Effectiveness of programme for reducing cardiovascular risk for men in one general practice

Menˈs health: whatˈs a GP to do?

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.

[Effectiveness of cardiovascular prevention in primary care]

OBJECTIVES

To evaluate the modification of risk factors and of coronary risk (CR) in adults (14-75 years old) after a period of 1 to 5 years in the PAPPS (special prevention programme).

DESIGN

Multi-centre intervention study with no before-and-after random allocation.

SETTING

Primary care.

PARTICIPANTS

Patients included in the PAPPS at 3 health centres, 634 monitored for five years, 890 for four years, 1605 for 3 years and 2829 for 2 years, were evaluated.Interventions. Minimum counselling to give up tobacco and over-consumption of alcohol, and educational and pharmacological measures to reduce cholesterol and blood pressure.

MAIN MEASUREMENTS

Recording of blood pressure, cholesterol, weight, and tobacco and alcohol consumption. CR was determined in the sub-group of 30-75 years old. These variables were determined at the start and end of the various monitoring periods.

RESULTS

CR was reduced by between 0.2 and 0.3%; systolic blood pressure, by between 0.4 and 0.9 mmHg; diastolic pressure, by between 0.3 and 0.7 mmHg; cholesterol, by between 0.5 and 2.5 mg/dl; percentage of smokers, by between 0.3 and 2.8%; and over-consumption of alcohol, by between 0.2 and 1%.

CONCLUSIONS

Scant success of the interventions to reduce CR and risk factors in the population as a whole. The main use of cardiovascular prevention programmes with many factors resides in detecting high-risk patients for subsequent intervention.

[Effectiveness of preventive activities at 8 years of their introduction in a general medicine practice in a health center]

OBJECTIVES

Main: to assess the change in coronary risk (CR) in adults after 8 years of their involvement in the Programme of Preventive Activities and Health Promotion (PAPPS). Secondary: to determine the level of anti-tetanus vaccination reached and patients' compliance with activities.

DESIGN

"Before and after" intervention study without random allocation.

SETTING

A general medical clinic at a health centre.

PATIENTS

429 patients (204 men, 225 women) between 30 and 65 monitored for 8 years, recruited by active search for cases at daily consultations.

INTERVENTIONS

Blood pressure, cholesterol, weight, tobacco habit, alcohol intake, anti-tetanus vaccination state, CR calculation at 10 years on the Framingham scale, and degree of compliance with activities were all determined at the start, at 4 years and at 8 years. Data was obtained from the clinical notes.

RESULTS

Total population: a 0.8 drop in CR (CI difference: 0.4-1.2), equivalent to 8.5% of the initial figure. 64.4% increase in correct anti-tetanus vaccination (CI difference: 59.9-69). Compliance with activities at the start and after eight years: pressure 100%, 71%; tobacco consumption 99.5%, 71%; cholesterol determination 89%, 64%. Initially high CR sub-group: 6.7 drop of CR at 8 years (CI difference: 4.9-8.5), equivalent to 24.8% of the initial figure.

CONCLUSIONS

In the total population, the CR drop found was not clinically significant, whereas in the initially high CR sub-group the drop was. There should probably be an active search made for patients with high CR and action taken on them.

A review of recent dietary intervention trials in the United Kingdom to reduce blood cholesterol levels

A review of 14 UK studies conducted between 1980 and January 1997 showed that blood cholesterol levels can be reduced through screening followed by dietary and behavioural intervention in both general population and high risk individuals (hyperlipidaemic and angina patients). In most studies cholesterol levels were lowered moderately while changes in other risk factors were also in a positive direction. However, it is unclear whether the cholesterol reductions are sufficiently large to have a significant impact in lowering the risk of heart disease in the whole population.

Comparison between two programmes for reducing the levels of risk indicators of heart diseases among male professional drivers

OBJECTIVES

To compare two programmes for reducing the levels of risk indicators of heart diseases among professional drivers. The programmes were focused on changes of lifestyle. The aim of the programmes was to initiate and motivate a process of change within the driver, which in the long term should lead to permanent and sound health habits. One programme was based on health profile assessment and the other was a health examination.

METHODS

Altogether, 102 subjects were investigated (51 allocated to an intervention group and 51 to a reference group). The programme in the intervention group (health profile assessment) was based on revelatory communication, adjusted to the driver and contained individual and group activities. The reference group went through a health examination. In both groups blood pressure, serum lipid concentrations, body mass index, and estimated maximal oxygen uptake were measured and the lifestyle habits were surveyed by questionnaires at the start and at follow ups of 6 and 18 months.

