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- Bell, Katy J. L., et al.
(författare)
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Ambulatory blood pressure adds little to Framingham Risk Score for the primary prevention of cardiovascular disease in older men : secondary analysis of observational study data
- 2014
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Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 4:9, s. e006044-
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To determine the incremental value of ambulatory blood pressure (BP) in predicting cardiovascular risk when the Framingham Risk Score (FRS) is known. Methods: We included 780 men without cardiovascular disease from the Uppsala Longitudinal Study of Adult Men, all aged approximately 70 years at baseline. We first screened ambulatory systolic BP (ASBP) parameters for their incremental value by adding them to a model with 10-year FRS. For the best ASBP parameter we estimated HRs and changes in discrimination, calibration and reclassification. We also estimated the difference in the number of men started on treatment and in the number of men protected against a cardiovascular event. Results: Mean daytime ASBP had the highest incremental value; adding other parameters did not yield further improvements. While ASBP was an independent risk factor for cardiovascular disease, addition to FRS led to only small increases to the overall model fit, discrimination (a 1% increase in the area under the receiver operating characteristic (ROC) curve), calibration and reclassification. We estimated that for every 10 000 men screened with ASBP, 141 fewer would start a new BP-lowering treatment (95% CI 62 to 220 less treated), but this would result in 7 fewer cardiovascular events prevented over the subsequent 10 years (95% CI 21 fewer events prevented to 7 more events prevented). Conclusions: In addition to a standard cardiovascular risk assessment it is not clear that ambulatory BP measurement provides further incremental value. The clinical role of ambulatory BP requires ongoing careful consideration.
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| 2. |
- Dixon Woods, Mary, et al.
(författare)
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Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new
- 2011
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Innovation is often regarded as uniformly positive. In this paper, we see the role of innovation inquality improvement as more complicated. We identify three known paradoxes of innovation inhealthcare. First, some innovations diffuse rapidly, yet are of unproven value, limited value, or poserisks, while other innovations that could potentially deliver benefits to patients remain slow toachieve uptake. Second, participatory, cooperative approaches may be the best way of achievingsustainable, positive innovation, yet relying solely on such approaches may disrupt positiveinnovation. Third, improvement clearly depends upon change, but change always generates newchallenges. Quality improvement systems may struggle to keep up with the pace of innovation, yetevaluation of innovation is often too narrowly focused to understand the system-wide effects of newpractices or technologies. We propose a new recognition of the problems of innovation, and arguethat new approaches to addressing them are needed.
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| 3. |
- Gunnarsson, Ronny K, 1955, et al.
(författare)
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Improving antibiotics targeting using PCR point-of-care testing for group A streptococci in patients with uncomplicated acute sore throat
- 2021
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Ingår i: Australian Journal of General Practice. - 2208-794X .- 2208-7958. ; 50:1-2, s. 76-83
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Tidskriftsartikel (refereegranskat)abstract
- Background and objective Evidence supports some beneficial effects of antibiotics prescribed to patients with a sore throat and proven presence of group A streptococci (GAS). Methods A total of 283 patients were included from North and North-West Queensland, Australia, at their first presentation for uncomplicated acute sore throat. Patterns of antibiotic prescribing were explored before and after testing for GAS using a rapid point-of-care polymerase chain reaction (PCR) test. Results The results of the study showed the Australian Therapeutic Guidelines were often not adhered to. The PCR test reduced the proportion of patients prescribed antibiotics from 46% to 40%. The decision to prescribe antibiotics was changed in 30% of patients (P <0.001): before testing only 40% of patients prescribed antibiotics had a positive GAS PCR while this increased to 97% after testing. Discussion An easy-to-use point-of-care test to detect GAS allows better targeting of antibiotic prescribing in patients with an uncomplicated acute sore throat.
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| 4. |
- Karmali, Kunal N., et al.
(författare)
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Blood pressure-lowering treatment strategies based on cardiovascular risk versus blood pressure : A meta-analysis of individual participant data
- 2018
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Ingår i: PLoS Medicine. - : PUBLIC LIBRARY SCIENCE. - 1549-1277 .- 1549-1676. ; 15:3
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Tidskriftsartikel (refereegranskat)abstract
- Background: Clinical practice guidelines have traditionally recommended blood pressure treatment based primarily on blood pressure thresholds. In contrast, using predicted cardiovascular risk has been advocated as a more effective strategy to guide treatment decisions for cardiovascular disease (CVD) prevention. We aimed to compare outcomes from a blood pressure-lowering treatment strategy based on predicted cardiovascular risk with one based on systolic blood pressure (SBP) level.Methods and findings: We used individual participant data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) from 1995 to 2013. Trials randomly assigned participants to either blood pressure-lowering drugs versus placebo or more intensive versus less intensive blood pressure-lowering regimens. We estimated 5-y risk of CVD events using a multivariable Weibull model previously developed in this dataset. We compared the two strategies at specific SBP thresholds and across the spectrum of risk and blood pressure levels studied in BPLTTC trials. The primary outcome was number of CVD events avoided per persons treated. We included data from 11 trials (47,872 participants). During a median of 4.0 y of follow-up, 3,566 participants (7.5%) experienced a major cardiovascular event. Areas under the curve comparing the two treatment strategies throughout the range of possible thresholds for CVD risk and SBP demonstrated that, on average, a greater number of CVD events would be avoided for a given number of persons treated with the CVD risk strategy compared with the SBP strategy (area under the curve 0.71 [95% confidence interval (CI) 0.70-0.72] for the CVD risk strategy versus 0.54 [95% CI 0.53-0.55] for the SBP strategy). Compared with treating everyone with SBP >= 150 mmHg, a CVD risk strategy would require treatment of 29% (95% CI 26%-31%) fewer persons to prevent the same number of events or would prevent 16% (95% CI 14%-18%) more events for the same number of persons treated. Compared with treating everyone with SBP >= 140 mmHg, a CVD risk strategy would require treatment of 3.8% (95% CI 12.5% fewer to 7.2% more) fewer persons to prevent the same number of events or would prevent 3.1% (95% CI 1.5%-5.0%) more events for the same number of persons treated, although the former estimate was not statistically significant. In subgroup analyses, the CVD risk strategy did not appear to be more beneficial than the SBP strategy in patients with diabetes mellitus or established CVD.Conclusions: A blood pressure-lowering treatment strategy based on predicted cardiovascular risk is more effective than one based on blood pressure levels alone across a range of thresholds. These results support using cardiovascular risk assessment to guide blood pressure treatment decision-making in moderate- to high-risk individuals, particularly for primary prevention.
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