Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians

Cardiovascular disease risk communication and prevention: a meta-analysis

BACKGROUND AND AIMS

Knowledge of quantifiable cardiovascular disease (CVD) risk may improve health outcomes and trigger behavioural change in patients or clinicians. This review aimed to investigate the impact of CVD risk communication on patient-perceived CVD risk and changes in CVD risk factors.

METHODS

PubMed, Embase, and PsycINFO databases were searched from inception to 6 June 2023, supplemented by citation analysis. Randomized trials that compared any CVD risk communication strategy versus usual care were included. Paired reviewers independently screened the identified records and extracted the data; disagreements were resolved by a third author. The primary outcome was the accuracy of risk perception. Secondary outcomes were clinician-reported changes in CVD risk, psychological responses, intention to modify lifestyle, and self-reported changes in risk factors and clinician prescribing of preventive medicines.

RESULTS

Sixty-two trials were included. Accuracy of risk perception was higher among intervention participants (odds ratio = 2.31, 95% confidence interval = 1.63 to 3.27). A statistically significant improvement in overall CVD risk scores was found at 6-12 months (mean difference = -0.27, 95% confidence interval = -0.45 to -0.09). For primary prevention, risk communication significantly increased self-reported dietary modification (odds ratio = 1.50, 95% confidence interval = 1.21 to 1.86) with no increase in intention or actual changes in smoking cessation or physical activity. A significant impact on patients' intention to start preventive medication was found for primary and secondary prevention, with changes at follow-up for the primary prevention group.

CONCLUSIONS

In this systematic review and meta-analysis, communicating CVD risk information, regardless of the method, reduced the overall risk factors and enhanced patients' self-perceived risk. Communication of CVD risk to patients should be considered in routine consultations.

Shared Decision-Making in Cardiovascular Risk Factor Management: A Systematic Review and Meta-Analysis

Importance

The effect of shared decision-making (SDM) and the extent of its use in interventions to improve cardiovascular risk remain unclear.

Objective

To assess the extent to which SDM is used in interventions aimed to enhance the management of cardiovascular risk factors and to explore the association of SDM with decisional outcomes, cardiovascular risk factors, and health behaviors.

Data Sources

For this systematic review and meta-analysis, a literature search was conducted in the Medline, CINAHL, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov databases for articles published from inception to June 24, 2022, without language restrictions.

Study Selection

Randomized clinical trials (RCTs) comparing SDM-based interventions with standard of care for cardiovascular risk factor management were included.

Data Extraction and Synthesis

The systematic search resulted in 9365 references. Duplicates were removed, and 2 independent reviewers screened the trials (title, abstract, and full text) and extracted data. Data were pooled using a random-effects model. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Decisional outcomes, cardiovascular risk factor outcomes, and health behavioral outcomes.

Results

This review included 57 RCTs with 88 578 patients and 1341 clinicians. A total of 59 articles were included, as 2 RCTs were reported twice. Nearly half of the studies (29 [49.2%]) tested interventions that targeted both patients and clinicians, and an equal number (29 [49.2%]) exclusively focused on patients. More than half (32 [54.2%]) focused on diabetes management, and one-quarter focused on multiple cardiovascular risk factors (14 [23.7%]). Most studies (35 [59.3%]) assessed cardiovascular risk factors and health behaviors as well as decisional outcomes. The quality of studies reviewed was low to fair. The SDM intervention was associated with a decrease of 4.21 points (95% CI, -8.21 to -0.21) in Decisional Conflict Scale scores (9 trials; I2 = 85.6%) and a decrease of 0.20% (95% CI, -0.39% to -0.01%) in hemoglobin A1c (HbA1c) levels (18 trials; I2 = 84.2%).

Conclusions and Relevance

In this systematic review and meta-analysis of the current state of research on SDM interventions for cardiovascular risk management, there was a slight reduction in decisional conflict and an improvement in HbA1c levels with substantial heterogeneity. High-quality studies are needed to inform the use of SDM to improve cardiovascular risk management.

Cardiovascular Risk in Patients with Dyslipidemia and Their Degree of Control as Perceived by Primary Care Physicians in a Survey-TERESA-Opinion Study

OBJECTIVE

The aim of this study was to evaluate, through a survey, the opinion of primary care (PC) physicians on the magnitude of dyslipidemia and its degree of control in their clinical practice.

MATERIALS AND METHODS

An ecological study was carried out, in which the physicians were invited to participate by means of an online letter. Data were collected at a single timepoint and were based only on the experience, knowledge, and routine clinical practice of the participating physician.

RESULTS

A total of 300 physicians answered the questionnaire and estimated the prevalence of dyslipidemia between 2% and 80%. They estimated that 23.5% of their patients were high-risk, 18.2% were very high-risk, and 14.4% had recurrent events in the last 2 years. The PC physicians considered that 61.5% of their patients achieved the targets set. The participants fixed the presence of side-effects to statins at 14%. The statin that was considered safest with regard to side-effects was rosuvastatin (69%).

CONCLUSIONS

PC physicians in Spain perceive that the CVR of their patients is high. This, together with the overestimation of the degree of control of LDL-C, could justify the inertia in the treatment of lipids. Moreover, they perceive that one-sixth of the patients treated with statins have side-effects.

Decision aids to facilitate decision making around behavior change in the field of health promotion: A scoping review

OBJECTIVE

To broadly synthesize literature regarding decision aids (DAs) supporting decision making about diet, physical activity, sleeping and substance use a scoping review was performed.

METHODS

Multiple sources were used: (1) Scientific literature searches, (2) excluded references from a Cochrane review regarding DAs for treatments and screenings, and (3) results from additional searches. Interventions had to (1) support informed decision making and (2) provide information and help to choose between at least two options. Two researchers screened titles and abstracts. Relevant information was extracted descriptively.

RESULTS

Thirty-five scientific articles and four DAs (grey literature) were included. Results were heterogeneous. Twenty-nine (94%) studies described substance use DAs. All DAs offered information and value and/or preference clarification. Many other elements were included (e.g., goal-setting). DA's effects were mixed. Few studies used standardized measures, e.g., decisional conflict (n = 4, 13%). Some positive behavioral effects were reported: e.g., smoking abstinence (n = 1).

CONCLUSIONS

This research shows only some positive behavioral effects of DAs. However, studies reported heterogeneous results/outcomes, impeding knowledge synthesis. Areas of improvement were identified, e.g., establishing which intervention elements are effective regarding health behavior decision making.

PRACTICE IMPLICATIONS

DAs can potentially be beneficial in supporting people to change health behaviors - especially regarding smoking.

