Time for chronic disease care and management.

To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.

Effects of long term cholesterol lowering on coronary atherosclerosis in patient risk factor subgroups: the Simvastatin/enalapril Coronary Atherosclerosis Trial (SCAT).

This study examined the effects of long term cholesterol lowering therapy with simvastatin on progression and regression of coronary atherosclerosis, as determined by quantitative angiographic end points, in subgroups of patients with known coronary risk factors. In this randomized, placebo controlled clinical trial, the effect of simvastatin on coronary atherosclerosis was compared with that of placebo in 394 patients who had paired coronary angiograms taken an average of four years apart. The effects of treatment on the following prespecified subgroups were examined: sex, age (less than 65 years versus at least 65 years), smoking status (current or previous/never), history of diabetes mellitus or hypertension, and severity of coronary artery lesions (diameter at least 50% versus less than 50%). There were significantly smaller decreases in the average minimum diameters, between closeout and baseline angiograms, in all simvastatin-treated subgroups, compared with placebo. Trends toward or significantly smaller decreases in the average of the mean diameters, and similar smaller increases in percentage diameter stenosis were also seen in all subgroups. The slowing of angiographically demonstrable coronary atherosclerotic narrowing supports the contention that this treatment effect is causally related to the reduction of coronary events repeatedly seen in large outcome clinical trials of lipid lowering therapy. Also, this treatment effect occurs in the presence or absence of the traditional coronary risk factors.

Effects of the 1994 Canadian Cardiovascular Society clinical practice guidelines for congestive heart failure.

BACKGROUND: In 1994, the Canadian Cardiovascular Society (CCS) issued practice guidelines for the management of congestive heart failure (CHF), which strongly recommended the use of angiotensin-converting enzyme (ACE) inhibitors. OBJECTIVE: To compare a strategy of active implementation of the CCS guidelines for CHF with the usual passive approach on the use of ACE inhibitors in hospitalized patients with CHF. PATIENTS AND METHODS: The study was conducted in eight Canadian hospitals close to the time of release of the CCS guidelines for CHF in the summer of 1994. The patients comprised those who were admitted to the participating hospitals with a diagnosis of CHF during the study period. Active dissemination included stakeholder development of pocket cards outlining an algorithm for the management of CHF based on the CCS guidelines and was conducted at the two Edmonton, Alberta hospitals. The cards were widely disseminated in conjunction with a series of workshops and presentations. Passive dissemination occurred at six other hospitals, and involved only the distribution of the CCS guidelines in the usual fashion (with no structured dissemination program). The primary outcome measured was the use of ACE inhibitors in the six- to 12-month period before the release of the CCS guidelines, compared with after the release in the active and passive groups. RESULTS: In the active group, hospital records of 1170 patients with CHF were reviewed before, and 1279 were reviewed after, the release of the CCS guidelines. In the passive group, 3436 were reviewed before, and 1912 were reviewed after the release of the guidelines. ACE inhibitor use did not change significantly in the active group (52.4% before versus 50.9% after) or in the passive group (53.4% before versus 56.5% after). CONCLUSIONS: Neither the active nor passive approaches to the dissemination of the CCS guidelines for CHF had any impact on the use of ACE inhibitors in hospitalized patients with CHF. Further efforts to package, deliver and evaluate guidelines are needed.