摘要:

Attempts to modify physician behaviour and reduce practice variation with guidelines have had limited success, largely because of inadequate attention and resources devoted to implementing the guidelines in clinical production environments.While much of what determines the ultimate impact of a guideline has little to do with technology, information technology offers new and powerful methods for guideline implementation. These methods include concurrent and delayed patient-specific decision support. workflow modification. and delayed feedback of aggregate patient data. Ideally, technology should be used to reduce physician cognitive burden and workload while simultaneously achieving guideline objectives.The most effective use of information technology occurs when patient-specific decision support is delivered concurrently with no effort required on the part of the physician. Physician order entry systems provide the most straightforward means of accomplishing this. However, until the clinical information system infrastructure is in place to support patient-specific feedback during an encounter, implementation strategies such as nurse-initiated orders and disease state management remain viable and important alternatives.

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS

摘要:

Congestive heart failure (CHF), a state of abnormal cardiac function. is a common end-stage of heart disease, greatly shortening survival. In the US, as in many countries, it is an increasingly major burden on families and the healthcare system. Nearly 5 million people have CHF, it is the leading diagnosis in hospitalisations of persons aged 65 years and over, 13% of all deaths in 1993 had CHF mentioned on the death certificate, and healthcare expenditures amounted to $US17.5 billion in 1993.Prevalence, mortality, hospitalisations and visits to physicians for CHF are increasing. They are expected to continue increasing as the numbers of older persons in the population increase and as survival following coronary heart disease continues to improve. In a community cohort study, median survival following initial CHF was only 1.7 years in men and 3.2 years in women.The risk of CHF depends on a person's status with respect to predisposing diseases and risk factors. Hypertension, which is present in 50 million people, carries the largest attributable risk of CHF. Myocardial infarction carries the next highest attributable risk, followed by diabetes. Means for early detection and control of hypertension and myocardial infarction have been proven effective, however, they are not being fully utilised. The goal should be to prevent or limit myocardial damage before CHF ensues. Using ordinary office procedures, high risk candidates for CHF can be detected before overt manifestations present. Treatment of hypertension and left ventricular dysfunction can decrease incidence of CHF, and use of ACE inhibitors or vasodilators can prolong survival.

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS

摘要:

To assess the magnitude of the problem of stroke, data were summarised from several national surveys conducted by the National Center for Health Statistics. This report describes the occurrence of stroke and the utilisation of healthcare services for stroke in the US, with special attention to the population 65 years of age and over. In 1993, 150 108 deaths were attributed to stroke, the third leading cause of death. Death rates rose steeply with age and men had higher death rates than women. Death rates were lower in Whites than in Blacks with the exception of ages 85 and over. Considerable geographic variation in stroke mortality was also noted.Since 1979, stroke death rates have continued the long term decline, albeit slowed, in each age, sex and race group. There were probably nearly 3 million persons with diagnosed stroke in the civilian noninstitutionalised population in the US in 1994. In 1993, over 841 000 persons were discharged from short-stay hospitals with a principal diagnosis of stroke. The discharge rate was 328 per 100 000. The hospital fatality rate was 7.8% for all cerebrovascular disease.Since 1988, hospitalisation rates for stroke have changed little while hospital fatality rates have decreased. In 1994, there were 2 million visits to physicians' offices for stroke, 1.6 million in persons aged 65 and over. Among nursing home residents in the 1980s, the prevalence of diagnosed stroke was 193 per 1000. In 1995, expenditures for stroke totalled $US18 000 million in the US. Although mortality rates from stroke among persons 65 years of age and over have continued to decrease since 1979, disability and hospitalisation rates and utilisation of other services stress the need for even more vigorous efforts for primary prevention of stroke to reduce the burden of illness, and not just the mortality rate from stroke.

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS

摘要:

Stroke presents an important health problem which has an impact at personal, social and public health levels and exerts a major influence on the morbidity, mortality and healthcare costs of most populations. This article reviews the primary, secondary and tertiary interventions that could reduce the incidence or burden of stroke in the general population.A systematic (MEDLINE) computer search of the literature and review of the relevant information using standard techniques was used to assess the validity. importance and appropriateness of the evidence. This basic approach was supplemented with more detailed searches for relevant randomised trials.The results showed that primary prevention should be directed at the major risk factors of hypertension. smoking, diabetes mellitus, atrial fibrillation and lifestyle. We currently have evidence to support primary prevention treatment of hypertension, smoking cessation and antithrombotic treatment in atrial fibrillation. Secondary prevention measures with good evidence of benefit include the routine use of aspirin (acetylsalicylic acid), anticoagulation in atrial fibrillation and surgery for severe, symptomatic carotid stenosis. There is evidence to support organised (stroke unit) care to reduce the impact of stroke disease (tertiary prevention).Maximising health outcomes at a population level will need to include primary prevention directed at common risk factors, secondary prevention in high-risk individuals, and organised services for those who have suffered a stroke.

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS

摘要:

Patients are asymptomatic during the majority of HIV infection. The virus, however, is actively replicating, producing over 1 billion particles per day during this steady-state of the disease. Management of asymptomatic HIV infection involves initial recognition of infection and counselling to prevent its further spread.When HIV infection has been confirmed, assessment consists of a careful history, physical examination and laboratory studies. The latter include serological tests for past exposure to infectious agents such as syphilis, hepatitis viruses, cytomegalovirus and toxoplasmosis. A purified protein derivative (PPD) skin test should also be performed. The immunological and virological status of the patient is assessed by quantifying CD4+ count and plasma HIV RNA levels. With the aid of these data, a decision can be made on the use of antiretroviral therapy.Didanosine (ddI) is the only currently acceptable monotherapy. Combinations of antiretroviral drugs which have undergone evaluation include zidovudine (AZT) plus didanosine, zidovudine plus zalcitabine (ddC), zidovudine plus lamivudine (3TC), didanosine plus lamivudine, zidovudine plus didanosine plus nevirapine, zidovudine plus saquinavir, zidovudine plus zalcitabine plus saquinavir (D4T), zidovudine plus ritonavir, zidovudine plus lamivudine plus indinavir, and ritonavir plus saquinavir.The optimum combination treatment has not been defined, but many appear promising. In addition, treatment for subclinical infections and prophylaxis should be administered. These include treatment of all PPD-positive patients with isoniazid 300 mg/day orally for 1 year; prophylaxis againstPneumocystis cariniipneumonia for all patients with CD4+ counts <200/mm3with cotrimoxazole (trimethoprim plus sulfamethoxazole) one double-strength tablet daily, dapsone or dapsone plus trimethoprim; prophylaxis against toxoplasmosis in patients with CD4+ counts <100/mm3with cotrimoxazole or with dapsone plus pyrimethamine; prophylaxis against disseminatedMycobacterium aviumcomplex disease in patients with CD4+ counts <75/mm3with azithromycin 1200mg orally once weekly, clarithromycin 500mg orally twice daily, or rifabutin 300 mg/day orally; and prophylaxis againstStreptococcus pneumoniaepneumonia and bacteraemia by administration of the 23-valent pneumococcal vaccine.Although cytomegalovirus disease occurs in most patients with advanced HIV disease (CD4+ <50/mm3), primary prophylaxis is not recommended because of conflicting data concerning the efficacy of oral ganciclovir. Primary prophylaxis against cryptococcosis is not recommended because of the low incidence of this infection.

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS

ISSN:1173-8790    

出版商:ADIS    

年代:1997

数据来源: ADIS