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Barkas F, Sener YZ, Golforoush PA, Kheirkhah A, Rodriguez-Sanchez E, Novak J, Apellaniz-Ruiz M, Akyea RK, Bianconi V, Ceasovschih A, Chee YJ, Cherska M, Chora JR, D'Oria M, Demikhova N, Kocyigit Burunkaya D, Rimbert A, Macchi C, Rathod K, Roth L, Sukhorukov V, Stoica S, Scicali R, Storozhenko T, Uzokov J, Lupo MG, van der Vorst EPC, Porsch F. Advancements in risk stratification and management strategies in primary cardiovascular prevention. Atherosclerosis 2024; 395:117579. [PMID: 38824844 DOI: 10.1016/j.atherosclerosis.2024.117579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 06/04/2024]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of morbidity and mortality worldwide, highlighting the urgent need for advancements in risk assessment and management strategies. Although significant progress has been made recently, identifying and managing apparently healthy individuals at a higher risk of developing atherosclerosis and those with subclinical atherosclerosis still poses significant challenges. Traditional risk assessment tools have limitations in accurately predicting future events and fail to encompass the complexity of the atherosclerosis trajectory. In this review, we describe novel approaches in biomarkers, genetics, advanced imaging techniques, and artificial intelligence that have emerged to address this gap. Moreover, polygenic risk scores and imaging modalities such as coronary artery calcium scoring, and coronary computed tomography angiography offer promising avenues for enhancing primary cardiovascular risk stratification and personalised intervention strategies. On the other hand, interventions aiming against atherosclerosis development or promoting plaque regression have gained attention in primary ASCVD prevention. Therefore, the potential role of drugs like statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, omega-3 fatty acids, antihypertensive agents, as well as glucose-lowering and anti-inflammatory drugs are also discussed. Since findings regarding the efficacy of these interventions vary, further research is still required to elucidate their mechanisms of action, optimize treatment regimens, and determine their long-term effects on ASCVD outcomes. In conclusion, advancements in strategies addressing atherosclerosis prevention and plaque regression present promising avenues for enhancing primary ASCVD prevention through personalised approaches tailored to individual risk profiles. Nevertheless, ongoing research efforts are imperative to refine these strategies further and maximise their effectiveness in safeguarding cardiovascular health.
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Affiliation(s)
- Fotios Barkas
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
| | - Yusuf Ziya Sener
- Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Azin Kheirkhah
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elena Rodriguez-Sanchez
- Division of Cardiology, Department of Medicine, Department of Physiology, and Molecular Biology Institute, UCLA, Los Angeles, CA, USA
| | - Jan Novak
- 2(nd) Department of Internal Medicine, St. Anne's University Hospital in Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic; Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Maria Apellaniz-Ruiz
- Genomics Medicine Unit, Navarra Institute for Health Research - IdiSNA, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Ralph Kwame Akyea
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, United Kingdom
| | - Vanessa Bianconi
- Department of Medicine and Surgery, University of Perugia, Italy
| | - Alexandr Ceasovschih
- Internal Medicine Department, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Ying Jie Chee
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Mariia Cherska
- Cardiology Department, Institute of Endocrinology and Metabolism, Kyiv, Ukraine
| | - Joana Rita Chora
- Unidade I&D, Grupo de Investigação Cardiovascular, Departamento de Promoção da Saúde e Doenças Não Transmissíveis, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal; Universidade de Lisboa, Faculdade de Ciências, BioISI - Biosystems & Integrative Sciences Institute, Lisboa, Portugal
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Nadiia Demikhova
- Sumy State University, Sumy, Ukraine; Tallinn University of Technology, Tallinn, Estonia
| | | | - Antoine Rimbert
- Nantes Université, CNRS, INSERM, l'institut du Thorax, Nantes, France
| | - Chiara Macchi
- Department of Pharmacological and Biomolecular Sciences "Rodolfo Paoletti", Università Degli Studi di Milano, Milan, Italy
| | - Krishnaraj Rathod
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Lynn Roth
- Laboratory of Physiopharmacology, University of Antwerp, Antwerp, Belgium
| | - Vasily Sukhorukov
- Laboratory of Cellular and Molecular Pathology of Cardiovascular System, Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - Svetlana Stoica
- "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania; Institute of Cardiovascular Diseases Timisoara, Timisoara, Romania
| | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Tatyana Storozhenko
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Prevention and Treatment of Emergency Conditions, L.T. Malaya Therapy National Institute NAMSU, Kharkiv, Ukraine
| | - Jamol Uzokov
- Republican Specialized Scientific Practical Medical Center of Therapy and Medical Rehabilitation, Tashkent, Uzbekistan
| | | | - Emiel P C van der Vorst
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH Aachen University, 52074, Aachen, Germany; Aachen-Maastricht Institute for CardioRenal Disease (AMICARE), RWTH Aachen University, 52074, Aachen, Germany; Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-University Munich, 80336, Munich, Germany; Interdisciplinary Center for Clinical Research (IZKF), RWTH Aachen University, 52074, Aachen, Germany
| | - Florentina Porsch
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
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Starnecker F, Reimer LM, Nissen L, Jovanović M, Kapsecker M, Rospleszcz S, von Scheidt M, Krefting J, Krüger N, Perl B, Wiehler J, Sun R, Jonas S, Schunkert H. Guideline-Based Cardiovascular Risk Assessment Delivered by an mHealth App: Development Study. JMIR Cardio 2023; 7:e50813. [PMID: 38064248 PMCID: PMC10746971 DOI: 10.2196/50813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Identifying high-risk individuals is crucial for preventing cardiovascular diseases (CVDs). Currently, risk assessment is mostly performed by physicians. Mobile health apps could help decouple the determination of risk from medical resources by allowing unrestricted self-assessment. The respective test results need to be interpretable for laypersons. OBJECTIVE Together with a patient organization, we aimed to design a digital risk calculator that allows people to individually assess and optimize their CVD risk. The risk calculator was integrated into the mobile health app HerzFit, which provides the respective background information. METHODS To cover a broad spectrum of individuals for both primary and secondary prevention, we integrated the respective scores (Framingham 10-year CVD, Systematic Coronary Risk Evaluation 2, Systematic Coronary Risk Evaluation 2 in Older Persons, and Secondary Manifestations Of Arterial Disease) into a single risk calculator that was recalibrated for the German population. In primary prevention, an individual's heart age is estimated, which gives the user an easy-to-understand metric for assessing cardiac health. For secondary prevention, the risk of recurrence was assessed. In addition, a comparison of expected to mean and optimal risk levels was determined. The risk calculator is available free of charge. Data safety is ensured by processing the data locally on the users' smartphones. RESULTS Offering a risk calculator to the general population requires the use of multiple instruments, as each provides only a limited spectrum in terms of age and risk distribution. The integration of 4 internationally recommended scores allows risk calculation in individuals aged 30 to 90 years with and without CVD. Such integration requires recalibration and harmonization to provide consistent and plausible estimates. In the first 14 months after the launch, the HerzFit calculator was downloaded more than 96,000 times, indicating great demand. Public information campaigns proved effective in publicizing the risk calculator and contributed significantly to download numbers. CONCLUSIONS The HerzFit calculator provides CVD risk assessment for the general population. The public demonstrated great demand for such a risk calculator as it was downloaded up to 10,000 times per month, depending on campaigns creating awareness for the instrument.
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Affiliation(s)
- Fabian Starnecker
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
| | - Lara Marie Reimer
- School for Computation, Information and Technology, Technical University of Munich, Munich, Germany
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Leon Nissen
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Marko Jovanović
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Maximilian Kapsecker
- School for Computation, Information and Technology, Technical University of Munich, Munich, Germany
| | - Susanne Rospleszcz
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
- Institute of Epidemiology, Helmholtz Zentrum München German Research Center for Environmental Health (GmbH), Neuherberg, Germany
- Chair of Epidemiology, Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
| | - Moritz von Scheidt
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
| | - Johannes Krefting
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
| | - Nils Krüger
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
| | - Benedikt Perl
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Jens Wiehler
- BioM Biotech Cluster Development GmbH - BioM, Munich, Germany
| | - Ruoyu Sun
- BioM Biotech Cluster Development GmbH - BioM, Munich, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Heribert Schunkert
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
- Partner Site Munich Heart Alliance, German Center for Cardiovascular Disease (Deutsches Zentrum für Herz-Kreislauf-Forschung eV), Munich, Germany
- Medical Graduate Center, Technical University of Munich, Munich, Germany
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Christoffersen NB, Nilou FE, Thilsing T, Larsen LB, Østergaard JN, Broholm-Jørgensen M. Exploring targeted preventive health check interventions - a realist synthesis. BMC Public Health 2023; 23:1928. [PMID: 37798691 PMCID: PMC10557298 DOI: 10.1186/s12889-023-16861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Preventive health checks are assumed to reduce the risk of the development of cardio-metabolic disease in the long term. Although no solid evidence of effect is shown on health checks targeting the general population, studies suggest positive effects if health checks target people or groups identified at risk of disease. The aim of this study is to explore why and how targeted preventive health checks work, for whom they work, and under which circumstances they can be expected to work. METHODS The study is designed as a realist synthesis that consists of four phases, each including collection and analysis of empirical data: 1) Literature search of systematic reviews and meta-analysis, 2) Interviews with key-stakeholders, 3) Literature search of qualitative studies and grey literature, and 4) Workshops with key stakeholders and end-users. Through the iterative analysis we identified the interrelationship between contexts, mechanisms, and outcomes to develop a program theory encompassing hypotheses about targeted preventive health checks. RESULTS Based on an iterative analysis of the data material, we developed a final program theory consisting of seven themes; Target group; Recruitment and participation; The encounter between professional and participants; Follow-up activities; Implementation and operation; Shared understanding of the intervention; and Unintended side effects. Overall, the data material showed that targeted preventive health checks need to be accessible, recognizable, and relevant for the participants' everyday lives as well as meaningful to the professionals involved. The results showed that identifying a target group, that both benefit from attending and have the resources to participate pose a challenge for targeted preventive health check interventions. This challenge illustrates the importance of designing the recruitment and intervention activities according to the target groups particular life situation. CONCLUSION The results indicate that a one-size-fits-all model of targeted preventive health checks should be abandoned, and that intervention activities and implementation depend on for whom and under which circumstances the intervention is initiated. Based on the results we suggest that future initiatives conduct thorough needs assessment as the basis for decisions about where and how the preventive health checks are implemented.
