Journal - Annual review of nutrition (UNITED STATES )

Abstract :

Despite billions of dollars spent on targeted and population-wide strategies aimed at reducing human consumption of saturated fat and cholesterol, aspects of the diet-heart connection remain a source of debate. At least part of the uncertainty arises from a growing appreciation that the relationship between dietary habits, serum lipids, and atherosclerosis is more complex than was previously thought. While we wait for answers from clinical and basic research, what is to be done? This review examines evidence about clinical policies and population strategies for the primary prevention of coronary disease, with specific reference to diet and dyslipidemias. It also summarizes some current policies and offers conclusions about broad directions for further policy development.

Journal - JAMA : the journal of the American Medical Association (UNITED STATES )

Journal - Social science & medicine (1982) (ENGLAND )

Abstract :

Queues for in-patient surgery are commonplace in universal health care systems. Clinicians and hospitals usually manage these waiting lists with informal criteria for determining patient priority--a form of implicit rationing. To understand the workings of implicit rationing by queue, we took advantage of a natural experiment in the Canadian province of Ontario. Unprecedentedly severe supply-demand mismatch led to long waiting lists for coronary surgery [CABS] in Ontario during 1987-88. The crisis was resolved by increased funding and widespread adoption of a multifactorial clinical index for patient priority that was developed by an expert panel in 1989. Thus, we audited randomly chosen charts of patients who underwent coronary angiography at four Toronto hospitals during the crisis period, and calculated urgency scores for each case based on the multifactorial index. From 413 charts, 193 eligible patients were identified who proceeded to CABS. Waiting times did correlate with urgency ratings (r = 0.42, P < 0.0001). However, mean wait from catheterization to CABS varied among hospitals by as much as 8 weeks (P < 0.0001 after controlling for urgency scores). At the hospital with shortest queues, waiting times were twice as long for patients catheterized by cardiologists off-site vs those referred by on-site practitioners (P < 0.0001, after controlling for urgency scores); a similar form of bias was found at a second coronary surgery centre (P = 0.056, after controlling for urgency scores). Over half the patients waited longer than the maximum suggested for their category by the expert panel.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal - JAMA : the journal of the American Medical Association (UNITED STATES )

Abstract :

OBJECTIVES--To review the evidence regarding indications for pulmonary artery catheterization (PAC) in critically ill patients, and to propose a guideline-generating process that would encourage randomized controlled trials of PAC. DATA SOURCES--Computerized and manual search for randomized trials involving PAC as an integral part of the protocol, published as of October 1992. Manual search for guidelines endorsed by specialty societies and/or proposed by expert panels following an explicit group process. DATA SYNTHESIS--Four trials suggest benefit from PAC for pre- or perioperative management of high-risk surgical patients. Two others indicate that PAC for low-risk aortic aneurysm surgery confers no advantages. Use of PAC to guide therapy aimed at improved mixed venous oxygen saturation was beneficial compared with usual care with PAC in two small trials among patients with septic shock and severe trauma. Other PAC indications are either untested or inadequately tested by small trials. Large trials are needed, but trials to date have been impeded by clinicians' uncertainty about PAC and unwillingness to randomize critically ill patients. No published guidelines for PAC have used a formal group process and/or a hierarchical review of evidence to demarcate proven from unproven indications. CONCLUSIONS--We propose a research-promoting expert panel on indications for PAC. Aided by a critical literature review, experts would rate case scenarios on the need for routine PAC with or without a specified intervention strategy. Future trials should test indications where there is either consensus about the uncertainty of need for PAC, or interpanelist disagreement owing to inconclusive evidence. This process could facilitate practice guideline development, utilization management, and large trials of PAC and related interventions.

Journal - The Canadian journal of cardiology (CANADA )

Abstract :

In light of lengthy waiting lists for coronary surgery in Canada, a panel of 16 cardiologists and cardiac surgeons was convened to derive guiding principles for ranking how urgently diverse patients with angiographically proven coronary disease require revascularization. Factors likely to affect urgency were agreed upon by the panelists and incorporated into a case scenario questionnaire. Each panelist then rated 438 case scenarios with respect to maximum acceptable waiting time on a scale with seven time frames ranging from emergency surgery ('level 1') to delays of up to six months ('level 7'). The scenario rating process facilitated attainment of a panel consensus. The purpose of the principles is to assist in assigning priorities to patients according to both symptoms and risk of death or additional morbidity from ischemic events. The pattern or severity of the patient's anginal symptoms and the response of those symptoms to medical therapy emerged as the single most important determinant of the level of urgency. Anatomy and noninvasive tests of ischemic risk were the other key determinants of priority. All other factors were less important, and operated largely within a given level of urgency on the seven-point scale. The principles, including explicit ranking criteria divided according to angina class, are outlined in this final report. The panel specifically cautioned that adoption of such principles is not designed to countenance delays in treatment, but if necessary, should help form more rational queues for coronary revascularization.