Lipid-lowering interventions in managed care settings

Risk factor Identification and Assessment in Hypertension and Diabetes (RIAHD) study

The RIAHD (Risk factor Identification and Assessment in Hypertension and Diabetes) study was conducted as a non-interventional study in 699 patients with hypertension without additional risk factors (low-risk) or with additional risk factors (high-risk), primarily diabetes and/or micro/macroalbuminuria (MA/A). The RIAHD study aimed to assess novel cardiovascular risk factors (RFs) such as blood viscosity, inflammatory markers and selected genetic polymorphisms. In addition, the RIAHD study also aimed to examine home versus office blood pressures (BPs), objective cardiovascular risk according to ESH/ESC Systematic Coronary Risk Evaluation systems (SCORE) and subjectively expressed risk (clinical judgment) by physicians and patients. The health economic impact of other RFs, associated clinical conditions and target organ damage was also studied by evaluating healthcare utilization and sick leave in high-risk patients. In terms of circulating RFs, measured and calculated whole blood viscosity did not differ between the high and low-risk patient groups. Fibrinogen was significantly increased in the high-risk group, while hsCRP did not differ between the two groups. Self-measured BPs at home differed from BPs measured in the office. The average systolic home BPs was 11.8 mmHg lower in the low-risk group and 6.7 mmHg lower in the high-risk group. The diastolic home BPs averages differed 7.1 mm Hg and 4.1 mmHg from office BPs in the low-risk and high-risk groups, respectively. A higher home BP compared with the office BP, i.e. masked high BP values, was found in 21% of patients in the low-risk group and 32% of patients in the high-risk group. Global CV risk assessment (high-risk or low-risk) by the physicians corresponded well to objective risk evaluation (ESH/ESC) in the high-risk hypertensive patients, while physicians tended to underestimate the patients CV risk in the low-risk group (without diabetes and/or MA/A). Proper global risk assessment by judgement is often difficult in cardiovascular patients. The RIAHD study emphasizes the importance of performing a more extended RF assessment in hypertensive patients with as well as without diabetes and/or micro/macroalbuminuria in order to expose the full RF profile.

Electronic alerts versus on-demand decision support to improve dyslipidemia treatment: a cluster randomized controlled trial

BACKGROUND

Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system. However, randomized trials comparing these methods in a clinical setting are lacking. We studied the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners.

METHODS AND RESULTS

In a clustered randomized trial design, 38 Dutch general practices (77 physicians) and 87,886 of their patients (39,433 men 18 to 70 years of age and 48,453 women 18 to 75 years of age) who used the ELIAS electronic health record participated. Each practice was assigned to receive alerts, on-demand support, or no intervention. We measured the percentage of patients screened and treated after 12 months of follow-up. In the alerting group, 65% of the patients requiring screening were screened (relative risk versus control=1.76; 95% confidence interval, 1.41 to 2.20) compared with 35% of patients in the on-demand group (relative risk versus control=1.28; 95% confidence interval, 0.98 to 1.68) and 25% of patients in the control group. In the alerting group, 66% of patients requiring treatment were treated (relative risk versus control=1.40; 95% confidence interval, 1.15 to 1.70) compared with 40% of patients (relative risk versus control=1.19; 95% confidence interval, 0.94 to 1.50) in the on-demand group and 36% of patients in the control group.

CONCLUSIONS

The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners.

Identification of the Four Conventional Cardiovascular Disease Risk Factors by Dutch General Practitioners

BACKGROUND

Detecting and managing the four major conventional risk factors, smoking, hypertension, diabetes mellitus, and hypercholesterolemia, is pivotal in the primary and secondary prevention of cardiovascular disease (CVD).

OBJECTIVE

To assess the preventive activities of general practitioners (GPs) regarding the four conventional risk factors and the associated measurements for cardiovascular risk factors by GPs in relation to the time of the first clinical presence of CVD.

SETTING

Large longitudinal general practice research database (the Integrated Primary Care Information database) in the Netherlands from September 1999 to August 2003.

PARTICIPANTS AND METHODS

Patients > 18 year of age with newly diagnosed CVD with a valid history of at least 1 year before and after the first clinical diagnosis of CVD. Details on conventional risk factors and associated measurements for the four cardiovascular risk factors were assessed in relation to the first clinical diagnosis of CVD.

RESULTS

In total, 157,716 patients met the study inclusion criteria. Of the 2,594 patients with newly diagnosed CVD, at least one of the four investigated risk factors was observed in 76% of women and 73% of men. In 40% of cases, no risk factor was recorded before the date of the first CVD diagnosis. In 16% of cases, no associated measurements were present before the first CVD diagnosis.

CONCLUSION

In daily practice, GPs seem to focus on the secondary prevention of CVD. Intervention strategies that aim to influence GPs' case finding behavior should focus on increasing the awareness of physicians in performing risk factor-associated measurements in patients who are eligible for the primary prevention of CVD. Further research will have to show the feasibility and effectiveness of such intervention strategies.