Ultrasonography performed by primary care residents for abdominal aortic aneurysm screening.

A prospective pilot study was undertaken to assess a protocol to educate primary care residents in how to personally perform ultrasonography for abdominal aortic aneurysm screening. Resident exams were proctored by a primary care physician trained in ultrasonography and were scored on the level of competence in doing the examination. Patients had ultrasound performed by a resident, followed by repeat examination by the vascular lab. Primary care resident abdominal aortic imaging was achieved in 79 of 80 attempts. Four abdominal aortic aneurysms were identified. There were 75 normal examinations; resident ultrasonography results were consistent with the results of the vascular lab. Ten residents achieved an abdominal aortic ultrasound-independent competence level after an average of 3.4 proctored exams. The main outcome of this study is that a primary care resident, with minimal training in ultrasonography imaging, is able to rapidly learn the technique of ultrasonography imaging of the abdominal aorta.

Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association.

OBJECTIVE: To establish, in a single resource, up-to-date recommendations for primary care physicians regarding prevention strategies for a first stroke. PARTICIPANTS: Members of the National Stroke Association's (NSA's) Stroke Prevention Advisory Board and Cedars-Sinai Health System Department of Health Services Research convened on April 9, 1998, in an open meeting. The conference attendees, selected to participate by the NSA, were recognized experts in neurology (9), cardiology (2), family practice (1), nursing (1), physician assistant practices (1), and health services research (2). EVIDENCE: A literature review was carried out by the Department of Health Services Research, Cedars-Sinai Health System, Los Angeles, Calif, using the MEDLINE database search for 1990 through April 1998 and updated in November 1998. English-language guidelines, statements, meta-analyses, and overviews on prevention of a first stroke were reviewed. CONSENSUS PROCESS: At the meeting, members of the advisory board identified 6 important stroke risk factors (hypertension, myocardial infarction [MI], atrial fibrillation, diabetes mellitus, blood lipids, asymptomatic carotid artery stenosis), and 4 lifestyle factors (cigarette smoking, alcohol use, physical activity, diet). CONCLUSIONS: Several interventions that modify well-documented and treatable cardiovascular and cerebrovascular risk factors can reduce the risk of a first stroke. Good evidence for direct stroke reduction exists for hypertension treatment; using warfarin for patients after MI who have atrial fibrillation, decreased left ventricular ejection fraction, or left ventricular thrombus; using 3-hydroxy-3 methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for patients after MI; using warfarin for patients with atrial fibrillation and specific risk factors; and performing carotid endarterectomy for patients with stenosis of at least 60%. Observational studies support the role of modifying lifestyle-related risk factors (eg, smoking, alcohol use, physical activity, diet) in stroke prevention. Measures to help patients improve adherence are an important component of a stroke prevention plan.

Can practice guidelines safely reduce hospital length of stay? Results from a multicenter interventional study.

BACKGROUND: Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes. PATIENTS AND METHODS: We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. RESULTS: A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04). CONCLUSION: Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.

A prospective, multicenter study of a pneumonia practice guideline.

OBJECTIVE: To study the effect of a length of stay practice guideline on patient outcomes. DESIGN: A prospective, nonrandomized, interventional trial. SETTING: Six geographically distributed hospitals. PATIENTS: Two hundred forty-two consecutively hospitalized "low-risk" patients with pneumonia. MEASUREMENTS AND RESULTS: One hundred fifty-two patients (63%) completed the mailed postdischarge survey and were included in the analysis. Data were prospectively collected for 85 patients from the baseline observation period (B) and 67 patients from the intervention period (I). During the I, case managers provided physicians with patient risk information based on guideline recommendations. There was no significant change in guideline compliance (B vs I: 76.5% vs 83.6%; p=0.32) or length of stay (B vs I: 3.5 days [95% confidence interval, 3.2 to 3.8] vs 3.6 days [95% confidence interval, 3.3 to 4.0]). Also, there were no statistically significant effects of the intervention on patient outcomes, care following hospital discharge, and patient satisfaction scores. CONCLUSION: Patients in this study often had shorter lengths of stay than recommended by the practice guideline. This suggests that the external environment may have had a greater effect on physician behavior and length of stay than the practice guideline itself. Moreover, it demonstrates the importance of continuous assessment of physician practices immediately prior to, during, and after application of the clinical practice guideline.

The relation between systematic reviews and practice guidelines.

Clinical practice guidelines have been developed to improve the process and outcomes of health care and to optimize resource utilization. By addressing such issues as prevention, diagnosis, and treatment, they can aid in health care decision making at many levels. Several other decision aids are cast in the guideline lexicon, regardless of their focus, formulation, or format; this can foster misunderstanding of the term "guideline." Whether created or adapted locally or nationally, most guidelines are an amalgam of clinical experience, expert opinion, and research evidence. Approaches to practice guideline development vary widely. Given the resources required to identify all relevant primary studies, many guidelines rely on systematic reviews that were either previously published or created de novo by guideline developers. Systematic reviews can aid in guideline development because they involve searching for, selecting, critically appraising, and summarizing the results of primary research. The more rigorous the review methods used and the higher the quality of the primary research that is synthesized, the more evidence-based the practice guideline is likely to be. Summaries of relevant research incorporated into guideline documents can help to keep practitioners up to date with the literature. Systematic reviews have also been published on the dissemination and implementation strategies most likely to change clinician behavior and improve patient outcomes. These can be useful in more effectively translating research evidence into practice.

Developing evidence-based practice guidelines and pathways: the experience at the local hospital level.

BACKGROUND: Using an evidence-based approach to developing clinical practice guidelines at the local level promotes implementation by clinicians. In 1994 Cedars-Sinai Health System embarked on a joint project with VHA, Inc, to pilot test a software program, Clinical Cost-Reduction System (CCRS), featuring length-of-stay guidelines for low-risk patients with specific conditions. Data currently are being collected on the effect of the software on length-of-stay reductions and other important patient outcomes. THE NEED FOR A MORE COMPREHENSIVE SOFTWARE PROGRAM: To involve clinicians more actively in the development of guidelines, Cedars-Sinai sought to develop a software system for presenting organized medical information to hospitals interested in designing their own evidence-based clinical pathways. DEVELOPING THE CLINICAL PATHWAY CONSTRUCTOR (CPC): The CPC is a computerized grid for writing clinical pathways, backed by a database of information for select clinical conditions and categories of care. Multidisciplinary teams are to review the evidence presented in the database and then determine those guidelines they wish to encode into an actual pathway, which can then be printed out. The decision regarding which guidelines to use and which not to use rests entirely with the team designing a pathway; the program is intended to aid the team in developing appropriate guidelines that are evidence based, not to legislate guidelines. Data on the "portability" of the program are still being collected. SEARCHING AND SUMMARIZING THE LITERATURE: There are many challenges involved in searching, summarizing, and classifying the medical literature.