Absolute risk representation in cardiovascular disease prevention: comprehension and preferences of health care consumers and general practitioners involved in a focus group study

What factors preventing the older adults in China from living longer: a machine learning study

BACKGROUND

The fact that most older people do not live long means that they do not have more time to pursue self-actualization and contribute value to society. Although there are many studies on the longevity of the elderly, the limitations of traditional statistics lack the good ability to study together the important influencing factors and build a simple and effective prediction model.

METHODS

Based on the the data of Chinese Longitudinal Healthy Longevity Survey (CLHLS), 2008-2018 cohort and 2014-2018 cohort were selected and 16 features were filtered and integrated. Five machine learning algorithms, Elastic-Net Regression (ENR), Decision Tree (DT), Random Forest (RF), K-Nearest Neighbor (KNN), and eXtreme Gradient Boosting (XGBoost), were used to develop models and assessed by internal validation with CLHLS 2008-2018 cohort and temporal validation with CLHLS 2014-2018 cohort. Besides, the best performing model was explained and according to the variable importance results, simpler models would be developed.

RESULTS

The results showed that the model developed by XGBoost algorithm had the best performance with AUC of 0.788 in internal validation and 0.806 in temporal validation. Instrumental activity of daily living (IADL), leisure activity, marital status, sex, activity of daily living (ADL), cognitive function, overall plant-based diet index (PDI) and psychological resilience, 8 features were more important in the model. Finally, with these 8 features simpler models were developed, it was found that the model performance did not decrease in both internal and temporal validation.

CONCLUSIONS

The study indicated that the importance of these 8 factors for predicting the death of elderly people in China and built a simple machine learning model with good predictive performance. It can inspire future key research directions to promote longevity of the elderly, as well as in practical life to make the elderly healthy longevity, or timely end-of-life care for the elderly, and can use predictive model to aid decision-making.

Communicating cardiovascular risk: Systematic review of qualitative evidence

INTRODUCTION

Cardiovascular risk prediction models are widely used to help individuals understand risk and make decisions.

METHODS

Systematic review of qualitative evidence. We searched MEDLINE, Embase, PsycINFO and CINAHL. We included English-language qualitative studies on the communication of cardiovascular risk. We assessed study quality using Hawker et al.'s tool and synthesised data thematically.

RESULTS

Thirty-seven studies were included. Many patients think that risk scores are of limited practical value. Other sources of information feed into informal estimates of risk, which may lead patients to reject the results of clinical risk assessment when the two conflict. Clinicians identify a number of barriers to risk communication, including patients' limited understanding of risk and excessive anxiety. They use a range of strategies for adapting risk communication. Both clinicians and individuals express specific preferences for risk communication formats.

DISCUSSION

Ways of communicating risk that provide some comparison or reference point seem more promising. The broader context of communication around risk may be more important than the risk scoring instrument. Risk communication interventions, in practice, may be more about appeals to emotion than a rationalistic model of decision-making.

Patients' perspectives on adherence to cardiovascular screening consultation and lifestyle changes

BACKGROUND

Rheumatoid arthritis (RA) poses a significant health burden, with patients facing a twofold higher risk of cardiovascular diseases compared to the general population. As a results, the international recommendations set forth by the European Alliance of Associations for Rheumatology, advocate for a structured cardiovascular (CV) risk management and adherence to a healthy lifestyle for patients with RA. Unhealthy lifestyle factors not only impact overall health but also worsen inflammation and hinder treatment response in patients with RA Despite these recommendations, there remains a knowledge gap regarding patients' attitudes towards screening participation and lifestyle changes. Therefore, the aims of this study were firstly to explore the perspectives of patients with rheumatoid arthritis on participation and adherence to cardiovascular screening. Secondly, to explore patients' perspectives on lifestyle changes.

METHODS

Semi-structured interviews based on a hermeneutic approach were conducted. The analysis was guided by qualitative content analysis, employing an inductive approach.

RESULTS

Nine women and seven men, aged 47 to 76 years, diagnosed with RA, and who had attended at least one CV screening session, took part in the study. Two primary themes, along with four sub-themes, emerged from the analysis. The first main theme, Accepting an offer, encompassed the sub-themes of Engagement in the screening consultation and Risk awareness, reflecting participants' views on their involvement in, and commitment to, CV screening. The second theme pertained to participants' perspectives on lifestyle changes: Living with a chronic disease and embracing changes, described through the sub-themes of Motivation for lifestyle changes and Strategies to achieve lifestyle changes.

CONCLUSION

Motivations for taking part in the screening differed among the participants, ranging from simply accepting an invitation to joining as a proactive precaution. In general, there was unanimous agreement among the participants that the screening proved to be a positive encounter. While it may not have immediately prompted significant lifestyle alterations, it did enhance their awareness of risks and underscored the significance of maintaining a healthy lifestyle. Overall, the individual guidance and support for patients with rheumatoid arthritis should entail awareness of CV risk combined with support to lifestyle changes the participants want to pursue.

