The intervention resulted in a 19% overall improvement in prophylaxis rates, which is a significant achievement for any behavioural change intervention. There is, however, still a significant discrepancy between surgical and medical patient prophylaxis rates, which clearly warrants further attention.
Introduction. Obesity and diabetes are difficult to treat in public clinics. We sought to determine the effectiveness of the Metabolic Rehabilitation Program (MRP) in achieving long-term weight loss and improving glycaemic control versus “best practice” diabetes clinic (DC) in obese patients using a retrospective cohort study. Methods. Patients with diabetes and BMI > 30 kg/m2 who attended the MRP, which consisted of supervised exercise and intense allied health integration, or the DC were selected. Primary outcomes were improvements in weight and glycaemia with secondary outcomes of improvements in blood pressure and lipid profile at 12 and 30 months. Results. Baseline characteristics of both cohorts (40 MRP and 40 DC patients) were similar at baseline other than age (63 in MRP versus 68 years in DC, P = 0.002). At 12 months, MRP patients lost 7.65 ± 1.74 kg versus 1.76 ± 2.60 kg in the DC group (P < 0.0001) and 9.70 ± 2.13 kg versus 0.98 ± 2.65 kg at 30 months (P < 0.0001). Similarly, MRP patients had significant absolute reductions in %HbA1c at 30 months versus the DC group (−0.86 ± 0.31% versus 0.12% ± 0.33%, P < 0.038), with nonsignificant improvements in lipids and blood pressure in MRP patients. Conclusion. Further research is needed to establish the MRP as an effective strategy for achieving sustained weight loss and improving glycaemic control in obese patients with type 2 diabetes.
Background: The evidence regarding the prevalence of deep vein thrombosis (DVT) after foot and ankle surgery in elective patients that need to be 6 weeks non–weight bearing postoperatively is incomplete and has limitations. Methods: The prevalence of DVT in 114 procedures involving the hindfoot and midfoot was determined using ultrasonographic surveillance at 2 and 6 weeks after surgery. Results: The prevalence of DVT was observed to be 25.4%. The majority (68.9%) of DVTs were diagnosed at the ultrasonographic scan performed 2 weeks postoperatively. The remainder (31.1%) of DVTs were diagnosed at the 6-week postoperative ultrasonographic scan. At least 75% of the patients who had early and late DVT had no clinical symptoms or signs of DVT. The prevalence of DVT in clinically detectable patients was 6%. The average age of patients with early DVT was 62.2 years, significantly higher compared to those who had no DVT. The mean tourniquet time for patients with early DVT was 68.1 minutes, significantly higher compared to those without DVT. All DVTs detected were distal to the popliteal vein. Conclusions: The prevalence of clinically silent DVT was significantly higher than was previously thought. We believe this increased rate is directly attributable to the use of ultrasonographic surveillance postsurgery both at 2 and 6 weeks. The risk of DVT continued after the 2-week visit, and 30% of the DVTs were detected at the ultrasonographic scan at 6 weeks. Level of Evidence: Level II, prospective cohort.
In this retrospective observational study, we observed that principal and comorbid diagnoses of deep venous thrombosis (DVT) occurred at a rate of 1.02 and 4.86 per 1000 admissions. Principal DVT diagnosis admissions were more common in the public hospital (1.29 vs 0.57 per 1000; P < 0.001), while the private hospital had nearly three times the admissions with comorbid DVT (2.99 vs 8.23 per 1000; P < 0.001). In-hospital mortality was uncommon (0.2% and 1.6% for principal and comorbid DVT diagnoses, respectively), and this did not differ significantly between the two hospitals.
The impact of implementing a guideline on venous thromboembolism (VTE) prophylaxis was evaluated in a metropolitan private hospital with a before- and after-intervention study. This subsequent study aimed to identify if improved prophylaxis rates translated into cost savings and improved clinical outcomes. A conceptual decision-tree analytical model incorporating local treatment algorithms and clinical trial data was used to compare prophylaxis costs and clinical outcomes before and after the guideline implementation. The study analyzed data from 21,942 medical and surgical patients admitted to a 250-bed acute-care private hospital in Sydney, Australia. The modeled simulation estimated the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as adverse events such as heparin-induced thrombocytopenia (HIT), post-thrombotic syndrome (PTS), major bleeding, and mortality. The costs of prophylaxis therapy and treating adverse events were also calculated. The improvement in prophylaxis rates following the implementation of the guideline was estimated to result in 13 fewer deaths, 84 fewer symptomatic DVTs, 19 fewer symptomatic PEs, and 512 fewer hospital-bed days. Improved adherence to evidence-based prophylaxis regimens was associated with overall cost savings of $245,439 over 12 months. We conclude that improved adherence to evidence-based guidelines for VTE prophylaxis is achievable and is likely to result in fewer deaths, fewer VTE events, and a significant overall cost saving.
Venous thromboembolism is a significant cause of morbidity and mortality in hospitalised medical patients. Evidence-based guidelines exist for preventing VTE but unfortunately these guidelines are not always adhered to by clinicians. The aim of this study was to evaluate the acceptability, utility and clinical impact of an Educational Outreach Visit (EOV) on nurses' provision of mechanical prophylaxis to hospitalised medical patients using a prospective uncontrolled before-and-after design. Nurses received a one-to-one educational session on mechanical VTE prevention by a trained nurse facilitator. The EOV intervention was designed by a multidisciplinary group of healthcare professionals using social marketing theory.Eighty five of the 120 eligible nurses (71%) received the EOV. The median length of each visit was 11.5 minutes (interquartile range 10-15) and the median time spent arranging and conducting each visit was 63 minutes (interquartile range 49-85). Eighty four (98.8%) of the 85 participants gave a verbal commitment to trial the new evidence-based mechanical VTE prevention practices. However, there were no measurable improvements in the proportion of patients risk assessed (-1.7% improvement, 95% CI -7.0 to 10.3, p=0.68) or provided appropriate mechanical prophylaxis (-0.3% improvement, 95% CI -13.4 to 14, p=0.96).Researchers conclude that EOV should not be used to improve nurses use of mechanical VTE prevention as it has no measurable impact on clinical practice and is resource intensive requiring four and a half minutes of preparation for every minute spent face-to-face with participants. Further research into the specific mechanism of action is required to explain the variability in clinical effect seen with this intervention.
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