General health checks in adults for reducing morbidity and mortality from disease

Should Commercial Diagnostic Testing Be Stimulated or Discouraged? Analyzing Willingness-to-Pay and Market Externalities of Three Commercial Diagnostic Tests in The Netherlands

INTRODUCTION

Consumers may purchase commercial diagnostic tests (CDT) without prior doctor consultation. This paper analyzes three CDT markets-commercial cholesterol tests (CCT), direct-to-consumer genetic health tests (DGT) and total body scans (TBS)-in the context of the universal, collectively financed health care system of the Netherlands.

METHODS

An online willingness-to-pay (WTP) questionnaire was sent to a representative sample of 1500 Dutch consumers. Using contingent valuation (CV) methodology, an array of bids for three self-tests were presented to the respondents. The results were extrapolated to the Dutch population and compared to current prices and follow-up medical utilization, allowing analysis from a societal perspective.

RESULTS

Overall, 880 of 1500 respondents completed the questionnaire (response rate 59%). Of the respondents, 26-44% were willing to pay a positive amount for the CDT. Willingness-to-pay was correlated to age and household income, but not to health status or prior experience with these tests. At mean current prices of €29 for CCT, €229 for DGT and €1,650 for TBS, 3.3%, 2.5%, and 1.1%, were willing to purchase a CCT, DGT, and TBS, respectively. All three CDT resulted in net costs to the health system, estimated at €5, €16, and €44 per test, respectively. Reducing volumes by 90,000 CCTs (19%), 19,000 DGTs (5%) and 4,000 TBSs (2.5%) in 2019 would optimize welfare.

CONCLUSION

Most respondents were unwilling to consume CDT at any price or only if the CDT were provided for free. However, for a small group of consumers, societal costs exceed private benefits. Therefore, CDT regulation could provide small welfare gains.

Effect of social activities on health checkups and recommended doctor visits: a fixed-effects analysis in Japan

Health checkups are considered to promote occupational and public health. This study aimed to investigate the extent to which participation in social activities encourages middle-aged people to participate in health checkups and adhere to doctor-visit recommendations. We analyzed 337,024 longitudinal observational studies involving 33,420 individuals aged 50-59 yr in the baseline year (2005) derived from a nationwide, population-based, 14-wave survey. We estimated fixed-effects logistic models to elucidate how people's participation in health checkups and recommended doctor visits are affected by participation in social activities. Attending health checkups was positively associated with participation in social activities, with an odds ratio (OR) of 1.19 (95% confidence interval [CI]: 1.15-1.22) and a marginal effect of 3.3% (95% CI: 2.7%-3.9%). Adherence to doctor-visit recommendations was also positively associated with participation in social activities, with an OR of 1.15 (95% CI: 1.08-1.23) and a marginal effect of 3.3% (95% CI: 1.8%-4.8%), although the association was observed only among regular employees. These results provide new insights into the effectiveness of health checkups.

Using Polygenic Risk Scores for Prioritizing Individuals at Greatest Need of a Cardiovascular Disease Risk Assessment

Background The aim of this study was to provide quantitative evidence of the use of polygenic risk scores for systematically identifying individuals for invitation for full formal cardiovascular disease (CVD) risk assessment. Methods and Results A total of 108 685 participants aged 40 to 69 years, with measured biomarkers, linked primary care records, and genetic data in UK Biobank were used for model derivation and population health modeling. Prioritization tools using age, polygenic risk scores for coronary artery disease and stroke, and conventional risk factors for CVD available within longitudinal primary care records were derived using sex-specific Cox models. We modeled the implications of initiating guideline-recommended statin therapy after prioritizing individuals for invitation to a formal CVD risk assessment. If primary care records were used to prioritize individuals for formal risk assessment using age- and sex-specific thresholds corresponding to 5% false-negative rates, then the numbers of men and women needed to be screened to prevent 1 CVD event are 149 and 280, respectively. In contrast, adding polygenic risk scores to both prioritization and formal assessments, and selecting thresholds to capture the same number of events, resulted in a number needed to screen of 116 for men and 180 for women. Conclusions Using both polygenic risk scores and primary care records to prioritize individuals at highest risk of a CVD event for a formal CVD risk assessment can efficiently prioritize those who need interventions the most than using primary care records alone. This could lead to better allocation of resources by reducing the number of risk assessments in primary care while still preventing the same number of CVD events.

A correlation-based feature analysis of physical examination indicators can help predict the overall underlying health status using machine learning

As a systematic investigation of the correlations between physical examination indicators (PEIs) is lacking, most PEIs are currently independently used for disease warning. This results in the general physical examination having limited diagnostic values. Here, we systematically analyzed the correlations in 221 PEIs between healthy and 34 unhealthy statuses in 803,614 individuals in China. Specifically, the study population included 711,928 healthy participants, 51,341 patients with hypertension, 12,878 patients with diabetes, and 34,997 patients with other unhealthy statuses. We found rich relevance between PEIs in the healthy physical status (7662 significant correlations, 31.5%). However, in the disease conditions, the PEI correlations changed. We focused on the difference in PEIs between healthy and 35 unhealthy physical statuses and found 1239 significant PEI differences, suggesting that they could be candidate disease markers. Finally, we established machine learning algorithms to predict health status using 15-16% of the PEIs through feature extraction, reaching a 66-99% accurate prediction, depending on the physical status. This new reference of the PEI correlation provides rich information for chronic disease diagnosis. The developed machine learning algorithms can fundamentally affect the practice of general physical examinations.

Decline in Cognition from Mid-Life Improves Specificity of Mini-Mental State Examination: Diagnostic Test Accuracy in Caerphilly Prospective Study (CaPs)

BACKGROUND

The merit of using baseline cognitive assessments in mid-life to help interpret cross-sectional cognitive tests scores in later life is uncertain.

OBJECTIVE

Evaluate how accuracy for diagnosing dementia is enhanced by comparing cross-sectional results to a midlife measure.

METHODS

Cohort study of 2,512 men with repeated measures of Mini-Mental State Examination (MMSE) over approximately 10 years. Index test MMSE at threshold of 24 indicating normal, as a cross-sectional measure and in combination with decline in MMSE score from mid-life. Reference standard consensus clinical diagnosis of dementia by two clinicians according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

RESULTS

1,150 men participated at phase 4 of whom 75 had dementia. A cross-sectional MMSE alone produced a sensitivity of 60% (50% to 70%) and specificity 95% (94% to 97%) with a threshold of≥24 points indicating normal. For lower-scoring men in late life, with cross sectional scores of < 22, combining cross-sectional AND a three-point or more decline over time had a sensitivity of 52% (39% to 64%) and specificity 99% (99% to 100%). For higher-scoring men in later life, with cross sectional scores < 26 combining cross-sectional OR decline of at least three points had a sensitivity of 98% (92% to 100%) and specificity 38% (32% to 44%).

CONCLUSION

It may be helpful in practice to formally evaluate cognition in mid-life as a baseline to compare with if problems develop in future, as this may enhance diagnostic accuracy and classification of people in later life.

Prostate cancer screening behaviors among Indo-Guyanese

OBJECTIVE

The objective of this study was to explore prostate cancer screening behaviors among Indo-Guyanese men.

METHODS

This qualitative study was conducted in the surrounding neighborhood of Queens, New York during 2018 and 2019. In-depth, one-on-one interviews were conducted using 20 Indo-Guyanese men between the ages of 45 and 75.

RESULTS

The findings suggest that Indo-Guyanese men are being screened for prostate cancer at a very low rate. Only 30% (n = 6) of participants underwent prostate cancer screening. Four major themes were derived from the data, which could have contributed to the decreased level of screening. These included: (1) recommendations must come from their healthcare professional; (2) reluctance to engage in screening; (3) distrust of the medical system; and (4) screening only if symptoms are present or they know someone with prostate cancer.

CONCLUSIONS

Behavioral patterns for prostate cancer screening among Indo-Guyanese men share some similarities with other Caribbean countries. Clinicians and Healthcare Professionals should be culturally competent for the patients they serve. Understanding the behavioral variations within this diverse culture could help provide the highest possible care, specifically tailored to each patient.

Socio-economic inequalities in the chronic diseases management among Chinese adults aged 45 years and above: a cross sectional study

Backgrounds

Non-communicable diseases (NCDs) have become a priority public health issue. The aim of this study was to examine whether socio-economic inequalities exist in chronic disease management among Chinese adults, and whether the relationship between SES and chronic disease management mediated by social capital.

Methods

We used combined data from China Health and Retirement Longitudinal Study (CHARLS). A total of 19,291 subjects, including 14,905 subjects from 2011 survey, 2036 subjects from 2013, and 2350 subjects from 2015 was included in this study.