Major Limitations of Cardiovascular Risk Scores

Background. Epidemiological studies conducted in extensive population cohorts have led to the creation of numerous cardiovascular risk predictor models. However, these tools have certain limitations that restrict its applicability. The aim behind the following work is to summarize today's best-known limitations of cardiovascular risk assessment models through presenting the critical analyses conducted in this area, with the intention of offering practitioners a comprehensive understanding of these restrictions. Critical analyses revealed that these scales exhibit numerous limitations that could impact their performance. Most of these models evaluate cardiovascular risk based on classic risk factors and other restrictions, thereby negatively affecting their sensitivity. Scientists have made significant advancements in improving cardiovascular risk models, tailoring them to accommodate a wide range of populations and devising scales for estimating cardiovascular risks that can account for all prevailing restrictions. Better understanding these limitations could improve the cardiovascular risk stratification.

Personalised colorectal cancer screening strategies: Information needs of the target population

Prior faecal Hemoglobin (f-Hb) concentrations of a negative fecal immunochemical test (FIT) can be used for risk stratification in colorectal cancer (CRC) screening. Individuals with higher f-Hb concentrations may benefit from a shorter screening interval (1 year), whereas individuals with undetectable f-Hb concentrations could benefit from a longer screening interval (3 year). Individuals' views on personalised CRC screening and information needed to make a well-informed decision is unknown. We conducted three semi-structured focus groups among individuals eligible for CRC screening (i.e. men and women aged 55 to 75) in the Netherlands. Thematic analysis was used to analyse participants' information need on personalised CRC screening strategies. Fourteen individuals took part. The majority were positive about CRC screening and indicated that they would participate in personalised CRC screening. The rationale for a longer interval among those at lowest risk was, however, unclear for many. The preferred information on individual risk was variable: ranging from full information to only information on the personalised strategy without mentioning the risk. It was not possible to address everyone's need with a single approach. Additional communications, e.g. public media campaigns, billboards, videos on social media, were also suggested as necessary. This study showed that preferences on receiving information on individual CRC risk varied substantially and no consensus was reached. Introducing a personalised screening programme will require careful communication, particularly around the rationale for the strategy, and a layered approach to deliver information.

Reduced progression of carotid intima media thickness by personalised pictorial presentation of subclinical atherosclerosis in VIPVIZA-A randomised controlled trial

OBJECTIVES

Reduced progression of atherosclerosis can decrease the risk of cardiovascular disease (CVD). This study aimed at evaluating the effect of a pictorial intervention showing atherosclerotic severity on the progression of carotid atherosclerosis.

METHODS

A prospective randomised open-label blinded end-point trial with participants aged 40-60 years enroled from a routine CVD prevention programme. The intervention group (n: 1575) and their treating physicians received an image based presentation of subclinical atherosclerotic severity measured by carotid ultrasound. The control group (n: 1579) did not receive any information about ultrasound results. Carotid ultrasound at baseline and at 3-year follow-up contained plaque detection and measurements of carotid intima media thickness (cIMT). The left, right and bilateral-mean-cIMT, plaque prevalence and total plaque area (TPA) at 3-year follow-up were compared between groups. Significance level was set to p = 0.01 to adjust for multiple comparisons.

RESULTS

The intervention group revealed reduced cIMT progression in the left-mean-cIMT of -0.011 mm (p = 0.001) compared with the control group. The intervention effect on cIMT progression was most prominent in individuals with increased cIMT and plaque prevalence at baseline (-0.021 mm, p = 0.005). There were no differences in progression between groups for the right-and bilateral-mean-cIMT (-0.005 mm, p = 0.223 and -0.005 mm, p = 0.036, respectively), nor any differences between groups for plaque prevalence or TPA (odds ratio 0.88, p = 0.09 and 0.89, p = 0.21, respectively).

CONCLUSION

Pictorial presentation of subclinical atherosclerotic severity sent to both the individual and their treating physician resulted in significantly reduced left cIMT progression. Pictorial presentation has the potential to increase adherence in CVD prevention.

Melanoma risk assessment and management: a qualitative study among Australian general practitioners

Background

Preventive guidelines for melanoma recommend that patients at high risk of melanoma receive targeted screening; however, this requires careful selection of those at high risk. To the authors’ knowledge, there has been no previous research into how all physicians approach the selection and management of high-risk individuals. Melanoma risk-prediction models are available to assist in the identification of high-risk patients but are not routinely used clinically.

Aim

To examine how GPs assessed and managed melanoma risk, and the opportunities for using melanoma risk-prediction models in primary care.

Design and setting

Semi-structured telephone interviews were conducted with 20 Australian GPs.

Method

GPs who had completed a cross-sectional online questionnaire study on melanoma risk were purposively sampled and recruited. Semi-structured telephone interviews were conducted with Australian GPs between 9 July and 10 September 2019. Interviews were audiorecorded, professionally transcribed, and analysed using grounded theory.

Results

Melanoma risk assessment and its management can be understood as a linear workflow consisting of five clinical process domains with patient selection as the entry point. There was variation between GPs on the identification of melanoma risk factors, melanoma risk estimation, management, and patient education because of intuitive and analytical processes guiding risk assessment, and the influence of patient factors. GPs were largely receptive towards melanoma risk-prediction models, sharing facilitators for and barriers to their potential implementation.

Conclusion

Further primary care interventions sensitive to existing workflow arrangements may be required to standardise melanoma risk-assessment and management processes.

