients. We evaluated the system in a control group design: An experimental group consisting of 15 psychiatrists in private practice used the decision-support system, thus documenting the treatment of schizophrenic patients. Guideline-based algorithms were interactively and case specifically displayed on the PC-screen as soon as predefined triggers were met. A first control group in Munich provided treatment-as-usual, documenting the treatment via paper-pencil. Two further physician groups served as additional comparison groups: one also documented electronically using the decision-support system, however without receiving electronic guideline support, the second group carried out traditional quality circles while also using the paper-pencil approach. As a result of the intervention, we observed a strong initial but time-limited improvement with respect to the core aspects of outpatient treatment in schizophrenia in the experimental group. The findings suggest that decision-support systems, despite their limitations, can be used to enhance treatment outcome in schizophrenia outpatient care.