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By L. Luca. International Institue of the Americas.

As more "normal aging" becomes A second major issue with regard to risk assessment understood to represent pathology secondary to disease generic 1mg anastrozole visa, follows from these studies order 1 mg anastrozole. As the population ages purchase anastrozole 1mg without a prescription, the health-related behaviors, or environmental factors that proportion of individuals with subclinical illness that change with age, efforts to delineate causal factors could affect the status of other health markers increases. For instance, studies of weight and mortal- recently as 30 years ago, it was still believed that devel- ity in old age have shown no risk, an increased risk with opment of systolic hypertension in old age was "natural" thinness, an increased risk with heavier weight, and a process stemming from atherosclerosis. Harris postulated as not only unlikely to benefit the patient but treated to alter the course of health outcomes associated potentially contributing to risk. Third, older persons could be systolic blood pressure tended to increase later in life and recruited successfully to participate in clinical trials; they that this increase might represent a distinct physiologic would comply with the treatments and provide analyz- process from diastolic hypertension. This realization established pressure tended to increase with age in most populations, the viability of clinical trials in old age; however, even studies from isolated populations such as lifetime resi- today there remain major barriers to the participation of dents of mental hospitals showed that blood pressure did older persons in clinical trials, primarily based on mis- not increase very much at all over the life span. Last, results from trials of conditions common in with age should be considered as an inevitable conse- old age could provide important information about the quence of aging. Studies of the outcomes of systolic biology of disease in old age and the causes of these con- hypertension demonstrated that this was not a benign ditions and, if not the reversibility of biologic effects, at condition, but rather, whether in combination with dias- least the prevention of secondary outcomes. For instance, recent data on cal trials were needed to demonstrate that there was population-based magnetic resonance imaging studies of a benefit to treatment in terms of reduction of risk of the brain have suggested that hypertension may make a cardiovascular complications. The first clinical trials for major contribution to risk of small silent brain infarctions hypertension did not really address the issue of treatment that may contribute to cognitive decline34 and that treat- of systolic hypertension; in fact, the clinical trials focused ment of hypertension can lower risk of congestive heart primarily on diastolic blood pressure, the most common failure. Several major clinical trials were undertaken to Perspective on Hip Fracture address the issue of hypertension in old age. The first was the European Isolated Systolic Hypertension Study, Epidemiology of aging has contributed a novel perspec- which enrolled 840 older persons in 11 countries through- tive on how to attack the problem of fracture risk in out Europe. Osteoporosis and associated risk of fracture tension in the Elderly Program (SHEP) was established, is a major health problem for both elderly men and enrolling 4736 persons in a complicated protocol that women. Risk of mortality in the 6 months postfracture diovascular morbidity in the elderly, and these results remain high, and odds of full recovery of function are low. These studies established important principles for In the course of these studies, a perspective on fracture research in aging. First, age-related changes that were so has emerged that gives weight to both the classical common as to seem "normal" can carry risk. Second, endocrinologic perspective of hormones determining medical conditions in the elderly could be successfully osteoporotic risk and the geriatric perspective, which 5. Epidemiology and Aging 49 suggests that factors associated with frailty and increased 45 ture.

