Equity of access to CVD risk management using electronic clinical decision support in the coronary care unit.

BACKGROUND: Cardiovascular (CVD) risk management post myocardial infarction is inconsistently delivered with those who need the most receiving the least - the 'inverse care law.' The Acute PREDICT Initiative is a nurse led computerised decision support system (CDSS), to provide point-of-care guideline-based, patient-specific CVD risk management recommendations to all. METHODS: All patients admitted to Middlemore Hospital CCU over 2 years with acute CVD-related events potentially 'eligible' for PREDICT assessment were identified. Age, gender, ethnicity and a small area measure of socioeconomic status (NZDep01) were assessed. RESULTS: 1813/2246 (81%) of people admitted were eligible for a PREDICT assessment. Of those, 973 (54%) received a complete assessment. There were no important differences by quintile of deprivation or ethnicity between the patients receiving PREDICT and the rest. PREDICT assessments were less likely for the elderly (35.7% of >75years compared with 57.7% of <75years), for women (47.1% of women and 56.5% of men), and for those who had 5 or more previous admissions. CONCLUSIONS: Patients potentially at higher risk because of their ethnic or socioeconomic background received equitable access to in-hospital CVD risk management post MI using PREDICT. However, some other high-risk groups under-utilised the system.

Hormone therapy in postmenopausal women and risk of endometrial hyperplasia.

BACKGROUND: Declining circulating estrogen levels around the time of the menopause can induce unacceptable symptoms that affect the health and well being of women. Hormone therapy (both unopposed estrogen and estrogen/progestogen combinations) is an effective treatment for these symptoms, but is associated with risk of harms. Guidelines recommend that hormone therapy be given at the lowest effective dose and treatment should be reviewed regularly. The aim of this review is to identify the minimum dose(s) of progestogen required to be added to estrogen so that the rate of endometrial hyperplasia is not increased compared to placebo. OBJECTIVES: The objective of this review is to assess which hormone therapy regimens provide effective protection against the development of endometrial hyperplasia and/or carcinoma. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched January 2008), The Cochrane Library (Issue 1, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), Current Contents (1993 to May 2008), Biological Abstracts (1969 to 2008), Social Sciences Index (1980 to May 2008), PsycINFO (1972 to May 2008) and CINAHL (1982 to May 2008). Attempts were made to identify trials from citation lists of reviews and studies retrieved, and drug companies were contacted for unpublished data. SELECTION CRITERIA: Randomised comparisons of unopposed estrogen therapy, combined continuous estrogen-progestogen therapy and/or sequential estrogen-progestogen therapy with each other or placebo, administered over a minimum period of twelve months. Incidence of endometrial hyperplasia/carcinoma assessed by a biopsy at the end of treatment was a required outcome. Data on adherence to therapy, rates of additional interventions, and withdrawals due to adverse events were also extracted. DATA COLLECTION AND ANALYSIS: In this substantive update, forty five studies were included. Odds ratios were calculated for dichotomous outcomes. The small numbers of studies in each comparison and the clinical heterogeneity precluded meta analysis for many outcomes. MAIN RESULTS: Unopposed estrogen is associated with increased risk of endometrial hyperplasia at all doses, and durations of therapy between one and three years. For women with a uterus the risk of endometrial hyperplasia with hormone therapy comprising low dose estrogen continuously combined with a minimum of 1 mg norethisterone acetate or 1.5 mg medroxyprogesterone acetate is not significantly different from placebo (1mg NETA: OR=0.04 (0 to 2.8); 1.5mg MPA: no hyperplasia events). AUTHORS' CONCLUSIONS: Hormone therapy for postmenopausal women with an intact uterus should comprise both estrogen and progestogen to reduce the risk of endometrial hyperplasia.

Laparoscopy versus laparotomy for benign ovarian tumour.

