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Jones LK, Tilberry S, Gregor C, Yaeger LH, Hu Y, Sturm AC, Seaton TL, Waltz TJ, Rahm AK, Goldberg A, Brownson RC, Gidding SS, Williams MS, Gionfriddo MR. Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis. Implement Sci 2021; 16:40. [PMID: 33849601 PMCID: PMC8045284 DOI: 10.1186/s13012-021-01108-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins. METHODS AND RESULTS This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes. CONCLUSION Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes. TRIAL REGISTRATION PROSPERO CRD42018114952 .
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Affiliation(s)
- Laney K Jones
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA.
| | - Stephanie Tilberry
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, MO, USA
| | - Yirui Hu
- Population Health Sciences, Geisinger, Danville, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Terry L Seaton
- University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
- Population Health, Mercy Clinic-East Communities, St. Louis, MO, USA
| | | | - Alanna K Rahm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Anne Goldberg
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Samuel S Gidding
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
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St-Maurice J, Burns C, Wolting J. Applying Persuasive Design Techniques to Influence Data-Entry Behaviors in Primary Care: Repeated Measures Evaluation Using Statistical Process Control. JMIR Hum Factors 2018; 5:e28. [PMID: 30309836 PMCID: PMC6231847 DOI: 10.2196/humanfactors.9029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 03/08/2018] [Accepted: 06/29/2018] [Indexed: 11/26/2022] Open
Abstract
Background Persuasive design is an approach that seeks to change the behaviors of users. In primary care, clinician behaviors and attitudes are important precursors to structured data entry, and there is an impact on overall data quality. We hypothesized that persuasive design changes data-entry behaviors in clinicians and thus improves data quality. Objective The objective of this study was to use persuasive design principles to change clinician data-entry behaviors in a primary care environment and to increase data quality of data held in a family health team’s reporting system. Methods We used the persuasive systems design framework to describe the persuasion context. Afterward, we designed and implemented new features into a summary screen that leveraged several persuasive design principles. We tested the influence of the new features by measuring its impact on 3 data quality measures (same-day entry, record completeness, and data validity). We also measured the impacts of the new features with a paired pre-post t test and generated XmR charts to contextualize the results. Survey responses were also collected from users. Results A total of 53 users used the updated system that incorporated the new features over the course of 8 weeks. Based on a pre-post analysis, the new summary screen successfully encouraged users to enter more of their data on the same day as their encounter. On average, the percentage of same-day entries rose by 10.3% for each user (P<.001). During the first month of the postimplementation period, users compensated by sacrificing aspects of data completeness before returning to normal in the second month. Improvements to record validity were marginal over the study period (P=.05). Statistical process control techniques allowed us to study the XmR charts to contextualize our results and understand trends throughout the study period. Conclusions By conducting a detailed systems analysis and introducing new persuasive design elements into a data-entry system, we demonstrated that it was possible to change data-entry behavior and influence data quality in a reporting system. The results show that using persuasive design concepts may be effective in influencing data-entry behaviors in clinicians. There may be opportunities to continue improving this approach, and further work is required to perfect and test additional designs. Persuasive design is a viable approach to encourage clinician user change and could support better data capture in the field of medical informatics.
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Affiliation(s)
- Justin St-Maurice
- Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada.,Applied Health Information Science Program, School of Health & Life Sciences and Community Services, Conestoga College Institute of Technology and Advanced Learning, Kitchener, ON, Canada
| | - Catherine Burns
- Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- Sharon Rees
- Assistant professor Therapeutics and Prescribing, University of Nottingham
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Rafi I, Chowdhury S, Chan T, Jubber I, Tahir M, de Lusignan S. Improving the management of people with a family history of breast cancer in primary care: before and after study of audit-based education. BMC FAMILY PRACTICE 2013; 14:105. [PMID: 23879178 PMCID: PMC3734209 DOI: 10.1186/1471-2296-14-105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 07/08/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND In England, guidance from National Institute for Clinical Excellence (NICE) states women with a family history of breast cancer presenting to primary care should be reassured or referred.We reviewed the evidence for interventions that might be applied in primary care and conducted an audit of whether low risk women are correctly advised and flagged. METHODS We conducted a literature review to identify modifiable risk factors. We extracted routinely collected data from the computerised medical record systems of 6 general practices (population approximately 30,000); of the variables identified in the guidance. We implemented a quality improvement (QI) intervention called audit-based education (ABE) comparing participant practices with guidelines and each other before and after; we report odds ratios (OR) of any change in data recording. RESULTS The review revealed evidence for advising on: diet, weight control, physical exercise, and alcohol. The proportion of patients with recordings of family history of: disease, neoplasms, and breast cancer were: 39.3%, 5.1% and 1.3% respectively. There was no significant change in the recording of family history of disease or cancer; OR 1.02 (95% CI 0.98-1.06); and 1.08 (95% CI 0.99-1.17) respectively. Recording of alcohol consumption and smoking both increased significantly; OR 1.36 (95% CI 1.30-1.43); and 1.42 (95% CI 1.27-1.60) respectively. Recording lifestyle advice fell; OR 0.84 (95% CI 0.81-0.88). CONCLUSIONS The study informs about current data recording and willingness to engage in ABE. Recording of risk factors improved after the intervention. Further QI is needed to achieve adherence to current guidance.