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Affiliation(s)
- Nanna Bjørnbak Christoffersen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Freja Ekstrøm Nilou
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Trine Thilsing
- Research Unit of General Practice, University of Southern, Odense, Denmark
| | - Lars Bruun Larsen
- Research Unit of General Practice, University of Southern, Odense, Denmark
- Steno Diabetes Center Zealand, Holbæk, Denmark
| | | | - Marie Broholm-Jørgensen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
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Skjødt MK, Nicolaes J, Smith CD, Olsen KR, Cooper C, Libanati C, Abrahamsen B. Fracture Risk in Men and Women With Vertebral Fractures Identified Opportunistically on Routine Computed Tomography Scans and Not Treated for Osteoporosis: An Observational Cohort Study. JBMR Plus 2023; 7:e10736. [PMID: 37197322 PMCID: PMC10184021 DOI: 10.1002/jbm4.10736] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/26/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Vertebral fractures (VFs) have been associated with future fractures, yet few studies have evaluated whether this pertains to VFs available for identification on routine radiological imaging. We sought to evaluate the risk of subsequent fractures in subjects with VF identified opportunistically on computed tomography (CT) scans performed as part of routine clinical practice. From the radiology database of Holbæk Hospital we identified the first CT scan including the thorax and/or abdomen of 2000 consecutive men and women aged 50 years or older, performed from January 1, 2010 onward. The scans were assessed in a blinded approach to identify chest and lumbar VF, and these data linked to national Danish registers. Subjects were excluded if treated with an osteoporosis medication (OM) in the year prior to baseline (date of CT), and the remaining subjects with VF matched on age and sex in 1:2 ratio against subjects with no VF. We found that the risk of major osteoporotic fractures (hip, non-cervical vertebral, humerus, and distal forearm fractures) was higher for subjects with VF than without VF: incidence rates (IRs) were 32.88 and 19.59 fractures per 1000 subject-years, respectively, and the adjusted hazard ratio (HRadj) was 1.72 (95% confidence interval [CI], 1.03-2.86). Subsequent hip fracture IRs were 16.75 and 6.60; HRadj 3.02 (95% CI, 1.39-6.55). There were no significant differences in other fracture outcomes (including a pooled estimate of any subsequent fracture, except face, skull, and fingers: IRs 41.52 and 31.38; HRadj 1.31 [95% CI, 0.85-2.03]). Our findings suggest that subjects undergoing routine CT scans including the chest and/or abdomen are a high risk population in terms of fracture risk. Even within this group, subjects with VF are at higher risk of future major osteoporotic fracture (MOF), in particular hip fracture. Hence, systematic opportunistic screening for VF and subsequent fracture risk management is important to reduce the risk of new fractures. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Michael Kriegbaum Skjødt
- Department of MedicineHolbæk HospitalHolbækDenmark
- OPEN—Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern Denmark and Odense University HospitalOdenseDenmark
| | - Joeri Nicolaes
- UCB PharmaBrusselsBelgium
- Medical Image Computing, ESAT‐PSI, Department of Electrical EngineeringKU LeuvenLeuvenBelgium
| | - Christopher Dyer Smith
- OPEN—Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern Denmark and Odense University HospitalOdenseDenmark
| | - Kim Rose Olsen
- DaCHE, Institute of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology CenterUniversity of Southampton, Southampton General HospitalSouthamptonUK
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesOxford University HospitalsOxfordUK
| | | | - Bo Abrahamsen
- Department of MedicineHolbæk HospitalHolbækDenmark
- OPEN—Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern Denmark and Odense University HospitalOdenseDenmark
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesOxford University HospitalsOxfordUK
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Jamshidi A, Daroudi R, Aas E, Khalili D. A cost-effectiveness analysis of risk-based intervention for prevention of cardiovascular diseases in IraPEN program: A modeling study. Front Public Health 2023; 11:1075277. [PMID: 36908421 PMCID: PMC9999709 DOI: 10.3389/fpubh.2023.1075277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/23/2023] [Indexed: 03/14/2023] Open
Abstract
Background IraPEN, a program developed in Iran based on the World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions for primary healthcare, was launched in 2015. Preventive interventions for cardiovascular diseases (CVDs) are based on the level of risk calculated using the WHO CVD risk chart. Objective The main objective of this study was to measure the potential cost-effectiveness (CE) of IraPEN preventive actions for CVD in comparison with the status quo. Methods A CE analysis from a healthcare perspective was conducted. Markov models were employed for individuals with and without diabetes separately. Based on the WHO CVD risk chart, four index cohorts were constructed as low (<10%), moderate (10%-19%), high (20%-29%), and very high risk (≥30%). Life years (LY) gained and quality-adjusted life years (QALY) were used as the outcome measures. Results The intervention yields an incremental cost-effectiveness ratio (ICER) of $804, $551, and -$44 per QALY for moderate, high, and very high CVD risk in groups without diabetes, respectively. These groups gained 0.69, 0.96, and 1.45 LY, respectively, from the intervention. The results demonstrated an ICER of $711, $630, -$42, and -$71 for low, moderate, high, and very high-risk groups with diabetes, respectively, while they gained 0.46, 1.2, 2.04, and 2.29 years from the intervention. Conclusion The IraPEN program was highly cost-effective for all CVD risk groups in the individuals without diabetes except the low-risk group. The intervention was cost-effective for all patients with diabetes regardless of their CVD risk. The results demonstrated that the IraPEN program can likely provide substantial health benefits to Iranian individuals and cost savings to the national healthcare provider.
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Affiliation(s)
- Amirparviz Jamshidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Rajabali Daroudi
- Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Eline Aas
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Davood Khalili
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biostatistics and Epidemiology, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Drapkina OM, Kontsevaya AV, Kalinina AM, Avdeev SM, Agaltsov MV, Alexandrova LM, Antsiferova AA, Aronov DM, Akhmedzhanov NM, Balanova YA, Balakhonova TV, Berns SA, Bochkarev MV, Bochkareva EV, Bubnova MV, Budnevsky AV, Gambaryan MG, Gorbunov VM, Gorny BE, Gorshkov AY, Gumanova NG, Dadaeva VA, Drozdova LY, Egorov VA, Eliashevich SO, Ershova AI, Ivanova ES, Imaeva AE, Ipatov PV, Kaprin AD, Karamnova NS, Kobalava ZD, Konradi AO, Kopylova OV, Korostovtseva LS, Kotova MB, Kulikova MS, Lavrenova EA, Lischenko OV, Lopatina MV, Lukina YV, Lukyanov MM, Mayev IV, Mamedov MN, Markelova SV, Martsevich SY, Metelskaya VA, Meshkov AN, Milushkina OY, Mukaneeva DK, Myrzamatova AO, Nebieridze DV, Orlov DO, Poddubskaya EA, Popovich MV, Popovkina OE, Potievskaya VI, Prozorova GG, Rakovskaya YS, Rotar OP, Rybakov IA, Sviryaev YV, Skripnikova IA, Skoblina NA, Smirnova MI, Starinsky VV, Tolpygina SN, Usova EV, Khailova ZV, Shalnova SA, Shepel RN, Shishkova VN, Yavelov IS. 2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3235] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Verhoeff M, de Groot J, Burgers JS, van Munster BC. Development and internal validation of prediction models for future hospital care utilization by patients with multimorbidity using electronic health record data. PLoS One 2022; 17:e0260829. [PMID: 35298467 PMCID: PMC8929569 DOI: 10.1371/journal.pone.0260829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/17/2021] [Indexed: 12/05/2022] Open
Abstract
Objective To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. Design Retrospective cohort study. Setting A teaching hospital in the Netherlands (542 beds) Participants All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). Outcomes ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. Statistical analysis Multivariable logistic regression with forward selection. Results Evaluation of the models’ performance showed c-statistics of 0.70 (95% CI 0.69–0.72) for the hospitalization model, 0.72 (95% CI 0.70–0.74) for the ED visits model and 0.76 (95% 0.74–0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. Conclusions These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach.
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Affiliation(s)
- Marlies Verhoeff
- Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
- * E-mail:
| | - Janke de Groot
- Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - Jako S. Burgers
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Barbara C. van Munster
- Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Social Deprivation and Peripheral Artery Disease. Can J Cardiol 2021; 38:612-622. [PMID: 34971734 DOI: 10.1016/j.cjca.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/22/2021] [Indexed: 12/24/2022] Open
Abstract
The link between peripheral artery disease and socioeconomic status is complex. The objective of this narrative review is to explore this relationship in detail, including how social factors impact the development, management, and outcomes of peripheral artery disease. Although the current literature on this topic is limited, some patterns do emerge. Populations of low socioeconomic status appear to be at increased risk for the development of peripheral artery disease, due to factors such as increased prevalence of cardiovascular risk factors (i.e. cigarette smoking) and decreased access to care. However, variables that are more difficult to quantify, such as chronic stress and health literacy, also likely play a significant role. Among those who are living with peripheral artery disease, socioeconomic status can also affect disease management. Secondary prevention strategies, such as medication use, smoking cessation, and exercise therapy, are underutilized in socially deprived populations. This underutilization of evidence-based management leads to adverse outcomes in these groups, including increased rates of amputation and decreased post-operative survival. The recognition of the importance of social factors in prognosis is an important first step towards addressing this health disparity. Moving forward, interventions that help to identify those who are at high risk and help to improve access to care in populations of low socioeconomic status, will be critical to improving outcomes.
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Braillon A. Letter by Braillon Regarding Article, "Very High Coronary Artery Calcium (≥1000) and Association With Cardiovascular Disease Events, Non-Cardiovascular Disease Outcomes, and Mortality: Results From MESA". Circulation 2021; 144:e274. [PMID: 34694895 DOI: 10.1161/circulationaha.121.055717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mohan M, Dihoum A, Mordi IR, Choy AM, Rena G, Lang CC. Left Ventricular Hypertrophy in Diabetic Cardiomyopathy: A Target for Intervention. Front Cardiovasc Med 2021; 8:746382. [PMID: 34660744 PMCID: PMC8513785 DOI: 10.3389/fcvm.2021.746382] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022] Open
Abstract
Heart failure is an important manifestation of diabetic heart disease. Before the development of symptomatic heart failure, as much as 50% of patients with type 2 diabetes mellitus (T2DM) develop asymptomatic left ventricular dysfunction including left ventricular hypertrophy (LVH). Left ventricular hypertrophy (LVH) is highly prevalent in patients with T2DM and is a strong predictor of adverse cardiovascular outcomes including heart failure. Importantly regression of LVH with antihypertensive treatment especially renin angiotensin system blockers reduces cardiovascular morbidity and mortality. However, this approach is only partially effective since LVH persists in 20% of patients with hypertension who attain target blood pressure, implicating the role of other potential mechanisms in the development of LVH. Moreover, the pathophysiology of LVH in T2DM remains unclear and is not fully explained by the hyperglycemia-associated cellular alterations. There is a growing body of evidence that supports the role of inflammation, oxidative stress, AMP-activated kinase (AMPK) and insulin resistance in mediating the development of LVH. The recognition of asymptomatic LVH may offer an opportune target for intervention with cardio-protective therapy in these at-risk patients. In this article, we provide a review of some of the key clinical studies that evaluated the effects of allopurinol, SGLT2 inhibitor and metformin in regressing LVH in patients with and without T2DM.
