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F Gobel

Publications and source records attributed to F Gobel.

6 recordsLinked to original sources
PubMed2000

The role of clinical opinion leaders in guideline implementation and quality improvement.

BACKGROUND: The lag between the publication of clinical and health-services research and the application of this information is substantial and delays health-care improvement. A wide range of corrective strategies are being used to address this issue. OBJECTIVES: Evolution in the use of significant opinion leaders is described. Hospital quality improvement projects, undertaken by the Healthcare Education and Research Foundation (HERF), are used to illustrate the roles assumed by clinical opinion leaders. Specific theoretical frameworks are reviewed that are fundamental to successful implementation of opinion leader strategies, as well as key research on the use of clinical opinion leaders. RESULTS: Over the past 12 years, HERF has identified the need to address not only the information needs of clinicians and organizations but also the social and organizational factors that interfere with the application of research and guidelines. The complexity of this task cannot be underestimated. However, armed with well-developed guidelines and the opportunity to work within structured guideline implementation programs with well-defined objectives and systematically applied methods, HERF's experience suggest local clinicians and communities can meet this challenge.

Adrenergic beta-Antagonists↗
PubMed1998

Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial.

CONTEXT: The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood. OBJECTIVE: To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, beta-blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine). DESIGN: Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis. SETTING: Thirty-seven community hospitals in Minnesota. PATIENTS: All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention. INTERVENTION: Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback. MAIN OUTCOME MEASURES: Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug. RESULTS: Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of -0.03 at control hospitals (P=.04). For beta-blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours. CONCLUSIONS: Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, beta-blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients.

Adrenergic beta-Antagonists↗
PubMed1997

The effect of comorbidity on use of thrombolysis or aspirin in patients with acute myocardial infarction eligible for treatment.

OBJECTIVE: Growing evidence indicates that life-sustaining therapies for the treatment of acute myocardial infarction (AMI) are underused among patients eligible for therapy, including the elderly and women. We examined the effect of a patient's comorbidity burden on use of these highly effective therapies in eligible populations of individuals with AMI. DESIGN: Retrospective cohort design. SETTING AND PATIENTS: We reviewed the medical records of 2,409 individuals at 37 Minnesota hospitals from October 1992 through July 1993 with an admission diagnosis of AMI, suspected AMI, or rule-out AMI, who met electrocardiographic, laboratory, and clinical criteria for AMI. MEASUREMENTS AND MAIN RESULTS: Using multivariate logistic regression models, we determined the association between a validated comorbidity measure and the proportion of eligible patients who received thrombolysis or aspirin. Controlling for other factors previously reported to influence rates of study treatment, the odds of receipt of thrombolysis among patients with severe comorbidity was 0.49 (95% confidence interval [CI] 0.27, 0.88) when compared with individuals without such limitation. Similarly, the odds of aspirin treatment among study patients with severe comorbidity was 0.46 (95% CI 0.30 0.72), compared with individuals without severe comorbidity. We did not distinguish any differences in patterns of treatment with either study treatment among patients with mild or moderate comorbidity when compared with individuals without any concomitant comorbidity. CONCLUSIONS: This study indicates that patients with severe mental and physical comorbidities are less likely to receive standard therapies for AMI recommended in national treatment guidelines.

Aged↗
PubMed1996

Adherence to national guidelines for drug treatment of suspected acute myocardial infarction: evidence for undertreatment in women and the elderly.

BACKGROUND: Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings. METHODS: Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patients who received thrombolytic, beta-blocker, aspirin, and lidocaine hydrochloride therapy. The effects of patient age, gender, and hospital teaching status on the use of these treatments were estimated using logistic regression models. RESULTS: Eligibility for treatment ranged from 68% (n=1627) for aspirin therapy, 38% (n=906) for lidocaine therapy, and 30% (n=734) for thrombolytic therapy to 19% (n=447) for beta-blocker therapy. Seventy-two percent of patients eligible to receive a thrombolytic agent received this therapy; 53% received beta-blockers; 81% received aspirin; and 88% received lidocaine. Among patients ineligible for lidocaine therapy (n=1503), 20% received this agent. Use of study drugs was lower among eligible elderly patients, especially those older than 74 years (thrombolytic agent: odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; aspirin: odds ratio, 0.4, 95% confidence interval, 0.3 to 0.6; beta-blocker: odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Female gender was associated with lower levels of aspirin use among eligible patients (odds ratio, 0.7; 95% confidence interval, 0.6 to 0.9); and there was a trend toward lower levels of beta-blocker and thrombolytic use among eligible women. CONCLUSIONS: Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients. Lidocaine is still used inappropriately in a substantial proportion of patients with AMI. Increased adherence to AMI treatment guidelines is required for elderly patients and women.

Adrenergic beta-Antagonists↗
PubMed1991

Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis.

To determine if transesophageal echocardiography provides better visualization of valvular vegetations than transthoracic echocardiography, we used both methods to evaluate 24 consecutive patients (mean age, 54 years; 15 female patients and nine male patients) referred for symptoms suggestive of infectious endocarditis. Ten of the 24 patients had one or more valvular prostheses. Echocardiograms were classified as positive or negative based on visualization of valvular vegetations or abscesses. Of ten patients with a final diagnosis of infectious endocarditis on extended follow-up, transthoracic echocardiography was positive in five patients. Transesophageal echocardiography not only yielded abnormal findings in all ten of these patients, but also revealed additional information in four of the five patients with abnormal transthoracic echocardiographic examinations. Among the 14 patients who, on subsequent follow-up, were found not to have infectious endocarditis, transthoracic echocardiography was normal in 13 and falsely abnormal in one. Transesophageal echocardiography revealed no evidence of infectious endocarditis in any of these patients. The ten patients who were determined to have infectious endocarditis all had positive blood cultures and no alternative cause for their clinical presentation; in seven patients in this group who underwent operative or postmortem evaluation, infectious endocarditis was confirmed. All patients without infectious endocarditis were demonstrated to have other causes for their clinical presentation. We conclude that transesophageal echocardiography is a highly valuable test in the work-up of patients with suspected infectious endocarditis, especially those patients with inconclusive or normal transthoracic echocardiograms. In addition, transesophageal echocardiography may be of benefit to patients with previously documented infectious endocarditis and a complicated clinical course in whom additional cardiac lesions are suspected but not demonstrated by transthoracic echocardiography.

Abscess↗