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Affiliation(s)
- Imran Rafi
- Division of Population Health Sciences and Education, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
- Clinical Innovation and Research Centre (CIRC), Royal College of General Practitioners, 30 Euston Square, London NW1 2FB, UK
| | - Susmita Chowdhury
- PHG Foundation, 2 Worts Causeway, Cambridge, Cambridgeshire CB1 8RN, UK
| | - Tom Chan
- Department of Healthcare Management and Policy, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Ibrahim Jubber
- Division of Population Health Sciences and Education, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Mohammad Tahir
- Department of Healthcare Management and Policy, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Simon de Lusignan
- Department of Healthcare Management and Policy, University of Surrey, Guildford, Surrey GU2 7XH, UK
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Lusignan SD, de Lusignana S, Gallagher H, Jones S, Chan T, van Vlymen J, Tahir A, Thomas N, Jain N, Dmitrieva O, Rafi I, McGovern A, Harris K. Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results. Kidney Int 2013; 84:609-20. [PMID: 23536132 PMCID: PMC3778715 DOI: 10.1038/ki.2013.96] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 12/20/2022]
Abstract
Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.
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Affiliation(s)
| | - Simon de Lusignana
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK.
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Affiliation(s)
- Shah Ebrahim
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
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Alsanjari ON, de Lusignan S, van Vlymen J, Gallagher H, Millett C, Harris K, Majeed A. Trends and transient change in end-digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data. Int J Clin Pract 2012; 66:37-43. [PMID: 22171903 DOI: 10.1111/j.1742-1241.2011.02781.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND End-digit preference (EDP) is a known cause of inaccurate BP recording. Distortion has been reported around pay-for-performance (P4P) indicators. METHODS We studied sequential datasets (n = 148,000 to n = 900,000) and performed a longitudinal analysis of CONDUIT data (n = 250,000) over a 10-year period. We examined general trends in EDP and investigated the impact of diabetes and chronic kidney disease (CKD) P4P targets. RESULTS EDP reduces over time in both datasets; the percentage of patients with a zero EDP declined from 70% to 27% and 68% to 26% for SBP and DBP respectively. There is more zero EDP at the extremes of BP, but in people with chronic disease, the use of zero EDP was mainly seen at higher BP levels. P4P targets are associated with increased preference for the even end-digit just below target: in diabetes odds ratio (OR) is 1.47 (p = 0.003) for SBP, 1.19 (p = 0.09) for DBP and in CKD OR 1.65 (p < 0.001) for SBP and 1.48 (p = 0.0001) for DBP. Trends observed in pilot data were validated with a longitudinal set. CONCLUSIONS The decline in EDP is levelling off and P4P targets are associated with sub-target-EDP. Primary care should automate BP measurement and recording.
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Yoon SS(S, Carroll MD, Johnson CL, Gu Q. Cholesterol Management in the United States: The National Health and Nutrition Examination Survey, 1999 to 2006. Ann Epidemiol 2011; 21:318-26. [DOI: 10.1016/j.annepidem.2011.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 01/20/2011] [Accepted: 01/20/2011] [Indexed: 11/24/2022]
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How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis. Br J Gen Pract 2010; 60:403-9. [PMID: 20529495 DOI: 10.3399/bjgp10x502100] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with increased cardiovascular mortality and morbidity as well as progression to established renal failure. Interventions in primary care, particularly the lowering of blood pressure in individuals with CKD and proteinuria and diabetes, can slow disease progression. This evidence base is codified in national guidance and in a simplified form in pay-for-performance targets. Prior to conducting the QICKD study - a cluster of quality-improvement interventions with reduction of blood pressure as its primary outcome measure - a diagnostic analysis was conducted to assess the relevance of the intended interventions. AIM To understand practitioners' views of CKD and its management. METHOD Focus groups were held in five locations across England. Experienced facilitators developed a standardised approach and analysed data using the 'framework' approach. RESULTS Practitioners varied in their views of CKD and their embracing of the guidance. Some sought to implement the full guidance, others only the pay-for-performance targets. Nearly all practitioners had reservations as to whether CKD was really a disease; problematised the diagnosis of CKD purely on an estimate of glomerular filtration rate; questioned whether CKD in older people was part of natural ageing; and had experienced difficulty in explaining the condition to patients without frightening them. Most reported both problems and scepticism concerning the blood pressure targets, and acknowledged educational gaps. CONCLUSION Practitioners have disparate views about CKD. The quality-improvement interventions in the QICKD study will need to incorporate a large element of education. CKD guidelines may have been introduced without sufficient educational support.
