Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES FOR PRACTITIONERS
CLINICAL PRACTICE GUIDELINES FOR PRACTITIONERS
This combined reference has been developed as an educational tool by a statewide, interdisciplinary panel of providers, in collaboration with Blue Cross and Blue Shield of Missouri. It is intended to identify leading best practices and help practitioners reduce variation in practice patterns. It is not intended to include all possible methods of care for a particular condition, to identify all criteria for recommending a specific procedure, or to be a required treatment of a particular condition. The practitioner, at his/her discretion, is expected to exercise reasonable clinical judgment regarding the care each patient needs. Individual patient circumstances should always be taken into account. These guidelines are intended to serve as a foundation for a continuous process of collaboration with physicians and allied health providers to maintain and advance the knowledge base associated with best practices. Each of the Guidelines is based on recommendations from recognized specialty societies (i.e., ACOG, ACOG, AAFP, ACC, AAP, ACP-ASIM), national organizations (i.e., American Cancer Society, American Heart Association, March of Dimes), and governmental entities (i.e., U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention). An external panel of BCBSMo physicians and the BCBSMo Quality Improvement and Physician Review Committee (QIPRC) reviewed the revised guidelines on the basis of content, clarity and appropriateness. We hope you will find this manual useful in your practice. Information regarding current issues will be provided from time to time through guideline updates and periodic mailings. We invite your comments and suggestions. Please direct your communications to:
Sharon Hoffarth, MD, MPH, FACPM Medical Director, Quality Management Blue Cross and Blue Shield of Missouri 1831 Chestnut Street St. Louis, MO 63103-2275 Fax: (314) 923-8542
John J. Seidenfeld, MD, MSHA, FACP Senior Vice President and Corporate Medical Director
CONTENTS
CLINICAL PRACTICE GUIDELINES
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Evaluation of Abnormal Uterine Bleeding Premenopausal Patients Evaluation of Abnormal Uterine Bleeding Perimenopausal Patients Evaluation of Abnormal Uterine Bleeding Postmenopausal Patients Management of Vaginal Vault Prolapse Management of Uterine Leiomyomas Treatment of Endometriosis Dysfunctional Labor Induction of Labor Breech Presentation Non-Reassuring Fetal Status Fetal Macrosomia Vaginal Birth after Cesarean (VBAC) Pregnancy-Associated Hypertensive Disease Hypertension Hyperlipidemia Stable Angina Unstable Angina Congestive Heart Failure (CHF)
! Peptic Ulcer Disease ! GERD ! Diverticulosis and Diverticulitis ! Low Back Pain ! Carpal Tunnel Syndrome ! Uncomplicated Acute Bronchitis ! Community-Acquired Pneumonia (CAP) ! Asthma ! Depression ! Diabetes
Evaluation of Abnormal Uterine Bleeding

Legend: DHEA-S - dihydroepiandrosterone sulfate DUB - dysfunctional uterine bleeding FSH - follicle - stimulating hormone IUD - intrauterine device LH - luteinizing hormone OCP - oral contraceptive pills TSH - thyroid-stimulating hormone
PREMENOPAUSAL PATIENTS
Abnormal excessive uterine bleeding
Focused History & Physical Exam
Differential Diagnosis Includes: Complications of pregnancy Infections - uterus, cervix, vagina Trauma - laceration, abrasion, foreign body Cancer - gynecologic malignancy Benign lesions - uterus, cervix, vagina Systemic disease - thyroid, liver, coagulopathy, von Willebrands disease Iatrogenic - hormones, anticoagulants, intrauterine contraceptive devices Address cause of bleeding, such as: Treat infection Follow-up malignancy work-up: - Risk Factors: >35 years old <30 years old with a long-term history of oligoovulation or anovulation with exposure to unopposed estrogen. Obesity Evaluate for leiomyoma.
Includes: Gynecological and Obstetrical history Medication history Pelvic exam with Papanicolaou smear Diagnostic aids, to consider, as appropriate: Liver function tests Thyroid function tests Coagulation profile Pregnancy test CBC
Yes
Is cause of bleeding due to pelvic pathology, medication, systemic disease?
No
Is pregnancy test positive?
Yes
Pregnancy evaluation
No Evaluate for Dysfunctional Uterine Bleeding (DUB - bleeding not controlled by hormones , D&C or nonsteroidal anti-inflammatory agents) Determine ovulatory status No
Ovulatory
Anovulatory
Determine bleeding pattern
Adolescent?
Yes
Intermenstrual bleeding
Menorrhagia
Polymenorrhea
Oligomenorrhea
Determine TSH and prolactin levels
Reassure the patient or initiate Oral Contraceptive Pills (OCPs)
Evaluate for bleeding disorder
Consider evaluation for luteal phase defect
Progesterone withdrawal every 3 months, OCPs or clomiphene induction.
Normal
Abnormal
IUD?
Perform biopsy or ultrasonography to exclude uterine pathology Yes Remove IUD or begin a period of observation
OCPs or domiphene (serophene)
Risk for hypothalamic disorder (stress, eating disorder, high level of exercise)? No Consider evaluation for polycystic ovarian syndrome versus chronic anovulation (examination, consider determination of LH, FSH, DHEA-s and free testosterone on day 3 of cycle) Yes
Treat the disorder
Treat with OCPS or clomiphene
No
Cervical pathology? No Bleeding at ovulation?
Yes
Treat
OCPs
No
Yes
Begin period of observation
OCPs, progesterone withdrawal every 3 months, or clomiphene for ovulation induction
Physician focus for managing patients with abnormal uterine bleeding: As initial approach, to pre- and perimenopausal patients without genital tract lesions, uterine enlargement, IUDs, and not pregnant, treat conservatively. Indicator For those patients with DUB, and no other documented abnormal findings, the percentage of patients treated pharmacologically.
References: Oriel KA, Schrager S. Abnormal uterine bleeding. American Family Physician. 1999;10(5);1371-1380. Available online: http://www.aafp.org/afp/991001ap/1371.html. Accessed May 23, 2001. New Zealand Guidelines Group. Guidelines for the management of heavy menstrual bleeding. (1999, May) Available online: National Guideline Clearinghouse, http://www.guidelines.gov. Accessed May 21, 2001. Chuong CJ, Brenner PF. Management of abnormal uterine bleeding. American Journal of Obstetrics and Gynecology. 1996;175(3);787-792. Long C. Evaluation of patients with abnormal uterine bleeding. American Journal of Obstetrics and Gynecology. 1996;175(3);784-786.

PERIMENOPAUSAL PATIENTS
Abnormal uterine bleeding
Perform history and physical exam, including: Gynecological and Obstetrical history Medication history Pelvic exam with Papanicolaou smear Laboratory tests to consider, as appropriate: Follicle-stimulating hormone (FSH) Liver function tests Thyroid function tests Coagulation profile Pregnancy test (If positive, evaluate for complication of pregnancy) CBC
Determine beta human chorionic gonadotropin (-HCG)
Genital tract lesion present
Uterine enlargement present
Treat, perform biopsy or refer as appropriate
Consider transvaginal ultrasonography or sonohysterography
Positive
Evaluate for pregnancy Etiology still unclear Etiology identified
Negative
Perform hysteroscopy
Treat
Perform endometrial biopsy
Biopsy not possible
Perform transvaginal ultrasonography, sonohysterography or hysteroscopy, or dilation and curettage
Normal pathology or atrophy
Hyperplasia
Atypia or carcinoma
Cyclic hormonal regulation or begin a period of observation
Cyclic progesterone therapy; hyperplasia that persists requires D&C
Refer patient for treatment
Physician focus for managing patients with abnormal uterine bleeding: As initial approach, to pre- and perimenopausal patients without genital tract lesions, uterine enlargement, IUDs, and not pregnant, treat conservatively. Indicator For those patients with DUB, and no other documented abnormal findings, the percentage of patients treated pharmacologically.

POSTMENOPAUSAL PATIENTS
Abnormal uterine bleeding
Perform history and physical exam, including: Gynecological and Obstetrical history Medication history Pelvic exam with Papanicolaou smear Laboratory tests to consider, as appropriate: Liver function tests Thyroid function tests Coagulation profile Pregnancy test CBC
Genital tract lesion present Normal findings, receiving HRT?
Uterine enlargement present
Treat, perform biopsy or refer as appropriate
Consider performing transvaginal ultrasonography or sonohysterography
Yes Determine which HRT regimen (continuouscombined or sequential) and duration of HRT
No
Duration > 6 months
Duration < 6 months
If early withdrawal bleeding, increase progesterone dosage
Begin a period of observation Perform endometrial biopsy or transvaginal ultrasonography to exclude endometrial carcinoma Heavy or prolonged bleeding or breakthrough bleeding in > 2 cycles
Endometrial biopsy performed
Transvaginal ultrasonography performed
Abnormal findings
Normal findings
Endometrial stripe < 5 mm
Endometrial stripe > 5 mm
Uterine pathology identified
Bleeding stopped? No Yes
Atrophic endometrium
Perform endometrial biopsy or hysteroscopy with biopsy
Perform transvaginal ultrasonography, sonohysterography or hysteroscopy, depending on clinical suspicion
Begin period of observation
Physician focus for managing patients with abnormal uterine bleeding: As initial approach, to postmenopausal patients without genital tract lesions, or uterine enlargement, treat conservatively. Indicator For those patients with DUB, and no other documented abnormal findings, the percentage of patients treated pharmacologically.
Management of Vaginal Vault Prolapse

Symptoms may include: Symptoms may include: Asymptomatic Asymptomatic Pelvic Pressure Pelvic Pressure Pulling, aching sensation Pulling, aching sensation Urinary symptoms Urinary symptoms Bowel symptoms Bowel symptoms Sexual dysfunction Sexual dysfunction Protrusion of uterus or vagina through introitus Protrusion of uterus or vagina through introitus Vaginal/cervical ulceration with discharge/odor Vaginal/cervical ulceration with discharge/odor
History: History: Family Family Pregnancy Pregnancy Occupation Occupation Physical activity Physical activity Medication Medication Physical Exam: Physical Exam: Gynecological exam Gynecological exam Assess degree of prolapse (supine and standing) Assess degree of prolapse (supine and standing) Evaluate incontinence, and post-void residual urine Evaluate incontinence, and post-void residual urine Lab and diagnostic tests: Lab and diagnostic tests: If clinically indicated: If clinically indicated: Cervical cytology Cervical cytology Urinalysis and culture Urinalysis and culture Urodynamics Urodynamics Cystoscopy/urethroscopy Cystoscopy/urethroscopy
Symptoms of Vaginal Prolapse
Focused History and Physical Exam
Postmenopausal?
Yes
Consider hormone treatment: Hormone Replacement Therapy (HRT) Estrogen Replacement Therapy (ERT) Pills, patch, cream Estrodial vaginal ring (e.g., Estring)
No
Clinical observation with lifestyle modifications: Diet/weight control Increase fiber, fruit juice Decrease caffeine Avoid heavy lifting Quit smoking Medication Pelvic floor exercise (e.g. Kegel) Mechanical vault support (e.g. tampon, diaphragm, pessary)
No
Good response?
Yes
Follow up office visit in 6 months. Indications for Pessary use: Indications for Pessary use: Stress urinary incontinence Stress urinary incontinence Vaginal vault prolapse Vaginal vault prolapse Cystocele Cystocele Enterocele Enterocele Rectocele Rectocele Uterine prolapse Uterine prolapse Preoperative preparation Preoperative preparation
Good response?
Yes
Follow up office visit in 6 months or based on treatment option.
No
Counsel patient and consider surgical options: Reconstruction of pelvic anatomy with/without hysterectomy Vaginal obliterative procedures (e.g. colpocleisis, sacrospinous ligament fixation)
Preoperative estrogen replacement therapy: Preoperative estrogen replacement therapy: associated with reducing duration of associated with reducing duration of postoperative bladder catheterization in women postoperative bladder catheterization in women undergoing reconstructive surgery for pelvic undergoing reconstructive surgery for pelvic organ prolapse. organ prolapse.
Management of Vaginal Vault Prolapse
References: Margolis MT. Surgical options for treatment of vaginal vault prolapse procidentia and vaginal reconstruction. Contemporary OB-GYN. March 1999. Available online:http://obgyn.pdr.net/obgyn/public.htm?path=content/journals/g/data/1999/g3a/g3a023.html Accessed May 15, 2001. Viera AJ, Larkins-Pettigrew M. Practical use of the pessary. American Family Physician. May 1, 2000. Available online: http://www.aafp.org/afp/20000501/2719.html. Accessed May 21, 2001. Theofrastous JP, Addison WA, Timmins MC. Voiding function following prolapse surgery. Impact of estrogen replacement. Journal of Reproductive Medicine. December 1996; 41(12):881-4. Eriksen B. A randomized, open parallel-group study on the preventive effect of an estradiolreleasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women. American Journal of Obstetrics and Gynecology. 1999;180:1072-1079. ACOG. Pelvic Support Problems. (ACOG Patient Education). Washington, DC. 1995.
Management of Uterine Leiomyomas

Fibroids - benign smooth muscle tumors found in the submucous, intramural and/or subserosal regions of the uterus. Risk factors: Risk factors: Increasing age prior to Increasing age prior to menopause menopause Family history Family history African and Caribbean African and Caribbean American ethnicity American ethnicity Obesity Obesity Nulliparity/infertility Nulliparity/infertility Differential diagnosis: Differential diagnosis: Fibroma Fibroma Leiomyosarcoma Leiomyosarcoma Endometrial hyperplasia Endometrial hyperplasia Adnexal mass Adnexal mass Medical therapy may improve Medical therapy may improve hematologic profile or reduce hematologic profile or reduce mass in preparation for mass in preparation for surgery, but should not be surgery, but should not be used for more than six used for more than six months, or on an ongoing or months, or on an ongoing or repeated basis. repeated basis. Symptomatic?
Suspected Uterine Fibroids
Perform history and physical exam, including: Gynecological and Obstetrical history Medication history Pelvic exam with Papanicolaou smear Laboratory tests to consider, as appropriate Liver function tests Thyroid function tests Coagulation profile Pregnancy test CBC Endometrial sampling
Symptoms may include: Symptoms may include: Asymptomatic Asymptomatic Excessive uterine bleeding Excessive uterine bleeding Pelvic discomfort: Pelvic discomfort: Pain/pressure Pain/pressure Low back pain Low back pain Abdominal swelling Abdominal swelling Dyspareunia Dyspareunia Urinary Urinary urgency/frequency urgency/frequency Recurrent miscarriage Recurrent miscarriage Preterm labor Preterm labor Infertility Infertility
Confirm by: Transvaginal ultrasound, Transvaginal sonohysterogram (TVSH) Transabdominal ultrasound or Magnetic Resonance Imaging (MRI) (if location or nature of fibroid is uncertain or patient refuses TVSH)
No
Asymptomatic with fibroids >14 weeks size?
No
Follow-up in office in 6 months unless symptoms change.
Yes
Discuss options, including observation with patients.
Yes Offer medical management: Iron supplementation Non-steroidal anti-inflamatory drugs (NSAIDS) Hormone therapy Progestins Oral contraceptives GnRH - agonists: (+ add back therapy as indicated)
No
Successful treatment of symptoms?
Yes
Continue therapy 4-6 months.
Review at 6 months.
Discuss surgical options: Endometrial ablation to arrest bleeding. Myomectomy Hysteroscopic Laparascopic Abdominal Hysterectomy indicators: Bleeding causing anemia, lifestyle or hygiene problems Intractable pelvic pain + progressive dysmenorrhea Rapidly enlarging size Enlargement postmenopausal (R/O sarcoma) Pressure symptoms
Consider preoperative therapy with GnRH in women with large Consider preoperative therapy with GnRH in women with large uteri (>18 weeks size) for reduction in operative blood loss uteri (>18 weeks size) for reduction in operative blood loss With pre/peri-menoapausal patients, discuss options of SalpingoWith pre/peri-menoapausal patients, discuss options of Salpingooophorectomy or sparing ovaries oophorectomy or sparing ovaries
Physician focus for Management of Uterine Leiomyomas: For symptomatic women with first time diagnosis of leiomyomata, consider initial medical management. Indicator: Percentage of women with first time diagnosis receiving conservative medical management. Indicator: Percentage of women with first time diagnosis receiving surgical treatment. For symptomatic women with a > 1year history of leiomyomata, unresponsive to conservative treatment, consider surgical management. Indicator: Percentage of women with a > 1year history of leiomyomata and one or more of the following: anemia, intractable pain or pressure, rapidly enlarging tumor size who received surgical intervention.
References /Resources: New Zealand Guidelines Group. Guidelines for the management of uterine fibroids. (1999, August). Available online: National Guideline Clearinghouse, http://www.guideline.gov/VIEWS/summary.asp?guideline=1505. Accessed May 21, 2001. Garcia CR, Pfeifer S, Wallach E. Gynecologic disorders uterine fibroids: Treat or ignore? Patient Care Archive (1997, January). Available online: http://pc.pdr.net/pc/public.htm?path=content/journals/p/data/1997/p1a/p1a048.html. Accessed May 22, 2001. Shoupe, D. Hysterectomy or an alternative? Hospital Practice (2000, September). Available online: http://www.hosppract.com/issues/2000/09/shoupe.htm. Accessed May 22, 2001.
Treatment of Endometriosis
Prompt attention and treatment may Prompt attention and treatment may prove to be the best way of ameliorating prove to be the best way of ameliorating the recurrence of symptoms. the recurrence of symptoms. Symptoms suggestive of endometriosis Symptoms may include: Chronic pelvic pain Abnormal uterine bleeding Low abdominal pain Dysmenorrhea Dyspareunia Pain with defecation Infertility Moderate to Severe Pain Moderate to Severe Pain
Mild to Moderate Pain Mild to Moderate Pain
Empiric treatment with OCPS GnRH agonist or progestins
Diagnostic laparoscopy
Operative laparoscopy
Normal pelvis
Operative laparoscopy with postoperative empiric GnRH agonist therapy
Pelvic pain persists or returns
Laparoscopy with resection if disease present
Empiric treatment with GnRH agonist
Disease missed
Progressive disease because of inadequate resection
Residual disease
Retreatment with GnRH agonist with add-back therapy
Consider prolonged medical suppression with add-back therapy
Operative excision or biopsy
Retreatment with GnRH -
Empiric therapy with GnRH agonist for 2-3 mos
Empiric GnRH agonist for 6 mos + add-back therapy
Second operative laparoscopy with postoperative GnRH agonist
Pain improves? Yes No
Pain improves
Pain not improved
Postoperative GnRH agonist for residual disease + add-back therapy
Consider: Diagnostic laparoscopy A or Operative laparoscopy B
Review in 6 months
Full 6-mo course of GnRH agonist addback therapy
Consider prolonged medical suppression with add-back therapy
Yes Bilateral oophorectomy, Hysterectomy
Persistent problems or treatment failure?
No Review in 6 months
Diagnostic laparoscopy provides method of diagnosing most anatomic gynecologic disease states; only definitive test for detecting endometriosis. Operative laparoscopy allows surgical excision and ablation to be completed at time of diagnosis, decreasing time, cost, and side effects. Patient is spared a second surgery (laparotomy) if performed at time of diagnosis.
TREATMENT OF ENDOMETRIOSIS
Medical Treatment of Endometriosis

