Unperceived treatment gaps in acute coronary syndromes.

BACKGROUND: Despite a strong evidence-base for several therapies recommended in the management of acute coronary syndromes (ACS), many patients do not receive these therapies. The barriers preventing translation of evidence into practice are incompletely understood. The aim of this study was to survey clinicians regarding barriers to implementing recommendations of recently published national clinical guidelines and to determine the extent to which these impact clinical practice. METHODS: A survey of clinicians at hospitals included in Australian Collaborative Acute Coronary Syndromes Prospective Audit (ACACIA, n = 3402, PML0051) was conducted, measuring self-stated knowledge, beliefs and guideline-concordant behaviours in relation to their care of ACS patients. Correlations between individual respondents' self-estimated rates and clinician's institutional rates of guideline-concordant behaviours were performed. RESULTS: Most respondents (n = 50/86, 58%) were aware of current guidelines and their scope, achieving 7/10 (Interquartile Range (IQR) = 2) median score on knowledge questions. Belief in benefits and agreement with guideline-recommended therapy was high. However, none of these factors correlated with increased use of guideline therapies. Apart from clopidogrel (r(s) = 0.28, p < 0.01) and early interventional therapy for high-risk non-ST elevation myocardial infarction (r(s) = 0.31, p < 0.01), there were no significant correlations between individual clinicians' self-estimated rates of guideline-concordant practice and rates recorded in ACACIA data for their respective institution. CONCLUSION: Beliefs about practice do not match actual practice. False beliefs regarding levels of evidence-based practice may contribute to inadequate implementation of evidence-based guidelines. Strategies such as continuous real-time audit and feedback of information for the delivery of care may help clinicians understand their levels of practice better and improve care.

Potential survival gains in the treatment of myocardial infarction.

OBJECTIVES: To evaluate the potential impact of complete implementation of guideline recommendations in myocardial infarction (MI) care, and contrast this with new innovations. DESIGN: Modelling of potential events prevented from literature-based treatment effects and observed guideline recommendation utilisation rates. SETTING: Hospital-based care. PARTICIPANTS: Nationwide registry of 1630 patients with MI adjusted for age, gender and GRACE score extrapolated to a population of 10 000 patients. INTERVENTIONS: Literature-based efficacy estimates associated with guideline-recommended treatments and a putative treatment providing a 10-30% 12-month event reduction. MAIN OUTCOME MEASURES: Mortality and recurrent MI or stroke by 30 days and 30 days to 12 months. RESULTS: Adjusted-mortality rates for optimally managed patients with ST-segment MI (STEMI) and non-ST-segment MI (NSTEMI) to 30 days were 0.6% and 2.5%, respectively. Adjusted mortality from 30 days to 12 months was 1.8% among optimally managed patients. No reperfusion occurred in 31% of patients with STEMI. Fewer than four guideline treatments were prescribed in 26% of patients at discharge. Compared with in-hospital care, better application of secondary prevention treatments provided the greater absolute gains (STEMI 23 lives/10 000 patients by 30 days, NSTEMI 43 lives/10 000 by 30 days and secondary prevention 104 lives/10 000 by 12 months). A putative novel treatment reducing mortality by 30% among optimally managed patients would save a further 4 lives/10 000 by 12 months. CONCLUSIONS: Potential gains from improved clinical effectiveness in MI care are likely to compare favourably with benefits achieved though innovations, and should inform priorities in research and implementation strategies for improving MI outcomes.

Improving the management of acute coronary syndromes in Australia: translating evidence to outcomes.

Cardiovascular disease imposes a heavy burden of morbidity and mortality on the Australian community. This situation is likely to exacerbate as the number of elderly Australians increase. Management of acute coronary syndromes (ACS) is underpinned by a robust evidence base, which is outlined in clinical practice guidelines. Yet, despite wide diffusion of guidelines, many Australians who experience acute coronary syndromes do not receive optimal care. This article reviews what we have learnt from previous quality improvement initiatives and discusses what we need to know to improve acute coronary syndromes management in Australia.

Visual outcomes following lensectomy and vitrectomy for combined anterior and posterior persistent hyperplastic primary vitreous.

OBJECTIVE: To determine the visual outcome after surgery for persistent hyperplastic primary vitreous using modern vitreoretinal techniques. DESIGN: Retrospective medical record review during a 5-year period (June 1992 to June 1997). Information recorded for each patient included age, medical history, sex, results of preoperative ocular examination, age at diagnosis, procedure performed, intraoperative and postoperative complications, location and number of sclerotomy sites, type of aphakic rehabilitation, amblyopic therapy given, final visual acuity, and length of follow-up. RESULTS: Fourteen patients who underwent surgical management of combined anterior and posterior persistent hyperplastic primary vitreous were identified. Eleven patients underwent aphakic rehabilitation and aggressive amblyopic therapy consisting of occlusive therapy for several waking hours each day. One additional older patient received aphakic rehabilitation only. Ten eyes (71%) achieved a visual acuity of 20/300 or better, and 8 (57%) obtained a final visual acuity of 20/100 or better. Average length of follow-up was 22 months (range, 4-57 months). Nine patients were fitted with an aphakic soft contact lens, 2 older patients had a posterior chamber intraocular lens placed at the time of vitrectomy, and 1 patient wore aphakic spectacles. CONCLUSIONS: With modern vitreoretinal techniques, aphakic rehabilitation, and aggressive amblyopic therapy, useful vision can be obtained in the majority of patients with combined anterior and posterior persistent hyperplastic primary vitreous.

Regeneration of T lymphocytes from human bone marrow cells after depletion with methylprednisolone.

This study evaluates the propagation of T lymphocytes in bone marrow cells after in vitro methylprednisolone treatment. Previous studies from this laboratory showed that immunocompetent T lymphocytes could be eliminated from the bone marrow cells by incubation with 15 mg/ml (0.04 M) of methylprednisolone for 1 hr. The effectiveness of the chemoseparation was assessed by E-rosette forming cell assay, mitogen-induced lymphoblastogenic responses, and lymphocyte surface markers. In this study, bone marrow cells treated with different concentrations of methylprednisolone were cultured in the presence of PHA and Interleukin-2. The mitogen-induced lymphoblastogenesis was restored in the 15 mg/ml MP-treated bone marrow cells by the 8th day of culture in the presence of Interleukin-2. The cells in the culture were analyzed by E-rosette forming cell assay. It was shown that the predominant cells in the cultures were E-rosette forming cells. This study demonstrates that immunocompetent T lymphocytes can be regenerated in the presence of mitogen and Interleukin-2 from bone marrow cells treated with 15 mg/ml of methylprednisolone.