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Affiliation(s)
- Mohapradeep Mohan
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, United Kingdom.,Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Adel Dihoum
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Ify R Mordi
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Anna-Maria Choy
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Graham Rena
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom.,UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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12
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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13
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Grassmann F, Yang H, Eriksson M, Azam S, Hall P, Czene K. Mammographic features are associated with cardiometabolic disease risk and mortality. Eur Heart J 2021; 42:3361-3370. [PMID: 34338750 PMCID: PMC8423470 DOI: 10.1093/eurheartj/ehab502] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/01/2021] [Accepted: 07/15/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS In recent years, microcalcifications identified in routine mammograms were found to be associated with cardiometabolic disease in women. Here, we aimed to systematically evaluate the association of microcalcifications and other mammographic features with cardiometabolic disease risk and mortality in a large screening cohort and to understand a potential genetic contribution. METHODS AND RESULTS This study included 57 867 women from a prospective mammographic screening cohort in Sweden (KARMA) and 49 583 sisters. Cardiometabolic disease diagnoses and mortality and medication were extracted by linkage to Swedish population registries with virtually no missing data. In the cardiometabolic phenome-wide association study, we found that a higher number of microcalcifications were associated with increased risk for multiple cardiometabolic diseases, particularly in women with pre-existing cardiometabolic diseases. In contrast, dense breasts were associated with a lower incidence of cardiometabolic diseases. Importantly, we observed similar associations in sisters of KARMA women, indicating a potential genetic overlap between mammographic features and cardiometabolic traits. Finally, we observed that the presence of microcalcifications was associated with increased cardiometabolic mortality in women with pre-existing cardiometabolic diseases (hazard ratio and 95% confidence interval: 1.79 [1.24-2.58], P = 0.002) while we did not find such effects in women without cardiometabolic diseases. CONCLUSIONS We found that mammographic features are associated with cardiometabolic risk and mortality. Our results strengthen the notion that a combination of mammographic features and other breast cancer risk factors could be a novel and affordable tool to assess cardiometabolic health in women attending mammographic screening.
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Affiliation(s)
- Felix Grassmann
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Haomin Yang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
- Department of Epidemiology and Health Statistics, The School of Public Health, Fujian Medical University, Xuefu North Road 1, University Town, Fuzhou 350122, China
| | - Mikael Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
| | - Shadi Azam
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm 171 65, Sweden
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14
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2289] [Impact Index Per Article: 763.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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15
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A Review of Methodological Approaches for Developing Diagnostic Algorithms for Diabetes Screening. J Nurs Meas 2019; 27:433-457. [PMID: 31871284 DOI: 10.1891/1061-3749.27.3.433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Diagnostic algorithms are invaluable tools for screening diabetes. This review aimed to evaluate and identify the most robust methodological approaches for developing diagnostic algorithms for screening diabetes. METHODS Following a literature search, methodological quality of algorithm development studies was evaluated using the TRIPOD guidelines (Collins, Reitsma, Altman, & Moons, 2015). RESULTS Methods used for developing the algorithms included logistic regression models, classification and regression trees, Random Forest and TreeNet, Artificial Neural Networks, and Naïve Bayes. Methodological issues for algorithm development studies were related to handling of missing values, reporting recruitment methods, categorization of continuous variables, and statistical controls. CONCLUSIONS Most studies exhibited critical methodological flaws and poor adherence to reporting standards. Diabetes screening algorithms can easily be availed electronically and utilized by nurses at minimal cost even in underserved areas.
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16
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Si S, Moss J, Karnon J, Stocks N. Cost-effectiveness evaluation of the 45-49 year old health check versus usual care in Australian general practice: A modelling study. PLoS One 2018; 13:e0207110. [PMID: 30412596 PMCID: PMC6226178 DOI: 10.1371/journal.pone.0207110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/25/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To assess the potential cost-effectiveness of the 45-49 year old health check versus usual care in Australian general practice using secondary data sources. METHOD Risk factor profiles were generated for a hypothetical Australian cohort using data from the National Health Survey. Intervention effects were modelled based on a meta-analysis on risk factor changes in the 5 years after a health check. The Framingham Risk Equation was applied to estimate the 5-year cardiovascular disease (CVD) incidence in the health check and usual care group respectively. A Markov model was then constructed to extrapolate long-term CVD outcomes, health care costs and Quality Adjusted Life Years (QALYs) in both groups. Health check-related costs, applied to the health check group, were estimated from clinical guideline and experts' opinion. Lifetime costs, applied to both groups, included costs of hospitalization for CVD events and associated post-event health service use. The Incremental Cost-Effectiveness Ratio (ICER) was calculated for male and female patients respectively. RESULTS Compared to usual care, the health check reduced CVD incidence for both males (RR = 0.87) and females (RR = 0.91) over a 5-year time. In a lifetime projection, health check led to an average 0.008 and 0.003 QALYs gained per male and female participants respectively. The estimates ICERs were AU $42,355 and AU $133,504 per QALY gained for males and females, respectively. A probabilistic sensitivity analysis demonstrated a probability of cost-effectiveness of 17.5% and 0% for male and female attendees, assuming a willingness to pay threshold of AU $28,000 per QALY gained. CONCLUSION The 45-49 year old health check is associated with a small expected QALY gain per participant, though the persons avoiding CVD events experience large health gains. The mean ICER is larger than an empirical estimate of the threshold ICER and the evaluated health check is highly unlikely to be cost-effective.
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Affiliation(s)
- Si Si
- School of Public Health, Curtin University, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John Moss
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Jonathan Karnon
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, Australia
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17
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Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, Bart van der Worp H, van Dis I, Verschuren WMM. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Atherosclerosis 2018; 252:207-274. [PMID: 27664503 DOI: 10.1016/j.atherosclerosis.2016.05.037] [Citation(s) in RCA: 348] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Ugo Corrà
- Societie: European Society of Cardiology (ESC)
| | | | | | - Ian Graham
- Societie: European Society of Cardiology (ESC)
| | | | | | | | | | | | - Joep Perk
- Societie: European Society of Cardiology (ESC)
| | | | - Josep Redon
- Societie: European Society of Hypertension (ESH)
| | | | - Naveed Sattar
- Societie: European Association for the Study of Diabetes (EASD)
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18
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Griffin SJ, Bethel MA, Holman RR, Khunti K, Wareham N, Brierley G, Davies M, Dymond A, Eichenberger R, Evans P, Gray A, Greaves C, Harrington K, Hitman G, Irving G, Lessels S, Millward A, Petrie JR, Rutter M, Sampson M, Sattar N, Sharp S. Metformin in non-diabetic hyperglycaemia: the GLINT feasibility RCT. Health Technol Assess 2018; 22:1-64. [PMID: 29652246 PMCID: PMC5925436 DOI: 10.3310/hta22180] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The treatment of people with diabetes with metformin can reduce cardiovascular disease (CVD) and may reduce the risk of cancer. However, it is unknown whether or not metformin can reduce the risk of these outcomes in people with elevated blood glucose levels below the threshold for diabetes [i.e. non-diabetic hyperglycaemia (NDH)]. OBJECTIVE To assess the feasibility of the Glucose Lowering In Non-diabetic hyperglycaemia Trial (GLINT) and to estimate the key parameters to inform the design of the full trial. These parameters include the recruitment strategy, randomisation, electronic data capture, postal drug distribution, retention, study medication adherence, safety monitoring and remote collection of outcome data. DESIGN A multicentre, individually randomised, double-blind, parallel-group, pragmatic, primary prevention trial. Participants were individually randomised on a 1 : 1 basis, blocked within each site. SETTING General practices and clinical research facilities in Cambridgeshire, Norfolk and Leicestershire. PARTICIPANTS Males and females aged ≥ 40 years with NDH who had a high risk of CVD. INTERVENTIONS Prolonged-release metformin (500 mg) (Glucophage® SR, Merck KGaA, Bedfont Cross, Middlesex, UK) or the matched placebo, up to three tablets per day, distributed by post. MAIN OUTCOME MEASURES Recruitment rates; adherence to study medication; laboratory results at baseline and 3 and 6 months; reliability and acceptability of study drug delivery; questionnaire return rates; and quality of life. RESULTS We sent 5251 invitations, with 511 individuals consenting to participate. Of these, 249 were eligible and were randomised between March and November 2015 (125 to the metformin group and 124 to the placebo group). Participants were followed up for 0.99 years [standard deviation (SD) 0.30 years]. The use of electronic medical records to identify potentially eligible individuals in individual practices was resource intensive. Participants were generally elderly [mean age 70 years (SD 6.7 years)], overweight [mean body mass index 30.1 kg/m2 (SD 4.5 kg/m2)] and male (88%), and the mean modelled 10-year CVD risk was 28.8% (SD 8.5%). Randomisation, postal delivery of the study drug and outcome assessment using registers/medical records were feasible and acceptable to participants. Most participants were able to take three tablets per day, but premature discontinuation of the study drug was common (≈30% of participants by 6 months), although there were no differences between the groups. All randomised participants returned questionnaires at baseline and 67% of participants returned questionnaires by the end of the study. There was no between-group difference in Short Form questionnaire-8 items or EuroQol-5 Dimensions scores. Compared with placebo, metformin was associated with small improvements in the mean glycated haemoglobin level [-0.82 mmol/mol, 95% confidence interval (CI) -1.39 to -0.24 mmol/mol], mean estimated glomerular filtration rate (2.31 ml/minute/1.73 m2, 95% CI -0.2 to 4.81 ml/minute/1.73 m2) and mean low-density lipoprotein cholesterol level (-0.11 mmol/l, 95% CI -0.25 to 0.02 mmol/l) and a reduction in mean plasma vitamin B12 level (-16.4 ng/l, 95% CI -32.9 to -0.01 ng/l). There were 35 serious adverse events (13 in the placebo group, 22 in the metformin group), with none deemed to be treatment related. LIMITATIONS Changes to sponsorship reduced the study duration, the limited availability of information in medical records reduced recruitment efficiency and discontinuation of study medication exceeded forecasts. CONCLUSIONS A large, pragmatic trial comparing the effects of prolonged-release metformin and placebo on the risk of CVD events is potentially feasible. However, changes to the study design and conduct are recommended to enable an efficient scaling up of the trial. Recommendations include changing the inclusion criteria to recruit people with pre-existing CVD to increase the recruitment and event rates, using large primary/secondary care databases to increase recruitment rates, conducting follow-up remotely to improve efficiency and including a run-in period prior to randomisation to optimise trial adherence. TRIAL REGISTRATION Current Controlled Trials ISRCTN34875079. FUNDING The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 18. See the NIHR Journals Library website for further project information. Merck KGaA provided metformin and matching placebo.