Drug Danazol (Danocrine) Oral contraceptives Medroxyprogesterone suspension (Depo-Provera) Medroxyprogesterone (Provera) Norethindrone acetate (Aygestin) Leuprolide (Lupron) Gosarelin (Zoladex) Nafarelin (Synarel) Dosage 800 mg per day in 2 divided doses 1 pill per day (continuous or cyclic) 100 mg IM every 2 weeks for 2 months; then 200 mg IM every month for 4 months or 150 mg IM every 3 months 5-20 mg orally per day 5 mg per day orally for 2 weeks; then increase by 2.5 mg per day every 2 weeks up to 15 mg per day 3.75 mg IM every month for 6 months 3.6 mg SC (in upper abdominal wall every 28 days 400 mg per day: 1 spray in 1 nostril in a.m.; 1 spray in other nostril in p.m.; start treatment on day 2 to 4 of menstrual cycle Adverse Effects Estrogen deficiency, androgenic side effects Headache, nausea, hypertension Weight gain, depression, irregular menses or amenorrhea Same as other oral progestins Same as other oral progestins
Decrease in bone density, estrogen deficiency Estrogen deficiency Estrogen deficiency, bone density changes, nasal irritation
Surgical vs. Medical Treatment

Treatment Surgical Advantages Beneficial for infertility Long-term results may be better Definitive diagnosis Option for definitive treatment Lower initial cost Empiric treatment Effective for pain relief Disadvantages Expensive Invasive
Medical
Adverse effects common Not likely to improve fertility
Physician focus for Treating Endometriosis:

For appropriate patients with mild to moderate pain, try pharmacotherapy for initial treatment. Indicator: Percentage of patients receiving endocrine-based drug therapy. Bilateral oophorectomy and hysterectomy should be reserved for use in women with intractable pain who no longer desire pregnancy, and for whom conservative therapy failed. Indicator: Percentage of women who received operative laparoscopy with postoperative empiric drug therapy prior to definitive surgery.
References/Resources: Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician . 1999;60:1753-68. Available online: http://www.aafp.org/afp/991015ap/1753.html. Accessed May 10, 2001. Winkel C. Laparoscopy plus GnRH analogues: a practical approach to endometriosis. Contemporary ObGyn. April 1999.
Dysfunctional Labor
This guideline applies only to women in labor who meet ALL of the following criteria:
Nulliparous No concomitant medical problems Term pregnancy (36 weeks completed) Having contractions Singleton fetus Cephalic presentation No evidence of fetal distress Caregiver expects normal spontaneous vaginal delivery labor is NOT induced Patient in labor (see guideline limits to left and definition to right) Intrapartum care (see box to left)
Labor is defined as:

Regular contractions resulting in progressive dilation/effacement of cervix Cervical dilation 3 cm or greater Spontaneous rupture of membrane
Has SROM occurred?
no
Consider amniotomy, unless contraindicated*
Intrapartum care may include:

Chart evaluation Cervical exam Supportive care/comfort measures po fluids position changes back rubs, music, etc ambulation bath/shower Adequate pain relief nalbuphine hydrochloride (Nubain) butorphanol tartrate (Stadol) meperidine (Demerol) hydroxyzine hydrochloride (Vistaril) epidural or intrathecal narcotics for patients in active progressing labor Documentation of progress of labor Monitoring of fetal heart rate
yes <1 cm dilation x2 consecutive hours? no Stage II Labor
Failure to progress diagnosis-initiate active management of labor and consider:

yes Artificial rupture of membranes Ensure adequate maternal analgesia Oxytocin augmentation** Obtain an obstetrical/surgical consult if necessary
Progress? (fetal descent >1 cm/hr) no
yes
Normal vaginal delivery
Management of protraction disorder, consider:

Evaluation of maternal position and fetal position Evaluation of fluid balance Oxytocin augmentation** Obtain an obstetrical/surgical consult if necessary * Contraindications to amniotomy include: Presentation unknown, floating or unstable Cervix dilated <3cm Patient refuses **Contraindications to oxytocin augmentation include: unknown presentation or floating/unstable unable to monitor contractions adequately patient refuses ***Contraindications to operative vaginal delivery include: presenting part is too high provider is inexperienced fetal distress with inability to do timely operative vaginal delivery patient refuses yes Descent or rotation?
no
Cesarean-section
yes
Operative vaginal delivery contraindicated? *** no Operative vaginal delivery
Physician focus for managing dysfunctional labor: Emphasize close monitoring for early detection and intervention of failure to progress. Emphasize close monitoring for early detection and intervention of protracted labor
References/Resources: Dystocia and the Augmentation of Labor. ACOG Technical Bulletin. Number 218, December 1995. Hadi H. Cervical Ripening and Labor Induction: Clinical Guidelines. Clinical Obstetrics and Gynecology 2000;43(3):524-536. Institute for Clinical Systems Improvement. Health Care Guideline: Prevention, Diagnosis and Treatment of Failure to Progress in Obstetrical Labor. December 1999. http://www.icsi.org (2001, April 17) Ramsey, PS, Ramin KD, Ramin SM. Labor Induction. Current Opinion in Obstetrics and Gynecology 2000;12(6):463-473.
http://www.acog.org http://www.aafp.org http://www.icsi.org
Induction of Labor
Indications for inducing labor may include:
Pregnancy-induced hypertension, preeclampsia, or chronic hypertension Premature rupture of membranes Chorioamnionitis Suspected fetal jeopardy (i.e. fetal growth restriction, isoimmunization) Maternal medical problems (i.e. DM, renal disease, chronic pulmonary disease) Fetal demise Logistical factors (i.e. risk of rapid labor, distance from the hospital, psychosocial indications) Postdate pregnancy Oligohydramnios Abruptio placentae Consideration of Labor Induction
Absolute contraindications for inducing labor include:

Placenta or vasa previa Transverse fetal lie Prolapsed umbilical cord Previous transfundal uterine surgery Active genital herpes infection Pelvic structural abnormality Invasive cervical cancer
Do benefits to mother and fetus outweigh the risks of continuing the pregnancy?
no
ACOG Dating Criteria for term gestation:

Fetal heart tones documented for 20 wks by non-electronic fetoscope or for 30 wks by Doppler 36 weeks since positive serum or urine HCG pregnancy test was performed by a reliable laboratory An U/S measurement of crownrump length, obtained at 6-12 weeks, supports a gestational age of at least 39 wks An U/S obtained a 13-20 weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination Reconsider Induction
yes
Obstetric conditions that may require special care during induction (relative contraindications):
Mulitfetal gestation Polyhydramnios Maternal cardiac disease Abnormal fetal heart rate patterns not requiring emergency birth Grand mulitparity Severe hypertension Breech presentation Presenting part above the pelvic inlet One or more previous low-transverse cesarean deliveries
Does the patient meet dating criteria for term? yes Consider Bishop score (see page 2)
no
Is induction likely to be successful? yes
no
Fetal heart rate and uterine activity should be continuously monitored from the time the PGE2 vaginal insert is placed until at least 15 minutes after it is removed
Initiate cervical ripening (if appropriate) with one of the following: IV Oxytocin (Pitocin)--0.5-6 mU/min initial dose (max 25mU/min) Intracervical Dinoprostone gel (Prepidil)--0.5 mg initial dose, may repeat q6 hours (maximum of 3 doses in 24 hours) Intravaginal Dinoprostone insert (Cervidil)--10 m (once only) Intravaginal Misoprostol* (Cytotec)--25 ug initial dose, may repeat q3-6 hours (maximum of 6-8 doses) Wait at least 4 hours to begin oxytocin. Other options for cervical ripening include: stripping of the membranes, amniotomy, balloon catheters
Is cervix favorable? yes
no
Repeat doses of ripening agent as appropriate
Proceed with amniotomy and/or oxytocin induction (10U of oxytocin in 1 L of IV solution) as appropriate. *Do not use Misoprostol in patients with prior c-section or major uterine surgery.
Induction of Labor p.2

Bishop System of Cervical Scoring (Table from Harman et al)
Assessment score 0 1 2 3 Dilation (cm) 0 1-2 3-4 4-5 Effacement (%) 0-30 40-50 60-80 90-100 Fetal station -3 -2 -1, 0 +1, +2, +3 Consistency Firm Medium Soft -Position Posterior Mid Anterior --
Note: Add the score for each of the clinical assessments. If the total score is greater than 8, the success of induction approaches that of spontaneous labor. A Bishop score of "5 is associated with induction failure.
Possible complications associated with oxytocin infusion include:

Uterine Hyperstimulation --> uterine contractions more often than every 2 minutes that last longer than 90 seconds with or without fetal heart changes. Excessive uterine contractions may lead to uteroplacental hypoperfusion and fetal hypoxia, uterine rupture, or abruptio placentae. Hyperstimulation may be treated by decreasing or stopping the oxytocin and with administration of terbutaline 0.125 mg IV or SC. Water Intoxication --> because of its similarity to pituitary antidiuretic hormone (ADH), large doses can result in water intoxication that can lead to hyponatremia, confusion, convulsion, coma, congestive heart failure, and death. To avoid this complication, monitor intake and output closely and use oxytocin judiciously. Uterine Rupture --> occurs more commonly in multiparous patients, in those with previous uterine scar, with fetal malpresentations, and with multiple pregnancy or overdistended uterus. These conditions are relative contraindications to oxytocin use. Other complications of oxytocin infusion include: abruptio placentae, precipitous delivery, postpartum uterine atony and hemorrhage, neonatal hyperbilirubinemia, hypotension, and amniotic fluid embolism.
Physician focus for managing labor induction: Discuss risks/benefits with women considering induction and document in chart. Confirm adequate fetal dates prior to induction and document in chart.
References/Resources: Hadi H. Cervical Ripening and Labor Induction: Clinical Guidelines. Clnical Obstetrics and Gynecology 2000;43(3):524-536. Harman JH, Kim A. Current Trends in Cervical Ripening and Labor Induction. Am Fam Physician 1999;60:477-84. Induction of Labor. ACOG Practice Bulletin Number 10, November 1999. Ramsey, PS, Ramin KD, Ramin SM. Labor Induction. Current Opinion in Obstetrics and Gynecology 2000;12(6):463-473. Response to Searles Drug Warning on Misoprostol. ACOG Committee on Obstetric Practice. Number 248, December 2000. Rinehart BK, Terrone DA, Hudson C, Isler CM, Larmon JE, Perry KG. Lack of utility of standard labor curves in the prediction of progression during labor induction. Am J Obstet Gynecol 2000;182:1520-6. Simpson KR, Poole JH, Simpson KR. Labor Induction and Augmentation: Knowing When, and How, to Assist Women in Labor. AWHONN Lifelines 1998;2(6):39-42. Zlatnik FJ. Elective Induction of Labor. Clinical Obstetrics and Gynecology 1999;42(4):757-765.
http://www.acog.org/ http://www.aafp.org
Breech Presentation
Breech presentation by Leopolds maneuver or vaginal examination and at least 36 weeks gestation Advise patient of risk of cord prolapse with rupture of membranes and need for immediate evaluation if PROM occurs. Perform U/S to: Confirm position Determine amniotic fluid index (AFI) Note placental location r/o congenital anomalies r/o presence of nuchal cord
Confirms breech?
no
Routine prenatal care
yes Review contraindications Obtain informed consent
Exclusion Criteria for External Cephalic Version:

Multiple pregnancy Evidence of uteroplacental insufficiency Significant third-trimester bleeding Suspected intrauterine growth restriction Amniotic fluid abnormalities Uterine malformation Placenta previa Maternal cardiac disease Pregnancy-induced hypertension Uncontrolled hypertension A nonreassuring fetal monitoring pattern Major fetal anomaly Presence of exclusion criteria? no yes Assess for C-section or trial of labor
Attempt external cephalic version when >=37 weeks gestation (consider tocolysis for nulliparas)
Selection Criteria for Vaginal Breech Delivery:

Estimated fetal weight from 2,000 to 4,000 g (4 lb, 6 oz to 8 lb, 13 oz) Frank or complete breech presentation Flexed fetal head No major fetal anomalies or placenta previa on ultrasound Adequate magnetic resonance, computed tomography, x-ray, or clinical pelvimetry
Prior to version attempt: Draw CBC and type/screen Establish IV access Assess NST or BPP Following version attempt: Administer Rhogam (Rho (D) immune globulin) to Rh-negative women Perform NST and Ultrasound
Consider repeat version attempt weekly and monitor for spontaneous conversion to vertex
no
Successful version?
yes
Maternal self-assessment
Monitor for reversion to breech
Physician focus for Treating Breech Presentation: Perform a confirmatory ultrasound prior to performing external cephalic version attempt. Indicator: Percentage of women diagnosed with breech presentation (>35 weeks gestation) that receive a confirmatory ultrasound prior to undergoing external cephalic version attempt. Perform a non-stress test (NST) and an ultrasound following external cephalic version attempts. Indicator: Percentage of women undergoing external cephalic version attempts that receive postattempt NST and ultrasound.
References/Resources: Coco AS, Silverman SD. External Cephalic Version. American Family Physician 1998;58(3):731-744. External Cephalic Version. ACOG Practice Bulletin Number 13, February 2000. Hofmeyr GJ. External cephalic version facilitation for breech presentation at term (Cochrane Review) In: The Cochrane Library, 1, 2001. Oxford: Update Software. Hofmeyr GJ. External cephalic version for breech presentation before term (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. Management of the Breech Presentation. ACOG Technical Bulletin Number 95, August 1986. http://www.acog.org/ http://www.aafp.org
Non-Reassuring Fetal Status

Labor with Electronic Fetal Monitoring (EFM)
Reassuring FHR pattern?
yes
Continue labor monitoring until delivery
no yes
Emergency Interventions for Non-reassuring Patterns:

Check maternal blood pressure - if hypotensive and epidural in place, administer IVF bolus Change maternal position (lateral or knee-chest) Call anesthesia to evaluate, if no improvement If no epidural, give IVF bolus, and reposition - if no improvement, evaluate for cause of maternal hypotension Consider tocolysis (for uterine tetany or hyperstimulation) Decrease or discontinue oxytocin if infusing Consider amnioinfusion (for variable decelerations) Determine whether operative intervention is warranted and, if so, how urgently it is needed
Reassuring FHR pattern?
no
Vaginal delivery
yes
Delivery imminent?
Non-Reassuring Patterns:
Fetal tachycardia Fetal bradycardia Saltatory variability Variable decelerations associated with a non-reassuring pattern Late decelerations with preserved beat-to-beat variability no Perform Cesarean Section
Ominous Patterns:
Persistent late decelerations with loss of beat-to-beat variability Non-reassuring variable decelerations associated with loss of beat-to-beat variability Prolonged severe bradycardia Sinusoidal pattern Confirmed loss of beat-to-beat variability not associated with fetal quiescence, medications or severe prematurity
Fetal Heart Rate (FHR) tracing should be interpreted ONLY in the context of the clinical scenario, and any therapeutic intervention should consider the maternal condition as well as that of the fetus.
Non-Reassuring Fetal Status p.2