RESULTS

The results showed that in the intervention group the maximal oxygen uptake increased, as did exercise habits and the intention to practice good dietary habits. Variable working hours was the most common obstacle to change a health habit. In the reference group the maximal oxygen uptake increased and the concentration of serum total cholesterol and the number of people who perceived stress and loneliness decreased.

CONCLUSIONS

Both the health profile assessment and the health examination had an effect on the levels of some risk indicators of heart diseases. Both programmes turned out to be useful because of high participation during the entire period and a generally positive attitude among the subjects.

Broadening the evidence base for evidence-based guidelines. A research agenda based on the work of the U.S. Preventive Services Task Force

Evidence-based evaluations of clinical preventive services help define priorities for research in prevention as part of primary health care. In this article, we draw on our experiences with the U.S. Preventive Services Task Force (USPSTF) to outline some major areas where research is needed to define the appropriate use of specific screening tests, counseling interventions, immunizations, and chemoprophylaxis. Areas of particular importance included research to: (1) Identify effective and practical primary care interventions for modifying personal health practices of patients, especially around issues such as diet, exercise, alcohol and drug use, and risky sexual behavior; (2) Clarify the optimal periodicity for certain screening tests and counseling interventions; (3) Identify practical ways to allow patients to share decision-making about preventive care, especially for services of possible but uncertain benefit; (4) Examine the most sensitive and efficient ways to identify high-risk groups who may need different services than the average population; and (5) Expand the use of decision-analysis and cost-effectiveness analysis to help identify optimal use of clinical preventive services. Given the difficulty of large, prospective trials, we discuss the use of alternative research designs to fill in critical gaps in the evidence for the effectiveness of specific services. Finally, we note several issues of increasing importance that may need to be addressed by future work of the USPSTF: what are the most reliable and effective ways to (1) measure and (2) improve the delivery and quality of preventive care provided in the primary care setting.

Intensive cardiovascular risk factor intervention in a rural practice: a glimmer of hope?

BACKGROUND

Large trials of primary care-based health promotion to modify coronary heart disease risks have shown only modest benefits. Could more intensive intervention, with doctors sharing with practice nurses in health promotion, produce better health outcomes in the context of the small family practice? How cost-effective might these interventions be?

AIM

To assess the cost-effectiveness of an intensive programme of coronary heart disease (CHD) risk factor modification in a rural general practice in which doctors had a major input.

METHOD

A longitudinal study of changes in risk factors in a group of adult patients identified as having one or more major CHD risk factor and monitored for one to seven years. Patients were recruited from and followed up in health promotion clinics, routine practice nurse appointments, or routine doctors' surgeries. All received the practice's routine interventions to modify risk, and changes in risk factors were recorded. Time spent by members of the primary health care team on CHD health promotion was recorded over a two-year period.

RESULTS

From a practice list of 2040, 760 patients with one or more CHD risk factors were identified and followed up over a mean of 3.61 years (range six months to seven years). Significant improvements in each of the risk factors occurred, except in body mass index (BMI). Mean Dundee risk scores fell from 7.4 to 5.7 (by 23.3%). The annual cost to the practice (including doctor/nurse/secretarial time plus sundry practice expenses and laboratory costs, but excluding drug costs) was 6000 pounds. Cost per coronary death prevented was calculated as approximately 10,000 pounds.

CONCLUSION

The results show an effect on risk factors broadly similar but slightly greater in magnitude than that achieved in the OXCHECK and British Family Heart Studies of nurse-delivered risk factor intervention in primary care. The results suggest that more intensive effort in lifestyle modification and health promotion, with more active involvement of doctors, could produce significant additional benefit. The cost-effectiveness of this approach compares favourably with many other accepted measures in coronary heart disease prevention.

Nutrition screening in old people: its place in a coherent practice of preventive health care

The central demographic reality of our times is the rapid aging of our society. Preventive nutritional and preventive health care of older people, therefore, are pressing issues that must be contended with. Several strategies for this are possible, including the broadcasting of general nutritional and health messages to the population, the inclusion of preventive nutrition and health as part of routine primary care, and nutrition screening: a process of self-identification by the older population in which they judge for themselves whether they are at nutritional risk and, if so, seek the care of professionals. This review focuses on some of the necessities for screening: sensitive, specific, and inexpensively applied screening devices; and explicit interventions that do not have major public health benefit for those who screen negative. Unfortunately, there is little evidence that screening is beneficial, nor have the benefits of this strategy been compared with its alternatives. Thus, the ethical imperative of screening has not been met: that because the activity is being promoted (it is not initiated by the public), its benefit must be conclusive.