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Affiliation(s)
- Simon J Griffin
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nicholas Wareham
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Gwen Brierley
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Melanie Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Andrew Dymond
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Rose Eichenberger
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | | | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Kyla Harrington
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Graham Hitman
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Greg Irving
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Sarah Lessels
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | | | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Martin Rutter
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Mike Sampson
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Diabetes, Endocrinology and General Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Stephen Sharp
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
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Ueda P, Lung TWC, Lu Y, Salomon JA, Rahimi K, Clarke P, Danaei G. Treatment gaps and potential cardiovascular risk reduction from expanded statin use in the US and England. PLoS One 2018; 13:e0190688. [PMID: 29561843 PMCID: PMC5862405 DOI: 10.1371/journal.pone.0190688] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/19/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The updated national guidelines for cardiovascular risk assessment and lipid modification in the UK and US expand the indications for statin therapy in primary prevention to adults with moderate risk of cardiovascular disease (CVD) but many adults at high CVD risk remain untreated in both countries. We set out to identify treatment gaps in English and American adults at moderate and high risk of cardiovascular disease (CVD), and to estimate the number of CVD events that would be prevented from expanding statin therapy to those who are currently untreated. METHODS We used nationally representative samples of 10,375 English adults and 7,687 US adults aged 40-75 years and free of existing CVD from the Health Survey for England 2009-2013, and the National Health and Nutrition Examination Survey 2007-2012 in the US. We used the risk algorithms and the risk thresholds for statin therapy recommended by each country's national guideline to categorize the survey participants into moderate-risk (≥10% to <20% 10-year risk of CVD in England and ≥7.5% to <20% risk in the US) or high-risk (≥20%risk) and simulated the number of events that would be prevented from expansion of statin therapy to those currently untreated. RESULTS Close to half of adults at high CVD risk in England (46.0%) and the US (49.7%) were not receiving statins. Expanding statin use to 1.45 million high-risk adults in England would save 101,000 (95% CI = 81,000-120,000) CVD events in the next 10 years compared with 128,000 (103,000-154,000) CVD events that would be prevented from expanding treatment to 3.64 million untreated moderate-risk adults. In the US, expanding statin use to 5.27 million untreated high-risk adults would save 384,000 (305,000-461,000) CVD events over 10 years compared with 616,000 (493,000-738,000) CVD events that would be prevented from treating 20.29 million untreated moderate-risk adults. CONCLUSIONS In both England and the US, expanding statin therapy to untreated moderate-risk adults would prevent a comparable number of events as expanding statin use to a much smaller number of currently untreated high-risk adults. A large potential for CVD prevention remains from improving coverage of statin therapy among high-risk adults.
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Affiliation(s)
- Peter Ueda
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Yuan Lu
- Yale/ Yale-New Haven Hospital, Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, United States of America
| | - Joshua A. Salomon
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Kazem Rahimi
- The George Institute for Global Health, Oxford Martin School, University of Oxford, Oxford, United Kingdom
| | - Philip Clarke
- Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
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20
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Lawler M, Alsina D, Adams RA, Anderson AS, Brown G, Fearnhead NS, Fenwick SW, Halloran SP, Hochhauser D, Hull MA, Koelzer VH, McNair AGK, Monahan KJ, Näthke I, Norton C, Novelli MR, Steele RJC, Thomas AL, Wilde LM, Wilson RH, Tomlinson I. Critical research gaps and recommendations to inform research prioritisation for more effective prevention and improved outcomes in colorectal cancer. Gut 2018; 67:179-193. [PMID: 29233930 PMCID: PMC5754857 DOI: 10.1136/gutjnl-2017-315333] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Colorectal cancer (CRC) leads to significant morbidity/mortality worldwide. Defining critical research gaps (RG), their prioritisation and resolution, could improve patient outcomes. DESIGN RG analysis was conducted by a multidisciplinary panel of patients, clinicians and researchers (n=71). Eight working groups (WG) were constituted: discovery science; risk; prevention; early diagnosis and screening; pathology; curative treatment; stage IV disease; and living with and beyond CRC. A series of discussions led to development of draft papers by each WG, which were evaluated by a 20-strong patient panel. A final list of RGs and research recommendations (RR) was endorsed by all participants. RESULTS Fifteen critical RGs are summarised below: RG1: Lack of realistic models that recapitulate tumour/tumour micro/macroenvironment; RG2: Insufficient evidence on precise contributions of genetic/environmental/lifestyle factors to CRC risk; RG3: Pressing need for prevention trials; RG4: Lack of integration of different prevention approaches; RG5: Lack of optimal strategies for CRC screening; RG6: Lack of effective triage systems for invasive investigations; RG7: Imprecise pathological assessment of CRC; RG8: Lack of qualified personnel in genomics, data sciences and digital pathology; RG9: Inadequate assessment/communication of risk, benefit and uncertainty of treatment choices; RG10: Need for novel technologies/interventions to improve curative outcomes; RG11: Lack of approaches that recognise molecular interplay between metastasising tumours and their microenvironment; RG12: Lack of reliable biomarkers to guide stage IV treatment; RG13: Need to increase understanding of health related quality of life (HRQOL) and promote residual symptom resolution; RG14: Lack of coordination of CRC research/funding; RG15: Lack of effective communication between relevant stakeholders. CONCLUSION Prioritising research activity and funding could have a significant impact on reducing CRC disease burden over the next 5 years.
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Affiliation(s)
- Mark Lawler
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | | | | | - Annie S Anderson
- Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Gina Brown
- Department of Radiology, Royal Marsden Hospital, Sutton, UK
| | | | - Stephen W Fenwick
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Stephen P Halloran
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Daniel Hochhauser
- Department of Oncology, University College London Cancer Institute, London, UK
| | - Mark A Hull
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Viktor H Koelzer
- Molecular and Population Genetics Laboratory, University of Oxford, Oxford, UK
| | - Angus G K McNair
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Kevin J Monahan
- Family History of Bowel Cancer Clinic, Imperial College London, London, UK
| | - Inke Näthke
- School of Life Sciences, University of Dundee, Dundee, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
| | - Marco R Novelli
- Research Department of Pathology, University College London Medical School, London, UK
| | - Robert J C Steele
- Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Anne L Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Lisa M Wilde
- Bowel Cancer UK, London, UK
- Atticus Consultants Ltd, Croydon, UK
| | - Richard H Wilson
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | - Ian Tomlinson
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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21
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Abstract
PURPOSE OF REVIEW Many cases of CVD may be avoidable through lowering behavioural risk factors such as smoking and physical inactivity. Mobile health (mHealth) provides a novel opportunity to deliver cardiovascular prevention programs in a format that is potentially scalable. Here, we provide an overview of text messaging-based mHealth interventions in cardiovascular prevention. RECENT FINDINGS Text messaging-based interventions appear effective on a range of behavioural risk factors and can effect change on multiple risk factors-e.g. smoking, weight, blood pressure-simultaneously. For many texting studies, there are challenges in interpretation as many texting interventions are part of larger complex interventions making it difficult to determine the benefits of the separate components. Whilst there is evidence for text messaging improving cardiovascular risk factor levels in the short-term, future studies are needed to examine the durability of these effects and whether they can be translated to improvements in clinical care and outcomes.
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Affiliation(s)
- Harry Klimis
- University of Sydney, Sydney, NSW, Australia. .,Department of Cardiology, Westmead Hospital, PO Box 533, Wentworthville, NSW, Australia, 2145. .,The George Institute for Global Health, Sydney, NSW, Australia.
| | - Mohammad Ehsan Khan
- University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Westmead Hospital, PO Box 533, Wentworthville, NSW, Australia, 2145
| | - Cindy Kok
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Clara K Chow
- University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Westmead Hospital, PO Box 533, Wentworthville, NSW, Australia, 2145.,The George Institute for Global Health, Sydney, NSW, Australia
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Kievit W, Maurits JSF, Arts EE, van Riel PLCM, Fransen J, Popa CD. Cost-Effectiveness of Cardiovascular Screening in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:175-182. [PMID: 27159060 DOI: 10.1002/acr.22929] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 03/29/2016] [Accepted: 04/26/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Early detection and preemptive treatment of patients at risk is of great importance in reducing the excess risk of cardiovascular (CV) disease in rheumatoid arthritis (RA). However, it is unclear how much screening is cost-effective in RA. The objective is to assess whether CV screening in RA proves to be cost-effective from a medical perspective, using different scenarios based on different guidelines. METHODS A Markov chain model was used with a time horizon of 10 years. Parameter values were mainly obtained from literature and from RA patients screened for CV diseases at the Radboud University Medical Centre, Nijmegen, The Netherlands. The primary outcome was incremental cost-effectiveness expressed as costs per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analysis was performed and described in willingness-to-pay curves; several scenarios were built. RESULTS In the base case scenario, in 82% of the simulations, screening proved to be dominant compared to no screening. The mean QALY gain was 0.09 (95% percentile -0.07, 0.27), and the mean cost savings were €-1,057 (95% percentile -€2,825, €333). Different scenarios showed small differences in cost-effectiveness; the probability that screening is dominant remained high with the lowest probability being 50% for a very conservative scenario. CONCLUSION Screening for CV events in RA patients was estimated to be cost-effective with high chances of being less expensive and more effective. These results support endorsement of screening for CV risk in patients with RA.