Causes of Fetal Tachycardia:
Fetal hypoxia Maternal fever Hyperthyroidism Maternal or fetal anemia Parasympatholytic drugs Atropine Hydeoxyzine (Atarax) Sympathomimetic drugs Ritodrine (Yutopar) Terbutaline (Bricanyl) Chorioamnionitis Fetal Tachyarrhythmia Prematurity
Causes of Severe Fetal Bradycardia:

Prolonged cord compression Cord prolapse Tetanic uterine contractions Paracervical block Epidural and spinal anesthesia Maternal seizures Rapid descent Vigorous vaginal examination
Signs of Non-Reassuring Variable Decelerations that Indicate Hypoxemia:

Increased severity of the deceleration Late onset and gradual return phase Loss of shoulders on fetal heart rate (FHR) recording A blunt acceleration or overshoot after severe deceleration Unexplained tachycardia Saltatory variability Late decelerations or late return to baseline Decreased variability
Physician focus for managing non-reassuring fetal heart rate (FHR) patterns: Emphasize appropriate emergency interventions for non-reassuring or ominous fetal heart rate patterns.
References/Resources: Fetal Heart Rate Patterns: Monitoring, Interpretation, and Management. ACOG Technical Bulletin Number 207, July 1995. Institute for Clinical Systems Improvement. Health Care Guideline: Intrapartum Fetal Heart Rate Management. December 1999. http://www.icsi.org (2001, April 17) Morrison EH. Common Peripartum Emergencies. Am Fam Phys 1998;58(6):1593-1607 Sweha A, Hacker TW, Nuovo J. Interpretation of the Electronic Fetal Heart Rate During Labor. Am Fam Phys 1999;59(9):2487-2506. ACOG practice guideline.
Fetal Macrosomia
To date, no management algorithm involving selective interventions based on estimates of fetal weight has demonstrated efficacy in reducing the incidence of either shoulder dystocia or brachial plexus injuryplanned interventions based on estimates of fetal weight do not reduce the incidence of shoulder dystocia and do not decrease adverse outcomes attributable to fetal macrosomia.
--Sacks and Chen, Obstetrical and Gynecological Survey 2000
Current guidelines state that a planned cesarean delivery for a diabetic pregnant woman whose fetal weight estimates exceed 4250 to 4500 gm may be reasonable...
--ACOG Practice Patterns Number 7, October 1997
With an estimated fetal weight greater than 4500 gm, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery --ACOG Practice Bulletin Number 22, November 2000 For almost all macrosomic pregnancies including diabetic mothers, previous deliveries with shoulder dystocia, or women considering VBAC, expectant management with vigilance for evidence of fetopelvic disproportion will have optimal results.
--Zamorski and Biggs, American Family Physician 2001
Risk Factors for Fetal Macrosomia:

Maternal diabetes Maternal impaired glucose intolerance Multiparity Previous macrosomic infant Prolonged gestation Maternal obesity Excessive maternal weight gain Male fetus Parental stature Maternal age Maternal race Paternal birth weight Need for labor augmentation Prolonged second stage
Abnormal labor patterns and diagnostic criteria

Labor Pattern Protraction disorders Dilation Descent Arrest Disorders Dilation Descent Nulligravida <1.2 cm/h <1.0 cm/h >2 hours >1 hour Multipara <1.5 cm/h <2.0 cm/h >2 hours >1 hour
From ACOG Technical Bulletin No. 218
# Prepare and drill labor and delivery staff in the basics and
management of shoulder dystocia, including: McRoberts maneuver Suprapubic pressure on the impacted shoulder Woods maneuver Delivery of the posterior arm Zavanelli maneuver
Forceps should be used cautiously - if at all with fetal macrosomia.
Physician focus for delivery of the macrosomic fetus: Emphasize preparedness of staff for management of shoulder dystocia.
References/Resources: Fetal Macrosomia. ACOG Practice Bulletin Clinical Management Guidelines for ObstetricianGynecologists. Number 22, November 2000. Berkus MD, Conway D, Langer O. The Large Fetus. Clinical Obstetrics and Gynecology 1999;42(4):766784. Conway DL, Oded L. Elective delivery of infants with macrosomia in diabetic women: Reduced shoulder dystocia versus increased cesarean deliveries. Am J Obstet Gynecol 1998;178(5):922-25. Dystocia and the Augmentation of Labor. ACOG Technical Bulletin. Number 218, December 1995. Gonen R, Bader D, Ajami M. Effects of a policy of elective cesarean delivery in cases of suspected fetal macrosomia on the incidence of brachial plexus injury and the rate of cesarean delivery. Am J Obstet Gynecol 2000;183:1296-300. Rasmussen TL. The Use of Ultrasound to Identify Fetuses with Macrosomia in Diabetic Pregnancies: A Review of Current Literature. Journal of Diagnostic Medical Sonography 2000;16(2):76-79. Sacks DA, Chen W. Estimating Fetal Weight in the Management of Macrosomia. Obstetrical and Gynecological Survey 2000;55(4):229-239. Shoulder Dystocia. ACOG Practice Patterns, Evidence-Based Guidelines for Clinical Issues in Obstetrics and Gynecology. Number 7, October 1997. Sokol RJ, Chik L, Dombrowski MP, Zador IE. Correctly identifying the macrosomic fetus: Improving ultrasonography-based prediction. Am J Obstet Gynecol 2000;182;1489-95. Zamorski MA, Biggs WS. Management of Suspected Fetal Macrosomia. American Family Physician 2001;63:302-6.
Vaginal Birth after Cesarean Section

Pregnant woman with history of previous C-section
Contraindications to VBAC (and see page 2):

Previous classic C-section or T-shaped incision or other transfundal uterine surgery Contracted pelvis Previous uterine rupture or dehiscence Some maternal/fetal medical conditions (e.g., open neural tube defect or complete placenta previa) Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility Unknown uterine scar if there is a high likelihood of classical scar Rare psychological or social conditions
Obtain previous operative records for type of uterine incision Perform thorough history and physical
Contraindications to VBAC? no
yes
Counsel patient regarding benefits and risks of VBAC
Routine prenatal care and appropriately timed cesarean delivery
yes
Patient desires trial of labor?
no
Routine prenatal care until labor Instruct patient to report to hospital in active labor
Complicated labor results from:

Failure to progress (see Dysfunctional Labor guideline) Fetal distress (see Non-Reassuring Fetal Status During Labor guideline) Maternal complication (e.g. cardiac disease, exhaustion) Uterine Rupture The same considerations for intervention in labor apply to VBACs as for other attempted deliveries.
Special considerations of labor management (see page 2)
Normal labor? no
yes
Complicated labor management (see Page 2)
Repeat C-section
no
Vaginal birth appropriate?
yes
Vaginal birth
Vaginal Birth after Cesarean Section

(page 2)
The following are NOT contraindications to VBAC:

Two or more previous C-sections Previous failure to progress in labor and/or CPD Post C-section infection Vaginal delivery with a known overdistended uterus (i.e., twins, macrosomia, hydramnios)
Special considerations of labor management for VBAC candidates:

C-section team should be available within a short time (20-30 min). Intermittent auscultation or continuous electronic fetal heart rate monitoring should be done. Augmentation or induction of labor is not contraindicated. Uterine scars do not require manual exploration post-partum. Epidural anesthesia is not contraindicated. Amnioinfusion is not contraindicated Intrauterine pressure catheters are not necessary unless there are other obstetric indications. The use of prostaglandins in women with previous c-sections has not been thoroughly studied. Each situation should be weighed individually.
Physician focus for Vaginal Birth after C-section (VBAC): Discuss risks/benefits of VBAC with patient and document in chart Document prior uterine surgeries, including c-section(s) in patients chart. Facilities are encouraged to have a general VBAC policy that is agreed on by the obstetrics and gynecology department, with a built-in monitoring and evaluation system.
References/Resources: Vaginal Birth After Previous Cesarean Delivery. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists. Number 5, July 1999 AAFP Reference ManualClinical Policies. Trial of Labor versus Elective Repeat Cesarean Section for the Woman with a Previous Cesarean Section. April 1995. http://www.aafp.org/policy/camp/rep-505.html/ (2001, April 16) Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permezel M. Vaginal Birth After Caesarean Section: An Australian Multicentre Study. Obstetrical and Gynecological Survey 2000;55(11):680-682 Jongen VHWM, Halfwerk MGC, Brouwer WK. Vaginal Delivery After Previous Caesarean Section for Failure of Second Stage of Labour. Obstetrical and Gynecological Survey 1999;54(4):226-227. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Vaginal Birth After Cesarean. December 1999 http://www.icsi.org/guidelst.htm/ (2001, April 16) Wing DA and Paul RH. Vaginal Birth After Cesarean Section: Selection and Management. Clinical Obstetrics and Gynecology 1999;42(4):836-848.
ACOG practice guideline. VBAC.
Pregnancy-Associated Hypertensive Disease

The use of alcohol and tobacco during pregnancy should be strongly discouraged.
Findings suggestive of preeclampsia syndrome:
Blood pressure>=160 systolic or >=110 diastolic Proteinuria of 2.0 g or more in 24 hours (2+ or 3+ on qualitative examination) Increased serum creatinine (>1.2 mg/dL) Platelet count less than 100,000 cells/mm3 and/or evidence of microangiopathic hemolytic anemia Elevated hepatic enzymes (ALT or AST) Pulmonary edema Oliguria - <400cc/240 Intrauterine growth retardation or oligohydramnios Persistent headache or other cerebral or visual disturbances Persistent epigastric pain Consider bed rest Hypertension in pregnancy (>140/90 mmHg on two or more determinations)
Always carefully consider the risks and benefits to a woman and her fetus with continuing or initiating pharmacotherapy for hypertensive disease during pregnancy. Antihypertensive treatment for mild chronic hypertension benefits the mother, but the impact on perinatal outcomes is less clear.
HTN diagnosed before 20 weeks gestation? no
yes
Likely chronic hypertension
Outpatient management may be considered if compliance is expected to be good, hypertension is mild, and the fetus is normal.
Hospitalize patient and monitor closely for signs of fetal distress and symptoms of headache, visual disturbances, and right upper quadrant pain
Consider reducing dose or weaning current regimen. ACE-Inhibitors yes Preeclampsia symptoms or signs present?
and Angiotensin II Receptor Blockers MUST be discontinued due to risk of fetal abnormalities.
If SBP >=150 mmHg or DBP >=100 mmHg and treatment has not yet been initiated, see page 2 for options Consider work-up of secondary hypertension
no Consider initiation of antihypertensive agent if DBP is 100 mmHg or higher Continue close observation of woman and fetus. Initiate antihypertensive therapy if/when benefits to mother appear to outweigh risk to fetus.
Attempt to postpone delivery if hypertension is mild, and no renal, liver, or coagulation abnormalities are evident.
yes
Is patient at <32 weeks gestation?
Qualifying diagnosis for labor induction when pregnancies are at or near term:
HELLP syndrome Progressive renal failure Premonitory signs of eclampsia (including mild) Elevated blood pressure Fetal distress Administer magnesium sulfate for seizure prophylaxis during labor and delivery and for at least 24 hours post-partum by continuous IV infusion.
no Consider corticosteroids to accelerate fetal lung development.
Has patient experienced severe hypertension for 24-48 hours? OR Does patient have another qualifying diagnosis?
yes
Consider labor induction
no Continue close observation and monitoring of woman and fetus Bed rest Antihypertensive medications Magnesium sulfate for seizure prophylaxis
Monitor deep tendon reflexes, respiratory rate, and urinary output during magnesium sulfate administration
Pregnancy-Associated Hypertensive Disease (page 2)

Antihypertensive Drugs Used in Pregnancy (from NHLBI*):
Suggested Drug Central alpha-agonist Beta-blockers Comments Methyldopa is the drug of choice recommended by the NHBPEP** Working Group. Atenolol and metoprolol appear to be safe and effective in late pregnancy. Labetalol also appears to be effective. Beta-blockers can cause IUGR and low placental weight when used during the second trimester. Other potentially adverse effects include fetal bradycardia, impaired fetal compensatory response to hypoxia, and neonatal hypoglycemia. Potential synergism with magnesium sulfate may lead to precipitous hypotension. Fetal abnormalities, including death, can be caused, and these drugs should not be used in pregnancy. Diuretics are recommended for chronic hypertension if prescribed before gestation or if patients appear to be salt-sensitive. They are not recommended in preeclampsia. Hydralazine was the parenteral drug of choice, but is being replaced by IV labetalol or oral /SL nifedipine based on fewer maternal and perinatal adverse effects.
Calcium antagonists ACE-Inhibitors, Angiotensin II receptor blockers Diuretics
Direct vasodilators
Laboratory tests to consider in early gestation for women who are High-risk for preeclampsia*** or who present with hypertension before gestation week 20:
CBC serum creatinine and uric acid levels 24-hour urine collection for protein and creatinine IF routine urine analysis shows 1+ or greater protein with clean catch specimen Early sonogram for dating if conditions not optimal for clinical dating Baseline sonogram for evaluating fetal growth at 25 to 28 weeks
Laboratory evaluation for women who develop hypertension after gestation week 20--at initial diagnosis of hypertension, and consider repeating biweekly:
CBC protein excretion quantification (e.g., 24-hour collection) serum creatinine, uric acid, and transaminase levels serum albumin, lactic acid dehydrogenase, blood smear, and coagulation profile
Conditions Sometimes Confused with Preeclampsia or Eclampsia:

Viral hepatitis Acute fatty liver of pregnancy Acute pancreatitis Gallbladder disease Appendicitis Kidney stones Glomerulonephritis Hemolytic-uremic syndrome Exacerbation of systemic lupus erythematosus Autoimmune thrombocytopenia Thrombotic thrombocytopenic purpura Cerebral venal thrombosis Encephalitis of various causes Cerebral hemorrhage *NHLBI, National Heart, Lung, and Blood Institute (a division of the NIH). **NHBPEP, National High Blood Pressure Education Program ***High-risk for preeclampsia includes a history of increased blood pressure before conception or in a previous gestation; women with diabetes, collagen vascular disease, or underlying renal vascular or renal parenchymal disease; and those with a multifetal pregnancy.
Hypertension
Elevated blood pressure identified Goal blood pressure: <140/90 for adult without diabetes <130/80 for adults with diabetes Diagnostic tests to consider: CBC Electrolytes Creatinine Fasting glucose Urinalysis Lipid profile Electrocardiogram Complete history and physical exam, look for signs of end-organ damage Confirm elevated blood pressure within 1-8 weeks and perform diagnostic testing if BP still above normal Begin or continue lifestyle modifications* Smoking cessation Weight reduction Regular physical activity Moderation of alcohol intake Reduction of sodium intake Lipid measurement
Perform additional work-up as indicated.
yes
Is a secondary cause suspected?
no
Adequate response? no Start with a low dosage of a long-acting oncedaily drug and titrate.
yes
Encourage maintenance of lifestyle modifications and regular follow-up for monitoring
Initiate one of the following medications based upon the compelling indication:
ACE-Inhibitor Diabetes mellitus Heart failure (CHF)** Myocardial infarction Vascular disease
Beta blocker Uncomplicated hypertension Myocardial infarction Heart failure
Diuretic Uncomplicated hypertension Heart failure Isolated systolic hypertension (in older persons)
Long-acting dihydropyridine calcium antagonist Isolated systolic hypertension (in older persons)
Consider ARBs as an alternative to ACE inhibitors in patients unable to tolerate the latter. Substitute another drug from a different class
no
Is the drug well tolerated?
yes
Increase dose of initial agent. If maximal dose inadequate, add a second agent. no
Is goal blood pressure achieved? *Consider simultaneous initiation of pharmacotherapy if patient is a diabetic or has signs/symptoms of end-organ damage. **B-blockers should not be started during an acute worsening of clinical status or when patient has fluid overload. FDA-approved B-blockers for CHF include Carvedilol (Coreg), Bisoprolol (Zebeta) and Metoprolol succinate (Toprol XL)
yes Follow up at least every 6 months. Continue lifestyle modifications
Physician focus for Evaluating and Treating Hypertension (HTN): Prescribe ACE-Inhibitors (or nitrates plus hydralazine) for all CHF patients without contraindications.* Indicator: Percentage of adults with diagnosis of CHF treated with ACE-Inhibitors (OR nitrates plus hydralazine) Titrate ACE-Inhibitors to target dose, as tolerated, in patients with CHF. Indicator: Percentage of adults with diagnosis of CHF, treated with ACE-Inhibitors, at target doses. These target doses are outlined on page 2 of the CHF guideline. Prescribe B-blockers for CHF patients, NYHA Class I-III, without contraindications. Indicator: Percentage of adults with diagnosis of CHF treated with B-blockers.
* Angiotensin II Receptor Antagonists (ARB) may be used as an alternative to ACE inhibitors in patients who cannot tolerate the latter but have comorbid conditions for which ACE inhibitors are indicated. References/Resources: Kaplan NM. What is goal blood pressure for the treatment of hypertension? Archives of Internal Medicine 2001;161:1480-1482. Kaplan NM. Angiotensin II receptor antagonists in the treatment of hypertension. American Family Physician 1999;60:1185-90. Yarows S et al. University of Michigan Medical Center. UMMC Hypertension Guidelines. February 1997. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Hypertension Diagnosis and Treatment. November 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7) Kaplan NM. Treatment of Hypertension: Insights from the JNC-VI Report. Am Fam Physician 1998;58:1323-30.. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. (1994, June). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction. Clinical Practice Guideline No. 11. Retrieved from http://www.ahrq.gov/ (2001, March 7) University of Michigan Health System. Guidelines for Clinical Care: Heart FailureSystolic Dysfunction. http://cme.med.umich.edu/iCME/default.asp/ (2001, March 7) University of Washington Physicians. Heart Failure Due to Systolic Dysfunction (HF) Guidelines. http://healthlinks.washington.edu/guideline/hf/processes.html/ (2001, February 20) http://www.ahcpr.gov/clinic/cpgonline.htm http://www.americanheart.org http://www.hfsa.org http://www.praxis.md.com
Hyperlipidemia
C oronary Artery Disease (C A D ) Risk Factors:
Perform fasting lipid panel for all adults >20 years old every 5 years Calculate number of risk factors (see table to right)
Positive Risk Factors Age: M ale >=45 Fem ale >=55, or prem ature m enopause without HRT Fam ily history of prem ature CH D: Definite M I or sudden death before 55 y/o in father or other m ale firstdegree relative before 65 y/o in m other or other female firstdegree relative Current cigarette sm oking
Repeat screening every 5 years
Yes
LDLcholesterol less than 160 ?
No
Does patient have any risk factors?
H ypertension: >140/90* or on antihypertensive medication Low H DL-cholesterol <40 m g/dL* Diabetes m ellitus
No
Yes
Negative Risk Factors
H igh H DL-cholesterol > 60 m g/DL If H DL-cholesterol is > 60, subtract one risk factor *Confirm ed by m ore than one m easurem ent.
Determine goal LDL, based upon risk factors and baseline LDL-cholesterol
0-1 risk factor GOAL LDL-cholesterol is <160
2+ risk factors (10-year risk 20%)* GOAL LDL-cholesterol is <130
CHD or CHD equivalents (10-year risk >20%)* GOAL LDL-cholesterol is <100
Non-pharmacological treatment trial (3-12 months): Initiate dietary therapy: Step I diet (or Step II diet if known CAD or if patient is already on a Step I diet) Consider referral to dietician Initiate physical activity, weight management, and smoking cessation programs as indicated. Consider ruling out secondary causes of hyperlipidemia with urinalysis, TSH, blood sugar, alk phos, etc.
No
Is LDL >130? Yes
Recheck lipid levels in 6 weeks
Consider immediate initiation of a Statin for aggressive lipid reduction
Discuss with patient their risk level and preferences regarding continuing a trial of behavioral and dietary therapies or initiating lipid-lowering medication. Consider estrogen-replacement therapy in appropriate women
No
Has goal LDL-cholesterol been met?
Yes
Continue health maintenance and management
Yes Decision to initiate lipid-lowering therapy? No Initiate lipidlowering pharmacotherapy (see page 2) Yes *Using Framingham projections of 10-year absolute CHD risk to identify certain patients for more intensive treatment Has goal LDL-cholesterol been met?
Follow-up in office every 4-6 months for the first year, then at least annually
Recheck lipid levels in 6 weeks
No
Consider increasing dose of lipid-lowering agent or adding a second agent (see page 2)
Hyperlipidemia Page 2
Drug Class
Statins (HMG-CoA reductase inhibitors)
Indication
Drug of choice in patients with known CAD Reduces LDL-C 25-40% Reduces triglyceride levels Modest increase in HDL-C Demonstrated decreased mortality from CAD Typically first-line for primary prevention (hyperlipidemia without known CAD) Can reduce total cholesterol and LDL-C 15-30% Increases triglyceride levels Can be combined with other drugs (e.g. statins)for severe forms of hypercholesterolemia Reduces LDL-C cholesterol and triglycerides Increases HDL-C levels
Cautions/Contraindications
Contraindicated in active liver disease Hepatotoxicity occurs in <2% of patients, and is usually reversible Myositis is unusual complication Caution when combining with fibrates or niacin Gastrointestinal side effects may preclude or limit dosage
Bile Acid Sequestrants (Cholestyramine and colestipol HCl)
Niacin (i.e. Nicotinic acid, Niaspan)
Fibrates (i.e. gemfibrozil) Reduces triglyceride levelsmost valuable for treatment of very high triglyceride levels May elevate both LDL-C and HDL-C levels Can use as combination therapy with a statin for mixed lipid abnormalities monitor for myopathy and potential hepatic toxicity Should be considered as a possible alternative or adjunct to therapy for women with elevated LDL-cholesterol levels Increases HDL-C levels Reduces LDL-C levels
Contraindicated in chronic liver disease, severe gout Relative contraindication with peptic ulcer disease Flushing is common side effect. This may be alleviated by titrating dose, taking with a meal and/or pretreatment with aspirin Requires monitoring of liver function Doesnt usually produce substantial LDL-C reduction May elevate both LDL-C and HDL-C levels Myositis and gallstones are unusual complications Contraindicated in severe renal disease, severe hepatic disease Combine with progestins for women with intact uterus
Estrogen Replacement Therapy
Focus on the Patient: Simplify medication regimens Provide explicit patient instruction and use good counseling techniques to teach the patient how to follow the prescribed treatment Encourage the use of prompts to help patients remember treatment regimens Use systems to reinforce adherence and maintain contact with the patient Encourage the support of family and friends Reinforce and reward adherence Increase visits for patients unable to achieve treatment goal Increase the convenience and access to care Involve patients in their care through self-monitoring
Physician focus for Treating Hyperlipidemia: Select a statin for lipid-lowering therapy in patients with known coronary artery disease (CAD). Indicator: Percentage of adults diagnosed with hyperlipidemia with a co-existing diagnosis of CAD or MI that are treated with a statin. See patients diagnosed with hyperlipidemia for office follow-up within 4 months of initial diagnosis. Indicator: Percentage of adults diagnosed with hyperlipidemia with a follow-up appointment within 4 months of initial diagnosis.
References/Resources: Abookire SA, Karson AS, Fiskio J, Bates DW. Use and Monitoring of Statin Lipid-Lowering Drugs Compared With Guidelines. Arch Intern Med. 2001; 161:53-58. Ansell BJ, et al. An evidence-based assessment of the NCEP Adult Treatment Panel II guidelines. JAMA 1999: 282:2051-7. Harvard Pilgrim Health Care, Inc. Guidelines for lipid screening and management for primary and secondary prevention of coronary heart diseases (CHD) in adults. Released 1997 Oct. Accessed at the National Guideline Clearinghouse. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute. JAMA 2001:285(19): 2486-2497. Sikkink J, et al. Health Care Guideline: Treatment of Lipid Disorder in AdultsPatients Without Known Coronary Artery Disease. Institute for Clinical Systems Improvement (ICSI). November 2000. http://www.icsi.org/guidelst.htm/ Task Force, Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Dyslipidemia and Prevention of Atherogenesis. AACE medical guidelines for clinical practice for the diagnosis and treatment for dyslipidemia and prevention of atherogenesis. Endocrine Practice 2000. 6(2): 162-213 American Heart Association, Step I and II Diets: http://www.americanheart.org/Heart and Stroke A Z Guide/step1.html/
Stable Angina
ANGINA SIGNS/SYMPTOMS MAY INCLUDE: Pain/discomfort in chest and/or adjacent areas Nitroglycerin used to shorten/ alleviate/prevent angina attacks Anginal equivalent symptoms may include: nausea, palpitations, diaphoresis, unusual weakness or fatigue, shortness of breath (often with exertion) Signs/Symptoms of Angina Features of intermediate or high risk unstable angina: Rest pain lasting > 20 min. Age >65 y/o ST and T wave changes Pulmonary edema Elevated cardiac enzymes
Does patient have intermediate or high risk unstable angina? no
yes
Go to Unstable Angina Algorithm
Evaluation to include (where appropriate): Complete History and Physical EKG (optimally during symptoms) Blood work--CBC, chem profile, TSH, FLPs Chest X-ray Echocardiogram (if suspect dysfunction/failure) RISK ASSESSMENT: Low Intermediate Prior vascular dz. atypical >20 min C.P. @ rest (resolved) No High Accelerated tempo angina >20 min C.P. at rest (ongoing) Pulm edema MR murmur S3 hypotension >0.05mV ST changes BBB, sustained. v. tach
Assessment yields intermediate or high risk for adverse event? yes
Normal EKG
>.2 mV T-wave (or unchanged)
Contraindications to stress testing?
Yes Initiate Medical Therapy and Lifestyle Modification (see page 2) Follow-Up in 2-6 weeks
No
Consider cardiac catheterization or pharmacological stress test
Able to achieve necessary increased heart rate via stress test?
No
Treadmill results indicating high risk: <5 METs duration ST segment depression Hypotension Inability to attain target heart rate--85% of max predicted heart rate (MPHR=220-age) Exercise-induced angina Ventricular ectopy at low workload no
no
yes
Baseline EKG normal?
Yes Exercise stress test
Test results suggestive of high risk?
yes
Consider further evaluation with: Nuclear stress test Stress Echocardiography Cardiac catheterization
Do test results suggest significant lesions?
no
yes Refer for cardiac catheterization and myocardial revascularization.
Consider ECHO or nuclear stress test
Stable Angina (page 2)

Medical therapy and lifestyle modification recommendations (if no contraindications): B-blocker--titrate to achieve a resting heart rate of 50-60 beats per minute Calcium channel blocker* and/or nitrates** (if symptoms persist with B-blocker monotherapy) ACE-I for patients with CHF, LV dysfunction (EF<40), hypertension, or diabetes Aspirin 75-325 mg qd (or, Clopidogrel 75 mg/d if Aspirin contraindication) Lipid-lowering therapy (see Hyperlipidemia guideline) Low-cholesterol diet education Physical exercise education Smoking cessation Nitroglycerin (sublingual or spray)--patient must be instructed in its use. *Caution with negative inotropic agents IF impaired left ventricular function present (consider dihydropyridines as Ca-channel blockers of choice in compensated CHF) **Long-acting nitrates, with daily nitrate-free interval.
General Contraindications for Exercise Stress Test Consider pharmacologic stress test under the following circumstances: Acute thrombophlebitis or deep venous thrombosis Neuromuscular, musculoskeletal or arthritic condition that precludes treadmill exercise Patients inability or lack of desire to perform the test Easy fatigability Consider cardiac catheterization under the following circumstances: Recent (within 6 weeks) acute myocardial infarction Angina at rest Severe symptomatic left ventricular dysfunction Potentially life-threatening arrhythmias Acute pericarditis, myocarditis or endocarditis Severe aortic stenosis Acute pulmonary infarct or embolus Acute or serious general illness
Physician focus for Evaluating and Treating Stable Angina: See patients diagnosed with stable angina within two months of initial diagnosis. Indicator: Percentage of adults diagnosed with stable angina who have a follow-up appointment with their PCP or Cardiologist within 2 months of initial diagnosis Prescribe beta-Blocker therapy for patients with stable angina, unless contraindicated or not tolerated. Indicator: Percentage of adults with stable angina filling a prescription for a beta-Blocker. Prescribe short-acting nitrates (sublingual or spray) for all patients with stable angina, unless contraindicated. Indicator: Percentage of adults with the diagnosis of stable angina with a current nitroglycerin (sublingual or spray) prescription. This prescription could be recent or up to one-year prior.
References/Resources: Gibbons RJ, Chatterjee K, Dale J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation 1999: 99:2829-2848. Heidenreich PA, McDonald KM, Hastie T, Fadel B, Hagan V, Lee BK, Hlatky MA. Meta-analysis of Trials Comparing beta-Blockers, Calcium Antagonists, and Nitrates for Stable Angina. JAMA 1999; 281(20):1927-1936. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Stable Coronary Artery Disease. January 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7) Lehman G. et al. ICSI Health Care Guideline: Stable Coronary Artery Disease. Institute for Clinical Systems Improvement January 2000 Thadani U. Treatment of stable angina (Ischemic Heart Disease). Current Opinion in Cardiology1999; 14(4):349-358. Zanger DR, Solomon AJ, Gersh BJ. Contemporary Management of Angina: Part I. Risk Assessment. American Family Physician 1999; 60:2543-52. Zanger DR, Solomon AJ, Gersh BJ. Contemporary Management of Angina: Part II. Medical Management of Chronic Stable Angina American Family Physician 2000; 61:129-38. Agency for Healthcare Research and Quality, Clinical Practice Guidelines: http://www.ahcpr.gov/clinic/cpgonline.htm American Heart Association: http://www.americanheart.org Praxis MD: http://www.praxis.md.com
Unstable Angina
Signs/Symptoms of Angina ANGINA SIGNS/SYMPTOMS MAY INCLUDE: Pain/discomfort in chest and/or adjacent areas Nitroglycerin used to shorten/ alleviate/prevent angina attacks Anginal equivalent symptoms may include: nausea, palpitations, diaphoresis, unusual weakness or fatigue, shortness of breath (often with exertion)
Go to Stable Angina Algorithm
No
Intermediate or high risk unstable angina?
Features of intermediate or high risk Unstable Angina: Rest pain lasting > 20 min. Age >65 y/o ST and T wave changes Pulmonary edema Elevated cardiac enzymes
Evaluation to include (where appropriate): Complete History and Physical EKG (optimally during symptoms) Blood work--CBC, chem profile, TSH, FLPs Chest X-ray Echocardiogram (if suspect dysfunction/failure)
Yes
No
Is patient hemodynamically unstable?
Yes
Consider consultation for urgent cardiac cathetherization
Outpatient management Assessment yields intermediate or high risk for serious cardiac event? No
RISK ASSESSMENT (see Table I for a comprehensive outline): Low Intermediate High prior vasc dz. Accel tempo angina atypical >20 min C.P. @ rest >20 min C.P. at rest (resolved) (ongoing) Pulm edema, MR murmur, S3, hypotension Normal EKG >.2 mV T-wave >0.05mV ST changes (or unchanged) BBB, sust. v. tach, elevated troponin, CKMB levels Consider the following (unless contraindications) Aspirin (or a thienopyridine if ASA intolerant) O2 (2-4 L/min by NC) Nitroglycerin (SL, spray, transdermal, or IV) MSO4 (1-5 mg IV, repeat q15-30 min prn pain Trial of antacid if suspect GI origin of pain B-blocker (or, if contraindicated, a nondihydropyridine calcium antagonist) ACE-Inhibitor if persistent HTN and LV dysfunction (or CHF) and in patients with diabetes Antithrombotic regimen (IV unfractionated heparin or SQ low molecular weight heparin) Platelet glycoprotein IIb/IIIa (GP IIB/IIIa) receptor antagonist (IF continuing ischemia, high-risk features, or cath planned) Close monitoring of HR, BP, and cardiac rhythm Test results indicating high risk: <5 METs duration ST segment depression Hypotension Unable to attain target heart rate--85% of max predicted heart rate (MPHR=220-age) Exercise-induced angina Ventricular ectopy at low workload
Yes Inpatient management
Consider referral for cardiac catheterization (if patient is a candidate)
No
Yes
Symptom-free after 6-12 hours observation AND repeat EKG and cardiac markers negative?
Exercise Stress Test No Unable to exercise
Yes
Test results suggestive of high risk?
No
Outpatient management with re-evaluation within 72 hours
Yes If not already initiated, begin antithrombotic therapy (Unfractionated heparin + Aspririn or Low molecular weight heparin)
Initiate Medical Therapy and Lifestyle Modification (see page 2)
No Test results suggest significant lesions?
Consider further evaluation with: Nuclear stress test Stress Echocardiography Cardiac catheterization
Yes
Refer for cardiac catheterization and myocardial revascularization.
Physician focus for Evaluating and Treating Unstable Angina:
See patients admitted with a diagnosis of unstable angina for office follow-up within 3 days of diagnosis. Indicator: Percentage of adults admitted for 24 hours or less for unstable angina having a follow-up visit within 3 days (with PCP or Cardiologist). Prescribe beta-Blocker therapy for patients with unstable angina, unless contraindicated or not tolerated. Indicator: Percentage of adults with unstable angina filling a prescription for a beta-Blocker. Prescribe short-acting nitrates (sublingual or spray) for patients with unstable angina, unless contraindicated. Indicator: Percentage of adults with the diagnosis of unstable angina with a current nitroglycerin (sublingual or spray) prescription. This prescription could be recent or up to one-year prior. Prescribe ASA 75 to 325 mg/d unless contraindicated. (Clopidogrel 75 mg/d may be used for patients with contraindications to ASA.) Lipid lowering agents and diet for patients with low-density lipoprotein (LDL) cholesterol of >125 mg/dL. ACEIs for patients with CHF, LV dysfunction (EF<0.40), hypertension, or diabetes.
References/Resources: Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Unstable Angina). Circulation 2000;102:1193-1209. Clinical Practice Guideline, Unstable Angina: Diagnosis and Management (AHCPR Publication No. 940604) Hamm CW, Braunwald E. A Classification of Unstable Angina Revisited (Current Perspective). Circulation 2000:102:118-122. Mozaffarian D. Non-ST Elevation Acute Coronary Syndromes (Unstable Angina and Non-Q-wave Myocardial Infarction). Best Practice of Medicine 2001. Accessed from praxis.md web site (www.praxis.md.com) Article url: http://praxis.md/index.asp?page=bpm_brief&chapter=BPM01CA14. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. (1994, June). Clinical Practice Guideline, Unstable Angina: Diagnosis and Managment. Retrieved from http://www.ahrq.gov/ (2001, March 7) Agency for Healthcare Research and Quality, Clinical Practice Guidelines: http://www.ahcpr.gov/clinic/cpgonline.htm American Heart Association: http://www.americanheart.org
Congestive Heart Failure (CHF)

