A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care – a randomised controlled trial

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) ( M - H χ² = 4.33, df = 1, P  = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.     

Roundtable Discussion: “No One Can Condemn You to a C‐Section!”

Abstract: The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician. (BIRTH 37:3 September 2010)     

Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput: A Randomized Controlled Trial

Background Triage liaison physicians (TLPs) have been employed in overcrowded emergency departments (EDs); however, their effectiveness remains unclear.
Objectives To evaluate the implementation of TLP shifts at an academic tertiary care adult ED using comprehensive outcome reporting.
Methods A six-week TLP clinical research project was conducted between December 9, 2005, and February 9, 2006. A TLP was deployed for nine hours (11 ^am to 8 ^pm) daily to initiate patient management, assist triage nurses, answer all medical consult or transfer calls, and manage ED administrative matters. The study was divided into three two-week blocks; within each block, seven days were randomized to TLP shifts and the other seven to control shifts. Outcomes included patient length of stay, proportion of patients who left without complete assessment, staff satisfaction, and episodes of ambulance diversion.
Results TLPs assessed a median of 14 patients per shift (interquartile range, 13–17), received 15 telephone calls per shift (interquartile range, 14–20), and spent 17–81 minutes per shift consulting on the telephone. The number of patients and their age, gender, and triage score during the TLP and control shifts were similar. Overall, length of stay was decreased by 36 minutes compared with control days (4:21 vs. 4:57; p = 0.001). Left without complete assessment cases decreased from 6.6% to 5.4% (a 20% relative decrease) during the TLP coverage. The ambulance wait time and number of episodes of ambulance diversion were similar on TLP and control days.
Conclusions A TLP improved important outcomes in an overcrowded ED and could improve delivery of emergency medical care in similar tertiary care EDs.     

Simulation performance checklist generation using the Delphi technique

PURPOSE: Performance assessment using high fidelity simulation is problematic, due to the difficulty in developing valid and reliable evaluation tools. The Delphi technique is a consensus based content generation method used for multiple purposes such as policy development, best-evidence practice guidelines and competency assessments. The purpose of this study was to develop checklists using a modified Delphi technique to evaluate the performance of practicing anesthesiologists managing two simulated scenarios. METHODS: The templates for two simulation scenarios were emailed to five anesthesiologists who were asked to generate performance items. Data were collated anonymously and returned. An a priori decision was made to delete items endorsed by 相似文献   

Safety and Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review

Objectives:  To synthesize the evidence comparing the adverse event (AE) profile and clinical effectiveness of midazolam and propofol for procedural sedation (PS) in adults in the emergency care setting.
Methods:  The authors conducted a systematic review of randomized controlled trials (RCTs) and observational studies reporting the use of either midazolam and/or propofol for adult PS in the emergency department (ED). A systematic search strategy was developed and applied to six bibliographic reference databases. Three emergency medicine journals, the Canadian Adverse Drug Reaction Newsletter, and conference proceedings were hand-searched. Retrieved articles were reviewed and data were abstracted using standardized data collection. Trial quality was assessed using the Jadad score. The outcomes assessed were the proportion of patients with AEs and the pooled mean difference in the proportion of patients with successful PS.
Results:  Of 229 articles identified, 28 met the inclusion criteria for the analysis of AEs. Only one major AE to PS was found, resulting in no statistically significant difference in the proportion of major AEs between agents. Four studies were RCTs that met the inclusion criteria for the analysis of clinical effectiveness. Two trials met criteria for good quality. The RCTs enrolled between 32 and 86 patients, and the most common indications for PS were orthopedic reductions and cardioversions. There was a nonsignificant difference in the proportion of patients with successful PS in favor of propofol (effect difference 2.9%, 95% confidence interval (CI) = –6.5 to 15.2).
Conclusions:  The authors found no significant difference in the safety profile and the proportion of successful PS between midazolam and propofol for adults in the ED.