Health promotion in primary health care: the situation in England

National policy, including changes to the management of the National Health Service, is intended to increase the amount of primary and secondary prevention in primary health care in England. The growth of financial power of general practitioners makes them key decision-makers in planning and delivering health promotion. The vast majority of people in contact with their family doctor could benefit from making appropriate lifestyle modifications. However, the level and quality of health promotion activity in primary care is variable, with many patients not receiving interventions. A review of research indicates that both skepticism about the relationship between behaviour and risk factor, and lack of confidence in efficacy of health promotion in changing patient behaviour act as barriers to general practitioners taking on more health promotion activity. For prevention work to increase, therefore, general practitioners require more evidence of effective replicable interventions, and appropriate training on the design and implementation of programmes. The role of the Health Education Authority, the national agency for health promotion in England, in meeting these needs is described. The paper also includes a brief discussion of evaluation methods for assessing the success of health promotion interventions.

Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk

OBJECTIVE

To assess the value of health education for patients with angina in reducing risk factors for cardiovascular disease and lessening the effect of angina on everyday activities.

DESIGN

Randomised controlled trial of personal health education given every four months.

SETTING

18 general practices in the greater Belfast area.

SUBJECTS

688 patients aged less than 75 years and known to have had angina for at least six months; 342 randomised to receive education and 346 to no education.

MAIN OUTCOME MEASURES

Restriction of everyday activities, dietary habit, smoking habit, frequency of physical exercise; blood pressure, body mass index, and serum total cholesterol concentration at entry to trial and after two years.

RESULTS

317 in the intervention group and 300 in the control group completed the trial. At the two year review more of the intervention group (140, 44%) reported taking daily physical exercise than the control group (70, 24%). The intervention group also reported eating a healthier diet than the control group and less restriction by angina in any everyday activity. No significant differences were found between the groups in smoking habit, systolic or diastolic blood pressure, cholesterol concentration, or body mass index.

CONCLUSION

Despite having no significant effect on objective cardiovascular risk factors, personal health education of patients with angina seems to increase exercise and improve dietary habits and is effective in lessening the restriction of everyday activities.

General practice

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Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Imperial Cancer Research Fund OXCHECK Study Group

OBJECTIVE

To assess the effectiveness of health checks by nurses in reducing risk factors for cardiovascular disease in patients from general practice.

DESIGN

Randomised controlled trial.

SETTING

Five urban general practices in Bedfordshire.

SUBJECTS

2136 patients receiving an initial health check in 1989-91 and scheduled to be re-examined one year later in 1990-2 (intervention group); 3988 patients receiving an initial health check in 1990-2 (control group). All patients were aged 35-64 years at recruitment in 1989.

MAIN OUTCOME MEASURES

Serum total cholesterol concentration, blood pressure, body mass index, confirmed smoking cessation.

RESULTS

Mean serum total cholesterol was 2.3% lower in the intervention group than in the controls (difference 0.14 mmol/l (95% confidence interval 0.08 to 0.20)); the difference was greater in women (3.2%, P < 0.0001) than men (1.0%, P = 0.18). There was no significant difference in smoking prevalence, quit rates, or body mass index. Systolic and diastolic blood pressure were 2.5% and 2.4% lower respectively in the intervention group. The proportion of patients with diastolic blood pressure > or = 100 mm Hg was 2.6% (55/2131) in the intervention group and 3.4% (137/3987) in the controls (difference 0.9% (0.0 to 1.7)); the proportion with total cholesterol concentration > or = 8 mmol/l 4.8% (100/2068) and 7.6% (295/3905) (difference 2.7% (1.5 to 4.0)); and that with body mass index > or = 30 12.4% (264/2125) and 14.0% (559/3984) (difference 1.6% (-0.2 to 3.4)).

CONCLUSIONS

General health checks by nurses are ineffective in helping smokers to stop smoking, but they help patients to modify their diet and total cholesterol concentration. The public health importance of this dietary change depends on whether it is sustained.

Measurement and management of cardiovascular risk factors--is screening worthwhile?

Coronary heart disease has been described as Scotland's national disease and ways of reducing its incidence are therefore of paramount importance especially in younger males. A recent British Medical Journal paper has indicated that general practitioners can make little impact on patients' lifestyles. This paper shows that a cohort of Scottish men (Social Class III-V) responded well (80%) to offers of screening for risk factors of CHD, continued to attend for review and showed highly significant changes in their risk factor profiles. A committed enthusiastic primary care team have shown the potential for reducing coronary risk factors in so-called healthy men.