Explore the vast range of titles available.

Introduction Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention. Methods This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database). Results In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1–13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7–9.5) ml/kg/hour in the post-implementation period ( p  < 0.01). LOS decreased from 10 (6–16) days to 7 (5–11) days ( p  = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p  = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18 % (95 % confidence interval 9–27 %). The incidence of NSQIP complications decreased from 39 % to 25 % ( p  = 0.04). Conclusion These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries. Trial registration Clinicaltrials.gov NCT02057653 . Registered 17 December 2013.

There is an urgent imperative to generate and update accurate, unbiased, clinical practice guidelines, says Sheldon Greenfield

[...] as process measures and measures of risk factor control have improved in the U.S., a concomitant reduction in several major adverse outcomes (kidney failure, amputation) has been documented among the population with diabetes (6,15-17). Expansion of existing surveillance systems to include measures of risk factor control, patient characteristics and behaviors, risk preferences, indicators of primary prevention, and other measures could serve several useful purposes such as I permit more accurate assessment of care quality for patients at different levels of risk, insurance, and socioeconomic status and to assess geographic variations in care; Z promote monitoring of patient safety, drug safety, costs, adverse outcomes and unintended consequences (e.g., hypoglycemia and polypharmacy), and medication adherence; 3 prove useful within networks of Patient Centered Medical Homes or Accountable Care Organizations; and 4 facilitate systematic assessment of prevention efforts.

Purpose The purpose of this work is to describe the association between body mass index (BMI) and (1) management option for localized prostate cancer (PCa) and (2) disease‐specific quality of life (ds‐QoL) after treatment or active surveillance. Subjects/patients and methods We analysed data from men with localized PCa managed with radical prostatectomy (RP), radiation therapy (RT), or active surveillance (AS) in a prospective, population‐based cohort study. We evaluated the association between BMI and management option with multivariable multinomial logistic regression analysis. The association between BMI and ds‐QoL was assessed using multivariable longitudinal linear regression. Regression models were adjusted for baseline domain scores, demographics, and clinicopathologic characteristics. Results A total of 2378 men were included (medians [quartiles]: age 64 [59–69] years; BMI 27 kg/m2; 77% were non‐Hispanic white); 29% were obese (BMI ≥ 30). Accounting for demographic and clinicopathologic features, BMI ≥ 28 kg/m2 was inversely associated with the likelihood of receiving RP (compared with RT) and became statistically significant at BMI ≥ 33 kg/m2 (maximum adjusted relative risk ratio = 0.80, 95% CI 0.67 to 0.95, p = 0.013 for BMI ≥ 33 vs. 25). Conversely, BMI was not significantly associated with the likelihood of receiving AS compared with RT. After stratification by management option, obese men who underwent definitive treatment were not found to have clinically worse ds‐QoL. Obese men initially on AS appeared to have worse urinary incontinence than nonobese men, but this was not significant on an as‐treated sensitivity analysis. Conclusions Among men with localized PCa, those with BMI ≥ 33 kg/m2 were less likely to receive surgery than radiation. Obesity was not associated with ds‐QoL in men undergoing definitive treatment, nor in men who remained on AS.

Quality of Care and Outcomes in Type 2 Diabetic Patients A comparison between general practice and diabetes clinics Giorgia De Berardis , MSC (PHARM CHEM) 1 , Fabio Pellegrini , MS 1 , Monica Franciosi , MSC (BIOL) 1 , Maurizio Belfiglio , MD 1 , Barbara Di Nardo , HSDIP 1 , Sheldon Greenfield , MD 2 , Sherrie H. Kaplan , PHD MPH 2 , Marie C.E. Rossi , MSC (PHARM CHEM) 1 , Michele Sacco , MD 1 , Gianni Tognoni , MD 1 , Miriam Valentini , MD 1 , Antonio Nicolucci , MD 1 and on behalf of the QuED Study Group * 1 Department of Clinical Pharmacology and Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy 2 Center for Health Policy Research, University of California, Irvine, Irvine, California Address correspondence and reprint requests to Antonio Nicolucci, MD, Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Via Nazionale, 66030 S. Maria Imbaro, Chieti, Italy. E-mail: nicolucci{at}negrisud.it Abstract OBJECTIVE —The role of general practice and diabetes clinics in the management of diabetes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We compared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering. RESEARCH DESIGN AND METHODS —We prospectively evaluated the process and intermediate outcome measures over 2 years in a sample of 3,437 patients recruited by 212 physicians with different specialties practicing in 125 DOCs and 103 general practice offices. Process measures included frequency of HbA 1c , lipids, microalbuminuria, and serum creatinine measurements and frequency of foot and eye examinations. Outcome measures included HbA 1c , blood pressure, and total and LDL cholesterol levels. RESULTS —Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians’ specialties were not independently related to patient outcomes. CONCLUSIONS —Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels. DOC, diabetes outpatient clinic GP, general practitioner TIBI, Total Illness Burden Index Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. * ↵ * A complete list of the QuED Study Group can be found in the appendix . Accepted October 23, 2003. Received June 4, 2003. DIABETES CARE