Diagnostic tests to consider: CBC AST, alkaline phosphatase Sodium, potassium Creatinine, BUN Protein or albumin Urinalysis Thyroid function Magnesium, calcium Iron/ferritin Electrocardiogram Chest radiograph Symptoms and signs of heart failure Complete history and physical exam and clinically appropriate diagnostic tests Common Symptoms of CHF: Paroxysmal nocturnal dyspnea or supine cough Orthopnea Dyspnea or cough on exertion Edema in the lower extremities Decreased exercise tolerance Unexplained confusion, altered mental status, or fatigue Abdominal symptoms associated with ascites and/or hepatic engorgement Uncommon Symptoms of CHF: Pulmonary or systemic embolism in the absence of an obvious cause Unexplained pleural effusions Abnormal liver enzymes
Assess LV function (Echocardiogram, Radionuclide Ventriculogram)
Likely diastolic dysfunction, valvular heart disease, or a non-cardiac etiology (beyond scope of this guideline)
no
Is ejection fraction <40%
yes
Cath or image study suggests CAD?
yes
Reversible cause (e.g., ischemic or valvular heart disease)? no Systolic dysfunction. Determine symptom class and treat as follows (unless contraindications exist)
yes
Consider referral to address cause, then reconsider pharmacologic therapy
Include comprehensive patient education (see page 2)
Asymptomatic (NYHA Class 1) ACE-I* B-blocker*, **
Symptomatic (NYHA Class II-IIIa) ACE-I* B-blocker*, ** Diuretic (may be prn edema and congestion) If symptoms persist: Digoxin
Symptomatic with history of recent rest dyspnea (NYHA Class IIIb) ACE-I* B-blocker*, ** Diuretic (dosing may be modified depending upon magnitude of congestion) Spironolactone Digoxin
Symptomatic with rest dyspnea (NYHA Class IV) ACE-I* Diuretic (dosing may be modified depending upon magnitude of congestion) Spironolactone--monitor potassium (<5.0) and creatinine (<2.5) Digoxin
Consider Aspirin (especially if patient has known CAD) Consider warfarin anticoagulation in patients with left ventricular ejection fraction of 35% or less Warfarin anticoagulation in patients with heart failure and atrial fibrillation (goal INR= 2.0 to 3.0), unless contraindicated In symptomatic patients, if ACE-I is not tolerated, consider Hydralazine and Isosorbide Dinitrate combination. Alternatively, may consider Angiotensin II Receptor Blockers (ARBs), although not shown to have comparable decrease in mortality, available with beta blockers and ACE-I Avoid drugs that may exacerbate CHF: Class I anti-arrhythmics, NSAIDs, some first-generation calcium channel blockers (i.e., diltiazem, nifedipine, verapamil) *For ACE-I and B-blockers, start with very low doses and titrate to target dosage (see page 2) as tolerated **B-blockers should not be started during an acute worsening of clinical status or when patient has fluid overload. FDA-approved B-blockers include Carvedilol (Coreg), Bisoprolol (Zebeta) and Metoprolol succinate (Toprol XL)
CHF
Patient Education Low-salt diet Moderation of fluid intake Alcohol restriction Self-monitoring with daily weights (especially NYHA Class III-IV) Symptoms of exacerbation Smoking cessation (if applicable) Exercise regimen Importance of flu and pneumococcal vaccination
(Page 2)
ACE-I target doses Captopril 150 mg/d Enalapril maleate 20 mg/d Ramipril 10 mg/d Lisinopril 40 mg/d Quinapril hydrochloride 40 mg/d Tandolapril 4 mg/d *Renal function and serum potassium levels should be assessed within 1-2 weeks of initiation and every 2-3 months thereafter.
NYHA Class I II III IV
NYHA Symptom Description Asymptomatic. No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. Mildly symptomatic. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea. Moderately symptomatic. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnea. Symptoms at rest. Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Physician focus for Evaluating and Treating Congestive Heart Failure (CHF):
Prescribe ACE-Inhibitors (or nitrates plus hydralazine) for all CHF patients without contraindications. Indicator: Percentage of adults with diagnosis of CHF treated with ACE-Inhibitors (OR nitrates plus hydralazine) Titrate ACE-Inhibitors to target dose, as tolerated, in patients with CHF. Indicator: Percentage of adults with diagnosis of CHF, treated with ACE-Inhibitors, at target doses. These target doses are outlined on page 2 of the CHF guideline. Prescribe B-blockers for CHF patients, NYHA Class I-III, without contraindications. Indicator: Percentage of adults with diagnosis of CHF treated with B-blockers.
References/Resources: Chavey W et al, University of Michigan Health System. UMHS Heart Failure Guideline. August 1999. Farmer J, Torre G. Congestive Heart Failure: Specific Therapies. Current Practice of Medicine 1999; 2(11)2117-2131. Gomberg-Maitlnd M, Baran DA, Fuster V. Treatment of Congestive Heart Failure: Guidelines for the Primary Care Physician and the Heart Failure Specialist. Arch Int Med. 2001;161:342-352 Heart Failure Society of America (HFSA). HFSA Guidelines for Management of Patients with Heart Failure Caused by Left Ventricular Systolic DysfunctionPharmacological Approaches. Journal of Cardiac Failure 1999;5:357-382. Hood WB Jr, Dans A, Guyatt GH, Jaeschke R, McMurray J. Digitalis for treatment of congestive heart failure in patients in sinus rhythm (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Congestive Heart Failure in Adults. November 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7) Ramahi TM. Beta Blocker Therapy for Chronic Heart Failure. Am Fam Physician 2000;62:2267-74. University of Washington Physicians. Heart Failure Due to Systolic Dysfunction (HF) Guidelines. http://healthlinks.washington.edu/guideline/hf/processes.html Shamsham F, Mitchell J. Essentials of the Diagnosis of Heart Failure. Am Fam Physician 2000;61:1319-28. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. (1994, June). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction. Clinical Practice Guideline No. 11. Retrieved from http://www.ahrq.gov/ (2001, March 7) University of Michigan Health System. Guidelines for Clinical Care: Heart FailureSystolic Dysfunction. http://cme.med.umich.edu/iCME/default.asp/ (2001, March 7) University of Washington Physicians. Heart Failure Due to Systolic Dysfunction (HF) Guidelines. http://healthlinks.washington.edu/guideline/hf/processes.html/ (2001, February 20) http://www.ahcpr.gov/clinic/cpgonline.htm http://www.americanheart.org http://www.hfsa.org http://www.praxis.md.com
Peptic Ulcer Disease

Emphasize Non-Medical Treatment Recommendations throughout algorithm (see page 2) NonALARM SYMPTOMS (and risk factors for serious disease): GI bleeding, anemia Anorexia, weight loss Advanced age Dysphagia Long history of symptoms Protracted vomiting No history of ulcerogenic drugs Palpable mass Endoscopy Symptoms of Dyspepsia SYMPTOMS MAY INCLUDE: Epigastric abdominal pain Periodic pain relieved by food/antacids Pain may be worse at night Upper GI bleeding Bloating, belching, heartburn Nausea, vomiting Counsel on Non-medical anti-reflux precautions (see page 2)
Yes
Alarm Symptoms Present?
No
Are symptoms Yes more consistent with GERD?
Go to GERD pathway
Reconsider Diagnosis (ie. GERD)
No
Peptic Ulcer?
No Urea Breath Test or H. pylori serological testing ** Note: Some references allow for omission of initial H. pylori testing and progress directly to empiric treatment for H. pylori infection.
Yes Biopsy for H. pylori Rapid Urease Test (CLO-test)*
Positive? Yes
No
Positive?
Yes
Treat H. pylori Infection (see FDA approved list attached)
Reconsider Diagnosis-Consider Barium UGI or Endoscopy
No Consider Proton Pump Inhibitor trial (see page 2) Symptoms resolve? Reconsider Diagnosis (ie. Zollinger-Ellison, Crohns Disease, Malignancy) Yes Review in 6 months
No
*Antacids, Pepto-Bismol Antibiotics, and Proton Pump Inhibitors can all interfere with diagnosis. See page 2 for recommendations. **Serology cannot distinguish between active or previous infection in a patient with prior treatment for H. pylori.
PUD Page 2
Non-medical anti-reflux treatment recommendations: Avoid known risk factors: NSAIDS and corticosteroids tobacco alcohol caffeine (coffee, tea, cola) calcium-containing antacids Treatment options for H. pylori eradication using FDA-approved medications: Regimen Dose Duration Precautions/Comments 40 mg QD 2 weeks Then, Omeprazole 20 mg QD x 2 Omeprazole 500 mg TID weeks + Clarithromycin
Ranitadine + Clarithromycin Bismuth subsalicylate (Pepto Bismol) +Metronidazole +Tetracycline* a.k.a. HELIDAK 400 mg BID 500 mg TID 525 mg QID 2 weeks Then, Ranitadine 400 mg BID x 2 weeks Dysgeusia with clarithromycin Then, H2 receptor antagonist therapy as directed x 4 weeks *Although not FDA approved, Amoxicillin has been substituted for tetracycline for patients for whom tetracycline is not recommended. 10 days Penicillin allergy; dysgeusia with clarithromycin Then, Ranitadine 400 mg BID x 2 weeks Dysgeusia with clarithromycin Penicillin allergy; dysgeusia with clarithromycin Penicillin allergy; dysgeusia with clarithromycin
2 weeks
250 mg QID 500 mg QID
Lansoprazole +Clarithromycin +Amoxicillin Ranitadine +Clarithromycin
30 mg BID 500 mg TID 1 g BID 400 mg BID 500 mg BID
2 weeks
Omeprazole +Clarithromycin +Amoxicillin Lansoprazole +Clarithromycin Amoxicillin a.k.a. PREVPAK
20 mg BID 500 mg BID 1 g BID 30 mg BID 500 mg BID 1 g BID
10 days
10 days
Physician focus for Evaluating and Treating Peptic Ulcer Disease (PUD): Use FDA-approved medications in the identified regimens for H. pylori eradication. Indicator: Percentage of adults diagnosed with PUD and treated with one of the identified Regimens (PUD page 2) for H. pylori eradication. Prior to prescribing a second trial of H. pylori eradication treatment, perform appropriate diagnostic testing (endoscopy, barium swallow, or urea breath test). Indicator: Percentage of adults receiving endoscopy, barium swallow, or urea breath test before a second trial of H. pylori eradication treatment (unless such diagnostic measures were performed prior to the first treatment trial). See patients with recent diagnosis of PUD in the office within 6 months of diagnosis. Indicator: Percentage of adults diagnosed with PUD with a follow-up appointment within 6 months of diagnosis. Obtain biopsy for CLO test for H. pylori when performing endoscopy for PUD. Indicator: Percentage of adults who undergo endoscopy for PUD who have biopsy performed with CLO test for H. pylori (unless urea breath test or serological testing was performed within 6 months prior to endoscopy).
References/Resources: Anderson J and Gonzalez J. H. pylori infection: Review of the guideline for diagnosis and treatment. Geriatrics 2000 (June);55:44-49 Bazaldua OV and Schneider FD. Evaluation and Management of Dyspepsia. American Family Physician 1999;60(6):1773-1786. Delaney BC, Innes MA, Deeks J, Wilson S, Oakes R, Moayyedi P, Hobbs FDR, Forman D. Initial management strategies for dyspepsia (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software Graham DY. Peptic Ulcer Disease. Current Practice of Medicine 1999;2(12):2359-2366. Helicobacter pylori: Fact Sheet for Health Care Providers. Centers for Disease Control and Prevention. Updated July 1998. http://www.cdc.gov/ulcer/hpfacts.PDF (2001, February 26) Howden CW and Hunt RH. Guidelines for the Management of Helicobacter pylori Infection. The American Journal of Gastroenterology 1998;93(12):2330-2338. Moayyedi P, Soo S, Deeks J, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Rolfe A, Bennett C, Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. Soll AH. Medical Treatment of Peptic Ulcer Disease: Practice Guidelines. JAMA 1996;275(8):622-629. Helicobacter Foundation www.helico.com The Cochrane Group www.update-software.com American Academy of Family Practice www.aafp.org Dynamic Medical www.dynamicmedical.com CDC website on Ulcers http://www.cdc.gov/ulcer/
GERD
Emphasize Non-Medical Treatment Recommendations throughout algorithm (see page 2) NonSYMPTOMS MAY INCLUDE: Heartburn Substernal or epigastric burning pain or discomfort Nocturnal cough Belching, regurgitation, hypersalivation Chronic cough Hoarseness Recurrent asthma/bronchospasm Chronic nausea Reflux Symptoms ALARM SYMPTOMS: Dysphagia Weight loss GI blood loss (acute or chronic) Anemia Anorexia Counsel on Nonmedical anti-reflux Precautions (see page 2)
yes Endoscopy
Alarm Symptoms Present?
no
8-12 week empiric trial of H2-Receptor Antagonists BID (see page 2) Maintenance therapy with lowest effective dose of H2RA or OTC H2RA or antacid (on demand or continuous, as needed)
Good response?
yes
Follow-up in office within 6 months
Does endoscopy show signs of GERD? (i.e. erosive esophagitis, Barretts esophagus, peptic strictures, etc.)
no yes 8-12 week Proton Pump Inhibitor(PPI) treatment-titrate as needed (see page 2) Maintenance therapy with lowest effective dose of PPI or H2RA or OTC H2RA or antacid (on demand or continuous, as needed)
no
Good response?
yes
Follow-up in office within 6 months
no Confirm diagnosis with EGD, 24 hour esophageal pH study, or Barium Esophagram, depending upon clinical scenario Consider further diagnostic testing if patient requires continuous chronic therapy OR develops alarm symptoms
Reconsider diagnosis
no
Study confirms GERD?
yes
Consider surgical consultation for fundoplication
GERD page 2
Non-medical anti-reflux precautions: Lifestyle modification smoking cessation elevation of head of bed avoid overeating avoid eating within 3-4 hours of going to bed consider weight reduction avoid tight clothing Consider over the counter medications for mild symptoms: Antacids OTC H2-receptor blockers Avoid known risk factors: tobacco alcohol onions citrus fruits and juices spicy food caffeine (coffee, tea, cola) fatty foods chocolate peppermints tomato-based foods
Gastroesophageal Reflux Disease (GERD) Medication Review

Medication (Available Dosage Strengths) Cimetidine (Tagamet) (200mg, 300mg, 400mg, 800mg) Ranitidine (Zantac) (150mg, 300mg) Nizatidine (Axid) (150mg, 300mg) Famotidine (Pepcid) (20mg, 40mg) Omeprazole (Prilosec) (10mg, 20mg) Rabeprazole (Aciphex) (20mg) Pantoprazole (Protonix) (40mg) Lansoprazole (Prevacid) (15mg, 30mg) Metoclopramide (Reglan) (5mg, 10mg) Dosage Regimen 800-1600 mg/day in divided doses 300-600 mg/day in divided doses 600 mg/day in divided doses 40 mg/day in divided doses 20-60 mg/day in divided doses 20 mg/day 40 mg/day 30-60 mg/day in divided doses 40 mg/day in divided doses
Physician focus for Evaluating and Treating GERD: See patients diagnosed with GERD for office follow-up within 6 months of diagnosis. Indicator: Percentage of adults diagnosed with GERD with a follow-up appointment within 6 months of diagnosis.
References/Resources: DeVault KR, Castell DO, and The Practice Parameters Committee of the American College of Gastroenterology. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. American Journal of Gastroenterology. 1999. 94:1434-1442. Richter, JE. Gastroesophageal Reflux Disease. Current Practice of Medicine 1999. 2(12):2307-2315 Scott, M. and Gelhot, AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician 1999. 59(5):1161-1171. van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease (Cochrane Review). The Cochrane Library, 1, 2001. Oxford: Update Software. American Academy of Family Practice www.aafp.org Cochrane Library Abstracts http://www.update-software.com/cochrane/cochrane-frame.html Dynamic Medical www.dynamicmedical.com National Guideline Clearinghouse http://www.guidelines.gov/index.asp/
Diverticulosis and Diverticulitis