Perceived cardiovascular disease risk and tailored communication strategies among rural and urban community dwellers in Rwanda: a qualitative study

Background

In Rwanda, cardiovascular diseases (CVDs) are the third leading cause of death, and hence constitute an important public health issue. Worldwide, most CVDs are due to lifestyle and preventable risk factors. Prevention interventions are based on risk factors for CVD risk, yet the outcome of such interventions might be limited by the lack of awareness or misconception of CVD risk. This study aimed to explore how rural and urban population groups in Rwanda perceive CVD risk and tailor communication strategies for estimated total cardiovascular risk.

Methods

An exploratory qualitative study design was applied using focus group discussions to collect data from rural and urban community dwellers. In total, 65 community members took part in this study. Thematic analysis with Atlas ti 7.5.18 was used and the main findings for each theme were reported as a narrative summary.

Results

Participants thought that CVD risk is due to either financial stress, psychosocial stress, substance abuse, noise pollution, unhealthy diets, diabetes or overworking. Participants did not understand CVD risk presented in a quantitative format, but preferred qualitative formats or colours to represent low, moderate and high CVD risk through in-person communication. Participants preferred to be screened for CVD risk by community health workers using mobile health technology.

Conclusion

Rural and urban community members in Rwanda are aware of what could potentially put them at CVD risk in their respective local communities. Community health workers are preferred by local communities for CVD risk screening. Quantitative formats to present the total CVD risk appear inappropriate to the Rwandan population and qualitative formats are therefore advisable. Thus, operational research on the use of qualitative formats to communicate CVD risk is recommended to improve decision-making on CVD risk communication in the context of Rwanda.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13330-6.

Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines

OBJECTIVE

To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins.

METHODS

We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation.

RESULTS

In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively.

CONCLUSION

Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures.

PRACTICE IMPLICATIONS

Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.

Cardiovascular risk prediction in healthy older people

Identification of individuals with increased risk of major adverse cardiovascular events (MACE) is important. However, algorithms specific to the elderly are lacking. Data were analysed from a randomised trial involving 18,548 participants ≥ 70 years old (mean age 75.4 years), without prior cardiovascular disease events, dementia or physical disability. MACE included coronary heart disease death, fatal or nonfatal ischaemic stroke or myocardial infarction. Potential predictors tested were based on prior evidence and using a machine-learning approach. Cox regression analyses were used to calculate 5-year predicted risk, and discrimination evaluated from receiver operating characteristic curves. Calibration was also assessed, and the findings internally validated using bootstrapping. External validation was performed in 25,138 healthy, elderly individuals in the primary care environment. During median follow-up of 4.7 years, 594 MACE occurred. Predictors in the final model included age, sex, smoking, systolic blood pressure, high-density lipoprotein cholesterol (HDL-c), non-HDL-c, serum creatinine, diabetes and intake of antihypertensive agents. With variable selection based on machine-learning, age, sex and creatinine were the most important predictors. The final model resulted in an area under the curve (AUC) of 68.1 (95% confidence intervals 65.9; 70.4). The model had an AUC of 67.5 in internal and 64.2 in external validation. The model rank-ordered risk well but underestimated absolute risk in the external validation cohort. A model predicting incident MACE in healthy, elderly individuals includes well-recognised, potentially reversible risk factors and notably, renal function. Calibration would be necessary when used in other populations.

'Listen and learn:' participant input in program planning for a low-income urban population at cardiovascular risk

Background

Poverty increases the risk of cardiac disease, while diminishing the resources available to mitigate that risk. Available prevention programs often require resources that low-income residents of urban areas do not possess, e.g. membership fees, resources to purchase healthy foods, and safe places for physical activity. The aim of this study is to obtain participant input in order to understand the health-related goals, barriers, and strengths as part of planning a program to reduce cardiovascular risk.

Methods

In a mixed methods study, we used written surveys and focus groups as part of planning an intervention specifically designed to meet the needs of lower income individuals. Based on prior research, we used Self-Determination Theory (SDT) and its core constructs of autonomy, competence, and relatedness as the theoretical framework for analysis. The study collected information on the perspectives of low-income urban residents on their risks of cardiovascular disease, their barriers to and supports for addressing health needs, and how they addressed barriers and utilized supports. Focus group transcripts were analyzed using standard qualitative methods including paired coding and development of themes from identified codes.

Results

Participants had health goals that aligned with accepted approaches to reducing their cardiovascular risks, however they lacked the resources to reach those goals. We found a lack of support for the three SDT core constructs. The barriers that participants reported suggested that these basic psychological needs were often thwarted by their environments.

Conclusions

Substantial disparities in both access to health-promoting resources and in support for autonomy, competence, and relatedness must be addressed in order to design an effective intervention for a low-income population at cardiac risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10423-6.

Increased knowledge makes a difference! - general practitioners' experiences of pictorial information about subclinical atherosclerosis for primary prevention: an interview study from the VIPVIZA trial

OBJECTIVES

To explore how pictorial information on subclinical atherosclerosis affects GPs' perception of patient cardiovascular disease (CVD) risk, their communication with patients, and GPs' attitude to the treatment of CVD risk factors.

DESIGN, SETTING AND SUBJECTS

Fifteen individual interviews were conducted between March 2014 and December 2016, with GPs who had received pictorial information regarding their patients' subclinical atherosclerosis. The pictorial information was also received by the patients together with written information regarding atherosclerosis and CVD risk prior to the appointment with their GP. The interviews were recorded, transcribed and analyzed using qualitative content analysis.