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Affiliation(s)
- Wietske Kievit
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jake S F Maurits
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Elke E Arts
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Piet L C M van Riel
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, and Bernhoven Hospital, Uden, The Netherlands
| | - Jaap Fransen
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Calin D Popa
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, and Bernhoven Hospital, Uden, The Netherlands
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Vrca Botica M, Carkaxhiu L, Kern J, Pavlić Renar I, Botica I, Zelić I, Iliev D, Vrca A. How to improve opportunistic screening by using EMRs and other data. The prevalence of undetected diabetes mellitus in target population in Croatia. Public Health 2017; 145:30-38. [PMID: 28359387 DOI: 10.1016/j.puhe.2016.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Opportunistic screening for type 2 diabetes (T2D) has not been adopted as part of routine practice. The aim of the study was to investigate the yield of opportunistic target screening for T2D in Croatia and to evaluate the process of screening by using data from electronic medical record. STUDY DESIGN We conducted opportunistic screening in 23 general practitioners (GPs) in a population of 13,344 patients aged 45-70 years. METHODS First, after excluding patients with T2D, patients with risk factors for T2D were derived from the electronic medical record and GP's assessment during the preconsultation phase. Second, those with data about normoglycemia in past three years were excluded. Remaining patients started the consultation phase during their usual visit, when they were offered capillary fasting plasma glucose testing in the next consultation. RESULTS Prevalence of T2D was 10.9% (new 1.4%). A total of 5568 (46.1%) patients had risks and 2849 (51.2%) had data about normoglycemia in the last three years. Using those data, number needed to invite to screening (NNI) was reduced to half: from 46.1% to 22.5%. One hundred eighty-four patients were screened positive for T2D in two capillary fasting plasma glucose tests (yield 9.8%). Number needed to screen (NNS) in order to detect one T2D was 10.3 patients. Among risks for T2D, overweight was the best predictive factor for undiagnosed T2D (odds ratio [OR]: 2.11, confidence interval [CI]:1.41-3.15, P < .001). Logistic regression showed that in targeted population, overweight patients with a family history in fold were 2.5 times more likely to have T2D (OR: 2.54, CI 1.78-.61, P < .001). CONCLUSIONS Total yield in targeted population was 1,4%. By using data about normoglycemia from EMRs, NNI was reduced by half and NNS was 10.3 patients. Our findings suggest the model for improvement in opportunistic screening.
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Affiliation(s)
- M Vrca Botica
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - L Carkaxhiu
- Department of Family Medicine, University of Prishtina, Prishtina, Kosovo.
| | - J Kern
- Department of Informatics, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - I Pavlić Renar
- Department of Endocrinology, University Hospital Zagreb, Croatia.
| | - I Botica
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Zagreb, Croatia.
| | - I Zelić
- Private Family Practice Bukovje, Croatia.
| | - D Iliev
- Department of Family Medicine, University of Skopje, Macedonia.
| | - A Vrca
- Department of Neurology, Clinical Hospital Dubrava, Zagreb, Croatia.
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24
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2016 European Guidelines on cardiovascular disease prevention in clinical practice. Int J Behav Med 2017; 24:321-419. [DOI: 10.1007/s12529-016-9583-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Schülein S, Taylor KJ, Schriefer D, Blettner M, Klug SJ. Participation in preventive health check-ups among 19,351 women in Germany. Prev Med Rep 2017; 6:23-26. [PMID: 28210539 PMCID: PMC5310169 DOI: 10.1016/j.pmedr.2017.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/18/2017] [Accepted: 01/22/2017] [Indexed: 11/28/2022] Open
Abstract
In Germany, a biennial preventive health check-up has been available for individuals aged 35 and older since 1989. The check-up includes identification of cardiovascular disease risk factors and examinations for diabetes mellitus type 2 and kidney disease. Participation in preventive health check-ups among 19,351 women aged 35 to 74 in Germany in 2004 was investigated. Logistic regression was performed to examine associations between participation and age, marital status, education, socio-economic status (SES) and region of residence. In total, 53.4% of women attended at least every two years, 23.4% attended irregularly and 23.2% never attended. In adjusted models, single, divorced, separated or widowed women were less likely to have a preventive health check-up at least every two years compared to married women (OR 0.63, 95% CI 0.57–0.71), while women in eastern Germany were less likely to participate (OR 0.80, 95% CI 0.75–0.86) than women in western Germany. Education showed no association with having a preventive health check-up at least every two years; however, women with low SES were less likely to participate compared to those with high SES (OR 0.82, 95% CI 0.74–0.92). About half of eligible women reported participating in health check-ups at least every two years, with participation varying according to socio-demographic characteristics. Women who are less likely to participate may benefit from receiving invitation letters within the framework of an organised programme. The benefits of general health checks, however, need to be evaluated.
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Affiliation(s)
- Stefanie Schülein
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Georg-Brauchle-Ring 56, 80992 Munich, Germany
| | - Katherine J Taylor
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the University of Mainz, Obere Zahlbacher Str. 69. 55131 Mainz, Germany
| | - Dirk Schriefer
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Georg-Brauchle-Ring 56, 80992 Munich, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the University of Mainz, Obere Zahlbacher Str. 69. 55131 Mainz, Germany
| | - Stefanie J Klug
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, Georg-Brauchle-Ring 56, 80992 Munich, Germany
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26
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Tsujiguchi H, Hori D, Kambayashi Y, Hamagishi T, Asakura H, Mitoma J, Kitaoka M, Olando AE, Thao NTT, Yamada Y, Hayashi K, Konoshita T, Sagara T, Shibata A, Nakamura H. Sex- and Age-Specific Associations of Social Status and Health-Related Behaviors with Health Check Attendance: Findings from the Cross-Sectional Kanazawa Study. Health (London) 2017. [DOI: 10.4236/health.2017.99093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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Móczár C, Rurik I. Comparison of Cardiovascular Risk Screening Methods and Mortality Data among Hungarian Primary Care Population: Preliminary Results of the First Government-Financed Managed Care Program. Zdr Varst 2016; 54:154-60. [PMID: 27646722 PMCID: PMC4820151 DOI: 10.1515/sjph-2015-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 01/06/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Besides participation in the primary prevention, screening as secondary prevention is an important requirement for primary care services. The effect of this work is influenced by the characteristics of individual primary care practices and doctors’ screening habits, as well as by the regulation of screening processes and available financial resources. Between 1999 and 2009, a managed care program was introduced and carried out in Hungary, financed by the government. This financial support and motivation gave the opportunity to increase the number of screenings. Method 4,462 patients of 40 primary care practices were screened on the basis of SCORE risk assessment. The results of the screening were compared on the basis of two groups of patients, namely: those who had been pre-screened (pre-screening method) for known risk factors in their medical history (smoking, BMI, age, family cardiovascular history), and those randomly screened. The authors also compared the mortality data of participating primary care practices with the regional and national data. Results The average score was significantly higher in the pre-screened group of patients, regardless of whether the risk factors were considered one by one or in combination. Mortality was significantly lower in the participating primary practices than had been expected on the basis of the national mortality data. Conclusion This government-financed program was a big step forward to establish a proper screening method within Hungarian primary care. Performing cardiovascular screening of a selected target group is presumably more appropriate than screening within a randomly selected population. Both methods resulted in a visible improvement in regional mortality data, though it is very likely that with pre-screening a more cost-effective selection for screening may be obtained.
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Affiliation(s)
- Csaba Móczár
- Irinyi Health Center, General Practice, 22.sz.Irinyi utca, Kecskemét, 6000, Hungary
| | - Imre Rurik
- University of Debrecen, Department of Family and Occupational Medicine, Egyetem tér 1, 4032 Debrecen, Hungary
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Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37:2315-2381. [PMID: 27222591 PMCID: PMC4986030 DOI: 10.1093/eurheartj/ehw106] [Citation(s) in RCA: 4462] [Impact Index Per Article: 557.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Massimo F. Piepoli
- Corresponding authors: Massimo F. Piepoli, Heart Failure Unit, Cardiology Department, Polichirurgico Hospital G. Da Saliceto, Cantone Del Cristo, 29121 Piacenza, Emilia Romagna, Italy, Tel: +39 0523 30 32 17, Fax: +39 0523 30 32 20, E-mail: ,
| | - Arno W. Hoes
- Arno W. Hoes, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500 (HP Str. 6.131), 3508 GA Utrecht, The Netherlands, Tel: +31 88 756 8193, Fax: +31 88 756 8099, E-mail:
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29
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Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, De Backer G, Roffi M, Aboyans V, Bachl N, Bueno H, Carerj S, Cho L, Cox J, De Sutter J, Egidi G, Fisher M, Fitzsimons D, Franco OH, Guenoun M, Jennings C, Jug B, Kirchhof P, Kotseva K, Lip GYH, Mach F, Mancia G, Bermudo FM, Mezzani A, Niessner A, Ponikowski P, Rauch B, Rydén L, Stauder A, Turc G, Wiklund O, Windecker S, Zamorano JL. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur J Prev Cardiol 2016; 23:NP1-NP96. [PMID: 27353126 DOI: 10.1177/2047487316653709] [Citation(s) in RCA: 579] [Impact Index Per Article: 72.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Ugo Corrà
- Societies: European Society of Cardiology (ESC)
| | | | | | - Ian Graham
- Societies: European Society of Cardiology (ESC)
| | | | | | | | | | | | - Joep Perk
- Societies: European Society of Cardiology (ESC)
| | | | | | | | - Naveed Sattar
- European Association for the Study of Diabetes (EASD)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Leslie Cho
- Societies: European Society of Cardiology (ESC)
| | | | | | | | - Miles Fisher
- European Association for the Study of Diabetes (EASD)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lars Rydén
- Societies: European Society of Cardiology (ESC)
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Pimenta HB, Caldeira AP. [Cardiovascular risk factors on the Framingham Risk Score among hypertensive patients attended by family health teams]. CIENCIA & SAUDE COLETIVA 2016; 19:1731-9. [PMID: 24897474 DOI: 10.1590/1413-81232014196.20092013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 10/18/2013] [Indexed: 01/19/2023] Open
Abstract
The Framingham Risk Score (FRS) is used to stratify cardiovascular risk. This study sought to identify the prevalence of risk factors used in the FRS and the use of drugs that reduce cardiovascular risk among hypertensive patients attended by the Family Health Strategy (FHS). It is cross-sectional study, which evaluated a random sample of hypertensive patients in the FHS in northern Minas Gerais. Data were collected through interviews and from medical records. 505 hypertensive patients were evaluated in 9 municipalities of the region, with a predominance of women; 325 (64.4%), mean age of 66.4 years. In 90% of hypertensive patients there was at least one associated risk factor. The grouping of three or more factors occurred in 79 (15.7%) patients. Dyslipidemia was found in 188 (37.2%), diabetes in 101 (20%) and smoking in 36 (7.1%). The use of anti-hypertensive drugs was observed in 481 (95.2%) patients. The use of other cardioprotective drugs was higher among patients with 3 or more risk factors: 45.6% used antiplatelet and 27.8% used lipid-lowering drugs. The prevalence of risk factors from the FRS in the population studied was quite high and the use of cardioprotective drugs was seen to be restricted. Strategies to increase the use of FRS may improve the management of hypertension in the FHS.