BACKGROUND: Over the last 10 years laparoscopy and minilaparotomy have become increasingly common approaches for the surgical removal of benign ovarian tumours. However, in the event that a tumour is found to be malignant, laparotomy is the appropriate procedure. Careful preoperative assessment including transvaginal ultrasound with morphological scoring, colour doppler assessment of vascular quality, and serum cancer antigen 125 (CA 125) level is desirable. OBJECTIVES: To determine the benefits, harms, and cost of laparoscopy or minilaparotomy compared with laparotomy in women with benign ovarian tumours. SEARCH STRATEGY: We searched electronic databases, trial registers, and reference lists of published trial reports. Reference lists from trials and review articles were searched. SELECTION CRITERIA: All randomised controlled trials comparing either laparoscopy or minilaparotomy with laparotomy for benign ovarian tumours. DATA COLLECTION AND ANALYSIS: Eight review authors independently assessed the eligibility and quality of each study and extracted the data. MAIN RESULTS: The results of nine randomised controlled trials (N = 482 women) showed that laparoscopic surgery was associated with fewer adverse events of surgery (surgical injury or postoperative complications including fever or infection) (OR 0.3, 95% CI 0.2 to 0.5), less postoperative pain (VAS score WMD -2.4, 95% CI -2.7 to -2.0), greater likelihood of being pain free after two days (OR 7.42, 95% CI 4.86 to 11.33), and fewer days in hospital (WMD -2.88, 95% CI -3.1 to -2.7) than with laparotomy.In one study that reported costs, laparoscopy was associated with a significant reduction in costs compared to laparotomy (WMD - USD 1045, 95% CI -1348 to -742) in 1993. Very high levels of heterogeneity made it inappropriate to pool data on duration of surgery.Three RCTs compared laparoscopy versus minilaparotomy and found that laparoscopy was associated with reduced odds of any adverse event (surgical injury or postoperative complications) (OR 0.10, 95% CI 0 to 0.8) and lower VAS scores for pain (WMD -1.0, 95% CI -1.6 to -0.45). Duration of hospital stay ranged between 1 and 2.2 days, with substantial heterogeneity. AUTHORS' CONCLUSIONS: In women undergoing surgery for benign ovarian tumours, laparoscopy was associated with a reduction in fever, urinary tract infection, postoperative complications, postoperative pain, number of days in hospital, and total cost. These findings should be interpreted with caution since only a small number of studies were identified. These included a total of only 769 women and not all of the important outcomes were reported in each study.

The burden of modifiable cardiovascular risk factors in the coronary care unit by age, ethnicity, and socioeconomic status--PREDICT CVD-9.

AIMS: To investigate the burden of modifiable cardiovascular disease (CVD) risk factors in patients admitted to coronary care by age, ethnicity, and socioeconomic status. DESIGN AND SETTING: Cross-sectional study of patients presenting to the Middlemore Hospital Coronary Care Unit with an acute CVD event from July 2004 to June 2006. METHODS: CVD risk factor data was electronically collected using Acute PREDICT. Socioeconomic status was estimated using the NZ Deprivation 2001 index (NZDep01). RESULTS: Of 973 patients 34% were <55 years and 10% were <45 years, 24.8% were women, and 44.6% lived in areas classified as most deprived. 61.5% were European/other, 13.0% NZ Maori, 15.2% Pacific, and 10.3% South Asian. Younger patients, regardless of ethnicity, were much more likely to be smokers, be obese, have elevated LDL and trigyceride, and low HDL levels. Maori and Pacific patients were more likely than European/other patients to smoke, have diabetes, obesity, elevated triglycerides, and low HDL. These ethnic differences persisted across the age range. Increasing deprivation was associated with more smoking, obesity, hypertriglyceridaemia and diabetes, with the excess of smoking and obesity being most pronounced in younger patients. CONCLUSIONS: In patients presenting to coronary care, there is a high burden of adverse modifiable CVD risk factors, particularly in younger patients and among Maori and Pacific people from areas of high deprivation. These risk factors are a major and reversible contributor to future CVD risk in these groups, and an important target for secondary prevention programs.

