Improving eye care for veterans with diabetes: An example of using the QUERI steps to move from evidence to implementation: QUERI Series

<p>Abstract</p> <p>Background</p> <p>Despite being a critical part of improving healthcare quality, little is known about how best to move important research findings into clinical practice. To address this issue, the Department of Veterans Affairs (VA) developed the Quality Enhancement Research Initiative (QUERI), which provides a framework, a supportive structure, and resources to promote the more rapid implementation of evidence into practice.</p> <p>Methods</p> <p>This paper uses a practical example to demonstrate the use of the six-step QUERI process, which was developed as part of QUERI and provides a systematic approach for moving along the research to practice pipeline. Specifically, we describe a series of projects using the six-step framework to illustrate how this process guided work by the Diabetes Mellitus QUERI (DM-QUERI) Center to assess and improve eye care for veterans with diabetes.</p> <p>Results</p> <p>Within a relatively short time, DM-QUERI identified a high-priority issue, developed evidence to support a change in the diabetes eye screening performance measure, and identified a gap in quality of care. A prototype scheduling system to address gaps in screening and follow-up also was tested as part of an implementation project. We did not succeed in developing a fully functional pro-active scheduling system. This work did, however, provide important information to help us further understand patients' risk status, gaps in follow-up at participating eye clinics, specific considerations for additional implementation work in the area of proactive scheduling, and contributed to a change in the prevailing diabetes eye care performance measure.</p> <p>Conclusion</p> <p>Work by DM-QUERI to promote changes in the delivery of eye care services for veterans with diabetes demonstrates the value of the QUERI process in facilitating the more rapid implementation of evidence into practice. However, our experience with using the QUERI process also highlights certain challenges, including those related to the hybrid nature of the research-operations partnership as a mechanism for promoting rapid, system-wide implementation of important research findings. In addition, this paper suggests a number of important considerations for future implementation work, both in the area of pro-active scheduling interventions, as well as for implementation science in general.</p

The effect of endurance training on human ammonia metabolism

This thesis examines human ammonia (NH3) metabolism in trained and untrained individuals. Specifically, these aspects include: 1) plasma NH3 accumulation during exercise at similar absolute and relative work intensities; 2) plasma NH3 accumulation during recovery from maximal exercise; 3) the absolute and relative work intensities at which blood lactate (LA) and plasma NH3 concentrations begin to rapidly accumulate (i.e the LA breakpoint - LABP, and NH3 breakpoint - NH3BP); 4) the relationship between the NH3BP and LABP, and 5) the relationship between plasma NH3, blood (LA), and muscle fibre type

The influence of allopurinol on urinary purine loss after repeated sprint exercise in man

The influence of allopurinol on urinary purine loss was examined in 7 active male subjects (age 24.9 &plusmn; 3.0 years, weight 82.8 &plusmn; 8.3 kg, V˙o2peak 48.1 &plusmn; 6.9 mL &middot; kg&minus;1 &middot; min&minus;1). These subjects performed, in random order, a trial with 5 days of prior ingestion of a placebo or allopurinol. Each trial consisted of eight 10-second sprints on an air-braked cycle ergometer and was separated by at least a week. A rest period of 50 seconds separated each repeated sprint. Forearm venous plasma inosine, hypoxanthine (Hx) and uric acid concentrations were measured at rest and during 120 minutes of recovery from exercise. Urinary inosine, Hx, xanthine, and uric acid excretion were also measured before and for 24 hours after exercise. During the first 120 minutes of recovery, plasma Hx concentrations, as well as the urinary Hx and xanthine excretion rates, were higher (P &lt; .05) with allopurinol compared with the placebo trial. In contrast, plasma uric acid concentration and urinary uric acid excretion rates were lower (P &lt; .05) with allopurinol. The total urinary excretion of purines (inosine + Hx + xanthine + uric acid) above basal levels was higher in the allopurinol trial compared with placebo. These results indicate that the total urinary purine excretion after intermittent sprint exercise was enhanced with allopurinol treatment. Furthermore, the composition of urinary purines was markedly affected by this drug.<br /

Race-day carbohydrate intakes of elite triathletes contesting olympic-distance triathlon events

The aim of this study was to investigate the prerace and during-race carbohydrate intakes of elite-level triathletes contesting draft-legal Olympic-distance triathlon (ODT) events. Self-reported prerace and during-race nutrition data were collected at 3 separate ODT events from 51 elite senior and under-23 triathletes. One hundred twenty-nine observations of food and fluid intake representing actual prerace (n = 62) and during-race (n = 67) nutrition practices from 36 male and 15 female triathletes were used in the final analysis of this study. Female triathletes consumed significantly more carbohydrate on the morning before race start when corrected for body mass and race start time than their male counterparts (p &lt; .05). Male and female triathletes consumed 26% more energy (kJ/kg) and 24% more carbohydrate (g/kg) when commencing a race after midday (1:00-1:30 p.m.) than for a late morning (11:00-11:15 a.m.) race start. During the race, triathletes consumed less than 60 g of carbohydrate on 66% of occasions, with average total race intakes of 48 &plusmn; 25 and 49 &plusmn; 25 g carbohydrate for men and women, respectively. Given average race times of 1:57:07 hr and 2:08:12 hr, hourly carbohydrate intakes were &sim;25 g and &sim;23 g for men and women, respectively. Although most elite ODT triathletes consume sufficient carbohydrate to meet recommended prerace carbohydrate intake guidelines, during-race carbohydrate intakes varied considerably, with many failing to meet recommended levels.<br /

Creatine supplementation increases muscle total creatine but not maximal intermittent exercise performance

This study investigated creatine supplementation (CrS) effects on muscle total creatine (TCr), creatine phosphate (CrP), and intermittent sprinting performance by using a design incorporating the time course of the initial increase and subsequent washout period of muscle TCr. Two groups of seven volunteers ingested either creatine [Cr; 6 &times; (5 g Cr-H2O + 5 g dextrose)/day)] or a placebo (6 &times; 5 g dextrose/day) over 5 days. Five 10-s maximal cycle ergometer sprints with rest intervals of 180, 50, 20, and 20 s and a resting vastus lateralis biopsy were conducted before and 0, 2, and 4 wk after placebo or CrS. Resting muscle TCr, CrP, and Cr were unchanged after the placebo but were increased (P &lt; 0.05) at 0 [by 22.9 &plusmn; 4.2, 8.9 &plusmn; 1.9, and 14.0 &plusmn; 3.3 (SE) mmol/kg dry mass, respectively] and 2 but not 4 wk after CrS. An apparent placebo main effect of increased peak power and cumulative work was found after placebo and CrS, but no treatment (CrS) main effect was found on either variable. Thus, despite the rise and washout of muscle TCr and CrP, maximal intermittent sprinting performance was unchanged by CrS.<br /