Randomised controlled trial in northern England of the effect of a person knowing their own serum cholesterol concentration

Effectiveness and uptake of screening programmes for coronary heart disease and diabetes: a realist review of design components used in interventions

OBJECTIVE

To evaluate behavioural components and strategies associated with increased uptake and effectiveness of screening for coronary heart disease and diabetes with an implementation science focus.

DESIGN

Realist review.

DATA SOURCES

PubMed, Web of Knowledge, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register and reference chaining. Searches limited to English language studies published since 1990.

ELIGIBILITY CRITERIA

Eligible studies evaluated interventions designed to increase the uptake of cardiovascular disease (CVD) and diabetes screening and examined behavioural and/or strategic designs. Studies were excluded if they evaluated changes in risk factors or cost-effectiveness only.

RESULTS

In 12 eligible studies, several different intervention designs and evidence-based strategies were evaluated. Salient themes were effects of feedback on behaviour change or benefits of health dialogues over simple feedback. Studies provide mixed evidence about the benefits of these intervention constituents, which are suggested to be situation and design specific, broadly supporting their use, but highlighting concerns about the fidelity of intervention delivery, raising implementation science issues. Three studies examined the effects of informed choice or loss versus gain frame invitations, finding no effect on screening uptake but highlighting opportunistic screening as being more successful for recruiting higher CVD and diabetes risk patients than an invitation letter, with no differences in outcomes once recruited. Two studies examined differences between attenders and non-attenders, finding higher risk factors among non-attenders and higher diagnosed CVD and diabetes among those who later dropped out of longitudinal studies.

CONCLUSIONS

If the risk and prevalence of these diseases are to be reduced, interventions must take into account what we know about effective health behaviour change mechanisms, monitor delivery by trained professionals and examine the possibility of tailoring programmes according to contexts such as risk level to reach those most in need. Further research is needed to determine the best strategies for lifelong approaches to screening.

Using body mass index data in the electronic health record to calculate cardiovascular risk

BACKGROUND

Multivariable cardiovascular disease (CVD) risk calculators, such as the Framingham risk equations, can be used to identify populations most likely to benefit from treatments to decrease risk.

PURPOSE

To determine the proportion of adults within an electronic health record (EHR) for whom Framingham CVD risk scores could be calculated using cholesterol (lab-based) and/or BMI (BMI-based) formulae.

METHODS

EHR data were used to identify patients aged 30-74 years with no CVD and at least 2 years continuous enrollment before April 1, 2010, and relevant data from the preceding 5-year time frame. Analyses were conducted between 2010 and 2011 to determine the proportion of patients with a lab- or BMI-based risk score, the data missing, and the concordance between scores.

RESULTS

Of 122,270 eligible patients, 59.7% (n=73,023) had sufficient data to calculate the lab-based risk score and 84.1% (102,795) the BMI-based risk score. Risk categories were concordant in 78.2% of patients. When risk categories differed, BMI-based risk was almost always in a higher category, with 20.3% having a higher and 1.4% a lower BMI- than lab-based risk score. Concordance between lab- and BMI-based risk was greatest among those at lower estimated risk, including people who were younger, female, without diabetes, not obese, and those not on blood pressure- or lipid-lowering medications.

CONCLUSIONS

EHR data can be used to classify CVD risk for most adults aged 30-74 years. In the population for the current study, CVD risk scores based on BMI could be used to identify those at low risk for CVD and potentially reduce unnecessary laboratory cholesterol testing.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT01077388.

Assessing quality of a worksite health promotion programme from participants' views: findings from a qualitative study in Malaysia

BACKGROUND

An assessment of the process and outcomes of a health promotion programme is necessary for the continuous improvement of a programme.

OBJECTIVE

To explore the participants' perceptions of the quality and effectiveness of the 'Love Your Heart Programme'.

DESIGN

A qualitative study using semi-structured interviews with a purposive sample of participants of the 'Love Your Heart' programme. Interviews were based on an interview guide that grouped questions into four main subgroups: structure, process, immediate outcomes and impact. The interviews were audio-recorded, transcribed verbatim and analysed using the principles of grounded theory.

RESULTS

A total of 17 interviews were conducted. The participants were satisfied with the structural aspects of the programme. Different opinions arose regarding the ideal frequency and duration of the programme. The content of the seminars was thought to be too general. There was also a lack of interest in the 'Road to a Healthy Heart' booklet. All of the respondents had positive opinions about the communication skills and attitude of the health educator. The potential advantages and disadvantages of participating in the programme were discussed. Finally, the respondents expressed their satisfaction with the programme and the impact it had on them.

DISCUSSION AND CONCLUSIONS

In general, the participants who were interviewed held the programme, and the health educator conducted the programme in high regard. The suggestions that were received can be used to further improve the acceptability and feasibility of the programme.

Do people with diabetes understand their clinical marker of long-term glycemic control (HbA1c levels) and does this predict diabetes self-care behaviours and HbA1c?

OBJECTIVE

Research demonstrates that patients have a poor understanding of glycosylated haemoglobin A1c (HbA1c) and that this impacts on effective diabetes self-management. This study attempted to replicate these findings in a UK outpatient sample of people with diabetes.

METHOD

83 participants were recruited and asked to fill in a questionnaire assessing their understanding of HbA1c, diabetes self-care behaviours and diabetes-specific self-efficacy in relation to carrying out these self-care behaviours.

RESULTS

Only 26.5% of the participants were classified as having a good understanding of HbA1c. Correlational and univariate analyses indicated that this level of understanding was related to demographic variables, HbA1c levels and certain aspects of self-care and self-efficacy. A series of multiple regressions found that understanding was a significant predictor of HbA1c levels.

CONCLUSION

The majority of participants seemed to have a poor understanding of HbA1c and this was related to aspects of their diabetes management, self-efficacy and HbA1c levels.

PRACTICAL IMPLICATIONS

These findings provide support for the application of programmes and initiatives aimed at improving patients understanding of clinical disease markers.

Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature

BACKGROUND

Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms.

METHODS

We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers.

RESULTS

11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions.

CONCLUSION

Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.

Differences by Age and Race/Ethnicity in Knowledge About Hypercholesterolemia

This investigation sought to identify gaps in patients' knowledge about hypercholesterolemia and lipid-lowering therapy in an inner-city US population. Chart reviews and interviews were conducted for drug-treated hypercholesterolemic patients at 3 hospital-based cardiology practices in Bronx, NY. Univariate and multivariate analyses were used to assess whether race/ethnicity, sex, and age were predictors of knowledge. Subjects (n = 467, age 65.3 years) were 55% female, 38% Hispanic, 32% black, and 25% white. Most recognized hypercholesterolemia as a cause of heart disease (88%) and stroke (76%), although older subjects (>70 years) and Hispanic subjects, particularly non-English speakers, were significantly less likely to know about cardiovascular disease risks associated with hypercholesterolemia. Only 14% recalled their recent cholesterol levels, and recall was significantly lower among black, Hispanic, and older subjects. Overall, 31% expected to require lipid-lowering medications indefinitely in the future, while 66% did not know how long they would need to continue using medications. Blacks and Hispanics were significantly less likely to believe that they would need to continue taking medications indefinitely. Achieved lipid levels and self-reported medication adherence were relatively favorable although were unrelated to knowledge levels. In summary, among hypercholesterolemic patients in an urban population, relatively few knew their own cholesterol levels or expected to require medications indefinitely in the future. Older patients, black and Hispanic patients, and non-English speakers were significantly less likely to have accurate knowledge about hypercholesterolemia. Therefore, patient and community education efforts targeted to specific populations may lead to improved management of hypercholesterolemia in inner-city regions.

Metabolic Syndrome in a Screened Worksite Sample: Prevalence and Predictors

Relatively limited contemporary information is available about the magnitude of, and factors associated with, the metabolic syndrome in adult men and women. The purpose of our observational study was to describe the prevalence and predictors of the metabolic syndrome in a sample of employed adults attending a worksite cardiovascular screening program. The study sample consisted of 871 men and women between the ages of 21 and 77 years from 6 locations of the parent company. These individuals attended an employer-sponsored cardiovascular screening and wellness program during 2003. A standardized questionnaire was administered to all study participants and a number of different coronary risk factors were measured. Approximately 27% of the study sample was classified as having the metabolic syndrome. Men, persons with a history of hypertension, heart disease, or stroke, sedentary individuals, and those with an increased heart rate and higher levels of C-reactive protein were associated with presence of the metabolic syndrome. A relatively similar risk factor profile was noted in persons without a self-reported history of prior cardiovascular disease. The results of our cross-sectional observational study suggest that the prevalence of the metabolic syndrome is considerable. A number of demographic, comorbid, and other factors are associated with this syndrome. Increased attention to the metabolic syndrome, and modification of predisposing factors, remains of considerable public health and clinical importance.

Application of hair-mercury analysis to determine the impact of a seafood advisory

Following an official recommendation in the Faroe Islands that women should abstain from eating mercury-contaminated pilot whale meat, a survey was carried out to obtain information on dietary habits and hair samples for mercury analysis. A letter was sent to all 1180 women aged 26-30 years who resided within the Faroes, and the women were contacted again 1 year later. A total of 415 women responded to the first letter; the second letter resulted in 145 repeat hair samples and 125 new responses. Questionnaire results showed that Faroese women, on average, consumed whale meat for dinner only once every second month, but the frequency and meal size depended on the availability of whale in the community. The geometric mean hair-mercury concentration at the first survey was higher in districts with available whale than in those without (3.03 vs. 1.88 microg/g; P=0.001). The mercury concentration also depended on the frequency of whale meat dinners and on the consumption of dried whale meat. The 36 women who did not eat whale meat at all had a geometric mean hair-mercury concentration of 1.28 microg/g. At the time of the second survey, the geometric mean had decreased to 1.77 microg/g (P<0.001), although whale was now available in all districts. In comparison with previously published data on hair-mercury concentrations in pregnant Faroese women, these results document substantially lower exposures as well as a further decrease temporally associated with the issue of a stricter dietary advisory.

Educational level has a major impact on the representations of cholesterol: a study in 1579 hypercholesterolemic patients

OBJECTIVE

To determine the specific features of representations of cholesterol and hypercholesterolemia according to the educational level (EL) and gender among hypercholesterolemic (HC) subjects.

DESIGN

The knowledge, beliefs and personal opinions of 1579 hypercholesterolemic patients [58% males; 40% low EL; mean age 58.3 (SD = 11.5)], recruited by their general practitioners, were analyzed from the responses to a self-administered questionnaire.

RESULTS

In comparison with women, and after adjusting for EL, men were less likely to know the acceptable total cholesterol level (OR = 0.80; P < 0.05), more likely to perceive hypercholesterolemia as not being a serious disorder (OR = 1.33; P < 0.05), mainly due to overweight (OR = 1.74; P < 0.001), modern (OR = 1.41; P < 0.01), and carefree lifestyle (OR = 1.80; P < 0.01), and less able to commit themselves to a therapeutic project (diet is only possible if shared by the spouse or family, OR = 1.25; P < 0.05). In comparison with subjects with a middle/high EL, and after adjusting for gender, the least educated subjects exhibited lower dietary knowledge (P < 0.001) and less right beliefs (the presence of cholesterol in blood is normal, OR = 0.48; P < 0.001), expressed the most misconceptions concerning hypercholesterolemia and its attendant risks (high cholesterol can induce cancer, OR = 1.63, P < 0.01, or rheumatism, OR = 3.64; P < 0.001; it is possible to perceive high cholesterol levels before seeing the results of blood tests, OR = 1.48; P < 0.001), exhibited lower self-efficacy (it is discouraging to know that heredity plays a role in a health problem, OR = 1.42; P < 0.001) and were the least convinced by and motivated for treatment (treatment may be limited in time, OR = 1.32; P < 0.05, dieting is impossible if one has an active lifestyle including eating out, OR = 1.64; P < 0.001).

CONCLUSIONS

For distinctive reasons, male gender and low educational level, which are already recognized as cardiovascular risk factors, emerged from our study as limiting patient's personal involvement in the management of hypercholesterolemia. They attest to the need to support educational and informational messages aimed at alerting, convincing and motivating. To heighten the impact of such efforts, it would seem necessary to target specific messages to men and patients with low educational level.

Do persons with diabetes know their (A1C) number?

PURPOSE

The objective of this study was to compare self-reported knowledge about A1C testing with information from the medical record.

METHODS

A telephone survey was conducted among patients with diabetes in a rural fee-for-service practice and a community health center. Self-reported information regarding A1C testing, the last A1C value, and perceived blood glucose control was compared with the most current A1C value documented in the medical record.

RESULTS

Seventy five percent of survey respondents reported having 1 or more A1C tests in the past year, which generally agreed with information from their medical records. However, only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last A1C on the medical record. Among those with a documented A1C value, half described their blood glucose as very well controlled. The last A1C value, however, was < 7.0% in only half of those respondents.

CONCLUSIONS

Persons with diabetes were aware of their previous A1C testing but did not interpret the values accurately in relation to their own glycemic control. If clinicians expect patient knowledge and understanding of glycemic control measures to improve outcomes of care, patient education will need to emphasize the meaning of these values.

Screening and treating adults for lipid disorders

CONTEXT

Screening and treatment of lipid disorders in people at high risk for future coronary heart disease (CHD) events has gained wide acceptance, especially for patients with known CHD, but the proper role in people with low to medium risk is controversial.

OBJECTIVE

To examine the evidence about the benefits and harms of screening and treatment of lipid disorders in adults without known cardiovascular disease for the U.S. Preventive Services Task Force.

DATA SOURCES

We identified English-language articles on drug therapy, diet and exercise therapy, and screening for lipid disorders from comprehensive searches of the MEDLINE database from 1994 through July 1999. We used published systematic reviews, hand searching of relevant articles, the second Guide to Clinical Preventive Services, and extensive peer review to identify important older articles and to ensure completeness.

DATA SYNTHESIS

There is strong, direct evidence that drug therapy reduces CHD events, CHD mortality, and possibly total mortality in middle-aged men (35 to 65 years) with abnormal lipids and a potential risk of CHD events greater than 1% to 2% per year. Indirect evidence suggests that drug therapy is also effective in other adults with similar levels of risk. The evidence is insufficient about benefits and harms of treating men younger than 35 years and women younger than 45 years who have abnormal lipids but no other risk factors for heart disease and low risk for CHD events (less than 1% per year). Trials of diet therapy for primary prevention have led to long-term reductions in cholesterol of 3% to 6% but have not demonstrated a reduction in CHD events overall. Exercise programs that maintain or reduce body weight can produce short-term reductions in total cholesterol of 3% to 6%, but longer-term results in unselected populations have found smaller or no effect. To identify accurately people with abnormal lipids, at least two measurements of total cholesterol and high-density lipoprotein cholesterol are required. The role of measuring triglycerides and the optimal screening interval are unclear from the available evidence.

CONCLUSIONS

On the basis of the effectiveness of treatment, the availability of accurate and reliable tests, and the likelihood of identifying people with abnormal lipids and increased CHD risk, screening appears to be effective in middle-aged and older adults and in young adults with additional cardiovascular risk factors.

Correlates of knowledge of one's blood pressure and cholesterol levels among older members of a managed care plan

We examined factors predicting knowledge of one's blood pressure, total cholesterol, and high-density lipoprotein levels (HDL) among older persons who reported a recent blood pressure or cholesterol test. Data come from a self-administered, health risk assessment that was mailed to health plan members, age 55 and older, in a Santa Barbara, California medical group. Despite their universal access to health care and high levels of reported compliance with preventive health care screening practices, 41%, 49%, and 77% of respondents reported that they did not know their blood pressure, cholesterol, or HDL levels, respectively. After controlling for potential confounders, age and low income were inversely associated with the respondents' ability to report each level. In addition, current smoking and obesity were inversely associated with self-reported knowledge of both cholesterol measures. Persons taking medication for hypertension or hypercholesterolemia were much more likely than those not taking medication to be able to report their blood pressure and cholesterol levels. Except for persons currently undergoing treatment for related conditions, these results suggest that a substantial proportion of the older persons at high risk for cardiovascular disease do not know their levels of these important biological risk factors. This lack of knowledge has important implications for public health education, and may hinder risk-reduction efforts among the elderly.

Detection and evaluation of dyslipoproteinemia

The National Cholesterol Education Program Adult Treatment Panel II guidelines recommend that all adults 20 years of age and older undergo testing to detect dyslipoproteinemia. Clinical trials have proven conclusively that lowering levels of low-density lipoprotein (LDL) cholesterol reduces coronary heart disease (CHD) incidence and mortality and total mortality in patients with and without CHD. There is persuasive scientific evidence to include young adults, women, and the elderly in the recommendation for cholesterol management. In adult without CHD, testing can begin with measurement of total cholesterol (TC) and high-density lipoprotein (HDL) cholesterol in the nonfasting state, and the results can then be used to determine which individuals require a fasting lipoprotein analysis (total cholesterol, HDL, triglycerides, and estimation of LDL); patients with known CHD should begin with lipoprotein analysis. The level of LDL cholesterol and the presence or absence of other CHD risk factors determine the need for cholesterol-lowering therapy. Patients with known CHD are at highest risk for a CHD event and have the lowest LDL cholesterol goal (100 mg/dL); patients without CHD but with elevated LDL-C (130 mg/dL) and two or more other CHD risk factors are at high risk for developing CHD and have an LDL cholesterol goal of less than 130 mg/dL; patients free of CHD with high LDL cholesterol (160 mg/dL) but fewer than two other risk factors have a lower CHD risk and an LDL cholesterol goal of less than 160 mg/dL. Elevated triglyceride may be a marker for other factors that increase CHD risk. Raising HDL cholesterol, while not proven to be of benefit, is reasonable in patients at high CHD risk.

Impact of receiving blood cholesterol test results on dietary change

INTRODUCTION

The study objective was to determine the impact of receiving results of a blood cholesterol test on changes in dietary behaviors among individuals participating in a Health Risk Appraisal Program.

METHODS

This randomized trial of maintenance employees at six hospitals included two groups: Group 1 received their blood cholesterol test results at the pretest; Group 2 received results only at the posttest (16-20 weeks later). The pretest interview included (1) a 24-hour dietary recall; (2) an evaluation of dietary behaviors and suggestions on how to change; (3) height, weight, and blood cholesterol measurement. Five hundred employees participated, and 429 eligible employees completed both pretest and posttest interviews.

RESULTS

Blood cholesterol levels decreased by 4.8% (P < .001) and saturated fat intake decreased by 7.4% (P < .05). Regression analyses indicated that individuals more likely to have lowered saturated fat intake had higher pretest saturated fat intakes, had a family history of high blood cholesterol, and were light-maintenance employees (P < .05); no other variables were associated (receiving blood cholesterol test results, previous blood cholesterol test, pretest blood cholesterol levels, personal history of heart disease, BMI, age, gender, tobacco/alcohol use). Among subjects with normal cholesterol levels, those not receiving blood test results reduced saturated fat intake more than those receiving test results; both groups had similar saturated fat intakes (> 12%) greater than recommended intake (< 10%).

CONCLUSIONS

Screening programs should include an assessment of saturated fat intake as screening for blood cholesterol may provide normocholesterolemic subjects with a false sense of security.

Adults aged 20 and older should have their cholesterol measured

The guidelines of the National Cholesterol Education Program recommend that adults > or = 20 years of age should have their total and high-density lipoprotein cholesterol measured. This recommendation, which has been endorsed by representatives of > 40 medical and health organizations, is based on a large and diverse body of scientific evidence derived from animal, pathologic, genetic, biochemical, metabolic, and epidemiologic studies and clinical trials. Elevated cholesterol levels raise the risk of coronary heart disease (CHD) in men and women and in younger and older adults. Recent clinical trials have confirmed that cholesterol lowering reduces CHD morbidity and mortality and total mortality, without an increase in noncardiovascular mortality, in patients with and without CHD. Measuring cholesterol levels in adults > or = 20 years of age is necessary to provide an accurate assessment of CHD risk to an individual; to identify individuals who should lower their cholesterol levels, using diet and lifestyle changes as the primary treatment; and to reinforce population recommendations. Atherosclerosis begins early in life, and cholesterol levels in young adults predict CHD risk 30-40 years later. Cholesterol measurement can be used to motivate lifestyle changes that will reduce the long-term risk for CHD. Waiting until mid-life to find an elevated cholesterol loses a significant portion of the benefit. Cholesterol is a CHD risk factor in women and older adults, and recent trials show significant CHD risk reduction in these groups. While drug treatment is properly directed to patients with high CHD risk, in whom drugs are cost-effective, cholesterol measurement and lifestyle-based cholesterol lowering are necessary on a broader scale to reduce long-term CHD risk in adults aged > or = 20 years.