RESULTS

Three categories were identified in the analysis. Increased knowledge makes a difference: When patients had more in-depth knowledge regarding atherosclerosis, the consultation became more patient-centered and moved towards shared decision making. This is real, not just a number: GPs described their risk assessment and the patient's risk perception as more accurate with pictorial information about subclinical atherosclerosis. How to deal with the result - A passive to active approach: Some GPs acted promptly on the pictorial information while others took no action.

CONCLUSION AND IMPLICATIONS

Pictorial information regarding patients' subclinical atherosclerosis affected GPs' assessment of CVD risk. The communication shifted towards shared decision-making although the GPs' attitude to the result and treatment of CVD risk factors varied. Informing patients about examination results, both in writing and pictures, prior to a consultation can facilitate shared decision making and enhance preventive measures.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT01849575.KEY POINTSProviding pictorial information about carotid ultrasound results and information regarding atherosclerosis to GPs and patients affects primary prevention:•Informing patients about examination results prior to a consultation can be useful in clinical practice to enhance preventive measures•GPs experienced that increased patient knowledge resulted in a more patient-centered consultation and improved shared decision-making•GPs described their risk assessment and patients' risk perception as more accurate with pictorial information about subclinical atherosclerosis.

Risk work in dental practices: an ethnographic study of how risk is managed in NHS dental appointments

Ideas about disease risk underpin many preventive health strategies. These have assumed even greater importance in recent years as health policies place a growing emphasis on personal responsibility. This is reflected in new national contracts for National Health Service (NHS) dentistry that emphasise informing patients on their oral health risk status to persuade them to be accountable for their health. Thus, 'risk' is now central to the practice of dentistry, particularly primary care delivery. An ethnographic study in dental practices in England looked at how risk is acted on in dental settings. 368 dental appointments were observed in five dental practices over a year. The analysis shows three interrelating forms of risk work. Dentists position risk work as administrative to gain consent, translate risk through temporality to encourage action, whilst protecting rapport and their professional reputation through interactional risk work. This qualitative study demonstrates that the everyday nature of risk work in NHS dental practices is often implicit, defensive and focused on social interaction rather than the explicit discussions of individual lifestyle risks that policymakers assume. The study contributes to the literature on 'risk work' by illustrating how health professionals use risk to manage situationally sensitive contexts.

Predictive value of traditional risk factors for cardiovascular disease in older people: A systematic review

With increasing age, associations between traditional risk factors (TRFs) and cardiovascular disease (CVD) shift. It is unknown which mid-life risk factors remain relevant predictors for CVD in older people. We systematically searched PubMed and EMBASE on August 16th 2019 for studies assessing predictive ability of >1 of fourteen TRFs for fatal and non-fatal CVD, in the general population aged 60+. We included 12 studies, comprising 11 unique cohorts. TRF were evaluated in 2 to 11 cohorts, and retained in 0-70% of the cohorts: age (70%), diabetes (64%), male sex (57%), systolic blood pressure (SBP) (50%), smoking (36%), high-density lipoprotein cholesterol (HDL) (33%), left ventricular hypertrophy (LVH) (33%), total cholesterol (22%), diastolic blood pressure (20%), antihypertensive medication use (AHM) (20%), body mass index (BMI) (0%), hypertension (0%), low-density lipoprotein cholesterol (0%). In studies with low to moderate risk of bias, systolic blood pressure (SBP) (80%), smoking (80%) and HDL cholesterol (60%) were more often retained. Model performance was moderate with C-statistics ranging from 0.61 to 0.77. Compared to middle-aged adults, in people aged 60+ different risk factors predict CVD and current prediction models perform only moderate at best. According to most studies, age, sex and diabetes seem valuable predictors of CVD in old-age. SBP, HDL cholesterol and smoking may also have predictive value. Other blood pressure and cholesterol related variables, BMI, and LVH seem of very limited or no additional value. Without competing risk analysis, predictors are overestimated.

Development and usability testing of a very brief intervention for personalised cancer risk assessment to promote behaviour change in primary care using normalisation process theory

BACKGROUND

Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care.

METHODS

Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist.

RESULTS

The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min.

CONCLUSIONS

With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.

A cardiovascular risk prediction model for older people: Development and validation in a primary care population

Cardiovascular risk prediction is mainly based on traditional risk factors that have been validated in middle‐aged populations. However, associations between these risk factors and cardiovascular disease (CVD) attenuate with increasing age. Therefore, for older people the authors developed and internally validated risk prediction models for fatal and non‐fatal CVD, (re)evaluated the predictive value of traditional and new factors, and assessed the impact of competing risks of non‐cardiovascular death. Post hoc analyses of 1811 persons aged 70‐78 year and free from CVD at baseline from the preDIVA study (Prevention of Dementia by Intensive Vascular care, 2006‐2015), a primary care‐based trial that included persons free from dementia and conditions likely to hinder successful long‐term follow‐up, were performed. In 2017‐2018, Cox‐regression analyses were performed for a model including seven traditional risk factors only, and a model to assess incremental predictive ability of the traditional and eleven new factors. Analyses were repeated accounting for competing risk of death, using Fine‐Gray models. During an average of 6.2 years of follow‐up, 277 CVD events occurred. Age, sex, smoking, and type 2 diabetes mellitus were traditional predictors for CVD, whereas total cholesterol, HDL‐cholesterol, and systolic blood pressure (SBP) were not. Of the eleven new factors, polypharmacy and apathy symptoms were predictors. Discrimination was moderate (concordance statistic 0.65). Accounting for competing risks resulted in slightly smaller predicted absolute risks. In conclusion, we found, SBP, HDL, and total cholesterol no longer predict CVD in older adults, whereas polypharmacy and apathy symptoms are two new relevant predictors. Building on the selected risk factors in this study may improve CVD prediction in older adults and facilitate targeting preventive interventions to those at high risk.