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Barth JH, Jackson BM, Farrin AJ, Efthymiou M, Worthy G, Copeland J, Bailey KM, Romaine SPR, Balmforth AJ, McCormack T, Whitehead A, Flather MD, Nixon J, Hall AS. Change in serum lipids after acute coronary syndromes: secondary analysis of SPACE ROCKET study data and a comparative literature review. Clin Chem 2010; 56:1592-8. [PMID: 20729301 DOI: 10.1373/clinchem.2010.145631] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND It has long been an accepted belief that serum cholesterol significantly falls after myocardial infarction and that a return to pre-event levels takes approximately 3 months. The magnitude and clinical significance of this fall has recently been challenged. METHODS In the Secondary Prevention of Acute Coronary Events-Reduction Of Cholesterol to Key European Targets (SPACE ROCKET) trial, we measured serum lipids of individuals on day 1 and between days 2 and 4 after acute myocardial infarction (AMI). Second, we performed a thorough literature review and compared all studies reporting data on absolute changes in lipids immediately after AMI, using weighted means. RESULTS Of 1263 SPACE ROCKET participants, 128 had paired lipid measurements where both samples had been measured using identical methods at baseline and on days 2-4 after AMI. The mean lowering in total cholesterol between day 1 and day 2-4 was 0.71 mmol/L (95% CI 0.58-0.84; P < 0.0001) and in triglycerides was 0.10 mmol/L (-0.14-0.33; P = 0.405). A total of 25 papers showing absolute lipid changes post-AMI were identified. The combined data demonstrated a mean fall in total cholesterol of 9% to 11% from baseline over days 3-14 post-AMI, whereas for triglycerides, there was a rise of 18% from baseline to between day 9 and 12 weeks. CONCLUSIONS After a secondary analysis of SPACE ROCKET data and a comparison of previously published data, we report a 10% fall in total cholesterol after AMI-a difference that is of high clinical significance. Consequently, measurement of serum lipids in patients with AMI should be performed within the first hours after presentation.
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Affiliation(s)
- Julian H Barth
- Clinical Biochemistry, Leeds General Infirmary, Leeds, United Kingdom.
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Debar S, Kumarapeli P, Kaski JC, de Lusignan S. Addressing modifiable risk factors for coronary heart disease in primary care: an evidence-base lost in translation. Fam Pract 2010; 27:370-8. [PMID: 20418224 DOI: 10.1093/fampra/cmq025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Risk factors for cardiovascular disease can be modified in primary care. Electronic patient record (EPR) systems include embedded cardiovascular risk factor calculators and should facilitate this process. OBJECTIVE To observe how the evidence base for assessing and managing cardiovascular risk is implemented in practice. METHOD We compared the different risk calculators promoted for calculating cardiovascular risk in primary care using four test cases. We looked to see how these calculators were implemented in primary care EPR systems. We explored through a workshop which risk factors GPs thought were important and felt motivated to address as part of clinical care. RESULTS The risk calculators reviewed use different sets of risk factors and the levels of risk calculated for the same test patient profiles vary by up to 100%. The risk factor calculators embedded within UK computer systems all include the Framingham equation though there is variation in interface, default values and patient groups included. GPs showed consensus around the importance of managing smoking, blood pressure, obesity (body mass index), diabetes and cholesterol but also stressed the importance of providing personalized care and exercising professional judgement. CONCLUSIONS There appears to be an evidence-base lost in translation. Different guidelines calculate risk differently, and even when the same guideline is used, variation in implementation leads to further variation. Education and development of improved risk calculators should enable the most appropriate calculator to be used for an individual patient; accreditation of implementation could be achieved through the use of a standard set of test cases.