Integrated electronic decision support increases cardiovascular disease risk assessment four fold in routine primary care practice.

BACKGROUND: A decade of cardiovascular disease (CVD) risk-based guidelines, education programmes and widespread availability of paper-based risk prediction charts have not significantly influenced targeting of CVD risk management in New Zealand primary care practice. A web-based decision support system (PREDICT-CVD), integrated with primary care electronic medical record software was developed as one strategy to address this problem. METHODS: A before-after audit of 3564 electronic patient records assessed the impact of electronic decision support on documentation of CVD risk and CVD risk factors. Participants were patients meeting national guideline criteria for CVD risk assessment, registered with 84/107 (78.5%) general practitioners (GPs) in one large primary care organization who used electronic patient medical records, and had PREDICT-CVD installed. The GPs received group education sessions, practice IT support and a small risk assessment payment. Four weeks of practice visit records were audited from 1 month after installation of PREDICT-CVD, and during the same 4-week period 12 months earlier. RESULTS: Less than 3% of eligible patients had a documented CVD risk before PREDICT-CVD installation. This increased four-fold (RR=4.0; 95% confidence interval 2.4-6.5) after installation and documentation of all relevant CVD risk factors also increased significantly. CONCLUSION: Documentation of CVD risk in primary care patient records in New Zealand is negligible, despite being recommended as a prerequisite for targeted treatment for over 10 years, suggesting that previous strategies were ineffective. We demonstrate that integrated electronic decision support can quadruple CVD risk assessment in just one cycle of patient visits.

Gaps in primary care documentation of cardiovascular risk factors.

BACKGROUND: New Zealand guidelines recommend that cardiovascular risk management should be informed by the absolute risk of a cardiovascular event. This requires knowledge of a person's age, sex, ethnicity, medical and family history, blood pressure, total and HDL cholesterol, diabetes, and smoking status. AIM: To establish the extent of primary care documentation of cardiovascular risk factors. METHODS: An audit of electronic patient records was conducted in practices affiliated with an Auckland primary care organisation (ProCare Health Ltd). The audited population were patients eligible for risk assessment (all Maori and a random sample of non-Maori) who had a consultation with their general practitioner during a four week study period (1 year before the doctor first used cardiovascular electronic clinical decision support software). Audit nurses searched for risk factors documented prior to the study period. RESULTS: The records of 1680 individuals from 84 doctors were audited. The study periods prior to which the records were inspected ranged from August 2001 to June 2003. The proportions of records with risk factors documented were: blood pressure 81.8%, cholesterol 62.4%, smoking status 41.5%, diabetes status 16.1%, all these risk factors 6.8%. Recording of blood pressure and of cholesterol was higher in those with cardiovascular disease or diabetes. Recording of blood pressure increased with increasing age, then levelled off at about age 60 years. Documentation of cholesterol was lowest in the oldest and youngest age groups, and in women (at all ages) compared to men. CONCLUSIONS: Primary care documentation of cardiovascular risk factors was incomplete. Whilst many doctors may know whether patients are smokers or have diabetes, systematic documentation of these factors in particular, is not occurring. In order to realise the large potential benefits associated with population-based cardiovascular risk assessment and management, a substantial investment by government, healthcare organisations, health professionals, and patients is required to collect and record this information.

Will a web-based cardiovascular disease (CVD) risk assessment programme increase the assessment of CVD risk factors for Maori?

BACKGROUND: Maori suffer disproportionately from cardiovascular disease despite the national priority of reducing inequalities. National guidelines on the clinical management of CVD risk recommend a comprehensive risk assessment be completed as a prerequisite for identifying patients most likely to benefit from treatment. METHODS: A retrospective audit of GPs using PREDICT-CVD (an electronic risk assessment and management tool) was designed with adequate explanatory power for Maori to determine if it could increase CVD risk assessment without increasing inequalities. 1680 electronic medical records (EMRs) prior to implementation and 1884 after implementation of PREDICT were audited. RESULTS: Documentation of CVD risk increased from 3.2% of EMRs to 14.7% of EMRs in Maori, and from 2.8% to 10.5% in non-Maori. The documentation of individual CVD risk factors also increased post-implementation of the tool. CONCLUSIONS: The implementation of PREDICT-CVD was as likely to increase documentation of CVD risk assessment and risk factors in Maori as in non-Maori. However documentation was still low in Maori despite known high prevalence of CVD risk factors. A comprehensive quality-driven implementation programme is recommended, including targeting risk assessment for those most in need.