Implementing Patient and Family Involvement Interventions for Promoting Patient Safety: A Systematic Review and Meta-Analysis

OBJECTIVE

The aims of the study were to evaluate and to quantify the effects of patient and family involvement (PFI) interventions on patient safety by synthesizing the available global data.

METHODS

Four databases were searched to identify relevant studies that have assessed the impact of PFI on patient safety up to March 2019. Reference lists of potential selected articles were also used to identify additional relevant studies. Effect sizes (ESs) were calculated using random and fixed effects models. Statistical heterogeneity was measured using the I2 test.

RESULTS

Twenty-two studies met the review criteria. The meta-analysis showed that PFI were beneficial in significantly reducing adverse events (ES = -0.240, P < 0.001), decreasing the length of hospital stay (ES = -0.122, P < 0.001), increasing patient safety experiences (ES = 0.630, P = 0.007), and improving patient satisfaction (ES = 0.268, P = 0.004). However, the PFI interventions did not significantly enhance the perception of patient safety (ES = 0.205, P = 0.09) or the quality of life (ES = 0.057, P = 0.61). Moreover, moderate-to-high heterogeneity was found for all impacts except adverse events (I2 = 0%) and length of hospital stay (I2 = 35%). A funnel plot indicated a low degree of publication bias for the adverse event outcome.

CONCLUSIONS

The synthesized evidence in this review demonstrates the benefits of PFI for promoting patient safety. However, further studies should extend the research scope to fill the existing gaps for both the type of PFI interventions and the patient safety outcomes.

Impact of educational interventions on primary prevention of cardiovascular disease: A systematic review with a focus on physical activity

Background: Evidence from epidemiological and experimental studies illustrates the beneficial impact of healthy lifestyle behaviours on cardiovascular risk.

Objectives: To assess the effectiveness of primary care health education interventions designed to promote healthy lifestyles on physical activity levels and cardiovascular risk.

Methods: A computer-aided search on PubMed and Scopus was performed to identify relevant studies published from January 2000 to October 2016. Two authors independently selected studies for inclusion and extracted data, including intervention characteristics and outcome measures, namely physical activity and cardiovascular risk or risk factors.

Results: Of the 212 identified studies, 15 met the inclusion criteria. The 15 studies enrolled 6727 participants; the sample size varied between 74 and 878 adults. Fourteen studies assessed physical activity by questionnaire and only one study used accelerometry. Eight of the 15 studies showed improvements in the physical activity levels after the intervention, ranging from 5% to 26% in those where significant changes between groups were detected. Most studies reported significant positive effects of the health education interventions on cardiovascular risk factors, mainly on lipid profile, blood pressure and cardiovascular risk score.

Conclusion: The health education interventions, in primary care, seem to improve daily physical activity, cardiovascular risk factors and risk score.

Risk scoring for the primary prevention of cardiovascular disease

BACKGROUND

The current paradigm for cardiovascular disease (CVD) emphasises absolute risk assessment to guide treatment decisions in primary prevention. Although the derivation and validation of multivariable risk assessment tools, or CVD risk scores, have attracted considerable attention, their effect on clinical outcomes is uncertain.

OBJECTIVES

To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes, risk factor levels, preventive medication prescribing, and health behaviours.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2016, Issue 2), MEDLINE Ovid (1946 to March week 1 2016), Embase (embase.com) (1974 to 15 March 2016), and Conference Proceedings Citation Index-Science (CPCI-S) (1990 to 15 March 2016). We imposed no language restrictions. We searched clinical trial registers in March 2016 and handsearched reference lists of primary studies to identify additional reports.

SELECTION CRITERIA

We included randomised and quasi-randomised trials comparing the systematic provision of CVD risk scores by a clinician, healthcare professional, or healthcare system compared with usual care (i.e. no systematic provision of CVD risk scores) in adults without CVD.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies, extracted data, and evaluated study quality. We used the Cochrane 'Risk of bias' tool to assess study limitations. The primary outcomes were: CVD events, change in CVD risk factor levels (total cholesterol, systolic blood pressure, and multivariable CVD risk), and adverse events. Secondary outcomes included: lipid-lowering and antihypertensive medication prescribing in higher-risk people. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data using 95% confidence intervals. We used a fixed-effects model when heterogeneity (I²) was at least 50% and a random-effects model for substantial heterogeneity (I² > 50%). We evaluated the quality of evidence using the GRADE framework.

MAIN RESULTS

We identified 41 randomised controlled trials (RCTs) involving 194,035 participants from 6422 reports. We assessed studies as having high or unclear risk of bias across multiple domains. Low-quality evidence evidence suggests that providing CVD risk scores may have little or no effect on CVD events compared with usual care (5.4% versus 5.3%; RR 1.01, 95% confidence interval (CI) 0.95 to 1.08; I² = 25%; 3 trials, N = 99,070). Providing CVD risk scores may reduce CVD risk factor levels by a small amount compared with usual care. Providing CVD risk scores reduced total cholesterol (MD -0.10 mmol/L, 95% CI -0.20 to 0.00; I² = 94%; 12 trials, N = 20,437, low-quality evidence), systolic blood pressure (MD -2.77 mmHg, 95% CI -4.16 to -1.38; I² = 93%; 16 trials, N = 32,954, low-quality evidence), and multivariable CVD risk (SMD -0.21, 95% CI -0.39 to -0.02; I² = 94%; 9 trials, N = 9549, low-quality evidence). Providing CVD risk scores may reduce adverse events compared with usual care, but results were imprecise (1.9% versus 2.7%; RR 0.72, 95% CI 0.49 to 1.04; I² = 0%; 4 trials, N = 4630, low-quality evidence). Compared with usual care, providing CVD risk scores may increase new or intensified lipid-lowering medications (15.7% versus 10.7%; RR 1.47, 95% CI 1.15 to 1.87; I² = 40%; 11 trials, N = 14,175, low-quality evidence) and increase new or increased antihypertensive medications (17.2% versus 11.4%; RR 1.51, 95% CI 1.08 to 2.11; I² = 53%; 8 trials, N = 13,255, low-quality evidence).

AUTHORS' CONCLUSIONS

There is uncertainty whether current strategies for providing CVD risk scores affect CVD events. Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm. There were multiple study limitations in the identified studies and substantial heterogeneity in the interventions, outcomes, and analyses, so readers should interpret results with caution. New models for implementing and evaluating CVD risk scores in adequately powered studies are needed to define the role of applying CVD risk scores in primary CVD prevention.

