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Biomedical subjects

I A Scott

Publications and source records attributed to I A Scott.

At least 19 recordsLinked to original sources
PubMed2006

Early invasive versus conservative strategies for unstable angina & non-ST-elevation myocardial infarction in the stent era.

BACKGROUND: In patients with unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) two strategies are possible: a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia. OBJECTIVES: To determine the benefits of an invasive compared to a conservative strategy for treating UA/NSTEMI in the stent era. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (Issue 3 2005), MEDLINE and EMBASE were searched from 1996 to September 2005 with no language restrictions. SELECTION CRITERIA: Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI. DATA COLLECTION AND ANALYSIS: We identified 5 studies (7818 participants). Using intention-to-treat analysis with random effects models, summary estimates of relative risk (95% confidence interval [CI]) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction; all-cause death or non-fatal myocardial infarction; and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using chi-square and variance (I(2)) methods. MAIN RESULTS: In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy; relative risk 1.59 (95% CI 0.96 to 2.64). Mortality and myocardial infarction assessed at 2-5 years in two trials were significantly decreased by an invasive strategy with relative risk of 0.75 (95% CI 0.62 to 0.92) and 0.75 (95% CI 0.61 to 0.91) respectively. The composite end-point of death or non-fatal myocardial infarction was significantly decreased by an invasive strategy at several time points after initial hospitalization. The incidence of early (<4 months) and intermediate (6-12 months) refractory angina were both significantly decreased by an invasive strategy; relative risk 0.47 (95% CI 0.32 to 0.68) and 0.67 (95% CI 0.55 to 0.83) respectively, as were early and intermediate rehospitalization rates with relative risk 0.60 (95% CI 0.41 to 0.88) and 0.67 (95% CI 0.61 to 0.74) respectively. The invasive strategy was associated with a two-fold increase in the relative risk of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the relative risk of bleeding. AUTHORS' CONCLUSIONS: An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI.

Angina, Unstable↗
PubMed2006

Using a clinical pathway and education to reduce inappropriate prescribing of enoxaparin in patients with acute coronary syndromes: a controlled study.

AIMS: To evaluate efficacy of a pathway-based quality improvement intervention on appropriate prescribing of the low molecular weight heparin, enoxaparin, in patients with varying risk categories of acute coronary syndrome (ACS). METHODS: Rates of enoxaparin use retrospectively evaluated before and after pathway implementation at an intervention hospital were compared to concurrent control patients at a control hospital; both were community hospitals in south-east Queensland. The study population was a group of randomly selected patients (n = 439) admitted to study hospitals with a discharge diagnosis of chest pain, angina, or myocardial infarction, and stratified into high, intermediate, low-risk ACS or non-cardiac chest pain: 146 intervention patients (September-November 2003), 147 historical controls (August-December 2001) at the intervention hospital; 146 concurrent controls (September-November 2003) at the control hospital. Interventions were active implementation of a user-modified clinical pathway coupled with an iterative education programme to medical staff versus passive distribution of a similar pathway without user modification or targeted education. Outcome measures were rates of appropriate enoxaparin use in high-risk ACS patients and rates of inappropriate use in intermediate and low-risk patients. RESULTS: Appropriate use of enoxaparin in high-risk ACS patients was above 90% in all patient groups. Inappropriate use of enoxaparin was significantly reduced as a result of pathway use in intermediate risk (9% intervention patients vs 75% historical controls vs 45% concurrent controls) and low-risk patients (9% vs 62% vs 41%; P < 0.001 for all comparisons). Pathway use was associated with a 3.5-fold (95% CI: 1.3-9.1; P = 0.012) increase in appropriate use of enoxaparin across all patient groups. CONCLUSION: Active implementation of an acute chest pain pathway combined with continuous education reduced inappropriate use of enoxaparin in patients presenting with intermediate or low-risk ACS.

Angina, Unstable↗
PubMed2006

On the need for probity when physicians interact with industry.

Physicians are expected to practice scientifically sound medicine, to be critical of industry claims, and to be immune from making clinical decisions biased by commercial sponsorship and marketing. The reality, as argued in this article, is that much of medical research, in its conduct and reporting, is distorted by commercial interests and that physician decision-making remains vulnerable to the effects of subliminal commercial promotion which has the potential to create conflicts of interest, or perceptions thereof, and undermine public trust. Research is presented that may encourage physicians to view recently revised Royal Australasian College of Physicians (RACP) guidelines on the ethical relationships between the medical profession and industry as an attempt to deal with such conflicts in protecting our authority and standing within the community.

