A Call for Appropriate Evidence and Outcomes-Based Use and Measurement of Anticoagulation for Atrial Fibrillation: Moving the Population Towards Improved Health Via Multiple Stakeholders.

A multidimensional approach involving consideration of available resources, individual patient characteristics, patient preferences, and cost of treatment is often required to optimize clinical decision making in the management of atrial fibrillation (AF). In order to bring together varying perspectives on effective tactics and to formulate innovative strategies to improve the management of AF, a think tank consortium of advisors was assembled from across the spectrum of health care stakeholders. Focus groups were conducted and facilitated by a moderator and a notetaker. Participants were asked to comment on preliminary data for the increased prevalence of AF, patterns of treatment, impact of adherence with anticoagulants on clinical and economic outcomes, and opportunities for optimizing treatment.Several recommendations to reach short- and long-term goals in improving AF management emerged from the focus group discussions. These recommendations specifically targeted 3 stakeholder groups--patients/caregivers, physicians, and payers--and addressed the need for better understanding of determinants of undertreatment and nonadherence for those on anticoagulation therapy. Recommendations included the use of real-world data studies to understand regional and demographic patterns of treatment and outcomes, the development of an enhanced national quality standard for anticoagulation, and engaging patients in shared decision making to optimize satisfaction with treatment. Actionable strategies were presented to address gaps related to anticoagulation management. Balancing new anticoagulants' higher prescription costs and safety concerns with their superior effectiveness and convenience of administration for at-risk individuals would require a concerted effort involving patients and their caregivers, physicians, and payers.

Photooxidation of methylnaphthalenes.

Studies on the photooxidation of methyl-substituted aromatic hydrocarbons have revealed that whereas electron density is a determinant of endoperoxide formation, steric factors are most important in influencing the stability of the endoperoxide. Additional information on the energetics of the reactions and on the magnitude of the steric interactions was obtained using calculations at the B3LYP/6-311+G* level of theory.

Longitudinal assessment of a diabetes care management system in an integrated health network.

OBJECTIVE: To describe the results of longitudinal assessment of the results of a disease management process developed in a large integrated health care system that successfully improved care for patients with diabetes. Outcome measures included rates of testing of hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL), rate of annual eye exams, and LDL and HbA1c values. METHODS: Intermountain Health Care (IHC) initiated the development of a Diabetes Care Management System (DCMS) in early 1998. The DCMS was developed as a comprehensive population-based disease management system. It includes provider education programs; performance feedback to physicians; clinical quality performance incentives for physicians; patient education programs; patient incentive, reminder systems to encourage compliance with best care process models; and tracking of physician behavior change and patient compliance with diabetes therapy. A multifaceted intervention and education approach was chosen because of the complexity of the diabetes treatment process. RESULTS: The percentage of patients with at least one annual HbA1c test increased from 78.5% in 1998 to 90.5% in 2002. During the same time period, the percentage of patients whose most recent HbA1c was less than 7.0 increased from 33.5% to 52.8%, average HbA1c decreased from 8.1 to 7.3, and the percentage of patients whose most recent HbA1c was greater than 9.5 decreased from 34.6% to 21.4%. The percentage of patients who had an LDL cholesterol screening test within the prior 2 years increased from 65.9% in 1998 to 91.7% in 2002. During the same time period, the percentage of patients whose most recent LDL cholesterol was less than 130 mg/dL increased from 39.9% to 69.8%. The percentage of diabetes patients who had an annual eye exam increased from 52% in 1998 to 62% in 2002. CONCLUSION: A multifaceted approach to improving diabetes management has led to improved performance in clinical measures related to diabetes care that have been shown to reduce the risk of patients with diabetes developing diabetes- related complications. All components of the diabetes management continuum of care, including primary care physicians, specialists, office staff, patients, diabetes educators, and others, were involved in the care improvement activities.