Expanding vocabularies for complementary and alternative medicine therapies

OBJECTIVE

There is a significant consumer demand for complementary and alternative medicine (CAM) therapies as possible alternatives to drugs in the treatment and prevention of chronic diseases. Expanding controlled vocabularies to include CAM treatment relations could help meet those needs by facilitating information retrieval from the published literature. The purpose of this study is to design and evaluate two methods to semi-automatically extract CAM treatment-related semantic predications (subject-predicate-object triplets) from the biomedical literature using the Semantic Medline database (SemMedDB).

METHODS

Predications were retrieved from SemMedDB, a database of semantic predications extracted from article abstracts available in Medline. Predications were retrieved for 20 biologically-based and 3 mind-body CAM therapies. The first method (allMedline) retrieved predications from any Medline citation, while the second method (soundStudies) only retrieved predications from scientifically sound clinical studies. Filtering criteria were applied to identify the predications focusing on the treatment and prevention of medical disorders using various CAM modalities. The disorders were extracted for each CAM therapy and ranked by occurrence. A reference vocabulary, composed of 20 biologically-based and 3 mind-body CAM therapies, was developed to evaluate the performance of each method according to precision and recall of the top 100 ranked concepts as well as average precision and recall.

RESULTS

The difference between allMedline and soundStudies in terms of median precision for the top 100 concepts ranked by occurrence was significant (21.0% versus 27.0%, p < .001). The soundStudies method had significantly higher precision (7.0% vs 11.5%, p < .001) and the allMedline had significantly higher recall (37.1% vs 25.6%, p < .001).

CONCLUSION

The soundStudies method may be useful for extracting treatment-related predications from the biomedical literature for the highest ranked concepts. Additional work is needed to improve the algorithm as well as identify and report shortcomings for future enhancements of the tools used to populate SemMedDB.

A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers: study protocol

BACKGROUND

Cancer is a leading cause of mortality and morbidity worldwide. Prevention is recognised by many, including the World Health Organization, to offer the most cost-effective long-term strategy for the control of cancer. One approach that focuses on individuals is the provision of personalised risk information. However, whether such information motivates behaviour change and whether the effect is different with varying formats of risk presentation is unclear. We aim to assess the short-term effect of providing information about personalised risk of cancer in three different formats alongside lifestyle advice on health-related behaviours, risk perception and risk conviction.

METHODS

In a parallel group, randomised controlled trial 1000 participants will be recruited through the online platform Prolific. Participants will be allocated to either a control group receiving cancer-specific lifestyle advice alone or one of three intervention groups receiving the same lifestyle advice alongside their estimated 10-year risk of developing one of the five most common preventable cancers, calculated from self-reported modifiable behavioural risk factors, in one of three different formats (bar chart, pictograph or qualitative scale). The primary outcome is change from baseline in computed risk relative to an individual with a recommended lifestyle at three months. Secondary outcomes include: perceived risk of cancer; anxiety; cancer-related worry; intention to change behaviour; and awareness of cancer risk factors.

DISCUSSION

This study will provide evidence on the short-term effect of providing online information about personalised risk of cancer alongside lifestyle advice on risk perception and health-related behaviours and inform the development of interventions.

TRIAL REGISTRATION

ISRCTN17450583. Registered 30 January 2018.

Presentation of laboratory test results in patient portals: influence of interface design on risk interpretation and visual search behaviour

Background

Patient portals are considered valuable instruments for self-management of long term conditions, however, there are concerns over how patients might interpret and act on the clinical information they access. We hypothesized that visual cues improve patients’ abilities to correctly interpret laboratory test results presented through patient portals. We also assessed, by applying eye-tracking methods, the relationship between risk interpretation and visual search behaviour.

Methods

We conducted a controlled study with 20 kidney transplant patients. Participants viewed three different graphical presentations in each of low, medium, and high risk clinical scenarios composed of results for 28 laboratory tests. After viewing each clinical scenario, patients were asked how they would have acted in real life if the results were their own, as a proxy of their risk interpretation. They could choose between: 1) Calling their doctor immediately (high interpreted risk); 2) Trying to arrange an appointment within the next 4 weeks (medium interpreted risk); 3) Waiting for the next appointment in 3 months (low interpreted risk). For each presentation, we assessed accuracy of patients’ risk interpretation, and employed eye tracking to assess and compare visual search behaviour.

Results

Misinterpretation of risk was common, with 65% of participants underestimating the need for action across all presentations at least once. Participants found it particularly difficult to interpret medium risk clinical scenarios. Participants who consistently understood when action was needed showed a higher visual search efficiency, suggesting a better strategy to cope with information overload that helped them to focus on the laboratory tests most relevant to their condition.

Conclusions

This study confirms patients’ difficulties in interpreting laboratories test results, with many patients underestimating the need for action, even when abnormal values were highlighted or grouped together. Our findings raise patient safety concerns and may limit the potential of patient portals to actively involve patients in their own healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0589-7) contains supplementary material, which is available to authorized users.

