Size-Reduced Basis Set Calculation of Accurate Isotropic Nuclear Magnetic Shieldings Using CTOCD-GRRO and GPRO Methods in Amino Acids and Oligopeptides.

The origin-independent magnetically induced CTOCD-GRRO and -GPRO (after continuous transformation of the origin of the current density-gradient of ρ and gradient of a power of ρ) current densities are shown to vary linearly with respect to their own defining α and ß parameters. The same is reflected in the connected magnetic properties, in particular the magnetic shielding. This is exploited to find values for α and ß that, using small basis sets, provide isotropic nuclear magnetic shieldings matching an accurate prediction, chosen as the complete basis set limit. An application to the 20 naturally occurring amino acids shows that different nuclei require different values of the parameters, which have been determined at the BHandHLYP/6-31+G(d,p) level with or without consideration of diversified chemical environments. Using CTOCD-GRRO and -GPRO methods, equipped with the optimized parameters at this low-cost level of calculation, 1H, 13C, 15N, and 17O magnetic shielding constants in glutathione, ophthalmic acid, and thyrotropin-releasing hormone are predicted with nearly the same accuracy as that of much more expensive calculations.

A rapid-cycle collaborative model to promote guidelines for acute myocardial infarction.

BACKGROUND: This American College of Cardiology (ACC) Acute Myocardial Infarction (AMI) Guidelines Applied in Practice (GAP) collaborative in Michigan represented ACC's third initiative, in partnership with local health care coalitions and the Michigan Peer Review Organization. The GAP Pilot Project formed the basis for this project, which supported caregivers' efforts to improve their processes and consistently apply the evidence-based guidelines for AMI care. THE SOUTHEAST MICHIGAN EXPANSION PROJECT: The Institute for Healthcare Improvement (IHI) Breakthrough Series model of improvement was modified to merge the GAP Pilot Project's design with a rapid-cycle quality improvement model. The collaborative included learning sessions that focused on five phases--planning, tool implementation, monitoring tool use, remeasurement, and results--and on increasing tool use rates in each phase. CONCLUSIONS: Building on the work of two previous efforts, the ACC AMI GAP projects yielded substantial collective knowledge. Developing and fostering a collaborative culture allowed hospital teams to avoid barriers or overcome them successfully based on others' experiences and collectively solve problems, and it shortened the learning curve and accelerated QI.

Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative.

CONTEXT: Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals. OBJECTIVE: To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI. DESIGN AND SETTING: The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan. PATIENTS: A random sample of Medicare and non-Medicare patients at baseline (July 1998--June 1999; n = 735) and following intervention (September 1--December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January--December 1998; n = 513) and at remeasurement (March--August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group. INTERVENTION: The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators. MAIN OUTCOME MEASURES: Differences in adherence to quality indicators (use of aspirin, beta-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group. RESULTS: Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P =.02) and beta-blockers (65% vs 74%; P =.04) on admission and use of aspirin (84% vs 92%; P =.002) and smoking cessation counseling (53% vs 65%; P =.02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators. CONCLUSIONS: Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.