Non-specific complaints: chronic constipation abdominal pain fluctuating bowel habits diarrhea and/or flatulence LLQ abdominal pain Symptoms may include: Abdominal pain (typically LLQ but may be midline or RLQ) Leukocytosis Fever Palpable, tender mass Nausea, vomiting, constipation, diarrhea, dysuria, or urinary frequency
Symptoms of acute Diverticulitis
Physical exam, including rectal exam, stool test for occult blood, and pelvic exam for women.
Physical exam, including rectal and pelvic exams as appropriate
Consider colonic imaging studies: Contrast Barium Enema Sigmoidoscopy Colonoscopy Plain abdominal radiographs (flat and upright) Consider CXR, CBC, U/A, blood cultures if indicated Asymptomatic (or non-acute symptoms)?
Note: The majority of cases of diverticulosis are asymptomatic, and the diagnosis is usually made by incidental discovery on endoscopy or barium enema.
No
Yes High fiber diet (see Nutrition Guide) Adequate fluid intake Consider fiber supplements and/or stool softeners
Free air on XRAY?
Yes Surgical consult
No
CT scan, Ultrasound (may be particularly useful in female patients), or water-soluble contrast enema*
No Is diagnosis certain?
Yes Is study consistent w/diverticulitis? No Reconsider diagnosis Yes Is patient stable for outpatient therapy? No IV Fluids NPO/clear liquid diet Broad spectrum IV antibiotics (see page 2) Avoid morphine for analgesia** No Adequate response to outpt. tx? Yes Continue conservative management. Consider Barium enema and Sigmoidoscopy or Colonoscopy in 10-14 days to corroborate diagnosis and rule out other causes of exacerbation. High fiber diet after symptoms resolve (see Nutrition Guide) Yes Clear liquid diet Hold high-fiber foods Broad spectrum antibiotics (see page 2)
Good response?
Yes
No Consider CT scan and/or surgical consult
*Endoscopic exams and Barium Enema are NOT recommended during acute phase of attack because of risk of perforation. **Can increase intracolonic pressure and worsen symptoms
Diverticulitis page 2
Broad Spectrum Antibiotic Therapy for Acute Diverticulitis Goal is for aerobic and anaerobic coverage--below is a list of possible medications (and combinations) to meet this goal. Recommended duration of intravenous and/or po therapy is 7-10 days.
Parenteral Options (choose one of the five listed options): 1) Metronidazole or Clindamycin PLUS Aminoglycoside (e.g. gentamicin or tobramycin) or 3rd generation Cephalosporin (e.g. ceftazidime, cefotaxime, ceftriaxone) or Monobactam (e.g. aztreonam) or 2) Piperacillin/Tazobactam or 3) Ampicillin-sulbactam (e.g. Unasyn) or 4) 2nd generation Cephalasporin (e.g. cefoxitin or cefotetan) or 5) Ticarcillin/Clavulanate (Timentin) Enteral Options (choose one of the three listed options): 1) Metronidazole or Clindamycin PLUS Ciprofloxacin or TMP/SMZ DS BID or 2) Augmentin or 3)Trovafloxin
Bulk-forming over-the-counter agents: Methylcellulose Polycarbophil Psyllium Brand name OTC bulk-forming agents: Alramucil Citrucel Cologel Effer-syllium Fiberall Fibercon Konsyl Maltsupex Metamucil Mylanta Fiber Supplement Reguloid
Physician focus for Evaluating and Treating Diverticulosis and Diverticulitis: Select antibiotic therapy that covers BOTH anaerobic and aerobic bacteria. Indicator: Percentage of adults diagnosed with diverticulitis and treated with one of the identified broad-spectrum antibiotics or antibiotic combinations. Select abdominal plain film XRAY and/or CT scan of the abdomen and/or Ultrasound of the abdomen for diagnostic testing during early evaluation of symptoms. Indicator: Percentage of adults receiving abdominal plain-film XRAY and/or CT scan of the abdomen and/or Ultrasound of the abdomen within four days of initial diagnosis of acute diverticulitis. See patients diagnosed with diverticulitis for office follow-up within 6 months of diagnosis. Indicator: Percentage of adults diagnosed with diverticulitis with a follow-up appointment within 6 months of diagnosis. Perform appropriate confirmatory diagnostic evaluation following hospitalization for initial diagnosis and treatment for acute diverticulitis (barium enema &/or sigmoidoscopy &/or colonoscopy approximately 2 weeks after admission for acute diverticulitis). Indicator: Percentage of adults who receive barium enema and/or sigmoidoscopy and/or colonoscopy approximately two weeks after admission for acute diverticulitis. Avoid invasive diagnostic procedures (e.g. sigmoidoscopy/colonoscopy, barium enema) during evaluation of acute diverticulitis. Indicator: Percentage of adults receiving a barium enema and/or endoscopic exam (colonoscopy or sigmoidoscopy) during acute phase of diverticulitis.
References/Resources: Diverticular Disease of the Colon. In L.M. Tierney, Jr., S.J. McPhee, M.A. Papadakis (Eds.), CURRENT Medical Diagnosis and Treatment 2000 (pp. 641-644). New York, NY: Lange Medical Books/McGrawHill. Ferzoco LB, et al. Acute diverticulities. N Engl J Med May 21, 1998; 338:1521-6. Roberts P, Abel M, Rosen L, et al. (The Standards Task Force American Society of Colon and Rectal Surgeons). Practice Paramenters for Sigmoid DiverticulitisSupporting Documentation. Diseases of the Colon and Rectum 1995; 38(2): 125-32. Stollman NH and Raskin JB, Diagnosis and Management of Diverticular Disease of the Colon in Adults (Practice Guidelines). The American Journal of Gastroenterology 1999; 94(11): 3110-3121. Available at www-east.elsevier.com/ajg/issues/9411/ajg1501fla.htm Taylor TV. Diverticulitis. Current Practice of Medicine 1999; 2(12): 2422-2429. The Cochrane Group www.update-software.com American Academy of Family Practice www.aafp.org Dynamic Medical www.dynamicmedical.com
Low Back Pain

Signs/Symptoms of Acute Low Back Pain Acute Low Back Pain: pain does not radiate past the knee duration of symptoms <6 weeks Comprehensive History and Physical Exam Critical Exclusionary Diagnoses: Cauda equina syndrome Progressive neurological deficit Fracture Neoplasm Infection Chronic pain syndrome Persistent pain resulting from previous spinal surgery Extra-spinal conditions
Consider referral to appropriate specialist for care
yes
Are Critical Exclusionary Diagnoses Present? no
Initiate up to 4 weeks of conservative therapy, which may include: Patient education Activity modification Oral medication (ie. NSAIDs) Self-applied thermal modalities Manual medicine modalities (as prescribed by Osteopathic or Chiropractic physicians)
Repeat history. Perform AP and lateral spine XRAYS.
no
Are symptoms improved?
yes
Continue useful conservative measures, perform exercise, and return to regular activity as appropriate.
Is there a neuro deficit on exam OR are X-rays abnormal?
no
Consider treatment modifications for an additional four weeks: Change oral analgesic Manual medicine modalities (as prescribed by Osteopathic or Chiropractic physicians) Consider the following clinical pictures and consider referral to appropriate specialist:
yes Are symptoms improved ?
yes
no
Herniated Nucleus Pulposus: young patient (20-50 years) predominant leg pain with or w/o neuro deficit tension signs present
Unremitting Low Back Pain:
Spondylolysis or Lytic Spondylolisthesis or Degenerative Spondylolisthesis/Stenosis: Rule out instability or neurological deficit.
Spinal Stenosis: patients over 50 years variable neurologic findings leg pain and/or back pain that is increased with upright posture
Mild or moderate Pain control and exercise training back first aid oral or epidural corticosteroids joint mobility stabilization
Clinically severe or poor response Order confirmatory studies: MRI CT myelogram electrodiagnostic studies
Consider confirmatory studies: MRI CT myelogram electrodiagnostic studies bone scan psychological eval
Consider nonoperative options: NSAIDs trial of bracing 1-3 injection program Active exercise treatment psych eval
If severe symptoms or poor response to nonoperative tx, consider confirmatory studies: MRI CT myelogram
Counsel patient and consider surgical options if: Poor response to conservative measures and/or Pathology found on confirmatory studies suggest surgical treatment and correlate with clinical symptoms
Low Back Pain

Systemic Causes Dangerous local causes of back pain Tumor Disk space infection Epidural abscess Fractures Osteoporosis with fracture Disk herniation Spinal Stenosis Spondylolisthesis Congenital Isthmic Degenerative Traumatic Tumor related Failed back surgery syndrome Arachnoiditis
Page 2
Table 1 Differential Diagnosis of Back Pain (adapted from University of Michigan Health System Guideline)
Local pathology that mimics radiating low back pain Osteoarthritis of the hip Aseptic necrosis of the femoral head Sciatic nerve injury due to pressure, stretch or piriformis muscle entrapment Cyclic radiating low back pain endometriosis on the sciatic nerve/ sacral plexus Intrapelvic massesbenign or malignant Peroneal (fibular) nerve entrapment at the fibular head Sacroiliac joint dysfunction Facet joint syndrome Internal disk disruption
Aortic aneurysm Renal infection Renal calculi Peritonitis Tumors Subacute bacterial endocarditis Metabolic disorders Porphyria Sickle cell disease Renal osteodystrophy Seronegative spondylitic arthritis: Ankylosing spondylitis Reiters syndrome Arthritis of ulcerative colitis Psoriatic arthritis Other arthritis: Diffuse Idiopathic Skeletal Hyperostosis (DISH) Schuermans epiphisitis Rheumatoid arthritis-uncommon Connective tissue disorders: Marfans syndrome Ehlers-Danlos syndrome Myopathy Inflammatory radiculopathy
Gordon Waddels five non-organic pain signs 1. Overreaction during the exam 2. Simulated testing--pain with axial loading or rotation of the pelvis and shoulders in the same plane 3. Distracted testing--test straight leg raise while distracted when sitting. 4. Superficial, non-anatomical or variable tenderness. When skin rolling over the back markedly increases the pain 5. Non-anatomical motor or sensory disturbances. Positive when sensory loss does not follow a dermatome or entire leg is numb or without stretch or when there is a ratchety giveway on strength testing. Presence of two or more of these findings correlates with poor surgical outcome, but not rehabilitation outcome. Patient is at risk for becoming chronically disabled. Should not be interpreted as specific for malingering.
Physician focus for Evaluating and Treating Acute Low Back Pain Prescribe a conservative treatment plan for patients with Acute Low Back Pain before ordering diagnostic radiological studies (unless critical exclusionary diagnoses are present). Indicators: Percentage of patients with low back pain receiving AP or lateral x-rays. Percentage of patients with low back pain receiving MRI or CT.
References/Resources: American Academy of Orthopaedic Surgeons/North American Spine Society (AAOS/NASS) Spine Algorithm Task Force. Clinical guideline on low back pain. Released 1996. Accessed at the National Guideline Clearinghouse, http://www.guidelines.gov/index.asp/ (2001, February 20) Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back pain and sciatica (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Adult Low Back Pain. November 1999. http://www.icsi.org/guidelst.htm/ (2001, February 20) Low Back Pain Syndrome (LBP). http://www.dynamicmedical.com/ (2001, February 20) Marcus DA. Treatment of Nonmalignant Chronic Pain. Am Fam Physician 2000;61:1331-8, 1345-6. Tulder MW van, Scholten RJPM, Koes BW, Deyo RA. Non-steroidal anti-inflammatory drugs for low back pain (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. (1994, December). Acute Low Back Problems in AdultsClinical Practice Guideline Number 14. Retrieved from http://www.ahrq.gov/ U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. (1993, February). Acute Pain Management In Adults: Operative ProceduresQuick Reference Guide for Clinicians No. 1a. Retrieved from http://www.ahrq.gov/ University of Michigan Health System. (1997, November) Guidelines for Clinical CareAcute Low Back Pain. http://cme.med.umich.edu/iCME/default.asp (2001, February 26) University of Washington Physicians. Acute Low Back Limitation Guidelines. http://healthlinks.washington.edu/guideline/alb/processes.html/ Well Close Square rheumatology resource: the back examination. (Online). http://www.wellclosesquare.co.uk/rheum/back.htm/ (2001, February 26)
Carpal Tunnel Syndrome

HISTORY: Family or personal history of diabetes thyroid connective tissue diseases Pregnancy History of trauma Occupational history Hobbies Change in the level of activity PHYSICAL EXAM (may be normal): Regional exam Cervical spine and upper extremities exam Tinel test Phalen test Thumb abduction strength testing Proximal compression test at elbow yes Symptoms of Median Nerve Compression SYMPTOMS MAY INCLUDE: parasthesia and/or mild pain in the distribution of the median nerve (palmar side of thumb, index, middle and part of ring finger and generally excludes the little finger) intermittent or constant pain weakness or clumsiness of the hand aggravation of pain during sleep (see page 2 for Differential Diagnosis) may have improvement of symptoms with shaking or massaging the hand
Focused History and Physical Exam
Is thenar weakness or wasting present?
no
Perform laboratory evaluation, as indicated by history and physical exam (see page 2)
Metabolic cause for symptoms? no Consider specialist referral AND/OR additional diagnostic testing (see page 2)
yes
Treat any metabolic cause for symptoms
2-6 week trial of conservative therapy: Patient education Activity modification/alter aggravating factors (may include ergonomic modifications at workplace) Neutral-position splinting (full time) Analgesics (NSAIDS if not contraindicated) Manual medicine modalities (as prescribed by Osteopathic or Chiropractic physicians)
Follow up in 2 weeks
Continue conservative management; patient may resume normal activities as tolerated. yes no Good response?
yes
Good response? No
CONSIDER the following diagnostic and therapeutic options: Physical therapy for flexibility, mobility, and strength Corticosteroid injection Alternative NSAID Manual medicine modalities (as prescribed by Osteopathic or Chiropractic physicians)
CTS
Page 2
Diagnostic Testing for Carpal Tunnel Syndrome: Depending on the presenting symptoms and/or response to conservative management, consider: Laboratory testing: TSH pregnancy test blood sugar Imaging (radiography or magnetic) wrist cervical spine chest Electrophysiology Electromyography (EMG) Nerve conduction studies (NCS) Further endocrine, hematologic, or neuropathy evaluation as indicated.
Differential Diagnosis for Carpal Tunnel Syndrome: Cervical Radiculopathy (especially C7) Angina pectoris deQuervains tenosynovitis Complex regional pain syndrome (aka Reflex Sympathetic Dystrophy) Osteoarthritis Rheumatoid arthritis Brachial plexopathy Proximal median neuropathy Peripheral neuropathy Vascular or neurogenic thoracic outlet syndrome Central disorders such as multiple sclerosis and cerebral infarction
Potential Aims for Medical Groups When Using this Carpal Tunnel Syndrome Guideline: Request patient to follow-up in office within two months of initial diagnosis of carpal tunnel syndrome. Indicator: Percentage of adults diagnosed with carpal tunnel syndrome who have a follow-up appointment within two months. Treat all patients with carpal tunnel syndrome (without thenar weakness/wasting and without metabolic cause for CTS) with neutral-position wrist splinting. Indicator: Percentage of adults receiving a wrist splint at the time of initial diagnosis. Attempt a trial of conservative management for all patients with carpal tunnel syndrome (without thenar weakness/wasting and without metabolic cause for CTS) before ordering an EMG or nerve conduction study. Indicator: Percentage of adults with carpal tunnel syndrome undergoing EMG or nerve conduction study that have had at least one prior claim for diagnosis of carpal tunnel syndrome (or hand parasthesias, etc.) by their PCP during the six months prior to diagnosis.
References/Resources: American Academy of Orthopedic Surgeons (AAOS) Task Force on Clinical Algorithms; AAOS Committee on Clinical Policies. Clinical guideline on wrist pain. 1999. Accessed at the National Guideline Clearinghouse, http://www.guidelines.gov/index.asp/ American Society of Plastic Surgeons (ASPS). Carpal tunnel syndrome. Released Jan 24, 1998. Accessed at the National Guideline Clearinghouse, http://www.guidelines.gov/index.asp/ DArcy CA, McGee S. Does This Patient Have Carpal Tunnel Syndrome? (The Rational Clinical Exam) JAMA 2000;283(23):3110-3117. Novak LM. Carpal Tunnel Syndrome (Protocol). Lippincotts Primary Care Practice 2000;4(6):642-648. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter for carpal tunnel syndrome (summary statement). Neurology 1993;43:2406-2409. Walker WC, et al. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. 2000;81:424-9. American Academy of Family Practice www.aafp.org Cochrane Library Abstracts http://www.update-software.com/cochrane/cochrane-frame.html Dynamic Medical www.dynamicmedical.com National Guideline Clearinghouse http://www.guidelines.gov/index.asp/
Uncomplicated Acute Bronchitis