Multi-method laboratory user evaluation of an actionable clinical performance information system: Implications for usability and patient safety

INTRODUCTION

Electronic audit and feedback (e-A&F) systems are used worldwide for care quality improvement. They measure health professionals' performance against clinical guidelines, and some systems suggest improvement actions. However, little is known about optimal interface designs for e-A&F, in particular how to present suggested actions for improvement. We developed a novel theory-informed system for primary care (the Performance Improvement plaN GeneratoR; PINGR) that covers the four principal interface components: clinical performance summaries; patient lists; detailed patient-level information; and suggested actions. As far as we are aware, this is the first report of an e-A&F system with all four interface components.

OBJECTIVES

(1) Use a combination of quantitative and qualitative methods to evaluate the usability of PINGR with target end-users; (2) refine existing design recommendations for e-A&F systems; (3) determine the implications of these recommendations for patient safety.

METHODS

We recruited seven primary care physicians to perform seven tasks with PINGR, during which we measured on-screen behaviour and eye movements. Participants subsequently completed usability questionnaires, and were interviewed in-depth. Data were integrated to: gain a more complete understanding of usability issues; enhance and explain each other's findings; and triangulate results to increase validity.

RESULTS

Participants committed a median of 10 errors (range 8-21) when using PINGR's interface, and completed a median of five out of seven tasks (range 4-7). Errors violated six usability heuristics: clear response options; perceptual grouping and data relationships; representational formats; unambiguous description; visually distinct screens for confusable items; and workflow integration. Eye movement analysis revealed the integration of components largely supported effective user workflow, although the modular design of clinical performance summaries unnecessarily increased cognitive load. Interviews and questionnaires revealed PINGR is user-friendly, and that improved information prioritisation could further promote useful user action.

CONCLUSIONS

Comparing our results with the wider usability literature we refine a previously published set of interface design recommendations for e-A&F. The implications for patient safety are significant regarding: user engagement; actionability; and information prioritisation. Our results also support adopting multi-method approaches in usability studies to maximise issue discovery and the credibility of findings.

Responses to provision of personalised cancer risk information: a qualitative interview study with members of the public

BACKGROUND

It is estimated that nearly 600,000 cancer cases in the UK could have been avoided in the past five years if people had healthier lifestyles. A number of theories of behaviour change suggest that before people will change health behaviours, they must accept that a risk applies to them. This study aimed to explore the views of the public on receiving personalised cancer risk information and the potential for that information to motivate behaviour change.

METHODS

We conducted 27 interviews with members of the public (mean age 49 ± 23 years). Each participant completed a questionnaire to allow calculation of their risk of developing the most common cancers (10 for women, 8 for men). During the interviews we presented their risk using a web-based tool developed for the study and discussions covered their views on receiving that information. Each interview was audio-recorded and then analysed using thematic analysis.

RESULTS

Participants generally viewed the concept of personalised cancer risk positively. The first reaction of almost all when presented with their 10-year risk of an individual cancer without any further context was that it was low and not concerning. Views on what constituted a high risk ranged widely, from 0.5 to 60%. All felt seeing the impact of changes in lifestyle was helpful. For some this led to intentions to change behaviour, but reductions in risk were not always motivating as the risks were considered low and differences small.

CONCLUSIONS

Provision of personalised cancer risk was well received and may be a useful addition to other cancer prevention initiatives. Further work is needed in particular to develop ways to present cancer risk that reflect the general perception of what constitutes a risk high enough to motivate behaviour change and help patients contextualise a less well known health risk by providing a frame of reference.

Primary prevention of cardiovascular disease through population-wide motivational strategies: insights from using smartphones in stroke prevention

The fast increasing stroke burden across all countries of the world suggests that currently used primary stroke and cardiovascular disease (CVD) prevention strategies are not sufficiently effective. In this article, we overview the gaps in, and pros and cons of, population-wide and high-risk prevention strategies. We suggest that motivating and empowering people to reduce their risk of having a stroke/CVD by using increasingly used smartphone technologies would bridge the gap in the population-wide and high-risk prevention strategies and reduce stroke/CVD burden worldwide. We emphasise that for primary stroke prevention to be effective, the focus should be shifted from high-risk prevention to prevention at any level of CVD risk, with the focus on behavioural risk factors. Such a motivational population-wide strategy could open a new page in primary prevention of not only stroke/CVD but also other non-communicable disorders worldwide.

Development of an Australian cardiovascular disease mortality risk score using multiple imputation and recalibration from national statistics

OBJECTIVE

To develop and recalibrate an Australian 5-year cardiovascular disease (CVD) mortality risk score to produce contemporary predictions of risk.

METHODS

Data were pooled from six Australian cohort studies (n = 54,829), with baseline data collected between 1989 and 2003. Participants included were aged 40-74 years and free of CVD at baseline. Variables were harmonised across studies and missing data were imputed using multiple imputation. Cox proportional hazards models were used to estimate the risk of CVD mortality associated with factors mutually independently predictive (p < 0.05) and a 5-year risk prediction algorithm was constructed. This algorithm was recalibrated to reflect contemporary national levels of CVD mortality and risk factors using national statistics.

