Do clinical practice guidelines improve processes or outcomes in primary care?

BACKGROUND: Clinical practice guidelines (CPGs) are common, but it is not clear whether they improve care. METHODS: Quality indicators for processes and outcomes of care were obtained from a computerized system-wide database by patient administration and utilization management personnel unaware of this study and without connection to or interests in guideline implementation. These indicators were compared before and after guideline implementation. RESULTS: After the asthma CPG, nebulizer treatments, emergency department visits, and admissions decreased significantly (p < 0.001 for all three) and education increased significantly (p < 0.001). Periodic measurements of lung function and controller medication prescriptions were unchanged. After the diabetes mellitus CPG, microalbumin screens and education increased significantly (p < 0.001). Angiotensin-converting enzyme inhibitor prescriptions and yearly foot examinations decreased significantly, along with the percentage of patients with blood pressure of < or = 130/85 mm Hg (p < 0.001). Mean hemoglobin A(1C) levels did not change significantly. After the tobacco cessation CPG, screening and education increased significantly (p < 0.001 and p = 0.04, respectively). CONCLUSIONS: The asthma CPG improved some processes and all outcomes. The diabetes CPG improved two of the eight measured processes but had no effect on outcomes. Education and screening, but not counseling, improved with the tobacco CPG. CPGs appear to improve diagnostic and educational processes more than provider-dependent treatment processes. Outcomes were improved after implementation of the asthma CPG but not after the diabetes CPG.

Nonhealing skin lesions in a sailor and a journalist returning from Iraq.

US health care providers who are not familiar with cutaneous leishmaniasis may now begin to encounter more patients with this challenging entity as military personnel return from rotations in Iraq or Afghanistan. Diagnosis requires a skin scraping, aspiration, or biopsy, followed by examination by an experienced microscopist or pathologist. Demonstration of the parasite DNA by PCR or culture in special media can also be used to confirm the diagnosis. Sodium stibogluconate is the mainstay of therapy, but other options for selected cases include topical thermal or cryotherapy treatment and oral triazole compounds. Assistance is available through the CDC and, for Department of Defense beneficiaries, certain military facilities.

Management of peripheral arterial disease.

Peripheral arterial disease is common, but the diagnosis frequently is overlooked because of subtle physical findings and lack of classic symptoms. Screening based on the ankle brachial index using Doppler ultrasonography may be more useful than physical examination alone. Noninvasive modalities to locate lesions include magnetic resonance angiography, duplex scanning, and hemodynamic localization. Major risk factors for peripheral arterial disease are cigarette smoking, diabetes mellitus, older age (older than 40 years), hypertension, hyperlipidemia, and hyperhomocystinemia. Nonsurgical therapy for intermittent claudication involves risk-factor modification, exercise, and pharmacologic therapy. Based on available evidence, a supervised exercise program is the most effective treatment. All patients with peripheral arterial disease should undergo aggressive control of blood pressure, sugar intake, and lipid levels. All available strategies to help patients quit smoking, such as counseling and nicotine replacement, should be used. Effective drug therapies for peripheral arterial disease include aspirin (with or without dipyridamole), clopidogrel, cilostazol, and pentoxifylline.