Australia↗
PubMed2005

Cautionary tales in the clinical interpretation of therapeutic trial reports.

Practising clinicians are assailed daily with reports of new therapeutic clinical trials. The evidence-based medicine movement has developed critical appraisal methods for assessing the validity and impact of such studies. However, challenges persist in regards to the appropriate interpretation and application of trial results within everyday clinical settings. Using selected examples from recently published literature, we illustrate 15 cautionary themes for translating research evidence from therapeutic trials into clinical practice.

Evidence-Based Medicine↗
PubMed2004

Towards more effective use of decision support in clinical practice: what the guidelines for guidelines don't tell you.

The Brisbane Cardiac Consortium Clinical Support Systems Program used multiple strategies in optimising quality of care of patients with either of two cardiac conditions. One of these strategies was the development and active implementation of decision support systems centred on evidence-based, locally agreed clinical practice guidelines. Our experience in undertaking this task highlighted numerous operational challenges for which solutions were difficult to extract from existing published literature. In the present article we provide a methodology grounded in both theory and real-world experience that may assist others in developing and implementing systems of guideline-based decision support.

Clinical Trials as Topic↗
PubMed2003

Quality of care of patients hospitalized with congestive heart failure.

BACKGROUND: Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists. AIM: To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines. METHODS: A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions. RESULTS: Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%). CONCLUSIONS: Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.

Aged↗
PubMed2003

Clinical practice guidelines: perspectives of clinicians in Queensland public hospitals.

BACKGROUND: Clinical practice guidelines (CPG) have been shown to improve processes of care and clinical outcomes. The present study sought to determine how clinicians in Queensland public hospitals view and use such guidelines. METHODS: A self-administered questionnaire survey was conducted of a convenience sample of medical practitioners, nurses and allied-health professionals in 19 public hospitals. RESULTS: Of 333 surveyed clinicians, 216 returned questionnaires (65% response rate). Of these, 67% reported guideline use in their clinical area; more so in general than in tertiary hospitals (75% vs. 60%; P = 0.03) or in district hospitals (75% vs. 56%; P= 0.05). The guidelines were considered useful by 85% of respondents; 45% used them at least once a week. Lack of awareness of guidelines (45%) or inability to access them when needed (44%) prevented greater use. Concise, quick-reference formats were preferred to detailed texts (35%vs. 6%; P<0.001). Sixty percent of respondents became acquainted with guideline recommendations through informal discussions with colleagues rather than through organized awareness-raising (27%) or educational forums (41%; P < 0.001). Guideline endorsement by senior colleagues (68%) and peers (53%) was considered essential to maximizing uptake. Barriers to implementing guideline recommendations were encountered by 62% of clinicians, including insufficient clinical resources (29%) or time (24%), and conflict with accepted practice codes (19%). CONCLUSIONS: In general, clinicians working in public hospitals use CPG and view them positively. Based on free-text comments, a minority of non-medical respondents perceived guidelines and pathways as interchangeable tools. Improved uptake is dependent on increasing access, enhancing user-friendly guideline presentation, deploying local opinion leaders, and mitigating environmental barriers to implementation.

Adult↗
PubMed2002

Quality of care of patients hospitalized with acute coronary syndromes.

BACKGROUND: Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions. AIM: To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators. METHODS: Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main outcome measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received specific interventions (i.e. patients with clear indications and lacking contraindications). RESULTS: Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely performance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital, and post-hospital cardiac rehabilitation (47% and 7%, respectively). CONCLUSION: There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Aged↗
PubMed2001

The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction.

OBJECTIVE: To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI). DESIGN: Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database. SETTING: All Queensland public hospitals, July 1991 - June 1999. STUDY POPULATION: Patients with AMI admitted through the emergency department. INTERVENTION: Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995. MAIN OUTCOME MEASURES: Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions. RESULTS: Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97). CONCLUSIONS: Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.

Cardiology Service, Hospital↗
PubMed2001

What are appropriate rates of invasive procedures following acute myocardial infarction? A systematic review.