Exploring equity in primary-care-based physical activity interventions using PROGRESS-Plus: a systematic review and evidence synthesis

BACKGROUND

Little is known about equity effects in primary care based physical activity interventions. This review explored whether differences in intervention effects are evident across indicators of social disadvantage, specified under the acronym PROGRESS-Plus (place of residence, race/ethnicity, occupation, gender, religion, education, social capital, socioeconomic status, plus age, disability and sexual orientation).

METHODS

Six bibliographic databases were systematically searched for randomised controlled trials (RCTs) of physical activity interventions conducted in primary care. Harvest plots were used to synthesize findings from RCTs reporting subgroup or interaction analyses examining differences in intervention effects across levels of at least one PROGRESS-Plus factor.

RESULTS

The search yielded 9052 articles, from which 173 eligible RCTs were identified. Despite PROGRESS-Plus factors being commonly measured (N = 171 RCTs), differential effect analyses were infrequently reported (N = 24 RCTs). Where reported, results of equity analyses suggest no differences in effect across levels or categories of place of residence (N = 1RCT), race (N = 4 RCTs), education (N = 3 RCTs), socioeconomic status (N = 3 RCTs), age (N = 16 RCTs) or disability (N = 2 RCTs). Mixed findings were observed for gender (N = 22 RCTs), with some interventions showing greater effect in men than women and others vice versa. Three RCTs examined indicators of social capital, with larger post-intervention differences in physical activity levels between trial arms found in those with higher baseline social support for exercise in one trial only. No RCTs examined differential effects by participant occupation, religion or sexual orientation.

CONCLUSION

The majority of RCTs of physical activity interventions in primary care record sufficient information on PROGRESS-Plus factors to allow differential effects to be studied. However, very few actually report details of relevant analyses to determine which population subgroups may stand to benefit or be further disadvantaged by intervention efforts.

Bayesian network modeling: A case study of an epidemiologic system analysis of cardiovascular risk

An extensive, in-depth study of cardiovascular risk factors (CVRF) seems to be of crucial importance in the research of cardiovascular disease (CVD) in order to prevent (or reduce) the chance of developing or dying from CVD. The main focus of data analysis is on the use of models able to discover and understand the relationships between different CVRF. In this paper a report on applying Bayesian network (BN) modeling to discover the relationships among thirteen relevant epidemiological features of heart age domain in order to analyze cardiovascular lost years (CVLY), cardiovascular risk score (CVRS), and metabolic syndrome (MetS) is presented. Furthermore, the induced BN was used to make inference taking into account three reasoning patterns: causal reasoning, evidential reasoning, and intercausal reasoning. Application of BN tools has led to discovery of several direct and indirect relationships between different CVRF. The BN analysis showed several interesting results, among them: CVLY was highly influenced by smoking being the group of men the one with highest risk in CVLY; MetS was highly influence by physical activity (PA) being again the group of men the one with highest risk in MetS, and smoking did not show any influence. BNs produce an intuitive, transparent, graphical representation of the relationships between different CVRF. The ability of BNs to predict new scenarios when hypothetical information is introduced makes BN modeling an Artificial Intelligence (AI) tool of special interest in epidemiological studies. As CVD is multifactorial the use of BNs seems to be an adequate modeling tool.

Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practice organisation and healthcare system

Background

Although conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands.

Methods

We performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors.

Results

Twelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients’ lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals’ and patients’ views on patient’s knowledge and self-management.

Conclusions

Perceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients’ knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different.

Interventions to improve adherence to cardiovascular disease guidelines: a systematic review

BACKGROUND

Successful management of cardiovascular disease (CVD) is impaired by poor adherence to clinical practice guidelines. The objective of our review was to synthesize evidence about the effectiveness of interventions that target healthcare providers to improve adherence to CVD guidelines and patient outcomes.

METHODS

We searched PubMed, EMBASE, Cochrane Library, PsycINFO, Web of Science and CINAHL databases from inception to June 2014, using search terms related to adherence and clinical practice guidelines. Studies were limited to randomized controlled trials testing an intervention to improve adherence to guidelines that measured both a patient and adherence outcome. Descriptive summary tables were created from data extractions. Meta-analyses were conducted on clinically homogeneous comparisons, and sensitivity analyses and subgroup analyses were carried out where possible. GRADE summary of findings tables were created for each comparison and outcome.

RESULTS AND DISCUSSION

We included 38 RCTs in our review. Interventions included guideline dissemination, education, audit and feedback, and academic detailing. Meta-analyses were conducted for several outcomes by intervention type. Many comparisons favoured the intervention, though only the adherence outcome for the education intervention showed statistically significant improvement compared to usual care (standardized mean difference = 0.58 [95 % confidence interval 0.35 to 0.8]).

CONCLUSIONS

Many interventions show promise to improve practitioner adherence to CVD guidelines. The quality of evidence and number of trials limited our ability to draw conclusions.

Does Supplementation with Royal Jelly Improve Oxidative Stress and Insulin Resistance in Type 2 Diabetic Patients?

BACKGROUND

Animal studies have shown antioxidant effects of Royal Jelly (RJ) and its effect on insulin resistance as the most common complication of Type 2 diabetes. This study was conducted to determine the effect of RJ intake on serum total antioxidant capacity, Malondialdehyde and insulin resistance in T2DM.

METHODS

In this randomized controlled trial, forty-six type 2 diabetic patients, aged 25-65 years, with BMI of 20-30 kg/m(2), and HbA1c of 6-8% were included. The patients were randomly assigned to receive 1000 mg of RJ supplement or placebo, 3 times daily for 8 weeks. HOMA-IR, anthropometric measurements, fasting blood glucose, serum insulin, total antioxidant capacity and malondialdehyde level were measured.

RESULTS

In comparison with placebo, HOMA-IR decreased (P=0.015) while serum total antioxidant capacity increased significantly in RJ group (P=0.016). No significant difference was detected for serum insulin and MDA in two groups.

CONCLUSIONS

RJ intake may have favorable effects on serum TAC and HOMA-IR in diabetic patients.

A Multistep Maturity Model for the Implementation of Electronic and Computable Diagnostic Clinical Prediction Rules (eCPRs)

Introduction:

The use of Clinical Prediction Rules (CPRs) has been advocated as one way of implementing actionable evidence-based rules in clinical practice. The current highly manual nature of deriving CPRs makes them difficult to use and maintain. Addressing the known limitations of CPRs requires implementing more flexible and dynamic models of CPR development. We describe the application of Information and Communication Technology (ICT) to provide a platform for the derivation and dissemination of CPRs derived through analysis and continual learning from electronic patient data.