RESULTS

Over a mean 16.6 years follow-up, 1375 participants in the six studies died from CVD. The prediction model included age, sex, smoking, diabetes, systolic blood pressure, total and high-density lipoprotein cholesterol (HDLC), a social deprivation score, estimated glomerular filtration rate and its square and interactions of sex with diabetes, HDLC and deprivation score, and of age with systolic blood pressure and smoking. This model discriminated well when applied to a Scottish study population (c-statistic (95% confidence interval): 0.751 (0.709, 0.793)). Recalibration generally increased estimated risks, but well below those predicted by the European SCORE models.

CONCLUSIONS

The resulting risk score, which includes markers of both chronic kidney disease and socioeconomic deprivation, is the first CVD mortality risk prediction tool for Australia to be derived using Australian data. The primary model, and the method of recalibration, is applicable elsewhere.

The response to receiving phenotypic and genetic coronary heart disease risk scores and lifestyle advice - a qualitative study

BACKGROUND

Individuals routinely receive information about their risk of coronary heart disease (CHD) based on traditional risk factors as part of their primary care. We are also able to calculate individual's risk of CHD based on their genetic information and at present genetic testing for common diseases is available to the public. Due to the limitations in previous studies further understanding is needed about the impact of the risk information on individual's well-being and health-behaviour. We aimed to explore the short term response to receiving different forms of CHD risk information and lifestyle advice for risk reduction.

METHODS

We conducted fourty-one face-to-face interviews and two focus groups across England with participants from the INFORM trial who received a combination of individualised phenotypic and genotypic CHD risk scores and web-based lifestyle advice. Risk scores were presented in different formats, e.g. absolute 10 year risk was presented as a thermometer and expressed as a percentage, natural frequency and 'heart age'. Interviews and focus groups explored participants' understanding and reaction to the risk scores and attempts to change lifestyle during the intervention. We tape-recorded and transcribed the interviews and focus groups and analysed them using thematic analysis.

RESULTS

Three main themes were identified: limitations of risk scores to generate concern about CHD risk; the advantages of the 'heart age' format of risk score presentation in communicating a message of sub-optimal lifestyle; and intentions and attempts to make moderate lifestyle changes which were prompted by the web-based lifestyle advice.

CONCLUSIONS

There are a number of limitations to the use of risk scores to communicate a message about the need for a lifestyle change. Of the formats used, the 'heart age', if noticed, appears to convey the most powerful message about how far from optimal risk an individual person is. An interactive, user friendly, goal setting based lifestyle website can act as a trigger to initiate moderate lifestyle changes, regardless of concerns about risk scores.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.

Time-to-event versus ten-year-absolute-risk in cardiovascular risk prevention - does it make a difference? Results from the Optimizing-Risk-Communication (OptRisk) randomized-controlled trial

Background

The concept of shared-decision-making is a well-established approach to increase the participation of patients in medical decisions. Using lifetime risk or time-to-event (TTE) formats has been increasingly suggested as they might have advantages, e.g. in younger patients, to better show consequences of unhealthy behaviour. In this study, the most-popular ten-year risk illustration in the decision-aid-software arriba^TM (emoticons), is compared within a randomised trial to a new-developed TTE illustration, which is based on a Markov model.

Methods

Thirty-two General Practitioners (GPs) took part in the study. A total of 304 patients were recruited and counseled by their GPs with arriba^TM, and randomized to either the emoticons or the TTE illustration, followed by a patient questionnaire to figure out the degree of shared-decision-making (PEF-FB9, German questionnaire to measure the participation in the shared decision-making process, primary outcome), as well as the decisional conflict, perceived risk, accessibility and the degree of information, which are all secondary outcomes.

Results

Regarding our primary outcome PEF-FB9 the new TTE illustration is not inferior compared to the well-established emoticons taking the whole study population into account. Furthermore, the non-inferiority of the innovative TTE could be confirmed for all secondary outcome variables. The explorative analysis indicates even advantages in younger patients (below 46 years of age).

Conclusion

The TTE format seems to be as useful as the well-established emoticons. For certain patient populations, especially younger patients, the TTE may be even superior to demonstrate a cardiovascular risk at early stages. Our results suggest that time-to-event illustrations should be considered for current decision support tools covering cardiovascular prevention.

Trial registration

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered 2 February 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0393-1) contains supplementary material, which is available to authorized users.

Prevention of stroke: a strategic global imperative

The increasing global stroke burden strongly suggests that currently implemented primary stroke prevention strategies are not sufficiently effective, and new primary prevention strategies with larger effect sizes are needed. Here, we review the latest stroke epidemiology literature, with an emphasis on the recently published Global Burden of Disease 2013 Study estimates; highlight the problems with current primary stroke and cardiovascular disease (CVD) prevention strategies; and outline new developments in primary stroke and CVD prevention. We also suggest key priorities for the future, including comprehensive prevention strategies that target people at all levels of CVD risk; implementation of an integrated approach to promote healthy behaviours and reduce health disparities; capitalizing on information technology to advance prevention approaches and techniques; and incorporation of culturally appropriate education about healthy lifestyles into standard education curricula early in life. Given the already immense and fast-increasing burden of stroke and other major noncommunicable diseases (NCDs), which threatens worldwide sustainability, governments of all countries should develop and implement an emergency action plan addressing the primary prevention of NCDs, possibly including taxation strategies to tackle unhealthy behaviours that increase the risk of stroke and other NCDs.