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Kiselev AR, Balashov SV, Posnenkova OM, Prokhorov MD, Gridnev VI. Which Measures of Health Status Assessment are the Most Significant in Organized Cohorts with Low Current Cardiovascular Risk? The Screening Study of Penitentiary Staff in Saratov Region, Russia. Eurasian J Med 2016; 48:42-52. [PMID: 27026764 DOI: 10.5152/eurasianjmed.2015.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of the present study was to compare different methods of health status assessment in organized cohort of penitentiary employees in Saratov Region, Russian Federation. MATERIALS AND METHODS 1,014 penitentiary employees (81.8% male) aged 33.4±6.8 years were included in the cohort study. All participants underwent an annual preventive health examination in the Center of Medical and Social Rehabilitation of Russian Federal Penitentiary Service in Saratov Region. The prevalence of common cardiovascular risk factors was assessed. Risk Score and the number of fulfilled health metrics proposed by American Heart Association (AHA) were calculated for each participant. RESULTS It is shown that penitentiary staff in Saratov Region is characterized by low current risk score (1.2±0.8%), but high prevalence of such risk factors as increased body weight and obesity (51%), tobacco use or passive smoking (81%), and unhealthy diet (55%). 98.4% of participants had the Score level of ≤5%, but only 4.5% of penitentiary staff met the ideal cardiovascular health (they met all seven AHA health metrics). One fifth of the participants met three or less AHA health metrics. A statistically significant correlation between the risk Score and the number of fulfilled AHA health metrics is revealed (Chi-square = 5.1, p=0.024). The probability of fulfilment of less than 5 AHA health metrics in subjects with medium risk score is shown to be almost twofold greater than in subjects with low risk Score. However, there are a lot of differences in the assessment of cardiovascular health by risk Score and AHA health metrics. CONCLUSION AHA health metrics are more preferable than the risk Score or assessment of separate cardiovascular risk factors for preventive management in organized cohorts with low current cardiovascular risk such as penitentiary staff in Saratov Region.
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Affiliation(s)
- Anton R Kiselev
- Department of New Cardiological Informational Technologies, Research Institute of Cardiology, Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia
| | - Sergey V Balashov
- Center of Medical and Social Rehabilitation of Medical Unit no.64 of Russian Federal Penitentiary Service, Saratov, Russia
| | - Olga M Posnenkova
- Department of New Cardiological Informational Technologies, Research Institute of Cardiology, Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia
| | - Mikhail D Prokhorov
- Saratov Branch of the Institute of Radio Engineering and Electronics of Russian Academy of Sciences, Saratov, Russia
| | - Vladimir I Gridnev
- Department of New Cardiological Informational Technologies, Research Institute of Cardiology, Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia
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Raji Y, Mabayoje O, Bello T. Familial clustering of risk factors for cardiovascular disease among first-degree relatives of patients with chronic kidney disease in a sub-Saharan African population. Cardiovasc J Afr 2016; 26:S11-4. [PMID: 25962941 PMCID: PMC4547553 DOI: 10.5830/cvja-2015-041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective To determine the prevalence of risk factors for cardiovascular disease (CVD) in first-degree relatives (FDRs) of patients with chronic kidney disease (CKD) in a sub-Saharan African population. Methods This was a cross-sectional survey of 460 subjects (230 FDRs of patients with CKD and 230 healthy controls). Anthropometrics and blood pressures were measured. Spot urine and fasting venous blood samples were obtained for biochemical analysis. Results The prevalence of hypertension, diabetes mellitus, obesity and dyslipidaemia were significantly higher in FDRs of patients with CKD compared with the controls: 56 (24.3%) vs 29 (12.6%), p = 0.01; 20 (8.7%) vs 6 (2.6%), p = 0.01; 40 (17.4%) vs 24 (10.4%), p = 0.03 and 171 (74.3%) vs 138 (60.0%), p = 0.01, respectively. Hypertension (OR, 1.65), dyslipidaemia (OR, 1.72) and albuminuria (OR, 1.61) were independently associated with being a FDR of patients with CKD. Conclusion In this sub-Saharan African population, risk factors for CVD were more prevalent in the FDRs of patients with CKD than in healthy controls.
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Affiliation(s)
- Yemi Raji
- Nephrology Unit, Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Omolara Mabayoje
- Nephrology Unit, Department of Medicine, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Taslim Bello
- Nephrology Unit, Department of Medicine, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
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Dyakova M, Shantikumar S, Colquitt JL, Drew CM, Sime M, MacIver J, Wright N, Clarke A, Rees K. Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2016; 2016:CD010411. [PMID: 26824223 PMCID: PMC6494380 DOI: 10.1002/14651858.cd010411.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Screening programmes can potentially identify people at high cardiovascular risk and reduce cardiovascular disease (CVD) morbidity and mortality. However, there is currently not enough evidence showing clear clinical or economic benefits of systematic screening-like programmes over the widely practised opportunistic risk assessment of CVD in primary care settings. OBJECTIVES The primary objective of this review was to assess the effectiveness, costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of CVD. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE, EMBASE on 30 January 2015, and Web of Science Core Collection and additional databases on the Cochrane Library on 4 December 2014. We also searched two clinical trial registers and checked reference lists of relevant articles. We applied no language restrictions. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that assessed the effects of systematic risk assessment, defined as a screening-like programme involving a predetermined selection process of people, compared with opportunistic risk assessment which ranged from no risk assessment at all to incentivised case finding of CVD and related risk factors. Participants included healthy adults from the general population, including those who are at risk of CVD. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies. One review author extracted data and assessed them for risk of bias and a second checked them. We assessed evidence quality using the GRADE approach and present this in a 'Summary of findings' table. MAIN RESULTS Nine completed RCTs met the inclusion criteria, of which four were cluster-randomised. We also identified five ongoing trials. The included studies had a high or unclear risk of bias, and the GRADE ratings of overall quality were low or very low. The length of follow-up varied from one year in four studies, three years in one study, five or six years in two studies, and ten years in two studies. Eight studies recruited participants from the general population, although there were differences in the age ranges targeted. One study recruited family members of cardiac patients (high risk assessment). There were considerable differences between the studies in the interventions received by the intervention and control groups. There was insufficient evidence to stratify by the types of risk assessment approaches.Limited data were available on all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.92 to 1.02; 3 studies,103,571 participants, I² = 0%; low-quality evidence) and cardiovascular mortality (RR 1.00, 95% CI 0.90 to 1.11; 2 studies, 43,955 participants, I² = 0%), and suggest that screening has no effect on these outcomes. Data were also limited for combined non-fatal endpoints; overall, evidence indicates no difference in total coronary heart disease (RR 1.01, 95% CI 0.95 to 1.07; 4 studies, 5 comparisons, 110,168 participants, I² = 0%; low-quality evidence), non-fatal coronary heart disease (RR 0.98, 95% CI 0.89 to 1.09; 2 studies, 43,955 participants, I² = 39%), total stroke (RR 0.99, 95% CI 0.90 to 1.10; 2 studies, 79,631 participants, I² = 0%, low-quality evidence), and non-fatal stroke (RR 1.17, 95% CI 0.94 to 1.47; 1 study, 20,015 participants).Overall, systematic risk assessment appears to result in lower total cholesterol levels (mean difference (MD) -0.11 mmol/l, 95% CI -0.17 to -0.04, 6 studies, 7 comparisons, 12,591 participants, I² = 57%; very low-quality evidence), lower systolic blood pressure (MD -3.05 mmHg, 95% CI -4.84 to -1.25, 6 studies, 7 comparisons, 12,591 participants, I² = 82%; very low-quality evidence) and lower diastolic blood pressure (MD -1.34 mmHg, 95% CI -1.76 to -0.93, 6 studies, 7 comparisons, 12,591 participants, I² = 0%; low-quality evidence). One study assessed adverse effects and found no difference in psychological distress at five years (1126 participants). AUTHORS' CONCLUSIONS The results are limited by the heterogeneity between trials in terms of participants recruited, interventions and duration of follow-up. Limited data suggest that systematic risk assessment for CVD has no statistically significant effects on clinical endpoints. There is limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors. The completion of the five ongoing trials will add to the evidence base.
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Affiliation(s)
- Mariana Dyakova
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | - Saran Shantikumar
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | - Jill L Colquitt
- Effective Evidence LLP26 The CurveWaterloovilleHampshireUKPO8 9SE
| | - Christian M Drew
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | - Morag Sime
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | - Joanna MacIver
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | | | - Aileen Clarke
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
| | - Karen Rees
- Warwick Medical School, University of WarwickDivision of Health SciencesGibbet Hill CampusCoventryWarwickshireUKCV4 7AL
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de Boer AW, de Mutsert R, den Heijer M, Jukema JW, Rosendaal FR, Blom JW, Assendelft WJJ. Overweight can be used as a tool to guide case-finding for cardiovascular risk assessment. Fam Pract 2015; 32:646-51. [PMID: 26477010 DOI: 10.1093/fampra/cmv080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In general practice, it is too time-consuming to invite all patients for cardiovascular risk assessment. OBJECTIVE To examine how many patients with an indication for treatment with cardiovascular medication can be identified by ad hoc case-finding when all patients with overweight/obesity are invited for risk assessment. METHODS A cross-sectional analysis of the baseline measurements of the Netherlands Epidemiology of Obesity study, a population-based prospective cohort study in 6673 persons aged 45-65 years. We calculated the proportion of participants with a treatment indication using the risk prediction Systematic COronary Risk Evaluation (SCORE-NL 2011), for lean, overweight and obese participants. Participants with a history of cardiovascular disease, diabetes mellitus or rheumatoid arthritis or using cardiovascular medication were not eligible for ad hoc case-finding because they were already identified as being at risk and/or had been treated. RESULTS Of the study population, 30% had already been identified and/or treated with cardiovascular medication and were therefore not eligible for ad hoc case-finding. Of the eligible participants, 47% were lean, 41% overweight and 12% obese. Of the participants with overweight, 12% had a treatment indication and of the participants with obesity, 19% had a treatment indication. Of all participants with a treatment indication 24% were not yet treated. Of all participants with a new treatment indication, 70% had overweight or obesity. CONCLUSIONS Of the participants with a treatment indication, 24% were not yet treated. Inviting patients with overweight/obesity for cardiovascular risk assessment may help to detect 70% of these residual patients with a treatment indication.
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Affiliation(s)
- Anna W de Boer
- Department of Clinical Epidemiology and Department of Public Health and Primary Care, Leiden University Medical Center, Leiden,
| | | | - Martin den Heijer
- Department of Clinical Epidemiology and Department of Internal Medicine, VU Medical Center, Amsterdam
| | - Johan W Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden and
| | | | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Department of Primary and Community care, Radboud University Medical Center, Nijmegen, The Netherlands
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Implementation of NHS Health Checks in general practice: variation in delivery between practices and practitioners. Prim Health Care Res Dev 2015; 17:385-92. [PMID: 26522491 DOI: 10.1017/s1463423615000493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
UNLABELLED Aim To evaluate NHS Health Check implementation in terms of frequency of data recording, advice provided, referrals to community-based lifestyle support services, statin prescribing and new diagnoses, and to assess variation in these aspects between practices and health professionals involved in delivery. BACKGROUND Most NHS Health Checks are delivered by general practices, but little detail is known about the extent of variation in how they are delivered in different practices and by different health professionals. METHODS This was an observational study conducted in a purposively selected sample of 13 practices in Sefton, North West England. Practices used previously recorded information from their clinical management systems to identify patients with cardiovascular disease (CVD) risk ⩾20%, a potentially cost-effective approach. The evaluation was conducted during the first year of delivery in Sefton. Data were extracted from medical records of all patients identified, regardless of Health Check attendance. Findings Of the 2892 patients identified by the 13 practices, 1070 had received an NHS Health Check at the time of the study. Of these, only 936 (87.5%) had a recorded CVD risk score, with risk ⩾20% confirmed in 92.0%. Estimated risk category was correct in 456/677 (67.4%) of patients with estimated and actual risk scores. Significant variation was found between practices and health professionals in parameters recorded, tests requested, advice given and referrals for lifestyle support. Only 45.3% of patients had body mass index, smoking, alcohol, exercise, blood pressure and cholesterol all recorded. Lifestyle advice and referral into lifestyle services were documented in 80.6% and 6.4% of attenders, respectively, again with significant variation between practices and professionals. Statin prescribing rose in attenders from 19.6% to 34.6%. A similar proportion of attenders and non-attenders received new diagnoses. CONCLUSION Effort is required to reduce variation in how practices deliver and follow-up NHS Health Checks, to ensure the consistency of the programme.
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Wasser WG, Gil A, Skorecki KL. The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease. Rambam Maimonides Med J 2015; 6:RMMJ.10214. [PMID: 26241225 PMCID: PMC4524402 DOI: 10.5041/rmmj.10214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.
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Affiliation(s)
- Walter G. Wasser
- Division of Nephrology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Amnon Gil
- Division of Nephrology, Carmel Medical Center, Haifa, Israel
| | - Karl L. Skorecki
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Director of Medical and Research Development, Rambam Health Care Campus, Haifa, Israel
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Cordero A, Bertomeu-Martínez V, Mazón P, Fácila L, González-Juanatey JR. Erectile Dysfunction May Improve by Blood Pressure Control in Patients with High-Risk Hypertension. Postgrad Med 2015; 122:51-6. [DOI: 10.3810/pgm.2010.11.2223] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Engelsen CD, Koekkoek PS, Godefrooij MB, Spigt MG, Rutten GE. Screening for increased cardiometabolic risk in primary care: a systematic review. Br J Gen Pract 2014; 64:e616-26. [PMID: 25267047 PMCID: PMC4173724 DOI: 10.3399/bjgp14x681781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 05/20/2014] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear. AIM To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy. DESIGN AND SETTING Systematic review of studies performed in primary care in Western countries. METHOD MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities. RESULTS The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods. CONCLUSION The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.
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Affiliation(s)
- Corine den Engelsen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Paula S Koekkoek
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Merijn B Godefrooij
- CAPHRI-School for Public Health and Primary Care, Department of General Practice, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Mark G Spigt
- CAPHRI-School for Public Health and Primary Care, Department of General Practice, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Guy E Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
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Cassetta BD, Goghari VM. Ethical Considerations of Screening and Early Intervention for Clinical High-Risk Psychosis. ETHICS & BEHAVIOR 2014. [DOI: 10.1080/10508422.2014.880920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Yan LL, Fang W, Delong E, Neal B, Peterson ED, Huang Y, Sun N, Yao C, Li X, MacMahon S, Wu Y. Population impact of a high cardiovascular risk management program delivered by village doctors in rural China: design and rationale of a large, cluster-randomized controlled trial. BMC Public Health 2014; 14:345. [PMID: 24721435 PMCID: PMC3986438 DOI: 10.1186/1471-2458-14-345] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 04/04/2014] [Indexed: 12/21/2022] Open
Abstract
Background The high-risk strategy has been proven effective in preventing cardiovascular disease; however, the population benefits from these interventions remain unknown. This study aims to assess, at the population level, the effects of an evidence-based high cardiovascular risk management program delivered by village doctors in rural China. Methods The study will employ a cluster-randomized controlled trial in which a total of 120 villages in five northern provinces of China, will be assigned to either intervention (60 villages) or control (60 villages). Village doctors in intervention villages will be trained to implement a simple evidence-based management program designed to identify, treat and follow-up as many as possible individuals at high-risk of cardiovascular disease in the village. The intervention will also include performance feedback as well as a performance-based incentive payment scheme and will last for 2 years. We will draw two different (independent) random samples, before and after the intervention, 20 men aged ≥ 50 years and 20 women aged ≥60 years from each village in each sample and a total of 9,600 participants from 2 samples to measure the study outcomes at the population level. The primary outcome will be the pre-post difference in mean systolic blood pressure, analyzed with a generalized estimating equations extension of linear regression model to account for cluster effect. Secondary outcomes will include monthly clinic visits, provision of lifestyle advice, use of antihypertensive medications and use of aspirin. Process and economic evaluations will also be conducted. Discussion This trial will be the first implementation trial in the world to evaluate the population impact of the high-risk strategy in prevention and control of cardiovascular disease. The results are expected to provide important information (effectiveness, cost-effectiveness, feasibility and acceptability) to guide policy making for rural China as well as other resource-limited countries. Trial registration The trial is registered at ClinicalTrials.gov (NCT01259700). Date of initial registration is December 13, 2010.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China.
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Willis A, Rivers P, Gray LJ, Davies M, Khunti K. The effectiveness of screening for diabetes and cardiovascular disease risk factors in a community pharmacy setting. PLoS One 2014; 9:e91157. [PMID: 24690919 PMCID: PMC3972156 DOI: 10.1371/journal.pone.0091157] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 02/11/2014] [Indexed: 11/21/2022] Open
Abstract
Risk factors for cardiovascular disease including diabetes have seen a large rise in prevalence in recent years. This has prompted interest in prevention through the identifying individuals at risk of both diabetes and cardiovascular disease and has seen increased investment in screening interventions taking place in primary care. Community pharmacies have become increasingly involved in the provision of such interventions and this systematic review and meta-analysis aims to gather and analyse the existing literature assessing community pharmacy based screening for risk factors for diabetes and those with a high cardiovascular disease risk. Methods We conducted systematic searches of electronic databases using MeSH and free text terms from 1950 to March 2012. For our analysis two outcomes were assessed. They were the percentage of those screened who were referred for further assessment by primary care and the uptake of this referral. Results Sixteen studies fulfilled our inclusion criteria comprising 108,414 participants screened. There was significant heterogeneity for all included outcomes. Consequently we have not presented summary statistics and present forest plots with I2 and p values to describe heterogeneity. We found that all included studies suffered from high rates of attrition between pharmacy screening and follow up. We have also identified a strong trend towards higher rates for referral in more recent studies. Conclusions Our results show that pharmacies are feasible sites for screening for diabetes and those at risk of cardiovascular disease. A significant number of previously unknown cases of cardiovascular disease risk factors such as hypertension, hypercholesterolemia and diabetes are identified, however a significant number of referred participants at high risk do not attend their practitioner for follow up. Research priorities should include methods of increasing uptake to follow up testing and early intervention, to maximise the efficacy of screening interventions based in community pharmacies.
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Affiliation(s)
- Andrew Willis
- Diabetes Research Unit, University of Leicester, Leicester, United Kingdom
- * E-mail:
| | - Peter Rivers
- DeMontford University, Leicester, United Kingdom
| | - Laura J. Gray
- Diabetes Research Unit, University of Leicester, Leicester, United Kingdom
| | - Melanie Davies
- Diabetes Research Unit, University of Leicester, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Unit, University of Leicester, Leicester, United Kingdom
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Pandya A, Weinstein MC, Salomon JA, Cutler D, Gaziano TA. Who needs laboratories and who needs statins?: comparative and cost-effectiveness analyses of non-laboratory-based, laboratory-based, and staged primary cardiovascular disease screening guidelines. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:25-32. [PMID: 24425701 DOI: 10.1161/circoutcomes.113.000397] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early detection and treatment of cardiovascular disease (CVD) risk factors produces significant clinical benefits, but no consensus exists on optimal screening algorithms. This study aimed to evaluate the comparative and cost-effectiveness of staged laboratory-based and non-laboratory-based total CVD risk assessment. METHODS AND RESULTS We used receiver operating characteristic curve and cost-effectiveness modeling methods to compare strategies with and without laboratory components and used single-stage and multistage algorithms, including approaches based on Framingham risk scores (laboratory-based assessments for all individuals). Analyses were conducted using data from 5998 adults in the Third National Health and Nutrition Examination Survey without history of CVD using 10-year CVD death as the main outcome. A microsimulation model projected lifetime costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios for 60 Framingham-based, non-laboratory-based, and staged screening approaches. Across strategies, the area under the receiver operating characteristic curve was 0.774 to 0.780 in men and 0.812 to 0.834 in women. There were no statistically significant differences in area under the receiver operating characteristic curve between multistage and Framingham-based approaches. In cost-effectiveness analyses, multistage strategies had incremental cost-effectiveness ratios of $52,000/QALY and $83,000/QALY for men and women, respectively. Single-stage/Framingham-based strategies were dominated (higher cost and lower QALYs) or had unattractive incremental cost-effectiveness ratios (>$300,000/QALY) compared with single-stage/non-laboratory-based and multistage approaches. CONCLUSIONS Non-laboratory-based CVD risk assessment can be useful in primary CVD prevention as a substitute for laboratory-based assessments or as the initial component of a multistage approach. Cost-effective multistage screening strategies could avoid 25% to 75% of laboratory testing used in CVD risk screening with predictive power comparable with Framingham risks.