OBJECTIVE: To assess the evidence that higher rates of coronary angiography (CA) and revascularisation (RV) in the subacute phase of acute myocardial infarction (AMI) improve patient outcomes. DATA SOURCES: MEDLINE 1990 - December 1999, Current Contents 1990-1999, Cochrane Library (Issue 4, 1999), HealthSTAR 1990-1999, selected websites and bibliographies of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Studies selected were (1) randomised trials comparing outcomes of "invasive" versus "conservative" use of CA and RV following AMI; (2) observational studies with formal methods comparing outcomes of high versus low rates of use of these procedures; and (3) clinical practice guidelines (CPGs), expert panel statements and decision analyses which met critical appraisal criteria, and which specified procedural indications. Outcome measures were rates of mortality, re-infarction and limiting or unstable angina. DATA SYNTHESIS: 56 articles were identified; 24 met inclusion criteria. Pooled data from nine RCTs of "invasive" (CA rate 96%; RV rate 66%) versus "conservative" (CA rate 28%; RV rate 19%) strategies showed no significant differences in mortality or re-infarction rates. Pooled results from 12 observational studies showed no mortality differences, but an excess reinfarction rate (8.0% vs 6.4%; P<0.001) in high- versus low-rate populations. Evidence of survival benefit from procedural intervention was strongest for patients with recurrent ischaemia combined with left ventricular dysfunction. CONCLUSIONS: In the subacute phase of AMI, rates of CA and RV in excess of 30% and 20%, respectively, may not confer additional benefit in preventing death or re-infarction. However, variability between studies in design, patient selection, and extent of cross-over from medical to procedural groups, as well as limited data on symptom status, limits generalisability of results.

Angioplasty, Balloon, Coronary↗
PubMed2001

Molecular phylogeny of the Australian frog genera Crinia, Geocrinia, and allied taxa (Anura: Myobatrachidae).

We present a mitochondrial gene tree for representative species of all the genera in the subfamily Myobatrachinae, with special emphasis on Crinia and Geocrinia. This group has been the subject of a number of long-standing taxonomic and phylogenetic debates. Our phylogeny is based on data from approximately 780 bp of 12S rRNA and 676 bp of ND2, and resolves a number of these problems. We confirm that the morphologically highly derived monotypic genera Metacrinia, Myobatrachus, and Arenophryne are closely related, and that Pseudophryne forms the sister group to these genera. Uperoleia and the recently described genus Spicospina are also part of this clade. Our data show that Assa and Geocrinia are reciprocally monophyletic and together they form a well-supported clade. Geocrinia is monophyletic and the phylogenetic relationships with the genus are fully resolved with two major species groups identified: G. leai, G. victoriana, and G. laevis; and G. rosea, G. alba, and G. vitellina (we were unable to sample G. lutea). We confirm that Taudactylus forms the sister group to the other myobatrachine genera, but our data are equivocal on the phylogenetic position of Paracrinia. The phylogenetic relationships among Crinia species are well resolved with strong support for a number of distinct monophyletic clades, but more data are required to resolve relationships among these major Crinia clades. Crinia tasmaniensis and Bryobatrachus nimbus form the sister clade to the rest of Crinia. Due to the lack of generic level synapomorphies for a Bryobatrachus that includes C. tasmaniensis, we synonymize Bryobatrachus with Crinia. Crinia georgiana does not form a clade distinct from other Crinia species and so our data do not support recognition of the genus Ranidella for other Crinia species. Crinia subinsignifera, C. pseudinsignifera, and C. insignifera are extremely closely related despite differences in male advertisement call. A preliminary investigation of phylogeographic substructure within C. signifera revealed significant divergence between samples from across the range of this species.

Animals↗
PubMed2000

Optimising care of acute myocardial infarction: results of a regional quality improvement project.

The effects of a quality improvement intervention were evaluated in a before-after time-series study of 649 consecutive patients suffering acute myocardial infarction (AMI) in the West Moreton Health District over 2.5 years from March 1996 through to August 1998. After a 6-month baseline period, clinical practice guidelines were issued followed by sequential feedback to providers of clinical indicator data over a 1-year period. Resultant changes in practice were then evaluated during a 12-month post-intervention period. The proportion of eligible patients receiving early thrombolysis, lipid-lowering drugs and cardiac rehabilitation increased, respectively, from 30.8 to 70.0% (P = 0.001), from 23.4 to 56.4% (P = 0.003), and from 23.6 to 54.3% (P = 0.003). The in-hospital death rate, incidence of postinfarct angina and mean length of stay decreased, respectively, from 15.8 to 8.6% (P = 0.02), from 30.1 to 14.3% (P < 0.001), and from 7.4 to 6.3 days (P = 0.001). Despite the absence of control groups, the present study suggested that clinical guidelines combined with feedback of clinical indicators were useful in improving quality of care.

Age Factors↗