Results

Subjects living in urban setting, with higher education attainment and economic status were more likely to have annual health checks, and to be diagnosed for those with hypertension, diabetes and dyslipidemia (all P < 0.05). Social participation could mediate the association between social economic status (SES) and annual health checks, diagnosis of hypertension and dyslipidemia, and health education of hypertension. Health checks could mediate the association between social participation and the diagnosis of hypertension, diabetes and dyslipidemia. The proportions of mediation were 17.5, 23.9 and 8.9%, respectively. There were no mediating effects observed from cognitive social capital variable-perceived helpfulness.

Conclusion

It is necessary to deeply reform our social security system and enhance the social capital construction to promote those low SES people’s physical health.

Unwillingness to participate in health checks for cardiometabolic diseases: A survey among primary health care patients in five European countries

BACKGROUND AND AIMS

Since cardiometabolic diseases (CMD) are a frequent cause of death worldwide, preventive strategies are needed. Recruiting adults for a health check could facilitate the identification of individuals at risk for CMD. For successful results, participation is crucial. We aimed to identify factors related to unwillingness to participate in CMD health checks.

METHODS

We performed a cross-sectional study in the Czech Republic, Denmark, Greece, the Netherlands, and Sweden. A questionnaire was distributed among persons without known CMD consulting general practice between January and July 2017 within the framework of the SPIMEU study.

RESULTS

In total, 1354 persons responded. Nine percent was unwilling to participate in a CMD health check. Male gender, smoking, higher self-rated health, never been invited before, and not willing to pay were related to unwillingness to participate. The most mentioned reason for unwillingness to participate was "I think that I am healthy" (57%). Among the respondents who were willing to participate, 94% preferred an invitation by the general practitioner and 66% was willing to pay.

CONCLUSION

A minority of the respondents was unwilling to participate in a CMD health check with consistent results within the five countries. This provides a promising starting point to increase participation in CMD health checks in primary care.

Cost-effectiveness of a stepwise cardiometabolic disease prevention program: results of a randomized controlled trial in primary care

BACKGROUND

Cardiometabolic diseases (CMD) are the major cause of death worldwide and are associated with a lower quality of life and high healthcare costs. To prevent a further rise in CMD and related healthcare costs, early detection and adequate management of individuals at risk could be an effective preventive strategy. The objective of this study was to determine long-term cost-effectiveness of stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. A computer-based simulation model was used to project long-term health benefits and cost-effectiveness, assuming the prevention program was implemented in Dutch primary care.

METHODS

A randomized controlled trial in a primary care setting in which 1934 participants aged 45-70 years without recorded CMD or CMD risk factors participated. The intervention group was invited for stepwise CMD risk assessment through a risk score (step 1), additional risk assessment at the practice in case of increased risk (step 2) and individualized follow-up treatment if indicated (step 3). The control group was not invited for risk assessment, but completed a health questionnaire. Results of the effectiveness analysis on systolic blood pressure (- 2.26 mmHg; 95% CI - 4.01: - 0.51) and total cholesterol (- 0.15 mmol/l; 95% CI - 0.23: - 0.07) were used in this analysis. Outcome measures were the costs and benefits after 1-year follow-up and long-term (60 years) cost-effectiveness of stepwise CMD risk assessment compared to no assessment. A computer-based simulation model was used that included data on disability weights associated with age and disease outcomes related to CMD. Analyses were performed taking a healthcare perspective.

RESULTS

After 1 year, the average costs in the intervention group were 260 Euro higher than in the control group and differences were mainly driven by healthcare costs. No meaningful change was found in EQ 5D-based quality of life between the intervention and control groups after 1-year follow-up (- 0.0154; 95% CI - 0.029: 0.004). After 60 years, cumulative costs of the intervention were 41.4 million Euro and 135 quality-adjusted life years (QALY) were gained. Despite improvements in blood pressure and cholesterol, the intervention was not cost-effective (ICER of 306,000 Euro/QALY after 60 years). Scenario analyses did not allow for a change in conclusions with regard to cost-effectiveness of the intervention.

CONCLUSIONS

Implementation of this primary care-based CMD prevention program is not cost-effective in the long term. Implementation of this program in primary care cannot be recommended.

TRIAL REGISTRATION

Dutch Trial Register NTR4277 , registered on 26 November 2013.

Effect of Combined Statin and Antihypertensive Therapy in Patients with Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

This meta-analysis aimed to explore the preventive effects of combined statin and antihypertensive therapy on major cardiovascular outcomes in patients with hypertension.

METHODS

PubMed, Embase, and the Cochrane Library databases and reference lists of published studies were systematically searched throughout October 9, 2019. Studies designed as randomized controlled trials and investigating the effects of combined statin and antihypertensive therapy versus antihypertensive therapy alone were included. Data abstraction and quality of included studies were assessed by 2 independent authors. The summary results were calculated using relative risks (RRs) with 95% CIs employing a random-effects model.

RESULTS

A total of 8 randomized controlled trials including 38,618 patients were finally enrolled. The summary RRs indicated that the combined therapy significantly reduced the risk of major adverse cardiovascular events compared with antihypertensive therapy alone (RR 0.79; 95% CI 0.71-0.88; p < 0.001). Furthermore, the patients in the combined therapy group also experienced less myocardial infarction (RR 0.67; 95% CI 0.53-0.84; p = 0.001) and stroke risks (RR 0.82; 95% CI 0.72-0.94; p = 0.005), while no significant difference was observed between combined therapy and antihypertensive therapy alone regarding cardiac death (RR 0.96; 95% CI 0.84-1.08; p = 0.465) and all-cause mortality (RR 0.95; 95% CI 0.86-1.04; p = 0.277).

CONCLUSION

These findings suggested that combined statin and antihypertensive therapy was associated with more cardiovascular benefits compared with antihypertensive therapy alone.

Primary care visits increase utilization of evidence-based preventative health measures

BACKGROUND

Primary care visits can serve many purposes and potentially influence health behaviors. Although previous studies suggest that increasing primary care provider numbers may be beneficial, the mechanism responsible for the association is unclear, and have not linked primary care access to specific preventative interventions. We investigated the association between the number of times patients accessed their primary care provider team and the likelihood they received selected preventative health interventions.

METHODS

Patients with complete data sets from Sanford Health were categorized based on the number of primary care visits they received in a specified time period and the preventative health interventions they received. Patient characteristics were used in a propensity analysis to control for variables. Relative risks and 95% confidence intervals were calculated to estimate the likelihood of obtaining preventative measures based on number of primary care visits compared with patients who had no primary care visits during the specified time period.

RESULTS

The likelihood of a patient receiving three specified preventative interventions was increased by 127% for vaccination, 122% for colonoscopy, and 75% for mammography if the patient had ≥ 1 primary care visit per year. More primary care visits correlated with increasing frequency of vaccinations, but increased primary care visits beyond one did not correlate with increasing frequency of mammography or colonoscopy.

CONCLUSIONS

One or more primary care visits per year is associated with increased likelihood of specific evidence-based preventative care interventions that improve longitudinal health outcomes and decrease healthcare costs. Increasing efforts to track and increase the number of primary care visits by clinics and health systems may improve patient compliance with select preventative measures.

Simulations of future cardiometabolic disease and life expectancy under counterfactual obesity reduction scenarios

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HIAs provide simulations of future disease levels related to an array of obesity scenarios.

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In a relatively lean population, obesity still contribute to a substantial reduction in life expectancy.

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Large reductions in diabetes and multi-morbidity is estimated as an effect of reducing obesity.

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Incremental increase in future stroke and IHD cases is expected.

The aim of this study was to provide decision makers with an assessment of potential future health effects of interventions against overweight and obesity (OWOB). By means of the DYNAMO-HIA tool we conducted a health impact assessment simulating future prevented disease (ischemic heart disease (IHD), diabetes, stroke, and multi morbidity) incidence, prevalence and life expectancy (LE) related to a scenario where OWOB is reduced by 25% and a scenario where obesity is eliminated. The study covered projected number of persons living in Copenhagen, Denmark during year 2014–2040 (n 2040 = 742,129). Reducing the proportion of men/women with OWOB with 25% will increase population LE by 2.4/1.2 months and at the same time decrease LE with diabetes by 3.1/2.2 months. As a result of eliminating obesity, total LE will increase by 6.0/3.6 months and LE with diabetes will decrease with 9.8/10.3 months for men/women. We found no important effects on LE with IHD and stroke. This illustrates that the positive effects of lowering OWOB levels on IHD and stroke incidence is offset due to increasing total LE. Although the population of Copenhagen is relatively lean, reducing obesity levels will result in significant benefits for population cardiometabolic health status and LE. Future public health prevention programs may use the results as reference data for potential impact of reductions in OWOB.

Changes in Health-Risk Behavior, Body Mass Index, Mental Well-Being, and Risk Status Following Participation in a Stepwise Web-Based and Face-to-Face Intervention for Prevention of Lifestyle-Related Diseases: Nonrandomized Follow-Up Cohort Study

Background

Recent evidence suggests the effectiveness of stepwise, targeted approaches for the prevention of lifestyle-related diseases with combinations of web-based and face-to-face interventions showing promising results.

