Evidence based drug therapy : are optimal doses and multiple medication therapies realistic in patients with chronic heart failure

Background: Chronic Heart Failure (CHF) has a high mortality and morbidity. Large scale randomised controlled trials have proven the benefits of beta blockade and ACE inhibitors in reducing mortality in patients with CHF and expert guidelines mandate their use. In spite of these recommendations, important therapies are under-prescribed and under-utilised.

Method: 1015 consecutive patients enrolled in CHF management programs across Australia were surveyed during 2005-2006 to determine prescribing patterns in heart failure medications. These patients were followed-up for a period of 6 months.

Results: The survey revealed that beta blockers were prescribed to 80% of patients (more than 85% were on sub-optimal doses) and 70% were prescribed Angiotensin converting enzyme (ACE) inhibitors (approximately 50% were on sub-optimal dose). 19% of patients were prescribed Angiotensin receptor blockers (ARBs). By 6 months <25% of the patients who were on sub-optimal dose beta blockers or ACE inhibitors at baseline, had been up-titrated to maximum dose (p<0.0001). In CHF programs, were nurses were able to titrate medications, 75% of patients reached optimal dose of beta blockers compared to those programs with no nurse-led medication titration, where only 25% of patients reached optimal dose (p<0.004). When examining optimal dosage for any two of these mandatory medications, less patients were on optimal therapy. Beta blockers and ACE inhibitors, were both prescribed in combination in 60% of patients. While beta blockers and ARBs were prescribed to 15% of patients.

Conclusion: Whilst prescribing rates for a single medication strategy of beta blockers, or ACE inhibitors were greater than 70%, an increase in dosage of these medications and utilisation of proven combination therapy of these medications was poor. It is suggested that clinical outcomes for this cohort of patients could be further improved by adherence to evidence-based practice, ESC guidelines, and optimisation of these medications by heart failure nurses in a CHF program. On the basis of these findings and in the absence of ready access to a polypill, focussing on evidence-based practice to increase utilisation and optimal dosage of combination medication therapy is critical.

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

Variation in consumer outcomes : does the type of failure (process or outcome) matter?

Literature suggests that various customer outcomes are likely to be negative after a failed service encounter. Service failures can arise for many reasons and consumers may react differently, depending on the type of failure. This study focuses on exploring whether consumer outcomes differ based on whether the consumer experiences a process failure or outcome failure. The results from this study suggest that variations in consumer outcomes differ across the two types of failures; with consumers generally being more dissatisfied in outcome failure situations as compared to process failure situations.

Reducing consumer switching intentions following service failure : do empowerment and apology help?

This research explores the effectiveness of apology and empowerment as service recovery actions and their impact on consumers switching intentions within the hospitality industry. It also examines two different types of failure - process failure and outcome and whether consumer-switching intentions vary based on failure type. Results suggest that apology is effective in reducing switching intentions in both types of failure. Employee empowerment reduces switching intentions in outcome failure situations, but increases switching intentions in process settings. There is also an interaction effect of apology and empowerment in the outcome failure setting, but not in the process failure setting. Recommendations for managing service recovery are provided.

Role of organizational service recovery actions on sustomer switching intentions in a process based service failure : does speed of recovery matters?

The study examines how organizational activities of compensation and empowerment impact on consumers switching intentions and also whether these differ based on the speed of service recovery. Data is collected using hypothetical scenarios in a situation of process failure. It is found that there is no direct effect of either compensation or empowerment on switching intent, although the interaction effect is significant when recovery occurs quickly.

Necking and failure at low strains in a coarse-grained wrought Mg alloy

Tensile testing of rolled AZ31 alloy with a mean grain size of 80 μm reveals localization and failure prior to diffuse necking. Optical microscopy reveals that failure is caused by voids that have formed within twins. A simple localization criterion is proposed that captures the role of grain size in the effect. Such early failure is only predicted for coarse grain sizes, in line with observation.

The failure of dissertation advice books : toward alternative pedagogies for doctoral writing

Anxious doctoral researchers can now call on a proliferation of advice books telling them how to produce their dissertations. This article analyzes some characteristics of this self-help genre, including the ways it produces an expert–novice relationship with readers, reduces dissertation writing to a series of linear steps, reveals hidden rules, and asserts a mix of certainty and fear to position readers "correctly." The authors argue for a more complex view of doctoral writing both as text work/identity work and as a discursive social practice. They reject transmission pedagogies that normalize the power-saturated relations of protégé and master and point to alternate pedagogical approaches that position doctoral researchers as colleagues engaged in a shared, unequal, and changing practice

Visualisation of critical infrastructure failure

The paper explores the complexity of critical infrastructure and critical infrastructure failure (CIF), real life examples are used to discuss the complexity involved. The paper then discusses what Visualisation is and how Visualisation can be applied to a security situation, in particular critical infrastructure. The paper concludes by discussing the future direction of the research.