Model Components:

We propose a multistep maturity model for constructing electronic and computable CPRs (eCPRs). The model has six levels – from the lowest level of CPR maturity (literaturebased CPRs) to a fully electronic and computable service-oriented model of CPRs that are sensitive to specific demographic patient populations. We describe examples of implementations of the core model components – focusing on CPR representation, interoperability, electronic dissemination, CPR learning, and user interface requirements.

Conclusion:

The traditional focus on derivation and narrow validation of CPRs has severely limited their wider acceptance. The evolution and maturity model described here outlines a progression toward eCPRs consistent with the vision of a learning health system (LHS) – using central repositories of CPR knowledge, accessible open standards, and generalizable models to avoid repetition of previous work. This is useful for developing more ambitious strategies to address limitations of the traditional CPR development life cycle. The model described here is a starting point for promoting discussion about what a more dynamic CPR development process should look like.

From hypertension control to global cardiovascular risk management: an educational intervention in a cluster-randomised controlled trial

BACKGROUND

Guidelines on hypertension management recommend adjusting therapeutic efforts in accordance with global cardiovascular risk (CVR) rather than by blood pressure levels alone. However, this paradigm change has not yet arrived in German General Practice. We have evaluated the effect of an educational outreach visit with general practitioners (GPs), encouraging them to consider CVR in treatment decisions for patients with hypertension.

METHODS

Prospective cluster-randomised trial comprising 3443 patients with known hypertension treated by 87 GPs. Practices were randomly assigned to complex (A) or simple (B) intervention. Both groups received a guideline by mail; group A also received complex peer intervention promoting the concept of global CVR. Clinical data were collected at baseline and 6-9 months after intervention. Main outcome was improvement of calculated CVR in the predefined subpopulation of patients with a high CVR (10-year mortality ≥5%), but no manifest cardiovascular disease.

RESULTS

Adjusted for baseline the follow-up CVR were 13.1% (95% CI 12.6%-13.6%) (A) and 12.6% (95% CI 12.2%-13.1%) (B) with a group difference (A vs. B) of 0.5% (-0.2%-1.1%), p = 0.179. The group difference was -0.05% in patients of GPs familiar with global CVR and 1.1% in patients of GPs not familiar with with global CVR. However, this effect modification was not significant (p = 0.165). Pooled over groups, the absolute CVR reduction from baseline was 1.0%, p < 0.001. The ICC was 0.026 (p = 0.002). Hypertension control (BP <140/90 mmHg) improved in the same subpopulation from 38.1 to 45.9% in the complex intervention group, and from 35.6 to 46.5% in the simple intervention group, with adjusted follow-up control rates of 46.7% (95% CI 40.4%-53.1%) (A) and 46.9% (95% CI 40.3%-53.5% (B) and an adjusted odds ratio (A vs B) of 0.99 (95% CI 0.68-1.45), p = 0.966.

CONCLUSIONS

Our complex educational intervention, including a clinical outreach visit, had no significant effect on CVR of patients with known hypertension at high risk compared to a simple postal intervention.

TRIAL REGISTRATION

ISRCTN44478543 .

Web-based self-assessment health tools: who are the users and what is the impact of missing input information?

Background

Web-based health applications, such as self-assessment tools, can aid in the early detection and prevention of diseases. However, there are concerns as to whether such tools actually reach users with elevated disease risk (where prevention efforts are still viable), and whether inaccurate or missing information on risk factors may lead to incorrect evaluations.

Objective

This study aimed to evaluate (1) evaluate whether a Web-based cardiovascular disease (CVD) risk communication tool (Heart Age tool) was reaching users at risk of developing CVD, (2) the impact of awareness of total cholesterol (TC), HDL-cholesterol (HDL-C), and systolic blood pressure (SBP) values on the risk estimates, and (3) the key predictors of awareness and reporting of physiological risk factors.

Methods

Heart Age is a tool available via a free open access website. Data from 2,744,091 first-time users aged 21-80 years with no prior heart disease were collected from 13 countries in 2009-2011. Users self-reported demographic and CVD risk factor information. Based on these data, an individual’s 10-year CVD risk was calculated according to Framingham CVD risk models and translated into a Heart Age. This is the age for which the individual’s reported CVD risk would be considered “normal”. Depending on the availability of known TC, HDL-C, and SBP values, different algorithms were applied. The impact of awareness of TC, HDL-C, and SBP values on Heart Age was determined using a subsample that had complete risk factor information.

Results

Heart Age users (N=2,744,091) were mostly in their 20s (22.76%) and 40s (23.99%), female (56.03%), had multiple (mean 2.9, SD 1.4) risk factors, and a Heart Age exceeding their chronological age (mean 4.00, SD 6.43 years). The proportion of users unaware of their TC, HDL-C, or SBP values was high (77.47%, 93.03%, and 46.55% respectively). Lacking awareness of physiological risk factor values led to overestimation of Heart Age by an average 2.1-4.5 years depending on the (combination of) unknown risk factors (P<.001). Overestimation was greater in women than in men, increased with age, and decreased with increasing CVD risk. Awareness of physiological risk factor values was higher among diabetics (OR 1.47, 95% CI 1.46-1.50 and OR 1.74, 95% CI 1.71-1.77), those with family history of CVD (OR 1.22, 95% CI 1.22-1.23 and OR 1.43, 95% CI 1.42-1.44), and increased with age (OR 1.05, 95% CI 1.05-1.05 and OR 1.07, 95% CI 1.07-1.07). It was lower in smokers (OR 0.52, 95% CI 0.52-0.53 and OR 0.71, 95% CI 0.71-0.72) and decreased with increasing Heart Age (OR 0.92, 95% CI 0.92-0.92 and OR 0.97, 95% CI 0.96-0.97) (all P<.001).

Conclusions

The Heart Age tool reached users with low-moderate CVD risk, but with multiple elevated CVD risk factors, and a heart age higher than their real age. This highlights that Web-based self-assessment health tools can be a useful means to interact with people who are at risk of developing disease, but where interventions are still viable. Missing information in the self-assessment health tools was shown to result in inaccurate self-health assessments. Subgroups at risk of not knowing their risk factors are identifiable and should be specifically targeted in health awareness programs.

Ethical issues in cardiovascular risk management

Involving patients in decisions on primary prevention can be questioned from an ethical perspective, due to a tension between health promotion activities and patient autonomy. A nurse-led intervention for prevention of cardiovascular diseases, including counselling (risk communication, and elements of shared decision-making and motivational interviewing) and supportive tools such as a decision aid, was implemented in primary care. The aim of this study was to evaluate the nurse-led intervention from an ethical perspective by exploring in detail the experiences of patients with the intervention, and their views on the role of both the nurse and patient. The study had a qualitative design. 18 patients who had received the intervention participated. Data were gathered by in-depth interviews. The interviews were analysed using directed content analysis. The findings revealed that patients perceived the consultations not as an infringement on their autonomy, but as supportive to risk reduction efforts they tried but found hard to realise. They specifically emphasised the role of the nurse, and appreciated the nurse's realistic advice, encouragement, and help in understanding. Patients' views on and experiences with risk management are in line with notions of relational autonomy, caring cooperation and communicative action found in the literature. We conclude that patients define the relationship with the nurse as shared work in the process of developing a healthier lifestyle.