Objective

This paper reports on 1-year changes in health-risk behaviors, BMI, self-rated health, mental well-being, and risk of disease at 1-year follow-up after participation in a stepwise intervention that targeted persons at high risk of disease and persons with health-risk behavior. To this end, we distinguish between participants who took up the full intervention (web-based plus face-to-face) and those who received only the web-based intervention.

Methods

The Early Detection and Prevention (Danish acronym: TOF) pilot study was conducted as a nonrandomized, 1-year follow-up intervention study in two municipalities in the Region of Southern Denmark. A total of 9400 citizens born between 1957 and 1986 (aged 29 to 60 years) were randomly sampled from participating general practitioner (GP) patient-list systems and were invited to take part in the study. Participants were subsequently stratified into risk groups based on their responses to a questionnaire on health-risk behavior and data from their GP’s electronic patient record (EPR) system. All participants received a digital personal health profile with individualized information on current health-risk behavior and targeted advice on relevant health-risk behavior changes. In addition, patients at high risk of disease, as indicated by their digital health profile, were offered a targeted intervention at their GP. Patients who were not deemed at high risk of disease but who exhibited health-risk behaviors were offered a targeted intervention at their municipal health center (MHC). At 1-year follow-up, health-risk behaviors, self-rated health, BMI, and mental well-being were reassessed by questionnaire, and current information on diagnoses and medical treatment was retrieved from the EPRs.

Results

Of 598 patients at high risk of disease or with health-risk behavior, 135 took up the targeted intervention at their GP or MHC and 463 received the personal health profile only. From baseline to 1-year follow-up, the number of patients with unhealthy eating habits decreased, mean mental well-being increased, and smoking prevalence decreased in patients who had received the digital personal health profile alone. Among patients who took up the targeted intervention, unhealthy eating habits and sedentary lifestyles decreased and significant reductions in mean BMI were observed. At 1-year follow up, no health-risk behaviors were detected among 17.4% of patients who at baseline had exhibited health-risk behaviors or high risk of disease.

Conclusions

A stepwise targeted preventive approach using web-based and face-to-face elements may lead to favorable lifestyle changes. Specifically, a web-based approach may improve smoking and eating habits and mental well-being, whereas supplementary face-to-face interventions may be necessary to improve exercise habits and BMI.

Trial Registration

ClinicalTrials.gov NCT02797392; https://clinicaltrials.gov/ct2/show/NCT02797392

International Registered Report Identifier (IRRID)

RR2-10.1186/s12875-018-0820-8

Natriuretic peptide-guided treatment for the prevention of cardiovascular events in patients without heart failure

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Early intervention for those with high cardiovascular risk is crucial in improving patient outcomes. Traditional prevention strategies for CVD have focused on conventional risk factors, such as overweight, dyslipidaemia, diabetes, and hypertension, which may reflect the potential for cardiovascular insult. Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-proBNP), are well-established biomarkers for the detection and diagnostic evaluation of heart failure. They are of interest for CVD prevention because they are secreted by the heart as a protective response to cardiovascular stress, strain, and damage. Therefore, measuring NP levels in patients without heart failure may be valuable for risk stratification, to identify those at highest risk of CVD who would benefit most from intensive risk reduction measures.

OBJECTIVES

To assess the effects of natriuretic peptide (NP)-guided treatment for people with cardiovascular risk factors and without heart failure.

SEARCH METHODS

Searches of the following bibliographic databases were conducted up to 9 July 2019: CENTRAL, MEDLINE, Embase, and Web of Science. Three clinical trial registries were also searched in July 2019.

SELECTION CRITERIA

We included randomised controlled trials enrolling adults with one or more cardiovascular risk factors and without heart failure, which compared NP-based screening and subsequent NP-guided treatment versus standard care in all settings (i.e. community, hospital).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and selected studies for inclusion, extracted data, and evaluated risk of bias. Risk ratios (RRs) were calculated for dichotomous data, and mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous data. We contacted trial authors to obtain missing data and to verify crucial study characteristics. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, two review authors independently assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table.

MAIN RESULTS

We included two randomised controlled trials (three reports) with 1674 participants, with mean age between 64.1 and 67.8 years. Follow-up ranged from 2 years to mean 4.3 years.For primary outcome measures, effect estimates from a single study showed uncertainty for the effect of NP-guided treatment on cardiovascular mortality in patients with cardiovascular risk factors and without heart failure (RR 0.33, 95% CI 0.04 to 3.17; 1 study; 300 participants; low-quality evidence). Pooled analysis demonstrated that in comparison to standard care, NP-guided treatment probably reduces the risk of cardiovascular hospitalisation (RR 0.52, 95% CI 0.40 to 0.68; 2 studies; 1674 participants; moderate-quality evidence). This corresponds to a risk of 163 per 1000 in the control group and 85 (95% CI 65 to 111) per 1000 in the NP-guided treatment group.When secondary outcome measures were evaluated, evidence from a pooled analysis showed uncertainty for the effect of NP-guided treatment on all-cause mortality (RR 0.90, 95% CI 0.60 to 1.35; 2 studies; 1354 participants; low-quality evidence). Pooled analysis indicates that NP-guided treatment probably reduces the risk of all-cause hospitalisation (RR 0.83, 95% CI 0.75 to 0.92; 2 studies; 1354 participants; moderate-quality evidence). This corresponds to a risk of 601 per 1000 in the control group and 499 (95% CI 457 to 553) per 1000 in the NP-guided treatment group. The effect estimate from a single study indicates that NP-guided treatment reduced the risk of ventricular dysfunction (RR 0.61, 95% CI 0.41 to 0.91; 1374 participants; high-quality evidence). The risk in this study's control group was 87 per 1000, compared with 53 (95% CI 36 to 79) per 1000 with NP-guided treatment. Results from the same study show that NP-guided treatment does not affect change in NP level at the end of follow-up, relative to standard care (MD -4.06 pg/mL, 95% CI -15.07 to 6.95; 1 study; 1374 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

This review shows that NP-guided treatment is likely to reduce ventricular dysfunction and cardiovascular and all-cause hospitalisation for patients who have cardiovascular risk factors and who do not have heart failure. Effects on mortality and natriuretic peptide levels are less certain. Neither of the included studies were powered to evaluate mortality. Available evidence shows uncertainty regarding the effects of NP-guided treatment on both cardiovascular mortality and all-cause mortality; very low event numbers resulted in a high degree of imprecision in these effect estimates. Evidence also shows that NP-guided treatment may not affect NP level at the end of follow-up.As both trials included in our review were pragmatic studies, non-blinding of patients and practices may have biased results towards a finding of equivalence. Further studies with more adequately powered sample sizes and longer duration of follow-up are required to evaluate the effect of NP-guided treatment on mortality. As two trials are ongoing, one of which is a large multi-centre trial, it is hoped that future iterations of this review will benefit from larger sample sizes across a wider geographical area.

Evaluating the effectiveness of the NHS Health Check programme in South England: a quasi-randomised controlled trial

OBJECTIVE

To evaluate uptake, risk factor detection and management from the National Health Service (NHS) Health Check (HC).

DESIGN

This is a quasi-randomised controlled trial where participants were allocated to five cohorts based on birth year. Four cohorts were invited for an NHS HC between April 2011 and March 2015.

SETTING

151 general practices in Hampshire, England, UK.

PARTICIPANTS

366 005 participants born 1 April 1940-31 March 1976 eligible for an NHS HC.

INTERVENTION

NHS HC invitation.

MAIN OUTCOME MEASURES

HC attendance and absolute percentage changes and ORs of (1) detecting cardiovascular disease (CVD) 10-year risk >10% and >20%, smokers, and total cholesterol (TC) >5.5 mmol/L and >7.5 mmol/L; (2) diagnosing hypertension, type 2 diabetes mellitus, chronic kidney disease (CKD) and atrial fibrillation (AF); and (3) new interventions with statins, antihypertensives, antiglycaemics and nicotine replacement therapy (NRT).

RESULTS

HC attendance rose from 12% to 30% between 2011/2012 and 2014/2015 (p<0.001). HC invitation increased detection of CVD risk >10% (2.0%-3.6, p<0.001) and >20% (0.1%-0.6%, p<0.001-0.392), TC >5.5 mmol/L (4.1%-7.0%, p<0.001) and >7.5 mmol/L (0.3%-0.4% p<0.001), hypertension (0.3%-0.6%, p<0.001-0.003), and interventions with statins (0.2%-0.9%, p<0.001-0.017) and antihypertensives (0.1%-0.6%, p<0.001-0.205). There were no consistent differences in detection of smokers, NRT, or diabetes, AF or CKD. Multivariate analyses showed associations between HC invitation and detecting CVD risk >10% (OR 8.01, 95% CI 7.34 to 8.73) and >20% (5.86, 4.83 to 7.10), TC >5.5 mmol/L (3.72, 3.57 to 3.89) and >7.5 mmol/L (2.89, 2.46 to 3.38), and diagnoses of hypertension (1.33, 1.20 to 1.47) and diabetes (1.34, 1.12 to 1.61). OR of CVD risk >10% plus statin and >20% plus statin, respectively, was 2.90 (2.36 to 3.57) and 2.60 (1.92 to 3.52), and for hypertension plus antihypertensive was 1.33 (1.18 to 1.50). There were no associations with AF, CKD, antiglycaemics or NRT. Detection of several risk factors varied inversely by deprivation.