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Affiliation(s)
- Safia Debar
- Division of Community Health Sciences, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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de Lusignan S, Gallagher H, Chan T, Thomas N, van Vlymen J, Nation M, Jain N, Tahir A, du Bois E, Crinson I, Hague N, Reid F, Harris K. The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care. Implement Sci 2009; 4:39. [PMID: 19602233 PMCID: PMC2719588 DOI: 10.1186/1748-5908-4-39] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 07/14/2009] [Indexed: 11/14/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression Design Cluster randomised controlled trial (CRT) Methods This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education. The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD. A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention. Clinical Trials Registration ISRCTN56023731. ClinicalTrials.gov identifier.
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Affiliation(s)
- Simon de Lusignan
- Division of Community Health Sciences, St George's - University of London, London, SW17 0RE, UK.
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Belsey J, de Lusignan S, Chan T, van Vlymen J, Hague N. Abnormal lipids in high-risk patients achieving cholesterol targets: a cross-sectional study of routinely collected UK general practice data. Curr Med Res Opin 2008; 24:2551-60. [PMID: 18674409 DOI: 10.1185/03007990802321964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Lipid management in UK general practice targets the achievement of total cholesterol (TC) targets in high-risk individuals. Statins alone have a modest effect on non-LDL-C components of the lipid profile, leaving these patients at significant residual cardiovascular (CV) risk. Improving risk further would require the addition of non-statin therapies. This analysis explores what proportion of the UK population with cardiovascular disease (CVD) and TC levels at or below target may still be at risk because of residual dyslipidaemia. METHODS CV risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. Patients were categorised according to their prior CV history and use of statins. Mean values and proportions achieving treatment targets were assessed for TC, low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and triglycerides (TG). RESULTS In all, 48 499 patients with pre-existing CVD or diabetes were identified. 73% of statin-treated patients and 63% of untreated patients had a TC < or =5 mmol/L. 28.6% of patients treated to a TC target had LDL-C>3 mmol/L. Amongst those with both TC and LDL-C treated to target, 22.5% had low HDL-C and 37.2% had high triglyceride (TG). Within this group, more women than men had abnormal HDL-C (25.4 vs. 20.7%; p<0.0001). Patients with diabetes were more likely than non-diabetics to have abnormalities of both HDL-C (28.9 vs. 16.4%; p<0.0001) and triglyceride (44.9 vs. 29.5%; p<0.0001) despite normal TC and LDL-C. CONCLUSIONS Around 60% of high-risk patients have residual dyslipidaemias despite achieving the Quality and Outcomes Framework (QOF) TC target. New patterns of treatment are required in order to extend lipid management beyond simple total cholesterol lowering.
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Affiliation(s)
- Jonathan Belsey
- Primary Care Informatics, Division of Community Health Sciences, St. George's-University of London, London, UK
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Belsey J, de Lusignan S, van Vlymen J, Chan T, Hague N. Reducing coronary risk by raising HDL-cholesterol: risk modelling the addition of nicotinic acid to existing therapy. Curr Med Res Opin 2008; 24:2703-9. [PMID: 18700070 DOI: 10.1185/03007990802374633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Reduction in total cholesterol (TC) and LDL-cholesterol (LDL-C) forms one of the principal objectives of most cardiovascular secondary prevention strategies. Many patients being treated with statins, however, have significant residual dyslipidaemia, with many having suboptimal HDL-cholesterol (HDL-C) levels. The addition of nicotinic acid to a statin has been shown to improve this profile, although clinical outcome evidence is currently lacking. This study set out to model the impact of nicotinic acid therapy on cardiovascular risk in these patients, based on Framingham risk assessments on a cohort of patients drawn from UK general practitioner records. METHODS Cardiovascular risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. 23 262 statin-treated patients with established cardiovascular disease or diabetes were identified and their 4-year Framingham risk was estimated. Patients who had either TC or HDL-C outside the desirable range then had their lipid profile adjusted in accordance with the likely performance of nicotinic acid, and the Framingham risk was then re-assessed. RESULTS Baseline 4-year coronary risk in the group as a whole was 11.5% (95%CI: 11.4-11.6). After adjustment of the lipid profile, this was reduced to 9.7% (95%CI: 9.6-9.8), a reduction in risk of 15.9% (95%CI: 15.1-16.6). When modelling was limited to those with diabetes or an abnormal treated lipid profile, the magnitude of change was increased to 23-29% depending on sex and subgroup. CONCLUSIONS Risk factor modelling suggests that raising HDL-C levels using nicotinic acid in statin-treated patients is likely to yield significant incremental clinical benefits. The results of clinical trials currently under way are awaited with interest.
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Affiliation(s)
- Jonathan Belsey
- Primary Care Informatics, Division of Community Health Sciences, St. George's - University of London, London, UK.
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