The "Health Coaching" programme: a new patient-centred and visually supported approach for health behaviour change in primary care

BACKGROUND

Health related behaviour is an important determinant of chronic disease, with a high impact on public health. Motivating and assisting people to change their unfavourable health behaviour is thus a major challenge for health professionals. The objective of the study was to develop a structured programme of counselling in primary care practice, and to test its feasibility and acceptance among general practitioners (GPs) and their patients.

METHODS

Our new concept integrates change of roles, shared responsibility, patient-centredness, and modern communication techniques-such as motivational interviewing. A new colour-coded visual communication tool is used for the purpose of leading through the 4-step counselling process. As doctors' communication skills are crucial, communication training is a mandatory part of the programme. We tested the feasibility and acceptance of the "Health Coaching" programme with 20 GPs and 1045 patients, using questionnaires and semistructured interviewing techniques. The main outcomes were participation rates; the duration of counselling; patients' self-rated behavioural change in their areas of choice; and ratings of motivational, conceptual, acceptance, and feasibility issues.

RESULTS

In total, 37% (n=350) of the patients enrolled in step 1 completed the entire 4-Step counselling process, with each step taking 8-22 minutes. 50% of ratings (n=303) improved by one or two categories in the three-colour circle, and the proportion of favourable health behaviour ratings increased from 9% to 39%. The ratings for motivation, concept, acceptance, and feasibility of the "Health Coaching" programme were consistently high.

CONCLUSIONS

Our innovative, patient-centred counselling programme for health behaviour change was well accepted and feasible among patients and physicians in a primary care setting. Randomised controlled studies will have to establish cost-effectiveness and promote dissemination.

Standards for reporting randomized controlled trials in medical informatics: a systematic review of CONSORT adherence in RCTs on clinical decision support

INTRODUCTION

The Consolidated Standards for Reporting Trials (CONSORT) were published to standardize reporting and improve the quality of clinical trials. The objective of this study is to assess CONSORT adherence in randomized clinical trials (RCT) of disease specific clinical decision support (CDS).

METHODS

A systematic search was conducted of the Medline, EMBASE, and Cochrane databases. RCTs on CDS were assessed against CONSORT guidelines and the Jadad score.

RESULT

32 of 3784 papers identified in the primary search were included in the final review. 181 702 patients and 7315 physicians participated in the selected trials. Most trials were performed in primary care (22), including 897 general practitioner offices. RCTs assessing CDS for asthma (4), diabetes (4), and hyperlipidemia (3) were the most common. Thirteen CDS systems (40%) were implemented in electronic medical records, and 14 (43%) provided automatic alerts. CONSORT and Jadad scores were generally low; the mean CONSORT score was 30.75 (95% CI 27.0 to 34.5), median score 32, range 21-38. Fourteen trials (43%) did not clearly define the study objective, and 11 studies (34%) did not include a sample size calculation. Outcome measures were adequately identified and defined in 23 (71%) trials; adverse events or side effects were not reported in 20 trials (62%). Thirteen trials (40%) were of superior quality according to the Jadad score (≥3 points). Six trials (18%) reported on long-term implementation of CDS.

CONCLUSION

The overall quality of reporting RCTs was low. There is a need to develop standards for reporting RCTs in medical informatics.

Development and pilot of an internationally standardized measure of cardiovascular risk management in European primary care

Background

Primary care can play an important role in providing cardiovascular risk management in patients with established Cardiovascular Diseases (CVD), patients with a known high risk of developing CVD, and potentially for individuals with a low risk of developing CVD, but who have unhealthy lifestyles. To describe and compare cardiovascular risk management, internationally valid quality indicators and standardized measures are needed. As part of a large project in 9 European countries (EPA-Cardio), we have developed and tested a set of standardized measures, linked to previously developed quality indicators.

Methods

A structured stepwise procedure was followed to develop measures. First, the research team allocated 106 validated quality indicators to one of the three target populations (established CVD, at high risk, at low risk) and to different data-collection methods (data abstraction from the medical records, a patient survey, an interview with lead practice GP/a practice survey). Secondly, we selected a number of other validated measures to enrich the assessment. A pilot study was performed to test the feasibility. Finally, we revised the measures based on the findings.

Results

The EPA-Cardio measures consisted of abstraction forms from the medical-records data of established Coronary Heart Disease (CHD)-patients - and high-risk groups, a patient questionnaire for each of the 3 groups, an interview questionnaire for the lead GP and a questionnaire for practice teams. The measures were feasible and accepted by general practices from different countries.

Conclusions

An internationally standardized measure of cardiovascular risk management, linked to validated quality indicators and tested for feasibility in general practice, is now available. Careful development and pilot testing of the measures are crucial in international studies of quality of healthcare.

How do family physicians communicate about cardiovascular risk? Frequencies and determinants of different communication formats

Background

Patients understand information about risk better if it is communicated in numerical or visual formats (e.g. graphs) compared to verbal qualifiers only. How frequently different communication formats are used in clinical primary care settings is unknown.

Methods

We collected socioeconomic and patient understanding data using questionnaires and audio-recorded consultations about cardiovascular disease risk. The frequencies of the communication formats were calculated and multivariate regression analysis of associations between communication formats, patient and general practitioner characteristics, and patient subjective understanding was performed.

Results

In 73% of 70 consultations, verbal qualifiers were used exclusively to communicate cardiovascular risk, compared to numerical (11%) and visual (16%) formats. Female GPs and female patient's gender were significantly associated with a higher use of verbal formats compared to visual formats (p = 0.001 and p = 0.039, respectively). Patient subjective understanding was significantly higher in visual counseling compared to verbal counseling (p = 0.001).

Conclusions

Verbal qualifiers are the most often used communication format, though recommendations favor numerical and visual formats, with visual formats resulting in better understanding than others. Also, gender is associated with the choice of communication format. Barriers against numerical and visual communication formats among GPs and patients should be studied, including gender aspects. Adequate risk communication should be integrated into physicians' education.