CONCLUSIONS

HC invitation increased detection of cardiovascular risk factors, but corresponding increases in evidence-based interventions were modest.

The effectiveness of general practice-based health checks on health behaviour and incidence on non-communicable diseases in individuals with low socioeconomic position: a randomised controlled trial in Denmark

BACKGROUND

The effectiveness of health checks aimed at the general population is disputable. However, it is not clear whether health checks aimed at certain groups at high risk may reduce adverse health behaviour and identify persons with metabolic risk factors and non-communicable diseases (NCDs).

OBJECTIVES

To assess the effect of general practice-based health checks on health behaviour and incidence on NCDs in individuals with low socioeconomic position.

METHODS

Individuals with no formal education beyond lower secondary school and aged 45-64 years were randomly assigned to the intervention group of a preventive health check or to control group of usual care in a 1:1 allocation. Randomisation was stratified by gender and 5-year age group. Due to the real-life setting, blinding of participants was only possible in the control group. Effects were analysed as intention to treat (ITT) and per protocol. The trial was undertaken in 32 general practice units in Copenhagen, Denmark.

INTERVENTION

Invitation to a prescheduled preventive health check from the general practitioner (GP) followed by a health consultation and an offer of follow-up with health risk behaviour change or preventive medical treatment, if necessary.

PRIMARY OUTCOME MEASURES

Smoking status at 12-month follow-up. Secondary outcomes included status in other health behaviours such as alcohol consumption, physical activity and body mass index (measured by self-administered questionnaire), as well as incidence of metabolic risk factors and NCDs such as hypertension, hypercholesterolaemia, chronic obstructive pulmonary disease, diabetes mellitus, hypothyroidism, hyperthyroidism and depression (drawn from national healthcare registries).

RESULTS

1104 participants were included in the study. For the primary outcome, 710 participants were included in the per protocol analysis, excluding individuals who did not attend the health check, and 1104 participants were included in the ITT analysis. At 12-month follow-up, 37% were daily smokers in the intervention group and 37% in the control group (ORs=0.99, 95% CI: 0.76 to 1.30). No difference in health behaviour nor in the incidence of metabolic risk factors and NCDs between the intervention and control group were found. Side effects were comparable across the two groups.

CONCLUSION

The lack of effectiveness may be due to low intensity of intervention, a high prevalence of metabolic risk factors and NCDs among the participants at baseline as well as a high number of contacts with the GPs in general or to the fact that general practices are not an effective setting for prevention.

TRIAL REGISTRATION NUMBER

NCT01979107.

What should selective cardiometabolic prevention programmes in European primary care look like? A consensus-based design by the SPIMEU group

Background: Selective prevention of cardiometabolic diseases (CMD)—that is, preventive measures specifically targeting the high-risk population—may represent the most effective approach for mitigating rising CMD rates.

Objectives: To develop a universal concept of selective CMD prevention that can guide implementation within European primary care.

Methods: Initially, 32 statements covering different aspects of selective CMD prevention programmes were identified based on a synthesis of evidence from two systematic literature reviews and surveys conducted within the SPIMEU project. The Rand/UCLA appropriateness method (RAM) was used to find consensus on these statements among an international panel consisting of 14 experts. Before the consensus meeting, statements were rated by the experts in a first round. In the next step, during a face-to-face meeting, experts were provided with the results of the first rating and were then invited to discuss and rescore the statements in a second round.

Results: In the outcome of the RAM procedure, 28 of 31 statements were considered appropriate and three were rated uncertain. The panel deleted one statement. Selective CMD prevention was considered an effective approach for preventing CMD and a proactive approach was regarded as more effective compared to case-finding alone. The most efficient method to implement selective CMD prevention systematically in primary care relies on a stepwise approach: initial risk assessment followed by interventions if indicated.

Conclusion: The final set of statements represents the key characteristics of selective CMD prevention and can serve as a guide for implementing selective prevention actions in European primary care.

Is Master Health Checkup the Answer to Tackle the Rising Non-Communicable Disease Burden in India? - A Cross-Sectional Study

Background

Master Health Checkup (MHC) is a battery of tests done to detect and identify Non Communicable Diseases (NCDs) early. But it should also be noted that some tests in MHC have no known benefits for otherwise healthy adults. This study was conducted to evaluate the usefulness of MHC in a hospital based setting.

Methods

A cross-sectional study was conducted among 337 subjects aged 18 years and above who attended the MHC Clinic during the study period. They were subjected to interview and various biochemical investigations to estimate the number of newly diagnosed, clinically relevant abnormalities among apparently normal adults using standard guidelines. Categorical data summarized as frequencies with percentages. Chi-square test was used to compare proportions.

Results

Among the 337 participants, 244 were apparently normal with a gender distribution as 109 (44.7%) males and 135 (55.3%) females. The study was able to newly detect 12.3% with Type 2 diabetes, 37.7% in pre-diabetic stage, 54.1% with anaemia, 42.2% with dyslipidemia, 11.5% with hypothyroidism, 27% with liver disorders and 6.5% with renal disorders, about which the participants were unaware of. Females also had statistically significant association with dyslipidaemia and hypothyroidism compared to males with a p-value of 0.004, 0.026 respectively. Apparently normal participants aged > 35 years had strong statistical association with diabetic status and dyslipidemia compared to those aged between 18 – 35 years (p-value 0.001).

Conclusion

Based on the results from the study it is evident that a significant number of NCDs were newly identified by Master Health checkup (MHC).

Selective prevention of cardiometabolic diseases: activities and attitudes of general practitioners across Europe

Background

Cardiometabolic diseases (CMDs) are the number one cause of death. Selective prevention of CMDs by general practitioners (GPs) could help reduce the burden of CMDs. This measure would entail the identification of individuals at high risk of CMDs—but currently asymptomatic—followed by interventions to reduce their risk. No data were available on the attitude and the extent to which European GPs have incorporated selective CMD prevention into daily practice.

Methods

A survey among 575 GPs from the Czech Republic, Denmark, Greece, the Netherlands and Sweden was conducted between September 2016 and January 2017, within the framework of the SPIMEU-project.

Results

On average, 71% of GPs invited their patients to attend for CMD risk assessment. Some used an active approach (47%) while others used an opportunistic approach (53%), but these values differed between countries. Most GPs considered selective CMD prevention as useful (82%) and saw it as part of their normal duties (84%). GPs who did find selective prevention useful were more likely to actively invite individuals compared with their counterparts who did not find prevention useful. Most GPs had a disease management programme for individuals with risk factor(s) for cardiovascular disease (71%) or diabetes (86%).

Conclusions

Although most GPs considered selective CMD prevention as useful, it was not universally implemented. The biggest challenge was the process of inviting individuals for risk assessment. It is important to tailor the implementation of selective CMD prevention in primary care to the national context, involving stakeholders at different levels.

Self-rated health, lifestyle habits and risk assessment in 75-year-old persons attending preventive clinic visits with a nurse in primary health care: a cross-sectional study

AIM

To describe self-rated health in relation to lifestyle and illnesses and to identify risk factors for ill health such as pressure ulcers, falls and malnutrition among 75-year-old participants in a new clinical routine involving health assessment followed by tailored one-to-one health promotion at preventive clinic visits to a nurse at primary health care centres (PHCC).

BACKGROUND

There is a rapidly growing ageing population worldwide. It is central to health policy to promote active and healthy ageing. Preventive clinic visits to a nurse in primary health care were introduced as a new clinical intervention in a region in Sweden to improve the quality of health for the older adults.

DESIGN

A quantitative cross-sectional population-based study.

METHODS

The sample consisted of 306 individuals in six primary health care centres in Sweden aged 75 years who attended preventive clinic visits to a nurse. Data were collected from March 2014 to May 2015 during structured conversations with a nurse based on self-administered questionnaires, clinical examinations, risk assessments and after the clinic visit existing register data were collected by the researcher.

FINDINGS

Participants experienced good self-rated health despite being overweight and having chronic illnesses. Daily exercise such as walking and housework was more common than aerobic physical training. The majority had no problems with mobility but reported anxiety, pain and discomfort and had increased risk of falls.

CONCLUSION

It is important to encourage the older adults to live actively and independently for as long as possible. The healthy older adults may benefit from the clinical intervention described here to support the individual's ability to maintain control over their health. Such supportive assessments might help the healthy older adult to achieve active ageing, reducing morbidity and preventing functional decline.

Screening for reducing morbidity and mortality in malignant melanoma

BACKGROUND

Screening for malignant melanoma has the potential to reduce morbidity and mortality from the disease through earlier detection, as prognosis is closely associated with the thickness of the lesion at the time of diagnosis. However, there are also potential harms from screening people without skin lesion concerns, such as overdiagnosis of lesions that would never have caused symptoms if they had remained undetected. Overdiagnosis results in harm through unnecessary treatment and the psychosocial consequences of being labelled with a cancer diagnosis. For any type of screening, the benefits must outweigh the harms. Screening for malignant melanoma is currently practised in many countries, and the incidence of the disease is rising sharply, while mortality remains largely unchanged.

OBJECTIVES

To assess the effects on morbidity and mortality of screening for malignant melanoma in the general population.

SEARCH METHODS

We searched the following databases up to May 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registries, checked the reference lists of included and other relevant studies for further references to randomised controlled trials (RCTs), used citation tracking (Web of Science) for key articles, and asked trialists about additional studies and study reports.

SELECTION CRITERIA

RCTs, including cluster-randomised trials, of screening for malignant melanoma compared with no screening, regardless of screening modality or setting, in any type of population and in any age group where people were not suspected of having malignant melanoma. We excluded studies in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome) and studies performed exclusively in people with previous melanomas.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcomes of this review were total mortality, overdiagnosis of malignant melanoma, and quality of life/psychosocial consequences.

MAIN RESULTS

We included two studies with 64,391 participants. The first study was a randomised trial of an intervention developed to increase the rate of performance of thorough skin self-examination. The intervention group received instructional materials, including cues and aids, a 14-minute instruction video, and a brief counselling session, and at three weeks a brief follow-up telephone call from a health educator, aimed at increasing performance of thorough skin self-examination. The control group received a diet intervention with similar follow-up. The trial included 1356 people, who were recruited from 11 primary care practices in the US between 2000 and 2001. Participant mean age was 53.2 years and 41.7% were men. This study did not report on any of our primary outcomes or the following secondary outcomes: mortality specific to malignant melanoma, false-positive rates (skin biopsies/excisions with benign outcome), or false-negative rates (malignant melanomas diagnosed between screening rounds and up to one year after the last round). All participants were asked to complete follow-up telephone interviews at 2, 6, and 12 months after randomisation.The second study was a pilot study for a cluster-RCT of population-based screening for malignant melanoma in Australia. This pilot trial included 63,035 adults aged over 30 years. The three-year programme involved community education, an education and support component for medical practitioners, and the provision of free skin screening services. The mean age of people attending the skin screening clinics (which were held by primary care physicians in workplaces, community venues, and local hospitals, and included day and evening sessions) was 46.5 years, and 51.5% were men. The study included whole communities, targeting participants over 30 years of age, but information on age and gender of the whole study population was not reported. Study duration was three years (1998 to 2001), and outcomes were measured at the screening clinics during these three years. There was no further follow-up for any outcomes. The control group received no programme. The ensuing, planned cluster randomised trial in 560,000 adults was never carried out due to lack of funding. At the time of this review, there are no published or unpublished data on our prespecified outcomes available, and no results for mortality outcomes from the pilot study are to be expected.The risk of bias in these studies was high for performance bias (blinding study personnel and participants) and high or unclear for detection bias (blinding of outcome assessment). Risk of bias in the other domains was either unclear or low. We were unable to assess the certainty of the evidence for our primary outcomes as planned due to lack of data.

AUTHORS' CONCLUSIONS

Adult general population screening for malignant melanoma is not supported or refuted by current evidence from RCTs. It therefore does not fulfil accepted criteria for implementation of population screening programmes. This review did not investigate the effects of screening people with a history of malignant melanoma or in people with a genetic disposition for malignant melanoma (e.g. familial atypical mole and melanoma syndrome). To determine the benefits and harms of screening for malignant melanoma, a rigorously conducted randomised trial is needed, which assesses overall mortality, overdiagnosis, psychosocial consequences, and resource use.

Periodic health visits by primary care practice model, a population-based study using health administrative data

Background

The general health check, which includes the periodic health visit and annual physical exam, is not recommended to maintain the health of asymptomatic adults with no risk factors. Different funding mechanisms for primary care may be associated with the provision of service delivery according to recommended guidelines. We sought to determine how use of the periodic health visit for healthy individuals without comorbidities, despite evidence against its use, differed by primary care model.

Methods

Population-based cross-sectional study using linked health and administrative datasets in Ontario, Canada, where most residents are insured for physician services through Ontario’s single payer, provincially funded Ontario Health Insurance Plan. Participants included all living adults (> 19 years) in Ontario on January 1st, 2014, eligible for the Ontario Health Insurance Plan. Primary care enrollment model was the main exposure and included traditional fee-for-service, enhanced fee-for-service, capitation, team-based care, other (including salaried), and unenrolled. The main outcome measure was receipt of a periodic health visit during 2014. Age-sex standardized rates of periodic health visits performed during the one-year study period were analyzed by number of comorbid conditions.

Results

Of 10,712,804 adults in Ontario, 2,350,386 (21.9%) had a periodic health visit in 2014. The age-sex standardized rate was 6.1% (95% confidence interval [CI] 6.0, 6.1%) for healthy individuals. In the traditional fee-for-service model, the periodic health visit was performed for 55.3% (95% CI 54.4, 56.3%) of healthy individuals versus 10.2% (95% CI 10.0, 10.3%) in team-based care. Periodic health visit rates varied by primary care provider models. Traditional and enhanced fee-for-service models had higher rates across all comorbidity groups.

Conclusions

Patients whose primary care physicians are funded exclusively through fee-for-service had the highest rates of periodic health visits in healthy individuals. Primary care reform initiatives must consider the influence of remuneration on providing evidence-based primary care.

Screening for periodontal diseases by non-dental health professionals: a protocol for a systematic review and overview of reviews

BACKGROUND

Periodontal diseases are responsible for a vast burden of disease globally and are associated with other severe illnesses such as cardiovascular diseases or diabetes. Tests for early diagnosis of periodontal diseases and effective treatments are available. The effectiveness of screening for periodontal diseases to detect periodontal diseases at an early stage during periodic health examinations at primary care facilities, however, is unclear. The objective of this systematic review is to assess the benefits and risks of screening for periodontal diseases in adults during the periodic health examinations.

METHODS

We will use two methodological approaches: (1) a systematic review to assess the effectiveness and risk of harms of screening for periodontal diseases during periodic health examinations and (2) an overview of systematic reviews to determine the effectiveness of treatment approaches for early periodontal disease. We will search electronic databases (Ovid MEDLINE, Embase.com , the Cochrane Library, Epistemonikos, Centre for Reviews and Dissemination databases, PubMed (non-MEDLINE content)) for published studies as well as sources for grey literature to detect unpublished studies. Two authors will independently screen abstracts and full texts using pre-defined eligibility criteria, select studies, extract data, and assess the risk of bias of included studies or reviews. In general, we will conduct a systematic narrative synthesis. Criteria for conducting meta-analyses were defined a priori. Our primary outcomes of interest are tooth loss, loosening of teeth, and depletion of bone tissue. Secondary outcomes are gingivitis/gum inflammation, pocket depths, dental hygiene, lifestyle modifications (e.g., smoking, alcohol, nutrition), and toothache. We consulted a panel of experts and patient representatives to prioritize these outcomes. Two investigators will assess independently the certainty of the evidence for each outcome using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

DISCUSSION

We anticipate that our review will highlight the gaps in the available evidence about the effectiveness of screening for periodontal diseases during periodic health examinations. Implications for screening programs may be based on linked evidence about the validity of available screening tools and the effectiveness of early treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017081150.

Do cardiovascular disease prevention programs in northern Sweden impact on population health? An interrupted time series analysis

BACKGROUND

Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013.

METHODS

An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers.

RESULTS

Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27 years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences.

CONCLUSIONS

Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. They aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used individual screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is therefore important to assess whether general health checks do more good than harm. This is the first update of the review published in 2012.

OBJECTIVES

To quantify the benefits and harms of general health checks.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers on 31 January 2018. Two review authors independently screened titles and abstracts, assessed papers for eligibility and read reference lists. One review author used citation tracking (Web of Knowledge) and asked trial authors about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the trials. We contacted trial authors for additional outcomes or trial details when necessary. When possible, we analysed the results with a random-effects model meta-analysis; otherwise, we did a narrative synthesis.

MAIN RESULTS

We included 17 trials, 15 of which reported outcome data (251,891 participants). Risk of bias was generally low for our primary outcomes. Health checks have little or no effect on total mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.97 to 1.03; 11 trials; 233,298 participants and 21,535 deaths; high-certainty evidence, I² = 0%), or cancer mortality (RR 1.01, 95% CI 0.92 to 1.12; 8 trials; 139,290 participants and 3663 deaths; high-certainty evidence, I² = 33%), and probably have little or no effect on cardiovascular mortality (RR 1.05, 95% CI 0.94 to 1.16; 9 trials; 170,227 participants and 6237 deaths; moderate-certainty evidence; I² = 65%). Health checks have little or no effect on fatal and non-fatal ischaemic heart disease (RR 0.98, 95% CI 0.94 to 1.03; 4 trials; 164,881 persons, 10,325 events; high-certainty evidence; I² = 11%), and probably have little or no effect on fatal and non-fatal stroke (RR 1.05 95% CI 0.95 to 1.17; 3 trials; 107,421 persons, 4543 events; moderate-certainty evidence, I² = 53%).

AUTHORS' CONCLUSIONS

General health checks are unlikely to be beneficial.

Participants' expectations and experiences with periodic health examinations in Austria - a qualitative study

Background

The engagement of citizens in the development of evidence-based screening programs is internationally supported. The aim of our research was to explore the motivations and reasons of adult citizens in Austria for attending periodic health examinations (PHE) as well as their satisfaction with the way PHE are organized.

Methods

We conducted three focus groups with a random sample of previous attenders of PHE. Participants were stratified by age, gender, and education. The discussions were recorded, transcribed, and analyzed using a thematic analysis approach.

Results

Main motivations of attenders (n = 30) were to detect diseases early, to prevent suffering, and to live a long, healthy life. They believed that PHE work as an incentive of health behavior change. As possible reasons not to attend PHE, participants mentioned lack of awareness, time constraints, unpleasant prior experiences, and fear of harm or negative consequences. They wanted the range of examinations to be selected based on individual risks and to be more comprehensive. Some participants expressed frustration with the lack of time doctors dedicated to the examination or discussion of the results. Throughout the discussion, participants realized there is a great diversity among doctors in the quality of health examinations and how content is delivered.

Conclusion

The study showed that attenders of PHE have high expectations concerning the beneficial outcomes of PHE. They requested a comprehensive and individualized program that does not reflect the scientific evidence from effectiveness studies of PHE. These findings indicate serious shortcomings in the communication of benefits and harms of screening interventions and highlight the need for a more proactive communication about aims and content of the program.

Haemoglobin A1c and hearing impairment: longitudinal analysis using a large occupational health check-up data of Japan

OBJECTIVES

The aim of this study was to determine whether haemoglobin A1c (HbA1c) level is associated with the incidence of hearing impairment accounting for smoking status and diabetic condition at baseline.

METHODS

Participants were 131 689 men and 71 286 women aged 30-65 years and free of hearing impairment at baseline (2008) who attended Japanese occupational annual health check-ups from 2008 to 2015. We defined low-frequency hearing impairment at a hearing threshold >30 dB at 1 kHz and high frequency at >40 dB at 4 kHz in the better ear in pure-tone audiometric tests. HbA1c was categorised into seven categories. The association between HbA1c and hearing impairment was assessed using the Cox proportional hazards model.

RESULTS

On 5 years mean follow-up, high HbA1c was associated with high-frequency hearing impairment. In non-smokers, HbA1c≥8.0% was associated with high-frequency hearing impairment, with a multivariable HR (95% CI) compared with HbA1c 5.0%-5.4% of 1.46 (1.10 to 1.94) in men and 2.15 (1.13 to 4.10) in women. There was no significant association between HbA1c and hearing impairment in smokers. A J-shaped association between HbA1c and high-frequency hearing impairment was observed for participants with diabetes at baseline. HbA1c was not associated with low-frequency hearing impairment among any participants.

CONCLUSIONS

HbA1c ≥8.0% of non-smokers and ≥7.3% of participants with diabetes was associated with high-frequency hearing impairment. These findings indicate that appropriate glycaemic control may prevent diabetic-related hearing impairment.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: A systematic review

Background

Health checks for cardiometabolic diseases could play a role in the identification of persons at high risk for disease. To improve the uptake of these health checks in primary care, we need to know what barriers and facilitators determine participation.

Methods

We used an iterative search strategy consisting of three steps: (a) identification of key-articles; (b) systematic literature search in PubMed, Medline and Embase based on keywords; (c) screening of titles and abstracts and subsequently full-text screening. We summarised the results into four categories: characteristics, attitudes, practical reasons and healthcare provider-related factors.

Results

Thirty-nine studies were included. Attitudes such as wanting to know of cardiometabolic disease risk, feeling responsible for, and concerns about one’s own health were facilitators for participation. Younger age, smoking, low education and attitudes such as not wanting to be, or being, worried about the outcome, low perceived severity or susceptibility, and negative attitude towards health checks or prevention in general were barriers. Furthermore, practical issues such as information and the ease of access to appointments could influence participation.

Conclusion

Barriers and facilitators to participation in health checks for cardiometabolic diseases were heterogeneous. Hence, it is not possible to develop a ‘one size fits all’ approach to maximise the uptake. For optimal implementation we suggest a multifactorial approach adapted to the national context with special attention to people who might be more difficult to reach. Increasing the uptake of health checks could contribute to identifying the people at risk to be able to start preventive interventions.

Cardiovascular risk at health checks performed opportunistically or following an invitation letter. Cohort study

Background

A population-based programme of health checks has been established in England. Participants receive postal invitations through a population-based call–recall system but health check providers may also offer health checks opportunistically. We compared cardiovascular risk scores for ‘invited’ and ‘opportunistic’ health checks.

Methods

Cohort study of all health checks completed at 18 general practices from July 2013 to June 2015. For each general practice, cardiovascular (CVD) risk scores were compared by source of check and pooled using meta-analysis. Effect estimates were compared by gender, age-group, ethnicity and fifths of deprivation.

Results

There were 6184 health checks recorded (2280 invited and 3904 opportunistic) with CVD risk scores recorded for 5359 (87%) participants. There were 17.0% of invited checks and 22.2% of opportunistic health checks with CVD risk score ≥10%; a relative increment of 28% (95% confidence interval: 14–44%, P < 0.001). In the most deprived quintile, 15.3% of invited checks and 22.4% of opportunistic checks were associated with elevated CVD risk (adjusted odds ratio: 1.94, 1.37–2.74, P  < 0.001).

Conclusions

Respondents at health checks performed opportunistically are at higher risk of cardiovascular disease than those participating in response to a standard invitation letter, potentially reducing the effect of uptake inequalities.

Analytical typology of multiprofessional primary care models

Background

There is only limited evidence to support care redefinition and role optimization processes needed for scaling up of a stronger primary care capacity.

Methods

Data collection was based on a keyword search in MEDLINE, EMBASE and CINAHL databases. Three thousand, two hundred and twenty-nine documents were identified, 1851 met our inclusion criteria, 71 were retained for full-text assessment and 52 included in the final selection. The analysis process was done in four steps. In the end, the elements that were identified as particularly central to the process of transforming primary care provision were used as the basis of two typologies.

Results

The first typology is based on two structural dimensions that characterize promising multiprofessional primary care teams. The first is the degree to which the division of tasks in the team was formalized. The second dimension is the centrality and autonomy of nurses in the care model. The second typology offers a refined definition of comprehensiveness of care and its relationship with the optimization of professional roles.

Conclusions

The literature we analyzed suggests there are several plausible avenues for coherently articulating the relationships between patients, professionals, and care pathways. The expertise, preferences, and numbers of available human resources will determine the plausibility that a model will be a coherent response that is appropriate to the needs and environmental constraints (funding models, insurance, etc.). The typologies developed can help assess existing care models analytically or evaluatively and to propose, prospectively, some optimal operational parameters for primary care provision.

Levels of detection of hypertension in primary medical care and interventions to improve detection: a systematic review of the evidence since 2000

OBJECTIVES

In England, many hypertensives are not detected by primary medical care. Higher detection is associated with lower premature mortality. We aimed to summarise recent evidence on detection and interventions to improve detection in order to inform policies to improve care.

DESIGN

Data sources: systematic review of articles published since 2000. Searches of Medline and Embase were undertaken. Eligibility criteria: published in English, any study design, the setting was general practice and studies included patients aged 18 or over.

EXCLUSION CRITERIA

screening schemes, studies in primary care settings other than general practice, discussion or comment pieces.

PARTICIPANTS

adult patients of primary medical care services.

SYNTHESIS

study heterogeneity precluded a statistical synthesis, and papers were described in summary tables.

RESULTS

Seventeen quantitative and one qualitative studies were included. Detection rates varied by gender and ethnic group, but longitudinal studies indicated an improvement in detection over time. Patient socioeconomic factors did not influence detection, but living alone was associated with lower detection. Few health system factors were associated with detection, but in two studies higher numbers of general practitioners per 1000 population were associated with higher detection. Three studies investigated interventions to improve detection, but none showed evidence of effectiveness.

LIMITATIONS

The search was limited to studies published from 2000, in English. There were few studies of interventions to improve detection, and a meta-analysis was not possible.

CONCLUSIONS AND IMPLICATIONS

Levels of detection of hypertension by general practices may be improving, but large numbers of people with hypertension remain undetected. Improvement in detection is therefore required, but guidance for primary medical care is not provided by the few studies of interventions included in this review. Primary care teams should continue to use low-cost, practical approaches to detecting hypertension until evidence from new studies of interventions to improve detection is available.

Frequency and Determinants of Inappropriate Use of Treadmill Stress Test for Coronary Artery Disease

Background In developing countries like Pakistan, treatment is mediated by private and public healthcare setups with a limited budget for health facilities. Moreover, the inappropriate use of treadmill tests imposes a burden on healthcare resources and leads to unwarranted interventions. Our aim is to assess the prevalence and predictors of inappropriate referrals for the exercise tolerance test (ETT) to diagnose coronary artery disease (CAD) while taking public and private healthcare settings into consideration. Methods A cross-sectional study was conducted to find the prevalence of the inappropriate use of ETT to diagnose obstructive CAD and to determine the factors responsible for it. A total of 264 patients were enrolled from outpatient departments in Karachi. The inclusion criterion was the referral of treadmill testing for the diagnosis of CAT. The analysis was performed by logistic regression models to ascertain independent predictors of inappropriate use. Results Exercise stress tests were found to be inappropriate in 209 (79%) patients. The study indicated that the majority of patients had a low or very low pre-test probability of CAD. Diabetes, hypertension, and dyslipidemia were less frequent in the inappropriate as compared to the appropriate referrals (10%, 45%, and 16% versus 20%, 69%, and 32%). Both public and private sectors showed a high prevalence of inappropriate testing, but it was much higher in the latter (27% versus 73%, P < 0.001). In all regression models, the private healthcare system was the major independent predictor for inappropriate indications of ETT with an average odds ratio of 4.9 (P < 0.001). Conclusion The high prevalence of ETT referrals was found for the diagnosis of CAD. This result was consistent with both public and private healthcare systems, but it was considerably higher in private setups. Comorbidities, number of risk factors, and cardiovascular risk were not associated with the inappropriate use of ETT.

Primary care provider approaches to preventive health delivery: a qualitative study

AimThe objective of this study was to seek decision-making insights on the provider level to gain understanding of the values that shape how providers deliver preventive health in the primary care setting.

BACKGROUND

The primary care clinic is a core site for preventive health delivery. While many studies have identified barriers to preventive health, less is known regarding how primary care providers (PCPs) make preventive health decisions such as what services to provide, under what circumstances, and why they might choose one over another.

METHODS

Qualitative methods were chosen to deeply explore these issues. We conducted semi-structured, one-on-one interviews with 21 PCPs at clinics affiliated with an academic medical center. Interviews with providers were recorded and transcribed. We conducted a qualitative analysis to identify themes and develop a theoretical framework using Grounded Theory methods.FindingsThe following themes were revealed: longitudinal care with an established PCP-patient relationship is perceived as integral to preventive health; conflict and doubt accompany non-preventive visits; PCPs defer preventive health for pragmatic reasons; when preventive health is addressed, providers use multiple contextual factors to decide which interventions are discussed; and PCPs desired team-based preventive health delivery, but wish to maintain their role when shared decision-making is required. We present a conceptual framework called Pragmatic Deferral.

A Study of Anti-Fat Bias among Danish General Practitioners and Whether This Bias and General Practitioners' Lifestyle Can Affect Treatment of Tension Headache in Patients with Obesity

OBJECTIVES

The study investigated whether treatment options for episodic tension-type headache vary among general practitioners (GPs) in Denmark depending on the patients' weight status and gender, and whether these decisions can be explained by the GPs' own anti-fat bias and lifestyle.

METHODS

A cross-sectional questionnaire study with responses from 240 GPs on measures of anti-fat bias, healthiness of GPs' lifestyles, and reported patient treatment decisions.

RESULTS

GPs tended to exhibit negative explicit and implicit anti-fat bias. There were no differences in choice of medical treatment for patients with obesity and those of a normal weight. GPs were more likely to advise a general health check to a patient with obesity (p < 0.001). GPs treating a male patient with obesity were less likely to believe that their patient would comply with the advised treatment compared to those with a male patient of normal weight. Compared with other patient types (4.4-7.7%), GPs who treated a male patient with obesity (27.9%) were more likely to advise a general health check only and no diary-keeping or follow-up consultation (p < 0.001). This was explained by the healthiness of the GPs' lifestyles (Spearman's ρ = 0.367; p < 0.01).

CONCLUSION

Despite the presence of clear anti-fat bias, there were no differences in medical treatment, and GPs managed the general health of patients with obesity proactively. The fact that the GPs' own lifestyle influenced the likelihood that they would recommend diary-keeping and follow-up consultations for male patients with obesity is remarkable and requires further investigation.

Effect of population screening for type 2 diabetes and cardiovascular risk factors on mortality rate and cardiovascular events: a controlled trial among 1,912,392 Danish adults

AIMS/HYPOTHESIS

Health check programmes for chronic disease have been introduced in a number of countries. However, there are few trials assessing the benefits and harms of these screening programmes at the population level. In a post hoc analysis, we evaluated the effect of population-based screening for type 2 diabetes and cardiovascular risk factors on mortality rates and cardiovascular events.

METHODS

This register-based, non-randomised, controlled trial included men and women aged 40-69 years without known diabetes who were registered with a general practice in Denmark (n = 1,912,392). Between 2001 and 2006, 153,107 individuals registered with 181 practices participating in the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION)-Denmark study were sent a diabetes risk score questionnaire. Individuals at moderate-to-high risk were invited to visit their GP for assessment of diabetes status and cardiovascular risk (screening group). The 1,759,285 individuals registered with all other general practices in Denmark constituted the retrospectively constructed no-screening (control) group. Outcomes were mortality rate and cardiovascular events (cardiovascular disease death, non-fatal ischaemic heart disease or stroke). The analysis was performed according to the intention-to-screen principle.

RESULTS

Among the screening group, 27,177 (18%) individuals attended for assessment of diabetes status and cardiovascular risk. Of these, 1,533 were diagnosed with diabetes. During a median follow-up of 9.5 years, there were 11,826 deaths in the screening group and 141,719 in the no-screening group (HR 0.99 [95% CI 0.96, 1.02], p = 0.66). There were 17,941 cardiovascular events in the screening group and 208,476 in the no-screening group (HR 0.99 [0.96, 1.02], p = 0.49).

CONCLUSIONS/INTERPRETATION

A population-based stepwise screening programme for type 2 diabetes and cardiovascular risk factors among all middle-aged adults in Denmark was not associated with a reduction in rate of mortality or cardiovascular events between 2001 and 2012.

Predictors of all-cause mortality among 514,866 participants from the Korean National Health Screening Cohort

Background

There is not enough evidence regarding how information obtained from general health check-ups can predict individual mortality based on long-term follow-ups and large sample sizes. This study evaluated the applicability of various health information and measurements, consisting of self-reported data, anthropometric measurements and laboratory test results, in predicting individual mortality.

Methods

The National Health Screening Cohort included 514,866 participants (aged 40–79 years) who were randomly selected from the overall database of the national health screening program in 2002–2003. Death was determined from causes of death statistics provided by Statistics Korea. We assessed variables that were collected at baseline and repeatedly measured for two consecutive years using traditional and time-variant Cox proportional hazards models in addition to random forest and boosting algorithms to identify predictors of 10-year all-cause mortality. Participants’ age at enrollment, lifestyle factors, anthropometric measurements and laboratory test results were included in the prediction models. We used c-statistics to assess the discriminatory ability of the models, their external validity and the ratio of expected to observed numbers to evaluate model calibration. Eligibility of Medicaid and household income levels were used as inequality indexes.

Results

After the follow-up by 2013, 38,031 deaths were identified. The risk score based on the selected health information and measurements achieved a higher discriminatory ability for mortality prediction (c-statistics = 0.832, 0.841, 0.893, and 0.712 for Cox model, time-variant Cox model, random forest and boosting, respectively) than that of the previous studies. The results were externally validated using the community-based cohort data (c-statistics = 0.814).

Conclusions

Individuals’ health information and measurements based on health screening can provide early indicators of their 10-year death risk, which can be useful for health monitoring and related policy decisions.

Development of a questionnaire to evaluate patients' awareness of cardiovascular disease risk in England's National Health Service Health Check preventive cardiovascular programme

BACKGROUND

The National Health Service (NHS) Health Check is a cardiovascular disease (CVD) risk assessment and management programme in England aiming to increase CVD risk awareness among people at increased risk of CVD. There is no tool to assess the effectiveness of the programme in communicating CVD risk to patients.

AIMS

The aim of this paper was to develop a questionnaire examining patients' CVD risk awareness for use in health service research evaluations of the NHS Health Check programme.

METHODS

We developed an 85-item questionnaire to determine patients' views of their risk of CVD. The questionnaire was based on a review of the relevant literature. After review by an expert panel and focus group discussion, 22 items were dropped and 2 new items were added. The resulting 65-item questionnaire with satisfactory content validity (content validity indices≥0.80) and face validity was tested on 110 NHS Health Check attendees in primary care in a cross-sectional study between 21 May 2014 and 28 July 2014.

RESULTS

Following analyses of data, we reduced the questionnaire from 65 to 26 items. The 26-item questionnaire constitutes four scales: Knowledge of CVD Risk and Prevention, Perceived Risk of Heart Attack/Stroke, Perceived Benefits and Intention to Change Behaviour and Healthy Eating Intentions. Perceived Risk (Cronbach's α=0.85) and Perceived Benefits and Intention to Change Behaviour (Cronbach's α=0.82) have satisfactory reliability (Cronbach's α≥0.70). Healthy Eating Intentions (Cronbach's α=0.56) is below minimum threshold for reliability but acceptable for a three-item scale.

CONCLUSIONS

The resulting questionnaire, with satisfactory reliability and validity, may be used in assessing patients' awareness of CVD risk among NHS Health Check attendees.

Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study

Background

Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.

Methods

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively.

Results

Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.

Conclusions

Community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

Preventive healthcare for young children: A systematic review of interventions in primary care

High rates of preventable health problems amongst children in economically developed countries have prompted governments to seek pathways for early intervention. We systematically reviewed the literature to discover what primary care-targeted interventions increased preventive healthcare (e.g. review child development, growth, vision screening, social-emotional health) for preschool children, excluding vaccinations. MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for published intervention studies, between years 2000 and 2014, which reflected preventive health activities for preschool children, delivered by health practitioners. Analysis included an assessment of study quality and the primary outcome measures employed. Of the 743 titles retrieved, 29 individual studies were selected, all originating from the United States. Twenty-four studies employed complex, multifaceted interventions and only two were rated high quality. Twelve studies addressed childhood overweight and 11 targeted general health and development. Most interventions reported outcomes that increased rates of screening, recording and recognition of health risks. Only six studies followed up children post-intervention, noting low referral rates by health practitioners and poor follow-through by parents and no study demonstrated clear health benefits for children. Preliminary evidence suggests that multi-component interventions, that combine training of health practitioners and office staff with modification of the physical environment and/or practice support, may be more effective than single component interventions. Quality Improvement interventions have been extensively replicated but their success may have relied on factors beyond the confines of individual or practice-led behaviour. This research reinforces the need for high quality studies of pediatric health assessments with the inclusion of clinical end-points.

Effect of general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial

We aimed to examine the effect of a large population-based multifactorial screening and lifestyle intervention programme on 10-year incidence of diabetes. In a randomised trial of the general Danish population initiated in 1999-2001 59,616 men and women aged 30-60years were assigned to a five year screening and lifestyle counselling programme (n=11,629) or control group (n=47,987) and followed for ten years in nationwide registers. Intention to treat was applied and risk of diabetes was modeled by Cox regression and expressed as hazard ratios (HRs). We found that 1692 individuals had diabetes at baseline. Among 57,924 individuals without diabetes at baseline, 1267 emigrated, 2593 died and 3369 (Intervention group=684, Control group=2685) developed diabetes. We saw no significant difference in diabetes incidence between the groups after 10-year follow-up (Grey's test: p=0.22). In the first year of follow-up, incidence of diabetes was significantly higher in the intervention group than the control group (HR=1.68, 95%CI 1.29 to 2.29). We observed no difference in incidence of diabetes between the groups in the follow-up intervals from 1 to 6years or after 6-10years (HR=0.94, 0.83 to 1.06; HR=1.03, 0.91 to 1.17). Inviting the general population to participate in a repeated screening and lifestyle counselling programme over five years did not result in lower incidence of diabetes after 10years of follow-up. As expected, significantly more individuals were diagnosed with diabetes in the intervention group during the first year, but this was not followed by a decrease in the following years.

TRIALS REGISTRATION

Clinical trials NCT00289237.

Scottish Keep Well health check programme: an interrupted time series analysis

BACKGROUND

Effective interventions are available to reduce cardiovascular risk. Recently, health check programmes have been implemented to target those at high risk of cardiovascular disease (CVD), but there is much debate whether these are likely to be effective at population level. This paper evaluates the impact of wave 1 of Keep Well, a Scottish health check programme, on cardiovascular outcomes.

METHODS

Interrupted time series analyses were employed, comparing trends in outcomes in participating and non-participating practices before and after the introduction of health checks. Health outcomes are defined as CVD mortality, incident hospitalisations and prescribing of cardiovascular drugs.

RESULTS

After accounting for secular trends and seasonal variation, coronary heart disease mortality and hospitalisations changed by 0.4% (95% CI -5.2% to 6.3%) and -1.1% (-3.4% to 1.3%) in Keep Well practices and by -0.3% (-2.7% to 2.2%) and -0.1% (-1.8% to 1.7%) in non-Keep Well practices, respectively, following the intervention. Adjusted changes in prescribing in Keep Well and non-Keep Well practices were 0.4% (-10.4% to 12.5%) and -1.5% (-9.4% to 7.2%) for statins; -2.5% (-12.3% to 8.4%) and -1.6% (-7.1% to 4.3%) for antihypertensive drugs; and -0.9% (-6.5% to 5.0%) and -2.4% (-10.1% to 6.0%) for antiplatelet drugs.

CONCLUSIONS

Any impact of the Keep Well health check intervention on CVD outcomes and prescribing in Scotland was very small. Findings do not support the use of the screening approach used by current health check programmes to address CVD. We used an interrupted time series method, but evaluation methods based on randomisation are feasible and preferable and would have allowed more reliable conclusions. These should be considered more often by policymakers at an early stage in programme design when there is uncertainty regarding programme effectiveness.

Targeted case finding in the prevention of cardiovascular disease: a stepped wedge cluster randomised controlled trial

BACKGROUND

Individuals at high risk of cardiovascular disease (CVD) are undertreated.

AIM

To evaluate the effectiveness of a programme of targeted, nurse-led case finding for CVD prevention in primary care.

DESIGN AND SETTING

Targeted case finding for CVD prevention was implemented in urban West Midlands general practices between February 2009 and August 2012, and evaluated as a stepped wedge cluster randomised trial.

METHOD

Untreated patients aged 35-74 years and at ≥20% 10-year CVD risk were identified, invited for assessment by a project nurse, and referred to their GP for treatment initiation. The primary outcome was the proportion of high-risk patients prescribed antihypertensives or statins after exposure to the intervention compared with an equivalent period of time prior to exposure. Secondary outcomes included assessment of CVD risk factors.

RESULTS

In 26 sequentially randomised general practices the exposed group consisted of 2926 untreated high-risk patients identified at the start of the intervention, with 2969 patients identified at the start of the unexposed period. The trial was well balanced in terms of age, sex, and cardiovascular risk factors. In the exposed period 19.7% of patients were prescribed antihypertensives or statins, and 10.8% of patients in the unexposed period. After adjustment for clustering and temporal effects the risk difference was 15.5% (95% CI = 3.9 to 27.1, P = 0.009). Assessment of lipid levels increased significantly, at 26.4% (99% CI = 5.3 to 47.5, P = 0.001) CONCLUSION: Targeted case finding programmes can increase the number of high-risk patients started on antihypertensive and statin treatment.

General practitioners' barriers and facilitators towards new provider-initiated HIV testing strategies: a qualitative study

European guidelines recommend offering an HIV test to individuals who display HIV indicator conditions (ICs). UK guidelines recommend performing a ‘routine offer of HIV testing’ in primary care where HIV prevalence exceeds 2 in 1000. Implementation of new provider-initiated HIV testing strategies in general practice is limited, while the numbers of undiagnosed and late for care HIV patients remain high. We have explored Dutch general practitioners’ barriers to and facilitators of both strategies. We combined semi-structured in-depth interviews with focus groups. Nine general practitioners – key informants of sexually transmitted infection/HIV prevention and control – were selected for the interviews. Additionally, we organised focus groups with a broad sample of general practitioners (n = 81). Framework analysis was used to analyse the data. Various barriers were found, related to (1) the content of the guidelines (testing the right group and competing priorities in general practice), (2) their organisational implementation (lack of time, unclear when to repeat the HIV test and overlong list of ICs) and (3) the patient population (creating fear among patients, stigmatising them and fear regarding financial costs). Multiple general practitioners stated that performing a sexual risk assessment of patients is important before applying either strategy. Also, they recommended implementing the IC-guided approach only in high-prevalence areas and combining HIV tests with other laboratory blood tests. General practitioners tend to cling to old patterns of risk-based testing. Promoting awareness of HIV testing and educating general practitioners about the benefits of new provider-initiated HIV testing strategies is important for the actual uptake of HIV testing.