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The Process Evaluation To learn from the experience of the MTFs participating in the demonstration order anastrozole 1mg with mastercard, the RAND team used a participant-observer ap- proach to exchange information and facilitate shared learning with the MTFs throughout the demonstration and evaluation process 1mg anastrozole amex. The purposes of the process evaluation were to • document the actions and experiences of the Army MTFs partic- ipating in the demonstration for practice guideline implementa- tion and assess performance relative to each of the six critical success factors • identify areas where the policies generic 1 mg anastrozole with amex, systems, and processes estab- lished by AMEDD for guideline implementation can be strength- ened 16 Evaluation of the Low Back Pain Practice Guideline Implementation • assess the degree to which demonstration sites are able to build on their experiences with the demonstration guideline to imple- ment additional DoD/VA guidelines. To understand the full dynamics of a process as complex as practice guideline implementation, we gathered information on the interac- tions of the many aspects of the system in which the guidelines were being implemented and the roles of a variety of stakeholders. These groups included the implementation team, treatment program lead- ership, middle management, the clinical and administrative staff working with program residents, and the clients themselves. To cap- ture changes in structures and processes as guideline implementa- tion moved forward, information was collected at baseline and at two follow-up points in time during site visits to capture (1) early lessons from the implementation activities and (2) information on successes and challenges in implementing desired new practices. Analysis of Guideline Effects The purposes of the analysis of the effects of guideline implementa- tion were to • document the changes in clinical process and service activity in a program that is implementing a practice guideline • document changes in clinical practices that are attributable to the process changes that have occurred • develop metrics and measurement methods that can be adopted by the participating programs for routine monitoring of their continued progress on an ongoing basis. The first two purposes were the essence of the evaluation activities for the time period of the demonstration. A viable monitoring pro- cess, including well-chosen, relevant measures, is essential for an MTF to be able to retain the gains it achieves by modifying practices as recommended by the guideline. This feedback loop continues to provide MTF staff with program quality information, and it main- tains the visibility of the measures being reported as priorities for quality performance. Chapter Two METHODS AND DATA The RAND evaluation for the low back pain guideline demonstration gathered information about both the processes of implementing the practice guideline at participating MTFs and the effects of these implementation activities on delivery of care for low back pain patients. In this chapter, we summarize the methods and data for these two evaluation components. Implementation of a clinical practice guideline is one type of quality improvement intervention. An evaluation of any quality improve- ment intervention should recognize the incremental nature of these processes, which require time to achieve lasting practice improve- ments. A comprehensive evaluation of guideline implementation, therefore, would encompass the following three phases of emphasis: 1. Initial evaluation emphasis is on documenting the extent to which effective action plans are devel- oped and the intended actions are actually implemented. Process evaluation methods are used here, and feedback to participants is provided early in the process and is designed to help them strengthen their interventions. Subsequent emphasis is on monitoring short-term effects of the quality improvement in- terventions on service delivery methods and activity, applying a combination of process and impact (outcome) evaluation methods. The impact evaluation works with quantifiable measures that are rel- evant to the desired changes in either clinical processes or proximal outcomes.

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Te paper described a study in which patients who had just had heart attacks randomly received placebo or flecainide and were then switched from one to the other (a cross-over trial) discount anastrozole 1 mg mastercard. Te researchers counted the number of preventricular contractions (PVCs) as a measure of arrhythmias cheap anastrozole 1 mg online. When the flecainide patients were ‘crossed over’ to the placebo safe 1 mg anastrozole, the PVCs increased again. Suppression of arrythmias in 9 patients (PVCs = preventricular contractions) 50 45 40 35 30 25 20 15 10 5 0 Placebo Flecainide Placebo Flecainide Te conclusion was straightforward: flecainide reduces arrythmias and arrythmias cause heart attacks (the mechanism); therefore, people who have had heart attacks should be given flecainide. Te results were published in the New England Journal of Medicine and flecainide was approved by the United States Food and Drug Adminstration and became fairly standard treatment for heart attack in the United States (although it did not catch on in Europe or Australia). Tis showed that over raises two important issues: the 18 months following treatment, more than 10% of people who were given flecainide died, which was double the rate of deaths among a placebo group. In other words, up- Cardiac arrythmia suppression trial (CAST) to-date, good-quality research findings need to be available to all 100 medical practitioners on a routine basis. We must 90 move away from a flecaininde traditional mechanistic approach and look 85 for empirical evidence of effectiveness using 80 a clinically relevant 0 200 400 600 outcome (eg survival, improved quality of life). Days Unfortunately, because the initial studies had been widely published in medical texts, it was a long time before doctors caught up with the subsequent poor outcome data, which did not attract as much attention. Meanwhile, about 200,000 people were being treated with flecainide in the United States by 1989. Based on the trial evidence, this would have caused tens of thousands of additional heart attack deaths due to the use of flecainide. Although there References (flecainide): was published information, doctors were systematically killing people with Anderson JL, Stewart JR, Perry BA et flecainide because they did not know about the good quality outcome-based al (1981). Echt DS, Liebson PR, Mitchell LB et al In the flecainide example, the initial research was widely disseminated because (1991). Mortality and morbidity it was based on a traditional mechanistic approach to medicine and because in patients receiving ecainide, it offered a ‘cure’. Te Cardiac widely disseminated because it was counterintuitive and negative in terms Arrythmia Suppression Trial. Doctors continued to prescribe flecainide because England Journal of Medicine 324: they believed that it worked. However, most medical practitioners, particularly GPs, are overloaded with A book by physician and information. Unsolicited information received though the mail alone can medical humorist Oscar amount to kilograms per month and most of it ends up in the bin. London called ‘Kill as Few Patients as Possible’ gives a set Te total number of RCTs published has increased exponentially since the of ‘rules’ for clinical practice.

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