Differential Diagnosis: Community-Acquired Pneumonia Influenza Pertussis Asthma Tuberculosis Cystic fibrosis Lung cancer GERD Medication-induced cough Symptoms suggestive of acute bronchitis Symptoms may include: Cough with/without phlegm Cough lasting <3 weeks Sore throat Rhinorrhea Minimal/no change in breath sounds Low-grade fever Malaise
Focused history and physical exam
Purulent sputum, high fever, chills, systemic symptoms? Epi-link to case?
Seasonal, high fever, chills, systemic symptoms?
Severe symptoms or suspected pneumonia?
Yes Viral Bronchitis Bacterial Bronchitis
Yes Bronchitis associated with Influenza?
Yes Obtain Chest X-Ray
Symptomatic treatment Cough suppressants Acetaminophen or aspirin Bronchodilators for patients with asthma or COPD Explain rationale for no antibiotic treatment Patient education Increase fluids Adequate rest Avoid smoking or quit
Symptomatic treatment Cough suppressants Acetaminophen or aspirin Antibiotic treatment only if strong indication of bacterial infection, using narrow-spectrum agents: erythromycin tetracycline Patient education Increase fluids Adequate rest Avoid smoking or quit
Symptomatic treatment Cough suppressants Acetaminophen Antiviral agents amantadine (flu - A) rimantadine (flu- A) zanamivir (flu - A/B) oseltamivir (flu - A/B) Explain rationale for no antibiotic treatment Patient education Increase fluids Adequate rest Avoid smoking or quit
Chest X-ray shows infiltrates?
Yes Pneumonia diagnosis
Treat (See Community Acquired Pneumonia Guideline)
Follow-up if symptoms worsen
Administer flu vaccine annually to all persons at increased risk of complications
History: History: Signs and symptoms of cough Signs and symptoms of cough Exposure to persons with similar symptoms Exposure to persons with similar symptoms Exposure to irritants and allergens Exposure to irritants and allergens Underlying immune compromise or coexisting disease (i.e. heart Underlying immune compromise or coexisting disease (i.e. heart failure, cardiopulmonary disease, cystic fibrosis) failure, cardiopulmonary disease, cystic fibrosis) Physical Exam: Physical Exam: Assess severity and nature of cough and breathing Assess severity and nature of cough and breathing Pharyngeal inflammation, postnasal drip Pharyngeal inflammation, postnasal drip Inspect sputum for evidence of purulence Inspect sputum for evidence of purulence Perform complete chest exam Perform complete chest exam Lab and diagnostic tests: Lab and diagnostic tests: Lab tests are not indicated for otherwise healthy adults Lab tests are not indicated for otherwise healthy adults PPD skin test for persons at increased risk of TB PPD skin test for persons at increased risk of TB Chest film --only if severe symptoms or pneumonia suspected Chest film only if severe symptoms or pneumonia suspected Bronchoscopy --only if patient is severely immunocompromised, and Bronchoscopy only if patient is severely immunocompromised, and biopsies and/or special cultures are required to guide therapy (i.e. biopsies and/or special cultures are required to guide therapy (i.e. presence of unusual pathogen or patient fails to respond to treatment) presence of unusual pathogen or patient fails to respond to treatment)
Bronchitis treatment considerations: Bronchitis treatment considerations: Self-limited infection of bronchial tree Self-limited infection of bronchial tree Characterized by pronounced cough Characterized by pronounced cough Treatment focus is the management of cough and associated symptoms Treatment focus is the management of cough and associated symptoms Usually viral in origin Usually viral in origin Antibiotic therapy recommended only when bacterial component suspected Antibiotic therapy recommended only when bacterial component suspected Determine presence of underlying immune compromise or coexisting Determine presence of underlying immune compromise or coexisting diseases (i.e., pneumonia, cystic fibrosis, COPD, heart failure) diseases (i.e., pneumonia, cystic fibrosis, COPD, heart failure)
Physician focus for Evaluating and Treating Acute Bronchitis For patients with diagnosis of uncomplicated acute bronchitis, consider antibiotic treatment using firstline agents. Indicator: Percentage of patients diagnosed with uncomplicated acute bronchitis with pharmacy claims data for first-line agents (i.e. erythromycin or tetracycline). Indicator: Percentage of patients with uncomplicated acute bronchitis with pharmacy claims data for second-line agents (i.e. clarithromycin, ofloxin). For patients at increased risk of complications from influenza (i.e. 50 years, residents of chronic care facilities, those with cardiovascular or pulmonary disorder, and those with a chronic metabolic disorder), administer yearly flu vaccination. Indicator: Percentage of patients at increased risk of complications of influenza receiving a flu shot within the measurement year.
References/Resources: Chow AW. Acute bronchitis. Best Practices of Medicine (200,May). Available online: http://praxis.md/index.asp?page=bpm. Accessed May 11, 2001. Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Annals of Internal Medicine 2001;134:518-520. Becker L, Glazier R, McIsaac W, et al.: Antibiotics for acute bronchitis. Oxford: Update Software Cochrane Library. 1999. Hafner J-P, Ferro TJ. Acute bronchitis in adults: A modern approach to management. Hospital Medicine. 1998;34(8):41-50.
Community-Acquired Pneumonia(CAP)
CAP SYMPTOMS MAY INCLUDE: rigors pleuritic chest pain shortness of breath chest tightness deep cough sputum production fever >1000F or lasting >72 hours night sweats wheezing Symptoms suggestive of Community Acquired Pneumonia Obtain chest x-ray, especially if patient has two or more of these signs: Temp >1000 F (37.80 C) Pulse > 100 Decreased breath sounds Rales Respiratory rate > 20
Symptomatic treatment Patient education Explain rationale for no antibiotic treatment Follow-up if symptoms worsen
no
Comorbidities or clinical status suggest treatment of LRTI?
no
Chest x-ray suggests non-infectious process?
no
Chest x-ray shows infiltrate?
yes
yes
yes Pneumonia diagnosis-calculate Pneumonia Severity Index (PSI) (see box below)
Criteria for follow up:

difficulty breathing worsening cough worsening or onset of rigors fever persisting >48 hours medication intolerance Treat with macrolide, doxycycline, or TMP/SMX Out of guideline
Follow-up: By telephone 24-48 hours In office 6-8 weeks (consider f/u CXR to confirm resolution)
Patient education Criteria for follow-up Home care Smoking cessation Antibiotics Return to function/work Secondary prevention Contagion and recurrence Influenza/pneumococcal vaccine
Hospitalization (out of guideline)
no
Pneumonia Severity Index (PSI) < 91 points?
Pneumonia Severity Index (PSI) Score = total points accumulated below Demographic Factors Age Males Females Nursing Home Resident Comorbid Illnesses Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Physical Examination Findings Altered mental status Respiratory rate 30/minute Systolic BP<90mmHg Pulse 125/minute Laboratory Findings pH<7.35 BUN 30mg/dL(11mmol/L) Sodium < 130mEq/L Glucose > 250mg/dL(14mmol/L) Hgb<9gm (Hematocrit<30%) PO2 < 60mmHg(O2sat<90%)* (room air) Pleural effusion *patients with these findings may warrant hospitalization despite their risk classification. +30 +20 +20 +10 +10 +10 +10 yes +20 +20 +15 +10 no +30 +20 +10 +10 +10 age(yrs) age(yrs) -10 +10
Note: some patients with psychosocial and economic considerations, but a PSI score <91 may also require hospitalization.
yes
1st line antibiotics: amoxicillin/Clavulanate + macrolide*, OR Cefuroxime axetil/ cefpodoxime/cefprozil + macrolide*, OR fluoroquinolones *add a macrolide if there is a reasonable likelihood of an atypical agent causing the pneumonia
yes
Age >50 years?
no
Temperature <95F(35C)or 104F(40C) +15
Drug intolerance?
1st line antibiotics: macrolide or doxycycline
2nd line atibiotics: fluoroquinolones
CAP (Page 2)
Additional definitions from the Pneumonia Severity Index (PSI):
Neoplastic disease - any cancer, except basal or squamous cell carcinoma of the skin active at the time of presentation or within one year of presentation. Liver disease - clinical or histological cirrhosis or chronic active hepatitis. CHF - documented with history, physical exam or CXR findings; echo, MUGA; or left ventriculogram. CVD - clinical diagnosis of stroke or TIA; or documented stroke on CT or MRI. Renal disease - chronic renal disease; or abnormal BUN or creatinine.
Physician focus for Evaluating and Treating Community Acquired Pneumonia (CAP): For adults < 50 y/o diagnosed by CXR with CAP and treated as an outpatient, prescribe a macrolide, doxycycline, or TMP/SMX as first-line antibiotic choice (unless contraindicated or not tolerated) Indicator: Percentage of adults with CXR-confirmed diagnosis of CAP < 50 years old treated as an outpatient with a macrolide or doxycycline. For adults > 50 y/o diagnosed by CXR with CAP and treated as an outpatient, prescribe amoxicillin/clavulanate or cefuroxitime axetil/cefpodoxime/cefprozil (with or without a macrolide), or a fluoroquinolone for first-line antibiotic choice. Indicator: Percentage of adults with CXR-confirmed diagnosis of CAP > 50 years old treated with amoxicillin/clavulanate or cefuroxitime axetil/cefpodoxime/cefprozil (with or without a macrolide), or a fluoroquinolone. Counsel patients diagnosed with CAP regarding smoking cessation. Indicator: Percentage of adults diagnosed with CAP who receive smoking cessation education, as documented in the medical record (or billing charges).
References/Resources: Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice Guidelines for thr Management of Community Acquired Pneumonia in Adults. Clinical Infectious Diseases 2000;31:347-82. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. N Engl J Med 1997;336(4):243-50. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Community-Acquired Pneumonia. July 2000. http://www.icsi.org/guidelst.htm/ (2001, April 17) Marras TK, Gutierrez C, Chan CK. Applying a Prediction Rule To Identify Low-Risk Patients With Community-Acquired Pneumonia. Chest 2000;118(5):1339-1343. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A Controlled Trial of a Critical Pathway for Treatment of Community-Acquired Pneumonia. JAMA 2000;283(6):749-755. Moola S, et al. A multicenter study of grepafloxacin and clarithromycin in the treatment of patients wit community-acquired pneumonia. CHEST 1999;116:974-83.
Asthma symptoms may include:

wheezing breathlessness cough, productive or dry chest discomfort nocturnal cough history of persistent respiratory tract infections Conditions associated with asthma (e.g. nasal polyps, rhinitis, atopic dermatitis)
Asthma
Symptoms of Asthma Previous diagnosis of asthma? no yes
Establish a diagnosis of asthma: complete a thorough history and examination obtain spirometry
Indications for emergency care:

Peak flow less than 50% predicted normal Failure to respond to a 2-agonist Severe wheezing or coughing Extreme anxiety due to breathlessness Gasping for air, sweaty, or cyanotic Rapid deterioration over a few hours Severe retractions and nasal flaring Hunched forward NOTE: this guideline does not include treatment of patients requiring hospital care
History and physical Assess asthma triggers/allergens Measure pulmonary function spirometry - pre- and post- bronchodilator PEFR(designed as monitoring, not diagnostic tool) Consider consultation and/or allergy testing, particularly in children, as allergy vaccinations may prevent worsening of asthma
Assess asthma severity Treat and educate accordingly
SEVERITY
$symptoms < 2 times a week $asymptomatic and normal PEF between exacerbations $exacerbations are brief (few hours to a few days) $nighttime symptoms < 2 times a month $FEV1/FVC > 80 percent predicted and $PEF variability < 20 percent
DESCRIPTION /
DEFINITION Severe Persistent:

$continual symptoms $limited physical activity $frequent exacerbations $frequent nighttime symptoms $FEV1/FVC < 60 percent $PEF variability > 30 percent
Mild intermittent:
$symptoms > 2 times a week but < 1 time a day $exacerbations may affect activity $nighttime symptoms > 2 times a month $FEV1/FVC > 80 percent predicted and $PEF variability 20-30 percent
Mild Persistent:
$daily symptoms $daily use of inhaled shortacting beta2-agonist $exacerbations affect activity $exacerbations > 2 times a week; may last days $nighttime symptoms > 1 time a week $FEV1/FVC > 60 percent - < 80 percent predicted $PEF variability > 30 percent
Moderate Persistent:
ACUTE
$Inhaled 2 -agonist, prn, BUT < 1/week $Inhaled 2 -agonist, cromolyn, or nedocromil before exercise or allergen exposure $With viral infection: Inhaled 2 -agonist q4-6 hrs up to 24 hours (longer with physician consult) but no more than once every 6-8 weeks. Systemic corticosteroid if severe attack or history of severe attacks with infection If flares occur more often than every 6 weeks, seek consultation $None needed $Spirometry every 1-2 years in every patient; more often in unstable patients
AND
LONG-TERM Acute rescue:
TREATMENTS
$Short-acting bronchodilator: inhaled 2 -agonist as needed for symptoms, not to exceed 3-4x/dy $IF increased 2 -agonist use, may need to increase anti-infl tx.
Acute rescue:
$Short-acting bronchodilator: inhaled 2 -agonist as needed for symptoms, not to exceed 3-4x/dy
Acute rescue:
Long-term prevention:
Daily medications: $Anti-inflammatory: either inhaled corticosteroid, 200 mcg, cromolyn sodium, or nedocromil (children usually begin with trial of cromolyn or nedocromil). $SR theophylline to serum concentration of 5-15 mcg.mL is an alternative, but NOT preferred therapy. $Zafirlukast or zileuton may be considered for pts. > 12 y.o. $Montelukast may be used in pts. > 6 y.o. $Spirometry every 1-2 years in every patient; more often in unstable patients
$Short-acting bronchodilator: inhaled 2 -agonist as needed for symptoms, not to exceed 3-4x/dy $IF increased 2 -agonist use, may need to increase anti-infl tx.
Acute rescue:
Daily medications: $Anti-inflammatory: inhaled corticosteroid (med. dose) OR Inhaled corticosteroid AND long-acting bronchodilator, esp. for nighttime symptoms (2 agonist, SR theo, or long-acting 2 tablets) (inhaled preferred) If needed: $Anti-inflammatory: inhaled corticosteroids (med-high dose) AND Add a long-acting bronchodilator, esp. for nighttime symptoms (2 -agonist, SR theo, or long-acting 2 tablets) $Spirometry every 1-2 years in every patient; more often in unstable patients
Daily medications: $Anti-inflammatory: inhaled corticosteroid (800-2000 mcg/d) AND $Long-acting bronchodilator: either long-acting inhaled 2 agonist, sustained release (SR) theophylline, or long-acting 2 agonist tablets (inhaled preferred) AND $Coticosteroid tablets or syrup long term (2 mg/kg/day, max 60 mg/day) $Spirometry every 1-2 years in every patient; more often in unstable patients
Step 1 actions:
Teach basic facts about asthma Teach inhaler/spacer technique Discuss roles of medications Develop self-management plan Develop action plan for when and how to take rescue actions Discuss appropriate environmental control measures to avoid exposure to known triggers
Step 2 actions:
Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update selfmanagement plan
EDUCATION Step 3 actions:

Same as step 2 actions
Step 4 actions:
Step 2 and 3 actions plus: Refer to individual education/counseling
Schedule regular follow-up appointments
Asthma page 2
Common Asthma Triggers:
Tobacco smoking Passive tobacco, woodburning stove, or fireplace smoke Gastroesophageal reflux Sulfites Exercise Cold Air Pollutants Air pollutants Occupational exposures Medications -blockers Aspirin NSAIDs Outdoor allergens Pollens Fungi Respiratory tract infections Viral URI illnesses Sinusitis Bronchitis
Indoor allergens Domestic mites Animal allergens Cockroach allergens Fungi
Adapted from Gross and Ponte article and UMHS guideline
Interpreting Spirometry:
Problem Obstructive disease Restrictive disease Reversible disease FEV1 Decreased Decreased or normal Increased by 12 to 15 percent after administration of bronchodilator* FVC Normal or decreased Decreased FEV1/FVC% Decreased Normal or increased
FEV1=forced expiratory vlume in one second; FVC=forced vital capacity; FEV1/FVC%=FEV1 as percentage of FVC *Increased in comparison with the baseline FEV1 measurement before the bronchodilator was administered.
Adapted from Gross and Ponte article.
General Guidelines for Referral to an Asthma Specialist:

Referral is recommended when: Life threatening asthma exacerbations Is not meeting treatement goals, or unresponsive to therapy Atypical signs and symptoms Complicating comorbidities (e.g. sinusitis, nasal polyps, vocal cord dysfunction, COPD) Additional diagnostic testing indicated Additional patient education/guidance needed Immunotherapy considered Patient has severe persistent asthma Patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids Patient is under age 3 Confirmation of history that suggests occupational or environmental inhalant or ingested substance causing asthma.
Physician focus for managing patients with asthma: Prescribe anti-inflammatory medication to all patients with persistent asthma. Indicator: Percentage of patients with persistent asthma with prescriptions for an antiinflammatory medication. Monitor patients for overuse of -agonist medication and re-evaluate/educate patient. Indicator: Percentage of patients with greater than three MDIs filled at pharmacy in a 3 month period. Utilize objective measures (spirometry or peak flow) for accurate assessment of lung function. Indicator: Percentage of patients with asthma with spirometry or peak flow documented in the medical record at the last visit. Educate patients, including an asthma action plan. Indicator: Percentage of patients with asthma with an asthma action plan in the medical record. documented in their chart at the last visit. Counsel patients diagnosed with asthma regarding smoking cessation. Indicator: Percentage of adults diagnosed with asthma who receive smoking cessation education, as documented in the medical record (or billing charges).
References/Resources: Expert Panel Report 2: Guidelines for the Diagnosis and management of Asthma. National Institutes of Health. National Heart, Lung, and Blood Institute. NIH Publication No. 97-4051. July 1997 Green L, et al (Asthma Guideline Team). UMHS Asthma Guideline. University of Michigan Health System. January 2000. http://cme.med.umich.edu/iCME/default.asp (2001, April 17) Gross KM and Ponte CD. New Strategies in the Medical Management of Asthma. Am Fam Phys 1998;58(1):89-108. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Diagnosis and Management of Asthma. June 2000. http://www.icsi.org/guidelst.htm/ (2001, April 17)
www.aafp.org www.icsi.org www.nhlbi.nih.gov
DEPRESSION SYMPTOMS AND PRESENTATION MAY INCLUDE: multiple (>5/year) medical visits multiple unexplained symptoms sleep disturbances multiple worries or distress work or relationship dysfunction fatigue emotionally flat tearful
Depression
Symptoms or presentation suggestive of Depression Evaluate for secondary causes of depression, including: Psychosocial stressors (e.g. death of a loved one, job change, abuse, divorce) Medical illness (e.g. cancer, thyroid disease, stroke) Medications and withdrawal from medications (e.g. steroids, propanolol, hormonal therapy, reserpine, alphamethyldopa) Current substance abuse or withdrawal (e.g. alcohol, sedatives, anxiolytics, hypnotics, amphetamines) See CAGE (AID) screen on page 2
These guidelines are intended for use in the primary care setting
Interview for key symptoms of depression: Are you often sad, down, blue or teary? Do you have your usual interest in and look forward to enjoyable activities? Are you able to have fun or joy? How are you sleeping? How is your appetite? How is your energy level?
yes
Are key symptoms present?
no
Depression likely not present
Is patient suicidal or homicidal? Is patient psychotic? Is patients ability to function significantly impaired? See page 2 for assessment of suicidality
Secondary cause? no
yes
Address secondary cause and reevaluate
Involve mental health services/professionals
yes
Emergency?
Emergency may include: Suicidal thoughts/plans Assaultive or homicidal thoughts/plans Psychosis Significant ongoing inability to work and care for self/family
no Complete evaluation and diagnosis: DSM-IV criteria (see page 2) History of present illness (onset, severity, previous episodes, stressors) Pertinent medical history History of substance abuse Psychiatric co-morbidity (e.g., mania)
Major no depression?
Consider other mood and anxiety disorders or somatoform disorders
yes
Select pharmacotherapy based upon side-effect profiles, past medical history, and patient lifestyle
Discuss treatment options with patient: psychotherapy pharmacotherapy both Consider severity of symptoms, presence of psychosocial stressors, and presence of co-morbid conditions
Refer to psychotherapy and/or Initiate pharmacotherapy (see page 2)
yes
Is patient accepting of diagnosis and interested in treatment?
no
Schedule follow-up appointment and reevaluate
Follow-up in 4-6 weeks Continue treatment Pharmacotherapy: consider adjusting dose Psychotherapy: consider augmenting with medical therapy
Augment or change treatment Consider referral
no
Are symptoms improving?
somewhat
very much Assess response in 4-6 weeks
Depression page 2
Major Depressive Episode--DSM IV Criteria
Must have a total of five symptoms for at least two weeks. One of the symptoms must be depressed mood or loss of interest. Depressed mood. Markedly diminished interest or pleasure in all or almost all activities. Significant (>5% body weight) weight loss or gain or decrease or increase in appetite. Insomnia or hypersomnia. Psychomotor agitation or retardation. Feeling of worthlessness or inappropriate guilt. Diminished concentration or indecisiveness. Recurrent thoughts of death or suicide.
CAGE(AID) Screen
Have you ever: C felt you ought to cut down on your drinking or drug use? A had people annoy you by criticizing your drinking or drug use? G felt bad or guilty about your drinking or drug use? E had a drink or used drugs as an eye opener first thing in the morning to steady your nerves or get rid of a hang over or to get the day started? If substance abuse is present or suspected, consider referral for chemical dependency assessment.
Treatment (Patient Education Considerations)

Both pharmacologic and non-pharmacologic interventions may be effective depending on the severity of symptoms. For antidepressant medications, compliance with a therapeutic dose is more important than the specific drug selected. The following educational messages may increase adherence: Take the medication daily. Antidepressants must be taken for two to four weeks for a noticeable effect. Continue to take medicine even if feeling better. Do not stop taking antidepressant without checking with your provider. Contact your provider if you have questions about your medication.
Referral to Psychiatrist
Consider psychiatric consultation for patients with: History of mania or psychosis Condition not responding to trials of one or two medications Need for combination therapy Immediate psychiatric evaluation is necessary if patient may harm themselves or others.
Physician focus for management of depression: Increase the detection and diagnosis of depression in primary care through application of specific criteria. Indicator: Percentage of adults complaining of depression containing documentation of DSM-IV criteria at the time of initial diagnosis. Increase screening for depression in patients with somatic complaints. Indicator: Percentage of adults complaining of fatigue or sleep disorder who have documentation of screening for depression. Follow-up patients with newly diagnosed depression within 6 weeks of initial diagnosis. Indicator: Percentage of adult patients newly diagnosed with depression who have a follow-up appointment within 6 weeks.
References/Resources:
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Major Depression, Panic Disorder and Generalized Anxiety Disorder in Adults in Primary Care. March 1999. http://www.icsi.org/guidelst.htm/ (2001, April 17) Schulberg HC, Katon W, Simon GE, Rush AJ. Treating Major Depression in Primary Care Practice: An Update of the Agency for health Care Policy and Research Practice Guidelines. Archives of General Psyciatry 1998;55(12):1121-1127 Schwenk T and Terrell L et al (Depression Guideline Team). UMHS Depression Guideline. University of Michigan Health System. January 2000. http://cme.med.umich.edu/iCME/default.asp (2001, April 17) University of Washington Physicians. Major Depressive Disorder Guidelines. c. 2001 http://healthlinks.washington.edu/guideline/depr/ (2001, April 17) Whooley MA, Simon GE. Primary Care: Managing Depression in Medical Outpatients. New England Journal of Medicine 2000;343(26):1942-1950.
American Academy of Family Practice: www.aafp.org Institute for Clinical Systems Improvement: www.icsi.org University of Michigan Health Systems: http://cme.med.umich.edu/iCME/default.asp University of Washington Physicians: http://healthlinks.washington.edu/guideline/depr/ Agency for Healthcare Research and Quality: http://text.nlm.nih.gov American Medical Association: www.ama-assn.org/consumer/specond.htm National Depressive and Manic-Depressive Association: www.ndmda.org National Foundation for Depressive Illness: www.depression.org National Mental Health Association: www.nmha.org/ccd Psychology Information Hotline: www.psychologyinfo.com/depression
Screening and Diagnosis of Type 2 Diabetes

Asymptomatic, undiagnosed Patient meets > 1 risk factor for Diabetes Risk factors for diabetes: Over age 45 years Obese (> 120% desirable body weight or a BMI > 27kg/m2) Family history of diabetes High risk ethnic population including Hispanics, Native Americans, African Americans, Pacific Islanders Delivered a baby weighing > 9 lb or has been diagnosed with GDM Hypertensive Dyslipidemia especially HDL cholesterol level < 35mg/dl (0.90 mmol/l) and/or a triglyceride level > 250 mg/dl (2.82mmol/l). Had impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)* Yes Screen for Diabetes Mellitus: Random plasma glucose > 160 mg/dl or fasting blood glucose >126mg/dl?
Yes
Repeat FBG: >126 mg/dl or 2 hour GTT>200 mg/dl? Yes
No
Diagnosis: Impaired Glucose Tolerance
Discuss with patient diet, exercise, weight loss
Repeat Screening every 3 years
No
Diagnosis of Diabetes Confirmed: (Assess) HbA1c Blood glucose level Co-morbidities Ketones H&P and Weight Diet/nutrition
Re-evaluate 3-12 months.
Is Patient symptomatic BG>300mg/dl and/or Ketones >2+?
Is Patient asymptomatic and overweight BG > 400mg/dl and/or Ketones 2+?
Is Patient asymptomatic normal weight or overweight BG < 300mg/dl and non Ketotic or Ketones 1+? Yes
Yes Yes 1. Consider referral to Endocrinologist/Diabetic Specialist and/or 2. Consider hospitalization A. Initiate insulin therapy B. Implement patient management program
1. Initiate insulin therapy, treat contributing factors, and 2. Implement patient management program
1. Initiate counseling for diet/nutrition, exercise, weight control; 2. Consider insulin or oral agents; and 3. Implement patient management programs
See treatment goals *Impaired glucose tolerance: 2 hour glucose >140 mg/dl and <200 mg/dl. Impaired fasting glucose: FBS > 110 mg/dl and <126 mg/dl
Management of Patients with Diabetes Mellitus

Evaluation by Diabetes Clinical Management Team: Nutrition/diet Blood pressure Exercise counseling Diabetes education HGM (home glucose monitoring) Establish management plan and therapy goals (Refer to treatment goals)
Initial Intervention
Yes
Evaluate in 1 month: are goals met?
No
Evaluate quarterly: Monitor for complications Blood Pressure <130/85 8 Review HGM <120 mg/dl pre-meal, 140mg/dL bed time HbA1c* < 7.0 Foot exam Reinforce diabetes education (exercise, diet, weight control, medication compliance) Reassess diabetes self management skills
Start monotherapy oral hypoglycemic agents (OHA). Refer to Continuing Care Criteria.
Yes
Evaluate in 3 months: Are goals met? No Maximize oral hypoglycemic agents OR Add insulin OR Switch to Insulin Monotherapy OR Consider referral to endocrinologist
Continue quarterly follow-up: Evaluate combination therapy (See Evaluate quarterly box.)
Yes
Perform Annually: Dilated funduscopic eye (DRE) exam by ophthalmologist or optometrist. TSH Microalbumin measurement if urinalysis is negative for protein Lipid profile
Maximize Monotherapy or Add 2nd OHA. Evaluate after 3 months. Are goals met?
No
Continue quarterly/annual follow-up Evaluate therapy
Yes
Evaluate in 3 months: Are goals met? No Refer to endocrinologist
* HbA1c goal < 7.0, if > 7.0 re-evaluate treatment plan and medication.
Diabetes Management Goals

Testing/Examination Performance Goals: Quarterly Goals: Annual Goals:
HbA1c Urinary protein analysis Blood pressure Foot exam TSH Dilated funduscopic exam performed by an ophthalmologist or optometrist Fasting lipid profile Diabetes education with nutrition/exercise assessment Influenza vaccine yearly/pneumococcal vaccine every 10 years.
Treatment Goals: HbA1c < 7.0 (<8.5 for children ages 5-11, 7.5-9.3 for children <5) Home Glucose Monitoring a.c. <120mg/dl; h.s. <140mg/dl Blood Pressure <130/85 Lipid Profile: (LDL<100mg/dl, HDL>35 (men), >45 (women)). Triglycerides <200mg/dl
Screening for Complications:

Blood Pressure: Blood pressure should be maintained <130/85 Consider ACE inhibitor or as first choice Dyslipidemia: Start treatment/medication if LDL >130 mg/dl Start treatment/medication if CAD is present and LDL >100 mg/dl Consider treatment/medication for TRIG>200 and LDL/HDL>5 or HDL<35 mg/dl Nephropathy: Microalbuminuria/creatinine ratio anually (first a.m. urine preferred) for all Type 2 diabetic patients starting at diagnosis and any patient > 12 years of age and within 5 years of diagnosis. Peripheral neuropathy: Comprehensive Foot examination each visit; testing with 5.07 monofilament and clinical evaluation of nerve and vascular status at least annually.
Inform patients of the following: Never walk barefooted. Wear properly fitting soft shoes. Do not apply hot water or heating pads to feet. Break in new shoes slowly. Inspect feet daily, use mirror for plantar surfaces. Use second pair of shoes at night (larger size for edema). Keep foot clean, dry between the toes. Cut toenails straight across. Lubricate dry skin using non-greasy lotion or cream to Visit Foot Care Specialist regularly. Stop smoking. avoid cracking. Retinopathy: Annual dilated eye exam performed by ophthalmologist or optometrist for all Type 2 diabetic patients starting at diagnosis and any patient > 10 years of age within 3 to 5 years of diagnosis.
Consider for referral: Type 1 patients on intensive management or patients not meeting treatment goals should be referred to a diabetic specialist, diabetes nurse practitioner, and registered dietician. Selected patients to Endocrinology Type 1 patients not ideally controlled and/or candidates for intensive management Type 2 patients not optimally controlled on maximal effective oral hypoglycemic agents and/or insulin. Patient referral suggested by diabetes educator (and approved by PCP) Patients with recent DKA Complex patient with diabetes complications All patients for diabetes education at time of diagnosis and annually Children with Type 1 Diabetes
Diabetes Mellitus
References:
AACE Clinical Practice Guidelines for the Management of Diabetes Mellitus, The American Association of Clinical Endocrinologists and The American College of Endocrinology, 1995. Alliance Blue Cross Blue Shield, Practice Guideline for Diagnosis and Management of Diabetes, 1999. Alliance Blue Cross Blue Shield, Practice Guideline for Cardiovascular Risk Reduction (Hyperlipidemia), 1998. American Diabetes Association: Clinical Practice Recommendations 2000, Vol. 23, January 2000. Applied Therapeutics, 5 edition, Mary Anne Koda-Kimble, Lloyd Y. Young, 1992. Drug Facts and Comparisons. (Steven K. Hebel) (Facts and Comparisons, St. Louis, MO 1997). Drug Information Handbook. 5 Edition, Charles Lacy, ed. Lexi-Comp, Hudson, Ohio, 1998. Lovelace Healthcare Foundation, Inc. Episode of care: diabetes, 1997. Texas Diabetes Council, Texas Department of Health, 1998.
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Clinical Practice Guidelines

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CLINICAL PRACTICE GUIDELINES FOR PRACTITIONERS

CLINICAL PRACTICE GUIDELINES FOR PRACTITIONERS

Evaluation of Abnormal Uterine Bleeding

Is cause of bleeding due to pelvic pathology, medication, systemic disease?

Is pregnancy test positive?

Determine bleeding pattern

Determine TSH and prolactin levels

Reassure the patient or initiate Oral Contraceptive Pills (OCPs)

Evaluate for bleeding disorder

Consider evaluation for luteal phase defect

Progesterone withdrawal every 3 months, OCPs or clomiphene induction.

OCPs or domiphene (serophene)

Treat the disorder

Treat with OCPS or clomiphene

Cervical pathology? No Bleeding at ovulation?

Begin period of observation

OCPs, progesterone withdrawal every 3 months, or clomiphene for ovulation induction

Evaluation of Abnormal Uterine Bleeding

Determine beta human chorionic gonadotropin (-HCG)

Genital tract lesion present

Uterine enlargement present

Treat, perform biopsy or refer as appropriate

Consider transvaginal ultrasonography or sonohysterography

Evaluate for pregnancy Etiology still unclear Etiology identified

Perform endometrial biopsy

Biopsy not possible

Perform transvaginal ultrasonography, sonohysterography or hysteroscopy, or dilation and curettage

Normal pathology or atrophy

Cyclic hormonal regulation or begin a period of observation

Cyclic progesterone therapy; hyperplasia that persists requires D&C

Refer patient for treatment

Evaluation of Abnormal Uterine Bleeding

Genital tract lesion present Normal findings, receiving HRT?

Uterine enlargement present

Treat, perform biopsy or refer as appropriate

Consider performing transvaginal ultrasonography or sonohysterography

Duration > 6 months

Duration < 6 months

If early withdrawal bleeding, increase progesterone dosage

Endometrial biopsy performed

Transvaginal ultrasonography performed

Endometrial stripe < 5 mm

Endometrial stripe > 5 mm

Uterine pathology identified

Refer patient for treatment

Bleeding stopped? No Yes

Perform endometrial biopsy or hysteroscopy with biopsy

Refer patient for treatment

Perform transvaginal ultrasonography, sonohysterography or hysteroscopy, depending on clinical suspicion

Begin period of observation

Management of Vaginal Vault Prolapse

Symptoms of Vaginal Prolapse

Focused History and Physical Exam

Follow up office visit in 6 months or based on treatment option.

Management of Vaginal Vault Prolapse

Management of Uterine Leiomyomas

Suspected Uterine Fibroids

Asymptomatic with fibroids >14 weeks size?

Follow-up in office in 6 months unless symptoms change.

Discuss options, including observation with patients.

Successful treatment of symptoms?

Continue therapy 4-6 months.

Mild to Moderate Pain Mild to Moderate Pain