Where medicine and technology meet. Four strategies for gaining physician support and acceptance of evidence-based medicine.
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Biomedical subjects
Publications and source records attributed to G Ellrodt.
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Disease management is an approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across health care delivery systems. Evidence-based medicine is an approach to practice and teaching that integrates pathophysiological rationale, caregiver experience, and patient preferences with valid and current clinical research evidence. Using diabetes mellitus as an example, we describe the importance of evidence-based medicine to the development of disease management programs. We present a method for developing and implementing evidence-based clinical guidelines, clinical pathways, and algorithms and describe the creation of systems to measure and report processes and outcomes that could drive quality improvement in diabetes care. Multidisciplinary teams are ideally suited to develop, lead, and implement evidence-based disease management programs, since they play an essential role in the preventive, diagnostic, and therapeutic decisions for patients with diabetes throughout the course of their disease.
The efficacy of intravenous procainamide, infused at 30 mg/min to a maximum dose of 20 mg/kg, in converting atrial fibrillation was evaluated under electrocardiographic and blood pressure control in 21 patients. Nine patients had atherosclerotic heart disease, seven had valvular lesions, five had hypertension, and six had no apparent heart disease. Nine patients (converters), who reverted to sinus rhythm at a mean dose of procainamide of 13.3 +/- 3.6 mg/kg (mean plasma concentration, 7.4 +/- 3.9 micrograms/ml) had normal echocardiographic left atrial diameters. All but one of the remainder, the 12 non-converters, who received a mean drug dose of 13.1 +/- 3.5 mg/kg (mean plasma concentration 13.9 +/- 7.6 micrograms/ml), had atrial diameters exceeding 4.0 cm. QRS and QTc intervals were not altered significantly in converters, but were prolonged significantly in non-converters. No serious side effects from the infusion were encountered. Intravenous procainamide infusion appears to be a safe and rapidly effective method of converting recent-onset atrial fibrillation to sinus rhythm in patients with normal left atrial dimensions.
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Verapamil is a novel antiarrhythmic and antianginal agent which, although introduced in 1962, has only recently gained prominence not only as a significant agent in cardiovascular therapeutics but also as a powerful tool to examine the nature of some of the biophysical phenomena at the membrane of cardiac and other excitable tissues. Verapamil is the prototype of those agents which selectively inhibit membrane transport of calcium, an action which accounts for the drug's peripheral and coronary vasodilator properties, its effect on excitation-contraction coupling and hence its negative inotropic propensity, as well as its depressant effects on the sinus node and atrioventricular conduction. Its pharmacological effects are largely independent of the autonomic nervous system. The main therapeutic uses of the drug are in the management of atrial tachyarrhythmias, angina, and possibly hypertension. The overall exp:rimental and clinical data suggest that verapamil will become an important and safe addition to existing drug regimens, especially as an agent of choice for the short-term treatment of most cases of paroxysmal supraventricular tachycardias. The initial experience in other arrhythmias, angina and hypertension, is also sufficiently encouraging to justify further detailed clinical trials to define its potential role in cardiovascular therapeutics.
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