Arriba: effects of an educational intervention on prescribing behaviour in prevention of CVD in general practice

Background: Evidence on the effectiveness of educational interventions on prescribing behaviour modification in prevention of cardiovascular disease is still insufficient. We evaluated the effects of a brief educational intervention on prescription of hydroxymethylglutaryl-CoA reductase inhibitors (statins), inhibitors of platelet aggregation (IPA), and antihypertensive agents (AH).

Design: Cluster randomised controlled trial with continuous medical education (CME) groups of general practitioners (GPs).

Methods: Prescription of statins, IPA, and AH were verified prior to study start (BL), immediately after index consultation (IC), and at follow-up after 6 months (FU). Prescription in patients at high risk (>15% risk of a cardiovascular event in 10 years, based on the Framingham equation) and no prescription in low-risk patients (≤ 15%) were considered appropriate.

Results: An intervention effect on prescribing could only be found for IPA. Generally, changes in prescription over time were all directed towards higher prescription rates and persisted to FU, independent of risk status and group allocation.

Conclusions: The active implementation of a brief evidence-based educational intervention on global risk in CVD did not lead directly to risk-adjusted changes in prescription. Investigations on an extended time scale would capture whether decision support of this kind would improve prescribing risk-adjusted sustainably.

What are effective strategies to communicate cardiovascular risk information to patients? A systematic review

OBJECTIVE

To compare different interventions used to communicate cardiovascular risk and assess their impact on patient related outcomes.

METHODS

A systematic search of six electronic data sources from January 1980 to November 2008. Data was extracted from the included studies and a narrative synthesis of the results was conducted.

RESULTS

Fifteen studies were included. Only four studies assessed individuals' actual cardiovascular risk; the rest were analogue studies using hypothetical risk profiles. Heterogeneity in study design and outcomes was found. The results from individual studies suggest that presenting patients with their cardiovascular risk in percentages or frequencies, using graphical representation and short timeframes, is best for achieving risk reduction through behaviour change. However, this summary is tentative and needs further exploration.

CONCLUSION

Better quality trials are needed that compare different risk presentation formats, before conclusions can be drawn as to the most effective ways to communicate cardiovascular risk to patients.

PRACTICE IMPLICATIONS

Instead of directing attention to the accuracy of cardiovascular risk prediction, more should be paid to the effective presentation of risk, to help patients reduce risk by lifestyle change or active treatment.

The reduction of disability in community-dwelling frail older people: design of a two-arm cluster randomized controlled trial

BACKGROUND

Frailty among older people is related to an increased risk of adverse health outcomes such as acute and chronic diseases, disability and mortality. Although many intervention studies for frail older people have been reported, only a few have shown positive effects regarding disability prevention. This article presents the design of a two-arm cluster randomized controlled trial on the effectiveness, cost-effectiveness and feasibility of a primary care intervention that combines the most promising elements of disability prevention in community-dwelling frail older people.

METHODS/DESIGN

In this study twelve general practitioner practices were randomly allocated to the intervention group (6 practices) or to the control group (6 practices). Three thousand four hundred ninety-eight screening questionnaires including the Groningen Frailty Indicator (GFI) were sent out to identify frail older people. Based on their GFI score (≥5), 360 participants will be included in the study. The intervention will receive an interdisciplinary primary care intervention. After a comprehensive assessment by a practice nurse and additional assessments by other professionals, if needed, an individual action plan will be defined. The action plan is related to a flexible toolbox of interventions, which will be conducted by an interdisciplinary team. Effects of the intervention, both for the frail older people and their informal caregivers, will be measured after 6, 12 and 24 months using postal questionnaires and telephone interviews. Data for the process evaluation and economic evaluation will be gathered continuously over a 24-month period.

DISCUSSION

The proposed study will provide information about the usefulness of an interdisciplinary primary care intervention. The postal screening procedure was conducted in two cycles between December 2009 and April 2010 and turned out to be a feasible method. The response rate was 79.7%. According to GFI scores 29.3% of the respondents can be considered as frail (GFI ≥ 5). Nearly half of them (48.1%) were willing to participate. The baseline measurements started in January 2010. In February 2010 the first older people were approached by the practice nurse for a comprehensive assessment. Data on the effect, process, and economic evaluation will be available in 2012.

TRIAL REGISTRATION

ISRCTN31954692.

Adherence and decision AIDS: a model and a narrative review

BACKGROUND

Patient adherence to medication or lifestyle interventions is a serious concern. Interventions to improve adherence exist, but their effects are usually small. Several authors suggested that decision aids may positively affect adherence.

OBJECTIVE

. This presentation examines the role of decision aids in adherence research through development of a model and a narrative review.

METHODS

and

RESULTS

. I: A model was developed to organize pathways relating decision aids and adherence. There is clinical evidence for these pathways, suggesting that decision aids may potentially improve adherence. The model is helpful when considering measures to study decision aids and adherence. II: A narrative review of decision aids and adherence was done. A systematic search resulted in 11 randomized studies. Two studies, both in the hypertension management domain, were positive. Shortcomings were identified regarding the range of adherence measures, the sample size, and the

STUDY DESIGN

It is argued that outcomes for the option "nonadherent" behavior should be described explicitly in the decision aid to inform patients about the costs and benefits of nonadherent behavior.

CONCLUSIONS

. A relation between decision aids and adherence is plausible in view of the psychological and medical literature. A systematic search showed that experimental evidence relating decision aids and adherence is inconclusive. Rigorous trials on this topic are worthwhile. Such trials should employ adequate sample sizes, multiple adherence measures, and a control arm delivering usual care. The decision aid should describe the option "being nonadherent" and its outcomes.

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.

Potential use of 10-year and lifetime coronary risk information for preventive cardiology prescribing decisions: a primary care physician survey

BACKGROUND

Data are sparse regarding how physicians use coronary risk information for prescribing decisions.

METHODS

We presented 5 primary prevention scenarios to primary care physicians affiliated with an academic center and surveyed their responses after they were provided with (1) patient risk factor information, (2) 10-year estimated coronary disease risk information, and (3) 10-year and lifetime risk estimates. We asked about aspirin prescribing, lipid testing, and lipid-lowering drug prescribing.

RESULTS

Of 202 physicians surveyed, 99 (49%) responded. The physicians made guideline-concordant aspirin decisions 51% to 91% of the time using risk factor information alone. Providing 10-year risk estimates increased concordant aspirin prescribing when the 10-year coronary risk was moderately high (15%) and decreased guideline-discordant prescribing when the 10-year risk was low (2 of 4 cases). Providing the lifetime risk information sometimes increased guideline-discordant aspirin prescribing. The physicians selected guideline-concordant thresholds for initiating treatment with lipid-lowering drugs 44% to 75% of the time using risk factor information alone. Selecting too low or too high low-density lipoprotein cholesterol thresholds was common. Ten-year risk information improved concordance when the 10-year risk was moderately high. Providing lifetime risk information increased willingness to initiate pharmacotherapy at low-density lipoprotein cholesterol levels that were lower than those recommended by guidelines when the 10-year risk was low but the lifetime risk was high.