The natural history of acute histologic rejection without biochemical graft dysfunction in orthotopic liver transplantation: a systematic review.

Protocol biopsy results in the first few weeks after liver transplantation sometimes display histologic features of acute cellular rejection (ACR), even in the absence of significant clinical or biochemical dysfunction. At present there is no clear consensus about the need to treat such cases with adjuvant immunosuppression. This systematic review describes, from the available evidence, the natural history of untreated histologic ACR in the absence of biochemical graft dysfunction. An electronic search of the Medline, Embase, and Cochrane Library databases was performed to select studies that reported protocol liver biopsies in the early posttransplant period from 1983 to 2000. Studies that identified patients with ACR on protocol biopsy who were not treated with adjuvant immunosuppression formed the basis of the study group. Data from individual studies were extracted using standardized pro forma and pooled for descriptive analysis. The search identified 3431 studies, of which 516 were cited in full. Of these, 15 studies met all of the inclusion criteria. These 15 studies reported on 1566 patients who had protocol biopsies performed in the early posttransplant period, of which 1048 (67%) had histologic evidence of ACR. Three hundred and thirty one (32%) patients with histologic ACR on protocol biopsy had no associated biochemical graft dysfunction. Without treatment, only 14% of these patients subsequently developed biochemical graft dysfunction requiring adjuvant immunosuppression. Steroid-resistant rejection and chronic rejection both had a prevalence of 4% in patients with untreated histologic ACR and no biochemical graft dysfunction. Withholding adjuvant immunosuppression from patients with histologic ACR and no biochemical graft dysfunction seems to be safe, as long as graft function is carefully monitored. The rationale for performing protocol biopsies in the absence of biochemical graft dysfunction is questionable.

Cost effectiveness of pre-operative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy.

OBJECTIVE: To conduct a cost effectiveness analysis of pre-operative gonadotrophin releasing hormone agonists (GnRHa) in women with uterine fibroids undergoing hysterectomy or myomectomy. DESIGN: A cost effectiveness analysis using the effectiveness data from a systematic review of GnRHa. SETTING: Secondary care. SAMPLE: Women with uterine fibroids undergoing hysterectomy or myomectomy and women volunteers. METHODS: Effectiveness data were used from a systematic review to construct a model and to calculate the cost per surgical outcome avoided. In order to evaluate the value women place on the outcome, a willingness to pay analysis of women volunteers was undertaken. MAIN OUTCOME MEASURES: (a) The cost of avoiding abdominal hysterectomy and the cost of avoiding a vertical incision at either hysterectomy or myomectomy; (b) The value that women place on avoiding abdominal hysterectomy and on avoiding a vertical incision at either hysterectomy or myomectomy. All costs are in NZ dollars. RESULTS: For hysterectomy, the additional cost of treatment with GnRHa was NZ$1190 per case. The cost of avoiding one abdominal procedure was NZ$4577 per case and the cost of avoiding one vertical incision was NZ$6263. For a myomectomy, the additional cost of treatment with GnRHa was NZ$1535 per case. The cost of avoiding one vertical incision was NZ$4651 per case. These costs exceeded the benefit women placed on the outcomes. CONCLUSION: Although the pre-operative use of GnRHa results in benefits which include less frequent abdominal incisions in the case of hysterectomy and less frequent vertical incisions in the case of myomectomy, the benefits do not justify the costs. This study highlights the importance of considering both the benefits and costs in health care decisions.