National Care Guidelines Research Articles

Elderly people with multi-morbidity and acute coronary syndrome: Doctors’ views on decision-making

In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. 81% of the respondents reported extensive use of national guidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views on treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.

Not Just Big Kids

Atrial septal defects (ASDs), allowing blood to directly communicate between systemic and pulmonary arterial circulations at the atrial level, are among the most common congenital cardiac anomalies seen in the adult population. The degree of shunting across an ASD is directly related to the area of the ASD and inversely related to the compliance of the combined atrial-ventricular chambers on either side of the heart. Under normal physiological conditions, there is net left-to-right shunting across an ASD, as the left ventricle is far less compliant than the right ventricle. This shunt of fully oxygenated blood back to the right atrium results in a volume load to the right-sided heart chambers and to the pulmonary vasculature; if left untreated, large-volume left-to-right shunting can result in atrial arrhythmias, right ventricular diastolic and systolic failure, worsened functional class, decreased exercise capacity, left ventricular diastolic failure, and, uncommonly, development of pulmonary arterial hypertension.1 The indication to treat an ASD is typically related to its hemodynamic significance and its effects on the right ventricle. National care guidelines denote ASD closure with class IA recommendation in patients with evidence …

The Revision of Japan’s National Guidelines for Care and Education at Day Nursery and Its Problems

Abstract This article is written to introduce the main contents of the revised National Guidelines for Care and Education at Day Nursery (henceforth New Guidelines), which were recently announced by the Ministry of Health, Labor and Welfare (MHLW), and the challenges associated with these New Guidelines. The National Guidelines for Care and Education at Day Nursery is the national curriculum for Japan’s day nurseries, an official educational institution for preschools and kindergartens under the authority of the Ministry of Education, Culture, Sports, Science and Technology (MECST). The New Guidelines are the fourth revised edition of such a curriculum. Unlike the previously issued guidelines, the New Guidelines, which were publicly announced by the Minister of Health, Labor and Welfare, are legally binding as a minimum standard for child care and education. This article is focused on introducing (a) roles of day nurseries, (b) child care and education, (c) promotion of food education, (d) plans and evaluations of child care and education, and (e) transition from preschool to elementary school. Some additional points worthy of consideration, such as minimum standards for day nurseries, plans and self-evaluation of child care and education, problems of child care and education plans, and parental involvement are also included in this article. It is recommended the New Guidelines not be regarded as being faultless. Rather, positive efforts should be made based on the practices and studies of child care and education to improve the Guidelines in accordance with social trends.

PEDIATRIC ASTHMA PREVALENCE AND CARE AMONG NATIVE AMERICAN YOUTH IN SOUTHEASTERN MONTANA.

Objective To determine the period prevalence of asthma in youth accessing care at the Crow Service Unit in southeastern Montana during the years 1995-2005 and to evaluate adherence to national care guidelines. Setting The Crow Service Unit, an Indian Health Service area that includes one hospital and two satellite clinics and serves a user population of 11,400, approximately 5,200 of whom are less than 21 years old. Methods Retrospective electronic and manual chart review to identify pediatric patients (age less than 21 years old) with a diagnosis of asthma (ICD 493) who had at least one clinic visit during the given calendar year. Care given to pediatric patients during 2005 was evaluated by examining six discrete variables from the National Asthma Education and Prevention Program (NAEPP) guidelines. Results The prevalence rate for pediatric asthma from 1995 to 2005 was 8.3%. The period prevalence ranged from 6.94 to 10.38% (see Figure). Of the pediatric patients with asthma in 2005 (N = 454), assessment to describe the severity of the patient9s condition was performed in 29.7% (n = 135) of cases; spirometry was performed in 7.9% (n = 36) of cases; a written self-management plan was given or updated in 53.5% (n = 243) of cases; patient9s metered dose inhaler or nebulizer technique was assessed in 5.3% (n = 24) of cases; and a follow-up plan was generated in 56.2% (n = 255) of cases. Of the pediatric patients over age 5 years who had documented persistent asthma in 2005 (n = 14), 71% (n = 10) were treated with inhaled corticosteroids. Conclusion Although the prevalence rate of asthma among Native American youth at the Crow Service Unit is similar to the general US pediatric population rate for all races in 2001 (8.7%), adherence to national standards of asthma care is suboptimal.

Asthma pharmacotherapy and utilization by children in 3 managed care organizations

Background: Asthma is the most common chronic disease among children and the most frequent cause of hospitalization. Appropriate pharmacotherapy is a cornerstone of published national guidelines for the care of children with asthma. Objective: The goal was to compare the baseline pharmacotherapy and health care utilization from 1996 to 1997 in children with asthma at managed care organizations (MCOs). Methods: A common protocol was used to extract the study sample from 3 MCOs with automated claims and pharmacy databases. Children were selected if they were 3 to 15 years old as of June 1997 with 1 or more encounters (outpatient, emergency department visit, hospitalization) with an asthma diagnosis in the previous year. Results: Of the 13,352 children studied, less than 40% were given controllers during the 12-month interval, with ranges of 15% to 77% by level of bronchodilator use, 31% to 44% by age, and 38% to 42% by MCO. Among children given 6 or more bronchodilators, controller dispensing ranged from 73% to 89% among the 3 MCOs. Variability was most evident for inhaled corticosteroids, for which dispensing ranged from 51% to 70%. Rates of asthma hospitalization and emergency department visits also differed among the MCOs, ranging from 21 to 37 per 1000 person-years and 37 to 142 per 1000 person-years, respectively. Conclusion: Five years after dissemination of national guidelines for care, the pattern of asthma therapy does not reflect guideline recommendations. Variation among health care organizations with respect to asthma therapy and utilization of health services exists. In addition, controller medications may not be used by all children who could benefit from them. (J Allergy Clin Immunol 2000;106:1108-14.)

The Editors’ Choice

The Editors’ Choice

Comparing mothers' reports on the content of prenatal care received with recommended national guidelines for care.

Comparing mothers' reports on the content of prenatal care received with recommended national guidelines for care.