CONCLUSIONS

Providing 10-year coronary risk information improved some hypothetical aspirin-prescribing decisions and improved lipid management when the short-term risk was moderately high. High lifetime risk sometimes led to more intensive prescription of aspirin or lipid-lowering medication. This outcome suggests that, to maximize the benefits of risk-calculating tools, specific guideline recommendations should be provided along with risk estimates.

Improving lifestyle and risk perception through patient involvement in nurse-led cardiovascular risk management: a cluster-randomized controlled trial in primary care

OBJECTIVE

To determine if lifestyle improved at a short term through an intervention to involve patients in cardiovascular risk management by the practice nurse.

METHODS

The IMPALA study (2006, the Netherlands) was a cluster-randomised controlled trial involving 25 general practices and 615 patients who were eligible for cardiovascular risk management. The intervention consisted of (1) individual 10-year cardiovascular risk assessment, (2) risk communication, (3) use of a decision aid and (4) adapted motivational interviewing, applied by practice nurses in two consultations. Outcomes were smoking, alcohol, diet, physical activity and the secondary outcomes risk perception, anxiety, confidence about the decision and satisfaction with the communication, measured at baseline and after 12 weeks.

RESULTS

Patients of both groups improved their lifestyle, but no relevant significant differences between the groups were found. Intervention group patients improved in terms of the appropriateness of risk perception, although not significantly. Intervention group patients improved significantly in terms of appropriateness of anxiety and were more satisfied with the communication compared to control group patients.

CONCLUSION

The intervention seems to have improved the patients' risk perception, anxiety and satisfaction with the communication, which are important conditions for shared decision making. However, we found no additional effect of the intervention on lifestyle.

Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial

BACKGROUND

Preventive guidelines on cardiovascular risk management recommend lifestyle changes. Support for lifestyle changes may be a useful task for practice nurses, but the effect of such interventions in primary prevention is not clear. We examined the effect of involving patients in nurse-led cardiovascular risk management on lifestyle adherence and cardiovascular risk.

METHODS

We performed a cluster randomized controlled trial in 25 practices that included 615 patients. The intervention consisted of nurse-led cardiovascular risk management, including risk assessment, risk communication, a decision aid and adapted motivational interviewing. The control group received a minimal nurse-led intervention. The self-reported outcome measures at one year were smoking, alcohol use, diet and physical activity. Nurses assessed 10-year cardiovascular mortality risk after one year.

RESULTS

There were no significant differences between the intervention groups. The effect of the intervention on the consumption of vegetables and physical activity was small, and some differences were only significant for subgroups. The effects of the intervention on the intake of fat, fruit and alcohol and smoking were not significant. We found no effect between the groups for cardiovascular 10-year risk.

INTERPRETATION

Nurse-led risk communication, use of a decision aid and adapted motivational interviewing did not lead to relevant differences between the groups in terms of lifestyle changes or cardiovascular risk, despite significant within-group differences.

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Background

Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.

Objectives

Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.

Selection criteria

Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.

Outcome measure

Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.

Data collection and analysis

An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.

Main results

The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.

Conclusions

Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.

A novel programme to evaluate and communicate 10-year risk of CHD reduces predicted risk and improves patients' modifiable risk factor profile

AIMS

We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease (CHD) risk could lower patients' predicted Framingham CHD risk vs. usual care.

METHODS

The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospective, controlled, cluster-randomised trial in nine European countries, among patients at moderate cardiovascular risk. Following baseline assessments, physicians in the intervention group calculated patients' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme. Usual care physicians did not calculate patients' risk and provided usual care only. The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care.

RESULTS

Of 1103 patients across 100 sites, 524 patients receiving intervention, and 461 receiving usual care, were analysed for efficacy. After 6 months, mean predicted risks were 12.5% with intervention, and 13.7% with usual care [odds ratio = 0.896; p = 0.001, adjusted for risk at baseline (17.2% intervention; 16.9% usual care) and other covariates]. The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention (25.4%) than usual care (14.1%; p < 0.001), and 29.3% of smokers in the intervention group quit smoking vs. 21.4% of those receiving usual care (p = 0.04).

CONCLUSIONS

A physician-implemented CHD risk evaluation/communication programme improved patients' modifiable risk factor profile, and lowered predicted CHD risk compared with usual care. By combining this strategy with more intensive treatment to reduce residual modifiable risk, we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice.

Patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases in primary care

OBJECTIVE

Assessment of patients' responsiveness to a decision support tool for primary prevention of cardiovascular diseases (CVDs). The booklet focuses on barriers at patient level.

METHODS

Process evaluation of an intervention in primary care. Patients at high or potentially high-cardiovascular risk were asked by their GP to prepare themselves for a second consultation in order to participate in decisions on risk management.

OUTCOMES

Patients' actually having read the booklet and returning for the second consultation; comprehension and perceived relevance of the information; perceived reassurance.

RESULTS

17 GPs, in the intervention arm of a cluster RCT, issued 276 decision support tools during the first consultation and were instructed to ask them to return for a second consultation to discuss their CVD risk. Patients had a mean age of 54 years, 47% were male and 19% actually had a high cardiovascular risk. Data on 239 patients, a mixture of returnees and non-returnees, showed that they all read the booklet; comprehension was fair to good; 85% perceived the information as relevant; 68% of the patients felt reassured by the information. Satisfaction with the first consultation was higher in the non-returnees.

CONCLUSIONS

Cardiovascular prevention spread over two consultations with use of a decision support tool for patients is not easily applicable for GPs. However, based on the findings of good patients' responsiveness, we recommend further development and implementation of decision support tools in primary care.

PRACTICE IMPLICATIONS

Decision support for primary CV-prevention is welcomed by patients but needs further adjustment of both the GP and the organization of CV-prevention in primary care. Sharing information between professional and patient on a personal CV-risk management plan is difficult, more training is needed.

CRISTOPH - a cluster-randomised intervention study to optimise the treatment of patients with hypertension in General Practice

Background

Recent guidelines for the management of hypertension focus on treating patients according to their global cardiovascular risk (CVR), rather than strictly keeping blood pressure, or other risk factors, below set limit values. The objective of this study is to compare the effect of a simple versus a complex educational intervention implementing this new concept among General Practitioners (GPs).