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Affiliation(s)
- Ankur Pandya
- Department of Public Health, Weill Cornell Medical College, New York, NY
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Baker J, Mitchell R, Lawson K, Pell J. Ethnic differences in the cost-effectiveness of targeted and mass screening for high cardiovascular risk in the UK: cross-sectional study. Heart 2013; 99:1766-71. [DOI: 10.1136/heartjnl-2013-304625] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Grau M, Baena-Díez JM, Félix-Redondo FJ, Fernández-Berges D, Comas-Cufí M, Forés R, Marrugat J, Ramos R. Estimating the risk of peripheral artery disease using different population strategies. Prev Med 2013; 57:328-33. [PMID: 23769902 DOI: 10.1016/j.ypmed.2013.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/03/2013] [Accepted: 06/03/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study is to compare the clinical performance of different strategies, REASON, PREVALENT, Inter-Society Consensus (ISC), and the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines, in the selection of candidates for peripheral artery disease (PAD) screening using ankle-brachial index (ABI). METHOD Our work is a population-based cross-sectional study conducted in Extremadura (Spain) in 2007-2009. Participants were ≥50years old and free of cardiovascular disease. ABI and cardiovascular risk factors were measured. RESULT In total, 1288 individuals (53% women), with a mean age of 63years (standard deviation (SD) 9) were included. The prevalence of ABI <0.9 was 4.9%. REASON risk score identified 53% of the sample to screen with sensitivity of 87.3%, quite similar to that identified in ISC and ACC/AHA strategies (both 90.5%), and specificity of 48.3%, higher than that of the ISC (30.9%) and ACC/AHA (31.1%) strategies. Although the Youden index was 0.4 for both REASON and PREVALENT risk scores, the latter's sensitivity was 60.3%, almost 30 points less than all other strategies. CONCLUSION REASON risk score was the strategy with the highest clinical performance and efficiency, with sensitivity of 87.3% and specificity higher than that of the ISC and ACC/AHA strategies. Although very specific, the PREVALENT strategy had low sensitivity making it difficult to be implemented as a screening tool.
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Affiliation(s)
- Maria Grau
- Cardiovascular Epidemiology and Genetics, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
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Claes N, Jacobs N, Clays E, Schrooten W, De Bourdeaudhuij I. Comparing the effectiveness of two cardiovascular prevention programmes for highly educated professionals in general practice: a randomised clinical trial. BMC Cardiovasc Disord 2013; 13:38. [PMID: 23725092 PMCID: PMC3674968 DOI: 10.1186/1471-2261-13-38] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 05/20/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular disease is a major cause of mortality and morbidity and its prevalence is set to increase. While the benefits of medical and lifestyle interventions are established, the effectiveness of interventions which seek to improve the way preventive care is delivered in general practice is less so. The aim was to study and to compare the effectiveness of 2 intervention programmes for reducing cardiovascular risk factors within general practice. METHODS A randomised controlled trial was conducted in Belgium between 2007-2010 with 314 highly educated and mainly healthy professionals allocated to a medical (MP) or a medical + lifestyle (MLP) programme. The MP consisted of medical assessments (screening and follow-up) and the MLP added a tailored lifestyle change programme (web-based and individual coaching) to the MP. Primary outcomes were total cholesterol, blood pressure, and body mass index (BMI). The secondary outcomes were smoking status, fitness-score, and total cardiovascular risk. RESULTS The mean age was 41 years, 95 (32%) participants were female, 7 had a personal cardiovascular event in their medical history and 3 had diabetes. There were no significant differences found between MP and MLP in primary or secondary outcomes. In both study conditions decreases of cholesterol, systolic blood pressure, and diastolic blood pressure were found. Unfavourable increases were found for BMI (p < .05). A significant decrease of the overall cardiovascular risk was reported (p < .001). CONCLUSIONS Both interventions are effective in reducing cardiovascular risk. In our population the combined medical and lifestyle programme was not superior to the medical programme. TRIAL REGISTRATION ISRCTN23940498.
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Affiliation(s)
- Neree Claes
- Faculty of Medicine, Hasselt University, Agoralaan Building D, 3590, Diepenbeek, Belgium.
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Affiliation(s)
- Michael Soljak
- Department of Primary Care & Public Health, School of Public Health, Imperial College London, , London, UK
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Lenhard MJ, Maser RE, Kolm P, Healy MJ, Seshadri P. Screening blood donors for diabetes: analysis of use, accuracy, and cost. Transfusion 2013; 53:2776-81. [PMID: 23451798 DOI: 10.1111/trf.12135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 01/07/2013] [Accepted: 01/07/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The objective was to determine if a free, voluntary diabetes screening program as a part of the blood donation process might be cost-effective. STUDY DESIGN AND METHODS During the first 6 months of the program, 26,415 donors were screened using a single random plasma glucose (RPG) level. All donors were asked to eat before donation. Low-, moderate-, and high-risk groups were formed based on RPG levels (<140, 140-200, and >200 mg/dL). Contact with a telephone questionnaire was made with 139 of 178 (78%) of the persons in the high-risk group with 33 new cases of diabetes diagnosed by the donor's physician and 26 donors indicating that they were not diagnosed with diabetes. Sex- and age-matched donors in the low- and moderate-risk groups were contacted and administered the same questionnaire. RESULTS The three risk groups were similar, except for body mass index (28.1 ± 5.4 kg/m2 vs. 29.9 ± 5.5 kg/m2 vs. 32.7 ± 5.6 kg/m2 , p < 0.001). The discriminative effectiveness of screening was evaluated by the area under the receiver operating characteristics (AROC) curve. The AROC curve was 0.950 (95% confidence interval, 0.920-0.979) for the identification of diabetes. Using a RPG cutoff of 200 mg/dL, sensitivity was 100%, specificity was 82%, and positive predictive value was 56%. Cost analyses showed that the mean cost to screen, per donor, was less than $1. Cost per case identified was estimated to be less than $500 for a RPG cutoff of 200 mg/dL. CONCLUSIONS Screening during the blood donation process appears to be accurate, convenient, and inexpensive.
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Affiliation(s)
- M James Lenhard
- Diabetes and Metabolic Research Center, Christiana Care Health System (CCHS), Newark, Delaware; Diabetes and Metabolic Diseases Center (CCHS), the Department of Medical Laboratory Sciences, University of Delaware, Newark, Delaware; Blood Bank of Delmarva, Newark, Delaware; Christiana Care Outcomes Research, Newark, Delaware
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Selvarajah S, Haniff J, Kaur G, Guat Hiong T, Bujang A, Chee Cheong K, Bots ML. Identification of effective screening strategies for cardiovascular disease prevention in a developing country: using cardiovascular risk-estimation and risk-reduction tools for policy recommendations. BMC Cardiovasc Disord 2013; 13:10. [PMID: 23442728 PMCID: PMC3599418 DOI: 10.1186/1471-2261-13-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 02/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent increases in cardiovascular risk-factor prevalences have led to new national policy recommendations of universal screening for primary prevention of cardiovascular disease in Malaysia. This study assessed whether the current national policy recommendation of universal screening was optimal, by comparing the effectiveness and impact of various cardiovascular screening strategies. METHODS Data from a national population based survey of 24 270 participants aged 30 to 74 was used. Five screening strategies were modelled for the overall population and by gender; universal and targeted screening (four age cut-off points). Screening strategies were assessed based on the ability to detect high cardiovascular risk populations (effectiveness), incremental effectiveness, impact on cardiovascular event prevention and cost of screening. RESULTS 26.7% (95% confidence limits 25.7, 27.7) were at high cardiovascular risk, men 34.7% (33.6, 35.8) and women 18.9% (17.8, 20). Universal screening identified all those at high-risk and resulted in one high-risk individual detected for every 3.7 people screened, with an estimated cost of USD60. However, universal screening resulted in screening an additional 7169 persons, with an incremental cost of USD115,033 for detection of one additional high-risk individual in comparison to targeted screening of those aged ≥35 years. The cost, incremental cost and impact of detection of high-risk individuals were more for women than men for all screening strategies. The impact of screening women aged ≥45 years was similar to universal screening in men. CONCLUSIONS Targeted gender- and age-specific screening strategies would ensure more optimal utilisation of scarce resources compared to the current policy recommendations of universal screening.
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Affiliation(s)
- Sharmini Selvarajah
- Clinical Research Centre, Ministry of Health Malaysia, Kuala Lumpur, Malaysia.
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Tiessen AH, Smit AJ, Zevenhuizen S, Spithoven EM, Van der Meer K. Cardiovascular screening in general practice in a low SES area. BMC FAMILY PRACTICE 2012; 13:117. [PMID: 23228012 PMCID: PMC3564938 DOI: 10.1186/1471-2296-13-117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 11/15/2012] [Indexed: 11/10/2022]
Abstract
Background Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk. Methods In a region with a low mean SES, men and women aged ≥50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method. Results 521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP. Conclusion Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.
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Affiliation(s)
- Ans H Tiessen
- University of Groningen, University Medical Center Groningen, Dept, General Practice, Groningen, The Netherlands.
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Marshall T, Caley M, Hemming K, Gill P, Gale N, Jolly K. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT. BMC Public Health 2012; 12:908. [PMID: 23101763 PMCID: PMC3505746 DOI: 10.1186/1471-2458-12-908] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A pilot project cardiovascular prevention was implemented in Sandwell (West Midlands, UK). This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice. Those found to be eligible for treatment were offered treatment. During the pilot a higher proportion of high risk patients were started on treatment in the intervention practices than in control practices. Following the apparent success of the prevention project, it was intended to extend the service to all practices across the Sandwell area. However the pilot project was not a robust evaluation. There was a need for an efficient evaluation that would not disrupt the planned rollout of the project. METHODS/DESIGN Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practices, with the sequence of general practices determined randomly. This is a stepped wedge randomised controlled trial design. The target population is patients aged 35 to 74, without diabetes or cardiovascular disease whose ten-year cardiovascular risk, (determined from data in their electronic records) is ≥ 20%. The primary outcome is the number of high risk patients started on treatment, because these data could be efficiently obtained from electronic primary care records. From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practices before and after implementation of targeted case finding. Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs. Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians. Practical considerations meant that 26 practices in Sandwell could be randomised, including about 6,250 patients at high risk of cardiovascular disease. This gives sufficient power for evaluation. DISCUSSION It is possible to design a stepped wedge randomised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme.
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Affiliation(s)
- Tom Marshall
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Michael Caley
- Warwickshire Primary Care Trust, Westgate House, Market Street, Warwick, CV34 4DE, UK
| | - Karla Hemming
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Paramjit Gill
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Nicola Gale
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Kate Jolly
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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