Longitudinal Assessment of Quality of Life in Patients With Type 2 Diabetes and Self-Reported Erectile Dysfunction Giorgia De Berardis , MSCPHARMCHEM , Fabio Pellegrini , MSCSTAT , Monica Franciosi , MSCBIOLS , Maurizio Belfiglio , MD , Barbara Di Nardo , HSDIP , Sheldon Greenfield , MD , Sherrie H. Kaplan , PHD, MPH , Maria C.E. Rossi , MSCPHARMCHEM , Michele Sacco , MD , Gianni Tognoni , MD , Miriam Valentini , MD , Antonio Nicolucci , MD and on behalf of the QuED (Quality of Care and Outcomes in Type 2 Diabetes) Study Group * Address correspondence and reprint requests to Antonio Nicolucci, MD, Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Via Nazionale 8/A, 66030 S. Maria Imbaro (CH), Italy. E-mail: nicolucci{at}negrisud.it Abstract OBJECTIVE —In the context of the QuED (Quality of Care and Outcomes in Type 2 Diabetes) project, we evaluated the longitudinal changes over 3 years in quality of life (QoL) in patients with type 2 diabetes according to the presence or the development of erectile dysfunction (ED). RESEARCH DESIGN AND METHODS —Patients were requested to fill in a questionnaire investigating the presence of ED and QoL (SF-36 Health Survey, depression symptoms [Center for Epidemiologic Studies–Depression], and quality of sexual life) every 6 months for 3 years. The analyses were based on multilevel models, adjusted for patient clinical and sociodemographic characteristics. RESULTS —The study involved 1,456 patients, of whom 34% reported frequent erectile problems at baseline; 192 developed ED during the follow-up. No changes in QoL measures were detected in patients without ED; in those with ED at baseline, a worsening in all SF-36 scales was observed, reaching statistical significance for physical functioning ( P = 0.03). Among patients who developed ED during the study, a deterioration in all SF-36 dimensions and a worsening in depressive symptoms preceded the development of ED. The onset of ED was associated with a further marked worsening in physical functioning ( P = 0.0008), general health perception ( P = 0.02), and social functioning ( P = 0.04) on SF-36 subscales, as well as in the summary physical and mental components scores ( P = 0.04 and P = 0.07, respectively). The development of ED was also associated with a highly significant increase in depressive symptoms ( P = 0.001) and a marked decrease in quality of sexual life ( P < 0.0001). CONCLUSIONS —This longitudinal study documents for the first time the impact of ED onset on several aspects of QoL in patients with type 2 diabetes. The study also shows that QoL tended to further decrease during 3 years in patients with ED at baseline but not in those without this condition. CES-D, Center for Epidemiologic Studies–Depression CVD, cardiovascular disease ED, erectile dysfunction QoL, quality of life TIBI, Total Illness Burden Index Footnotes * ↵ * A complete list of QuED Study Group investigators can be found in the appendix . A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted July 29, 2005. Received March 31, 2005. DIABETES CARE

Provider-patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients. We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes. Cross-sectional survey, response rate 74%. A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities. Provider-patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding. Patients with language-discordant providers reported receiving less health education (beta = 0.17, p < 0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (beta = 0.28, p < 0.05), and were more likely to give low ratings to their providers (odds ratio [OR] = 1.61; CI = 0.97-2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients' perceptions of their providers. Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients' ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

ABSTRACT Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.

Growing interest in the doctor-patient relationship focuses attention on the specific elements of that relationship that affect patients' health outcomes. Data are presented for four clinical trials conducted in varied practice settings among chronically ill patients differing markedly in sociodemographic characteristics. These trials demonstrated that \"better health\" measured physiologically (blood pressure or blood sugar), behaviorally (functional status), or more subjectively (evaluations of overall health status) was consistently related to specific aspects of physician-patient communication. We conclude that the physician-patient relationship may be an important influence on patients' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk.