Cardiovascular risk estimation by professionally active cardiovascular nurses: results from the Basel 2005 Nurses Cohort

A survey on critical health competences among diabetes educators using the Critical Health Competence Test (CHC Test)

BACKGROUND

Diabetes associations claim to have a patient-centered approach in diabetes care including shared decision-making (SDM). Diabetes educators are important healthcare professionals for implementing the concept of informed SDM in diabetes care. They need critical health competences (CHC) in order to provide evidence-based information and to support patients in understanding the risks of the disease and also the possible benefits or harm of the healthcare options. Therefore, we surveyed the CHC of diabetes educators.

METHODS

We performed a cross-sectional survey using the validated Critical Health Competences (CHC) Test to measure CHC of certified diabetes educators and trainees in Germany. Diabetes educators were approached via newsletter, mailing lists or in person during the conference of the German Diabetes Association. Trainees were approached during their training sessions. We applied scenario 1 of the CHC test, which comprises 17 items with open-ended and multiple-choice questions. Mean person parameters with a range from 0 to 1000 were calculated to assess the levels of critical health competences and a multiple linear regression analysis was conducted to determine correlations between sociodemographic variables and levels of CHC.

RESULTS

A total of 325 participants, mean age 38.6 (±11.1) years, completed the CHC test; n = 174 (55.5%) were certified diabetes educators and n = 151 (46.5%) were trainees. The participants achieved a mean score of 409.84 person parameters (±88.10) (scale from 0 to 1000). A statistically significant association was found only between the level of education and the level of CHC (b = 0.221; p-value 0.002). Participants with grammar school education achieved higher mean scores compared to participants with secondary school education (432.88 ± 77.72 vs. 396.45 ± 85.95; mean difference 36.42 ± 9.29; 95%CI 18.15 to 54.71; p < 0.0001).

CONCLUSION

Diabetes educators achieved low competence scores and it can be assumed that they do not have sufficient CHC to conduct consultations based on the SDM principles. Poor CHC among healthcare providers are a major barrier for the implementation of SDM. Core concepts of evidence-based medicine should be implemented into the curricula for diabetes educators in order to increase their levels of CHC.

Flash mob studies: a novel method to accelerate the research process

Because the time between study conception and dissemination of findings generally takes long, efforts to reduce this lag are important. A solution to accelerate the research process can be found in flash mob research. This is a method to study clinically relevant questions on a large scale in a very short course of time. The research question and the set-up of the study should be exciting. Doing so, it attracts a large 'mob' of people who collect the data. Consequently, the generalizability of flash mob studies may be higher than that of traditional research studies.

Informed shared decision-making programme for patients with type 2 diabetes in primary care: cluster randomised controlled trial

OBJECTIVE

To translate an informed shared decision-making programme (ISDM-P) for patients with type 2 diabetes from a specialised diabetes centre to the primary care setting.

DESIGN

Patient-blinded, two-arm multicentre, cluster randomised controlled trial of 6 months follow-up; concealed randomisation of practices after patient recruitment and acquisition of baseline data.

SETTING

22 general practices providing care according to the German Disease Management Programme (DMP) for type 2 diabetes.

PARTICIPANTS

279 of 363 eligible patients without myocardial infarction or stroke.

INTERVENTIONS

The ISDM-P comprises a patient decision aid, a corresponding group teaching session provided by medical assistants and a structured patient-physician encounter.Control group received standard DMP care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary endpoint was patient adherence to antihypertensive or statin drug therapy by comparing prescriptions and patient-reported uptake after 6 months. Secondary endpoints included informed choice, risk knowledge (score 0-11 from 11 questions) and prioritised treatment goals of patients and doctors.

RESULTS

ISDM-P: 11 practices with 151 patients; standard care: 11 practices with 128 patients; attrition rate: 3.9%. There was no difference between groups regarding the primary endpoint. Mean drug adherence rates were high for both groups (80% for antihypertensive and 91% for statin treatment). More ISDM-P patients made informed choices regarding statin intake, 34% vs 3%, OR 16.6 (95% CI 4.4 to 63.0), blood pressure control, 39% vs 3%, OR 22.2 (95% CI 5.3 to 93.3) and glycated haemoglobin, 43% vs 3%, OR 26.0 (95% CI 6.5 to 104.8). ISDM-P patients achieved higher levels of risk knowledge, with a mean score of 6.96 vs 2.86, difference 4.06 (95% CI 2.96 to 5.17). In the ISDM-P group, agreement on prioritised treatment goals between patients and doctors was higher, with 88.5% vs 57%.

CONCLUSIONS

The ISDM-P was successfully implemented in general practices. Adherence to medication was very high making improvements hardly detectable.

TRIAL REGISTRATION NUMBER

ISRCTN77300204; Results.

Views of general practice staff about the use of a patient-oriented treatment decision aid in shared decision making for patients with type 2 diabetes: A mixed-methods study

Background

Decision aids can be used to support shared decision making (SDM). A patient‐oriented treatment decision aid (DA) was developed for type 2 diabetes but its use by general practice staff appeared to be limited.

Objectives

To explore views of practice staff towards SDM and the DA.

Design

A mixed‐methods study within the Dutch PORTDA‐diab trial.

Setting and participants

Included were 17 practices with staff members who were responsible for routine diabetes care and had worked with the DA, and 209 of their patients.

Methods

Interviews were conducted focusing on applicability, usefulness and feasibility of the DA. Interviews were tape‐recorded, transcribed verbatim and subjected to content analysis for identifying and classifying views. Patient‐reported data about the use of the DA were collected. Associations between specific views and use of the DA were tested using Pearson point‐biserial correlation.

Results

The majority of practice staff expressed positive views towards SDM, which was associated with making more use of the DA. Most of the staff expressed that the DA stimulated a two‐way conversation. By using the DA, several became aware of their paternalistic approach. Some staff experienced a conflict with the content of the DA, which was associated with making less use of the DA.

Conclusions

The DA was considered useful by practice staff to support SDM. A positive view towards SDM was a facilitator, whereas experiencing a conflict with the content of the DA was a barrier for making use of the DA.

Perceived Preparedness of Health Care Students for Providing Cardiovascular Disease Risk Assessment and Management

Early assessment and management of risk factors is known to have significant impact in preventing cardiovascular disease (CVD) and its associated burden. Cardiovascular disease risk assessment and management (CVDRAM) is best approached by teamwork across health care professionals. This study aimed at assessing health care students’ (HCSs) knowledge about the parameters needed for estimating CVD risk, their self-assessed preparedness/confidence and perceived barriers for the provision of CVDRAM services through a survey administered to third and fourth year pharmacy, medical, and nursing students in Qatar. Although all student cohorts achieved similar knowledge scores, less than half (n = 38, 47%) were able to identify all of the six main risk factors necessary to estimate absolute CVD risk, and a third (32%) were unable to identify total cholesterol as an independent risk factor necessary to estimate CVD risk. Training on the use of CVD risk assessment tools differed among the three student cohorts. All student cohorts also perceived similar levels of preparedness in CVDRAM. However, pharmacy students reported the highest preparedness/confidence with the use of the latest CVDRAM guidelines. The majority of statements listed under the barriers scale were perceived by the students as being moderate (median score = 3). Poor public acceptance or unawareness of importance of estimating CVD risk was the only barrier perceived as a major by nursing students. Future integration of interprofessional educational (IPE) activities in the CVDRAM curricula of HCSs may be a suitable strategy to minimize barriers and foster collaborative practice for the provision of CVDRAM services in Qatar.

Knowledge of cardiovascular disease in Turkish undergraduate nursing students

BACKGROUND

Cardiovascular disease is the number one cause of death worldwide. However, there is not enough data exploring student nurses' understanding, knowledge, and awareness of cardiovascular disease.

AIMS

To investigate knowledge of cardiovascular disease and its risk factors among undergraduate nursing students, with an emphasis on understanding of cardiovascular disease as the primary cause of mortality and morbidity, both in Turkey and worldwide.

METHODS

This cross-sectional survey assessed 1138 nursing students enrolled in nursing schools in Istanbul, Turkey. Data were collected using the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale and questions from the Individual Characteristics Form about students' gender, age, level of education, and family cardiovascular health history, as well as smoking and exercise habits.

RESULTS

Respondents demonstrated a high level of knowledge about cardiovascular disease, with years of education (p < 0.001), gender (p < 0.001), and high school type (p < 0.05) all significantly associated with CARRF-KL scores. However, more than half of the students were not aware that cardiovascular disease is the primary cause of mortality and morbidity in Turkey and worldwide. The majority of the respondents' body mass index (87%) and waist circumference values (females: 90.3%, males: 94.7%) were in the normal range and most were non-smokers (83.7%). However, more than half of the students did not exercise regularly and had inadequate dietary habits.

CONCLUSIONS

Although students were knowledgeable about cardiovascular disease and associated risk factors, there were significant gaps in their knowledge; these should be addressed through improved nursing curricula. While students were generally healthy, they could improve their practice of health-promoting behaviors.

A questionnaire on treatment satisfaction and disease specific knowledge among patients with acute coronary syndrome. II: Insights for patient education and quality improvement

OBJECTIVE

Secondary prevention for coronary heart disease is achieved by pharmaceutical control of risk factors and patients' own self management behaviour. To comply with longterm treatment patients need sufficient knowledge of their condition and should be satisfied with acute care. Therefore a questionnaire measuring both issues was constructed.

METHODS AND RESULTS

Latent class analysis applied in a sample of over 2000 patients suffering from acute coronary syndrome revealed 4 configurative patterns of knowledge and 5 distinct patterns of (dis-)satisfaction. Nearly 50% of all patients displayed insufficient knowledge upon discharge. Deficits clustered around misinformation on necessary lifestyle changes versus dysfunctional strategies for future emergency situations. Satisfaction and disease specific knowledge were interrelated in complex patterns.

CONCLUSIONS

Disease specific knowledge and satisfaction with treatment proved to be psychometrically valid indicators of the quality of the treatment process that might also have an impact on outcome.

PRACTICE IMPLICATIONS

A validated questionnaire is ready for routine administration after discharge of patients with acute coronary syndrome from acute hospital care. Patient education efforts and quality improvement in treatment centres might be effectively monitored using this questionnaire.

Cardiovascular risk factors and lifestyle habits among preventive cardiovascular nurses

The cornerstone of cardiovascular disease prevention is the promotion of a healthy lifestyle and the identification and reduction of cardiovascular risk factors. Cardiology nurses play a major role in counseling patients about lifestyle and cardiovascular risk factors. We used an e-mail survey to elicit self-reported prevalence of cardiovascular risk factors and healthy lifestyles among the Preventive Cardiovascular Nurses Association (PCNA) members and compared their risk profiles with published data for American cardiologists, the Nurses' Health Study 2, and the Behavioral Risk Factor Surveillance Survey data for women.

RESULTS

A total of 1,345 complete surveys were collected. The respondents were mostly women (96%), with mean (SD) age of 47.4 (8.7) years. More than 95% were not cigarette smokers, more than 50% had a healthy body mass index (<25), and more than 56% achieved the recommended levels of physical activity. Nevertheless, obesity (body mass index ≥ 30) was a health risk in one-fifth of PCNA respondents. The rates of hypertension (17%) and dyslipidemia (15%) were lower than rates reported in other national samples; however, the rate for family history of premature heart disease (20%) was similar to those reported in national samples. Since family history of premature heart disease may be a more significant risk factor in women, PCNA respondents with such a family history may require targeted interventions to further reduce their risk and improve their lifestyle behaviors.

CONCLUSION

PCNA nurses have more favorable lifestyle profiles compared with national samples. It can be expected that nurses who know their risk factors and who follow healthy lifestyle behaviors will be more effective in these counseling roles.

Barriers to cardiovascular disease risk scoring and primary prevention in Europe

The prevalence and burden of cardiovascular disease (CVD) is high, and it remains the leading cause of death worldwide. Unfortunately, many individuals who are at high risk for CVD are not recognized and/or treated. Therefore, programs are available to ensure individuals at risk for CVD are identified through appropriate risk classification and offered optimal preventative interventions. The use of algorithms to determine a global risk score may help to achieve these goals. Such global risk-scoring algorithms takes into account the synergistic effects between individual risk factors, placing increases in individual risk factors into context relative to the overall disease, allowing for a continuum of disease risk to be expressed, and identifying patients most likely to derive benefit from an intervention. The predictive value of risk scoring such as using the Framingham equation is reasonable, analogous to cervical screening, with area under the receiver operated characteristic curve a little over 70%. However, limitations do exist, and as they are identified adjustments can be made to the global risk-scoring algorithms. Limitations include patient-specific issues, such as variations in lifetime risk level, ethnicity or socio-economic strata, and algorithm-specific issues, such as discrepancies between different algorithms arising from varying risk factors evaluated. The use of currently developed algorithms is low in general practice, in part, because of the belief that the assessment may oversimplify the risk and/or lead to medication overuse. Additional hindrances to the use of risk scoring include government or local health policy, patient compliance issues and lack of time. A thorough, easy-to-use, and standardized tool for risk estimation would allow for improvements in the primary prevention of CVD.

Small but important errors in cardiovascular risk calculation by practice nurses: a cross-sectional study in randomised trial setting

BACKGROUND

Practice nurses play an increasingly important role in the prevention of cardiovascular diseases but we do not have evidence about the accuracy of their cardiovascular risk assessments during real practice consultations.

OBJECTIVES

To examine how nurses perform with regard to absolute 10-year cardiovascular risk assessment in actual practice.

DESIGN

Cross-sectional study.

SETTING

This study was nested in the IMPALA study, a clustered randomised controlled trial involving 24 general practices in The Netherlands.

PARTICIPANTS

24 practice nurses, trained in 10-year cardiovascular risk assessment, calculated the risk of a total of 421 patients without established cardiovascular diseases but eligible for cardiovascular risk assessment.

METHODS

The main outcome measure was the accuracy of risk assessments, defined as (1) the difference between the 10-year cardiovascular risk percentage calculated by nurses and an independent assessor, and (2) the agreement between the treatment categories assigned by the nurses (low, moderate or high risk) and those assigned by the independent assessor.

RESULTS

Thirty-one (7.4%) of the calculated risk percentages differed by more than our preset limits, 25 (81%) being underestimations. Elderly patients (OR 1.1, 95% CI 1.0-1.1), male patients (vs. female OR 3.1, 95% CI 1.2-7.3), and smoking patients (vs. non-smoking OR 3.8, 95% CI 1.7-8.9) were more likely to have their cardiovascular risk miscalculated. Ten (28%) of the 36 patients who should be assigned to the high-risk treatment category according to the independent calculation, were missed as high-risk patients by the practice nurses.

CONCLUSIONS

The overall standard of accuracy of cardiovascular risk assessment by trained practice nurses in actual practice is high. However, a significant number of high-risk patients were misclassified, with the probability that it led to missed opportunities for risk-reducing interventions. As cardiovascular risk assessments are frequently done by nurses in general practice, further specific training should be considered to prevent undertreatment.

Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature

BACKGROUND

Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms.

METHODS

We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers.

RESULTS

11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions.

CONCLUSION

Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.