Methods/design

A prospective longitudinal cluster-randomised intervention trial with 94 German GPs consecutively enroling 40 patients each with known hypertension. All GPs then received a written manual specifically developed to transfer the global concept of CVR into daily General Practice. After cluster-randomisation, half of the GPs additionally received a clinical outreach visit, with a trained peer discussing with them the concept of global CVR referring to example study patients from the respective GP. Main outcome measure is the improvement of calculated CVR six months after intervention in the subgroup of patients with high CVR (but no history of cardiovascular disease), defined as 10-year-mortality ≥ 5% employing the European SCORE formula. Secondary outcome measures include the intervention's effect on single risk factors, and on prescription rates of drugs targeting CVR. All outcome measures are separately studied in the three subgroups of patients with 1. high CVR (defined as above), 2. low CVR (SCORE < 5%), and 3. a history of cardiovascular disease. The influence of age, sex, social status, and the perceived quality of the respective doctor-patient-relation on the effects will be examined.

Discussion

To our knowledge, no other published intervention study has yet evaluated the impact of educating GPs with the goal to treat patients with hypertension according to their global cardiovascular risk.

Trial registration

ISRCTN44478543

Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial

PURPOSE

We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease (CVD) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations.

METHODS

The study was based on a pragmatic, cluster randomized controlled trial (phase III) with continuing medical education (CME) groups of family physicians as the unit of randomization. In the intervention arm, 44 physicians (7 CME groups) consecutively recruited 550 patients in whom cholesterol levels were measured. Forty-seven physicians in the control arm (7 CME groups) similarly included 582 patients. Four hundred sixty patients (83.6%) of the intervention arm and 466 patients (80.1%) of the control arm were seen at follow-up. Physicians attended 2 interactive CME sessions and received a booklet, a paper-based risk calculator, and individual summary sheets for each patient. Control physicians attended 1 CME-session on an alternative topic. Main outcome measures were patient satisfaction and participation after the index consultation, change in CVD risk status, and decisional regret at 6 months' follow-up.

RESULTS

Intervention patients were significantly more satisfied with process and result (Patient Participation Scale, difference 0.80, P<.001). Decisional regret was significantly lower at follow-up (difference 3.39, P = .02). CVD risk decreased in both groups without a significant difference between study arms.

CONCLUSION

A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret, without negatively affecting global CVD risk.

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.

Translating shared decision-making into health care clinical practices: proof of concepts

BACKGROUND

There is considerable interest today in shared decision-making (SDM), defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal is to bring together the resources and the expertise needed to develop an interdisciplinary and international research team on the implementation of SDM in clinical practice using a theory-based dyadic perspective.

METHODS

Participants include researchers from Canada, US, UK, and Netherlands, representing medicine, nursing, psychology, community health and epidemiology. In order to develop a collaborative research network that takes advantage of the expertise of the team members, the following research activities are planned: 1) establish networking and on-going communication through internet-based forum, conference calls, and a bi-weekly e-bulletin; 2) hold a two-day workshop with two key experts (one in theoretical underpinnings of behavioral change, and a second in dyadic data analysis), and invite all investigators to present their views on the challenges related to the implementation of SDM in clinical practices; 3) conduct a secondary analyses of existing dyadic datasets to ensure that discussion among team members is grounded in empirical data; 4) build capacity with involvement of graduate students in the workshop and online forum; and 5) elaborate a position paper and an international multi-site study protocol.

DISCUSSION

This study protocol aims to inform researchers, educators, and clinicians interested in improving their understanding of effective strategies to implement shared decision-making in clinical practice using a theory-based dyadic perspective.

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

BACKGROUND

Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management.

METHODS

A cluster-randomised controlled trial in 20 general practices, 10 practices in the intervention arm and 10 in the control arm, starting on October 2005. A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited. In both arms, the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management. Nurses in the intervention arm will receive an extended training in risk assessment, risk communication, the use of a decision aid and adapted motivational interviewing. This communication technique will be used to support the shared decision-making process about risk reduction. The intervention comprises 2 consultations and 1 follow-up telephone call. The nurses in the control arm will give usual care after the risk estimation, according to the national guideline. Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment. Secondary outcome measures are the patients' perception of risk and their motivation to change their behaviour. The measurements will take place at baseline and after 12 and 52 weeks. Clinical endpoints will not be measured, but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year.

DISCUSSION

The combined use of risk communication, a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51556722.

Primary Prevention of Cardiovascular Diseases in General Practice: Mismatch between Cardiovascular Risk and Patients' Risk Perceptions

Objective. Guidelines on primary prevention of cardiovascular disease (CVD) emphasize identifying high-risk patients for more intensive management, but patients' misconceptions of risk hamper implementation. Insight is needed into the type of patients that general practitioners (GPs) encounter in their cardiovascular prevention activities. How appropriate are the risk perceptions and worries of patients with whom GPs discuss CVD risks? What determines inappropriate risk perception? Method. Cross-sectional study in 34 general practices. The study included patients aged 40 to 70 years with whom CVD risk was discussed during consultation. After the consultation, the GPs completed a registration form, and patients completed a questionnaire. Correlations between patients' actual CVD risk and risk perceptions were analyzed. Results. In total, 490 patients were included. In 17% of the consultations, patients were actually at high risk. Risk was perceived inappropriately by nearly 4 in 5 high-risk patients (incorrect optimism) and by 1 in 5 low-risk patients (incorrect pessimism). Smoking, hypertension, and obesity were determinants of perceiving CVD risk as high, whereas surprisingly, diabetic patients did not report any anxiety about their CVD risk. Men were more likely to perceive their CVD risk inappropriately than women. Conclusion. In communicating CVD risk, GPs must be aware that they mostly encounter low-risk patients and that the perceived risk and worry do not necessarily correspond with the actual risk. Incorrect perceptions of CVD risk among men and patients with diabetes were striking.

Shared decision-making in the Netherlands--current state and future perspectives

Dutch government policy is aimed at introducing regulated competition among health care providers and among health care insurers and at empowering patients for being involved in decision-making in health care. Along with this, many Dutch organisations have been created to foster patient orientation within health care and increase patients' power for medical decision-making. The challenge is to deliver reliable and well-balanced information for patients and the public, eg. in patient-tailored web-based formats. The approach of patient participation in medical decision-making has been formally defined in a specific law (WGBO), and the principle of recognising the patient's view is increasingly reflected in the national guidelines for health care professionals. The theme of patient participation in medical decision making is a fairly widespread research topic theme in the Netherlands, including mutual exchange among the researchers in a vivid network. The real bottleneck is perhaps the implementation of patient participation into professional practice. Some recommendations for facilitating a change are made.