Post-Prandial Lipid Levels for Assessing Target Goal Achievement in Type 2 Diabetic Patients Taking Statin

It is inconvenient to perform serum lipid analysis in fasting state in diabetic patients with drug treatment. In patients with statin treatment and Asian diet, it has not been clearly known whether non-fasting values could be used for the clinical decision making in diabetic patients. In this study, fasting and post-prandial plasma lipid profiles of hospitalized type 2 diabetic patients taking statin, were measured in whom standard diabetic breakfast in traditional Korean style were provided. In repeated-measures ANOVA, there were no significant differences among fasting, post-prandial 2 and 4 hr low-density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol values. When compared to fasting levels, both post-prandial 2 hr and 4 hr LDL cholesterol levels were misclassified as not achieved target goal only in 4% of patients. Post-prandial HDL cholesterol matched with fasting values in women, without exception. In conclusion, the fasting and post-prandial LDL and HDL cholesterol levels are not significantly different each other and can be used in the assessment of achieving target goal in type 2 diabetes taking statin after Korean diet

Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register

Aims To investigate the application of the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QI) for acute myocardial infarction for the study of hospital performance and 30-day mortality. Methods and results National cohort study (n = 118,075 patients, n = 211 hospitals, MINAP registry), 2012-13. Overall, 16 of the 20 QIs could be calculated. Eleven QIs had a significant inverse association with GRACE risk adjusted 30-day mortality (all P < 0.005). The association with the greatest magnitude was high attainment of the composite opportunity-based QI (80-100%) vs. zero attainment (odds ratio 0.04, 95% confidence interval 0.04-0.05, P < 0.001), increasing attainment from low (0.42, 0.37- 0.49, P < 0.001) to intermediate (0.15, 0.13-0.16, P < 0.001) was significantly associated with a reduced risk of 30-day mortality. A 1% increase in attainment of this QI was associated with a 3% reduction in 30-day mortality (0.97, 0.97-0.97, P < 0.001). The QI with the widest hospital variation was ′fondaparinux received among NSTEMI′ (interquartile range 84.7%) and least variation ′centre organisation′ (0.0%), with seven QIs depicting minimal variation (<11%). GRACE risk score adjusted 30-day mortality varied by hospital (median 6.7%, interquartile range 5.4-7.9%). Conclusions Eleven QIs were significantly inversely associated with 30-day mortality. Increasing patient attainment of the composite quality indicator was the most powerful predictor; a 1% increase in attainment represented a 3% decrease in 30-day standardised mortality. The ESC QIs for acute myocardial infarction are applicable in a large health system and have the potential to improve care and reduce unwarranted variation in death from acute myocardial infarction

Determinants of avoidable deaths from ischemic heart disease in East and West Germany

Objective: Within Germany, a significant decrease in avoidable mortality from ischemic heart disease (IHD) has been observed since the early 1990s. The objective of this paper is to identify the specific reasons that have led to the decrease in the number of avoidable deaths from IHD in West and East Germany from 1996 to 2004. Methods: We analyzed the mortality rate from IHD of the male population aged less than 65 years on the regional level of German counties over the 1996–2004 period. Methodologically, after adjusting for a number of health structure variables, the socioeconomic structure of each region, and yearly time trends in avoidable mortality, we accounted for unobservable differences among regions by using a fixed-effect estimator. Results: Our main result reveals that the number of intracardiac catheter facilities, an important diagnostic tool for IHD, significantly accounts for decreases in avoidable mortality from IHD. This is important, as the modernization of the East German health sector included a considerable catching-up process in the number of IC facilities provided relative to West Germany. Conclusion: Our results suggest that the modernization of the East German health sector may have contributed to saving people from premature deaths

Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study

<p>Abstract</p> <p>Background</p> <p>Antihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing.</p> <p>Methods</p> <p>In this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.</p> <p>All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes.</p> <p>Results</p> <p>In all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001).</p> <p>Conclusions</p> <p>A multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.</p

A randomized trial to assess the impact of opinion leader endorsed evidence summaries on the use of secondary prevention strategies in patients with coronary artery disease: the ESP-CAD trial protocol [NCT00175240]

BACKGROUND: Although numerous therapies have been shown to be beneficial in the prevention of myocardial infarction and/or death in patients with coronary disease, these therapies are under-used and this gap contributes to sub-optimal patient outcomes. To increase the uptake of proven efficacious therapies in patients with coronary disease, we designed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care, with one-page treatment guidelines endorsed by local opinion leaders ("Local Opinion Leader Statement"). This trial is designed to evaluate the impact of these Local Opinion Leader Statements on the practices of primary care physicians caring for patients with coronary disease. In order to isolate the effects of the messenger (the local opinion leader) from the message, we will also test an identical quality improvement intervention that is not signed by a local opinion leader ("Unsigned Evidence Statement") in this trial. METHODS: Randomized trial testing three different interventions in patients with coronary disease: (1) usual care versus (2) Local Opinion Leader Statement versus (3) Unsigned Evidence Statement. Patients diagnosed with coronary artery disease after cardiac catheterization (but without acute coronary syndromes) will be randomly allocated to one of the three interventions by cluster randomization (at the level of their primary care physician), if they are not on optimal statin therapy at baseline. The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization. Secondary outcomes include examinations of the use of ACE inhibitors, anti-platelet agents, beta-blockers, non-statin lipid lowering drugs, and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms. Although randomization will be clustered at the level of the primary care physician, the design effect is anticipated to be negligible and the unit of analysis will be the patient. DISCUSSION: If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease, they can be easily modified and applied in other communities and for other target conditions