Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men and African Americans and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians.

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.

Practicing physician education in geriatrics: lessons learned from a train-the-trainer model.

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture-style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small-group, learner-centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community-based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self-reported knowledge, attitudes, and office-based practices on the target topics at the time of training and at the 6-month follow-up (P<.001) and two-thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off-the-shelf review (mean rating+/-standard deviation 4.1+/-0.71, with 1 = not at all and 5 = significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on-line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer-led, community-based sessions using principles of knowledge translation and evidence-based tool kits with materials for providers and patients.

Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians.

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

Peer Education Versus Computer-Based Education: Improve Utilization of Library Databases Among Direct Care Nurses.

A quasiexperimental study was conducted to demonstrate which teaching modality, peer education or computer-based education, improves the utilization of the library electronic databases and thereby evidence-based knowledge at the point of care. No significant differences were found between the teaching modalities. However, the study identified the need to explore professional development teaching modalities outside the traditional classroom to support an evidence-based practice healthcare environment.

Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians.

This guideline is based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center. The American College of Physicians nominated this topic to the Agency for Healthcare Research and Quality Evidence-Based Practice Center program as part of a concerted effort to complement the guidelines of the U.S. Preventive Services Task Force. The College recommends that all clinicians refer to the Task Force recommendations as part of an overall strategy for managing overweight and obesity, which should always include appropriate diet and exercise for all patients who are overweight or obese. The intent of this guideline is to provide recommendations based on a review of the evidence on pharmacologic and surgical treatments of obesity. The target audience is all clinicians caring for obese patients, defined as a body mass index of 30 kg/m2 or greater. This guideline is not intended to be used by commercial weight loss centers or for direct-to-consumer marketing by manufacturers and does not apply to patients with body mass indices below 30 kg/m2.

Bridging the workforce gap for our aging society: how to increase and improve knowledge and training. Report of an expert panel.

The healthcare workforce is currently unprepared for the increasing number of older persons and the complexities of their healthcare needs. Too few healthcare workers are adequately trained in geriatrics, and developers of educational curricula across healthcare disciplines have been slow to incorporate or require geriatric training. In April 2003, leaders in geriatrics met in Washington, D.C., to discuss and recommend solutions to the growing shortage of an appropriately trained workforce for geriatric research, education, and patient care. After considering data, presenting statistics, and offering insights into the future, the conference concluded by formulating recommendations to meet specific challenges. This report is a summary of the conference proceedings and recommendations, and it serves as a reminder that demographic trends and an everexpanding geriatric knowledge base demand not only attention, but also action.

Faculty development in geriatrics for clinician educators: a unique model for skills acquisition and academic achievement.

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.

Primary care management of chronic stable angina and asymptomatic suspected or known coronary artery disease: a clinical practice guideline from the American College of Physicians.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the second of 2 that provide guidance on the management of patients with chronic stable angina. This document covers treatment and follow-up of symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A previous guideline covered diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months and asymptomatic patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests.

Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.

Results of a multifaceted Intimate Partner Violence training program for pediatric residents.

OBJECTIVE: To evaluate the efficacy of a multifaceted Intimate Partner Violence (IPV) intervention on knowledge, attitudes, and screening practices of pediatric residents. METHODS: The intervention included: an on-site IPV counselor, IPV training for attending physicians, residents and social workers, and screening prompts. Evaluation included baseline and post-training surveys of residents, assessing their knowledge, attitudes, and comfort with IPV screening, patient chart reviews at baseline, 3 months, and 8 months for documentation of IPV screening, and review of the IPV counselor's client charts. RESULTS: Baseline chart review showed screening rates of less than 1%. Screening rates were 36.2% at 3 months and 33.1% at 8 months. After training, residents were more likely to know: IPV screening questions (47.1% vs. 100%); referral sources (34.3% vs. 82.9%); and the relationship between child abuse and IPV (52.9% vs. 97.1%). At baseline, barriers to IPV screening included time (50%), lack of knowledge of how to screen (26.5%) and where to refer (23.5%). Post-training, barriers were time (44%), presence of children (25.9%) or other adults (18.5%) in the room, and inappropriate location (18.5%). Post-training, none of the residents listed "lack of knowledge" or "lack of referral sources" as barriers to IPV screening. After 12 months, 107 victims of IPV were identified; most referred from inpatient units and subspecialty clinics. CONCLUSION: A multifaceted IPV intervention increased identification of IPV victims and markedly improved attitudes, comfort, and IPV screening practices of pediatric residents. IPV screening rates were sustainable with minimal ongoing training. PRACTICE IMPLICATIONS: Consideration should be given to the training and practice supports necessary to encourage IPV screening in the pediatric setting. Educational efforts that familiarize pediatricians with the content surrounding the risk and potential impact of IPV to children and families along with practice supports that make incorporating screening for IPV as easy as possible have the potential to increase the identification of this problem and promote referrals to IPV agencies for follow-up and intervention where needed.

Appropriate health care for older women.

Attaining the goal of appropriate medical care for older women requires knowledge of the changes of aging, skills in recognition and treatment of disease, and an effort to provide help and avoid harm. Iatrogenic disorders are particularly problematic in all elderly, dur to decreased stress tolerance, increased prevalence of illness, and atypical presentations of disease. Iatrogenic disorders are most commonly due to drugs; elderly women are particularly at risk dur to altered pharmacokinetics, multiple medical problems, difficulties with compliance, and inappropriate prescribing practices by physicians. In addition, research and development of drugs has often excluded both women and the elderly.Other types of treatment may also result in complications, including significant morbidity and mortality. Additionally, since invasive diagnostic procedures are a common cause of iatrogenic disorders, careful consideration of the usefulness of tests and the appropriateness of treatment is particularly important when caring for elderly women. Attention to the maintenance of function is also critical; the ability of the older woman to live independently may depend upon adequate nutrition, ambulation, continence, and cognition. Health care providers must be responsible for functional assessment and all possible support of these essential capabilities.