We appreciate the attention given by Andy Haines and Philip J Landrigan to the findings of The Lancet's Taskforce on NCDs and economics and our Series paper. 1 Haines and Landrigan emphasise our main findings that many premature NCD deaths will occur in lowincome and middle income countries by 2030, and that investments to manage NCDs cannot only reduce those premature deaths, but also provide economic gains and help achieve SustainableThe Lancet Taskforce on NCDs and economics could substantially enhance its influence and further increase the return on investment in NCD prevention if it were to expand its scope to include a new focus on prevention of pollution. The greatest beneficiaries will be people in the world's most rapidly developing and severely affected countries.We declare no competing interests.
The PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely. The objective of this study was to determine if a multimodal intervention could reduce PT/INR and aPTT testing in the emergency department (ED). This was a prospective multi-pronged quality improvement study at St. Michael's Hospital. The initiative involved stakeholder engagement, uncoupling of PT/INR and aPTT testing, teaching, and most importantly a revision to the ED order panels. After changes to order panels, weekly rates of PT/INR and aPTT testing per 100 ED patients decreased (17.2 vs 38.4, rate ratio=0.45 (95% CI 0.43-0.47), p<0.001; 16.6 vs 37.8, rate ratio=0.44 (95% CI 0.42-0.46), p<0.001, respectively). Rate of creatinine testing per 100 ED patients, our internal control, increased during the same period (54.0 vs 49.7, rate ratio=1.09 (95% CI 1.06-1.12); p<0.0001) while the weekly rate per 100 ED patients receiving blood transfusions slightly decreased (0.5 vs 0.7, rate ratio=0.66 (95% CI 0.49-0.87), p=0.0034). We found that a simple process change to order panels was associated with meaningful reductions in coagulation testing without obvious adverse effects.
S troke is the third leading cause of death in high-income countries, and accounts for substantial morbidity in those who survive. 1 Ischemic stroke is primarily due to a thrombotic or embolic event, and emboli frequently originate in the heart. 2 Transthoracic echocardiography can sometimes diagnose cardiac sources of embolism, such as atrial or ventricular thrombus, 3-5 and these generally require anticoagulation. Transthoracic echocardiography can also identify other causes of stroke that may require intervention, such as atrial abnormalities (e.g., patent foramen ovale, atrial myxoma) 6-8 or infective endocarditis. Transthoracic echocardiography is often recommended to plan secondary stroke management, but it is unclear how often this test provides clinically actionable findings. 4,9 Previous studies provide a range of conflicting estimates for how often transthoracic echocardiography might affect patient management because of changing opinions on what pathology is considered clinically relevant. 10,11 For example, dilated cardiomyopathy is no longer an indication for anticoagulation among patients with stroke. 12 Other findings previously considered to be incidental, such as patent foramen ovale, are now clinically actionable among patients with cryptogenic stroke. 6-8 Current stroke clinical practice guidelines do not reflect these nuanced data, making it challenging for physicians to know which patients should have transthoracic echocardiography after an ischemic stroke. 9,13,14 Furthermore, data that are both comprehensive and recent are lacking to further understanding of how often patients in routine care with stroke will have echocardiographic findings that are clinically actionable. Choosing Wisely 15 advocates against routine low-value care that is unlikely to improve patient care or is likely to cause harm. Transthoracic echocardiography is unlikely to cause direct patient harm but may cause indirect harm; for example, where incidental findings lead to invasive testing (i.e., transesophageal echocardiography) and expose patients to additional risks. Awaiting transthoracic echocardiography can also RESEARCH HEALTH SERVICES
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