The NHS Health Check in England: an evaluation of the first 4 years

OBJECTIVES

To describe implementation of a new national preventive programme to reduce cardiovascular morbidity.

DESIGN

Observational study over 4 years (April 2009--March 2013).

SETTING

655 general practices across England from the QResearch database.

PARTICIPANTS

Eligible adults aged 40-74 years including attendees at a National Health Service (NHS) Health Check.

INTERVENTION

NHS Health Check: routine structured cardiovascular check with support for behavioural change and in those at highest risk, treatment of risk factors and newly identified comorbidity.

RESULTS

Of 1.68 million people eligible for an NHS Health Check, 214 295 attended in the period 2009-12. Attendance quadrupled as the programme progressed; 5.8% in 2010 to 30.1% in 2012. Attendance was relatively higher among older people, of whom 19.6% of those eligible at age 60-74 years attended and 9.0% at age 40-59 years. Attendance by population groups at higher cardiovascular disease (CVD) risk, such as the more socially disadvantaged 14.9%, was higher than that of the more affluent 12.3%. Among attendees 7844 new cases of hypertension (38/1000 Checks), 1934 new cases of type 2 diabetes (9/1000 Checks) and 807 new cases of chronic kidney disease (4/1000 Checks) were identified. Of the 27,624 people found to be at high CVD risk (20% or more 10-year risk) when attending an NHS Health Check, 19.3% (5325) were newly prescribed statins and 8.8% (2438) were newly prescribed antihypertensive therapy.

CONCLUSIONS

NHS Health Check coverage was lower than expected but showed year-on-year improvement. Newly identified comorbidities were an important feature of the NHS Health Checks. Statin treatment at national scale for 1 in 5 attendees at highest CVD risk is likely to have contributed to important reductions in their CVD events.

Personalized medicine and stroke prevention: where are we?

There are many recommended pharmacological and non-pharmacological therapies for the prevention of stroke, and an ongoing challenge is to improve their uptake. Personalized medicine is seen as a possible solution to this challenge. Although the use of genetic information to guide health care could be considered as the apex of personalized medicine, genetics is not yet routinely used to guide prevention of stroke. Currently personalized aspects of prevention of stroke include tailoring interventions based on global risk, the utilization of individualized management plans within a model of organized care, and patient education. In this review we discuss the progress made in these aspects of prevention of stroke and present a case study to illustrate the issues faced by health care providers and patients with stroke that could be overcome with a personalized approach to the prevention of stroke.

Values and preferences for oral antithrombotic therapy in patients with atrial fibrillation: physician and patient perspectives

BACKGROUND

Exploration of values and preferences in the context of anticoagulation therapy for atrial fibrillation (AF) remains limited. To better characterize the distribution of patient and physician values and preferences relevant to decisions regarding anticoagulation in patients with AF, we conducted interviews with patients at risk of developing AF and physicians who manage patients with AF.

METHODS

We interviewed 96 outpatients and 96 physicians in a multicenter study and elicited the maximal increased risk of bleeding (threshold risk) that respondents would tolerate with warfarin vs. aspirin to achieve a reduction in three strokes in 100 patients over a 2-year period. We used the probabilistic version of the threshold technique.

RESULTS

The median threshold risk for both patients and physicians was 10 additional bleeds (10 P = 0.7). In both groups, we observed large variability in the threshold number of bleeds, with wider variability in patients than clinicians [patient range: 0-100, physician range: 0-50]. We observed one cluster of patients and physicians who would tolerate <10 bleeds and another cluster of patients, but not physicians, who would accept more than 35.

CONCLUSIONS

Our findings suggest wide variability in patient and physician values and preferences regarding the trade-off between strokes and bleeds. Results suggest that in individual decision making, physician and patient values and preferences will often be discordant; this mandates tailoring treatment to the individual patient's preferences.

Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour

BACKGROUND

Cardiovascular disease (CVD) remains the leading cause of death globally. Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions. An integral part of this approach is the use of CVD risk scores. Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies. We aim to evaluate short-term effects of providing different types of information about coronary heart disease (CHD) risk, alongside lifestyle advice, on health-related behaviours.

METHODS/DESIGN

In a parallel-group, open randomised trial, we are allocating 932 male and female blood donors with no previous history of CVD aged 40-84 years in England to either no intervention (control group) or to one of three active intervention groups: i) lifestyle advice only; ii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics; and iii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics. The primary outcome is change in objectively measured physical activity. Secondary outcomes include: objectively measured dietary behaviours; cardiovascular risk factors; current medication and healthcare usage; perceived risk; cognitive evaluation of provision of CHD risk scores; and psychological outcomes. The follow-up assessment takes place 12 weeks after randomisation. The experiences, attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups.

DISCUSSION

The INFORM study has been designed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.

The Stroke Riskometer(TM) App: validation of a data collection tool and stroke risk predictor

Background

The greatest potential to reduce the burden of stroke is by primary prevention of first-ever stroke, which constitutes three quarters of all stroke. In addition to population-wide prevention strategies (the ‘mass’ approach), the ‘high risk’ approach aims to identify individuals at risk of stroke and to modify their risk factors, and risk, accordingly. Current methods of assessing and modifying stroke risk are difficult to access and implement by the general population, amongst whom most future strokes will arise. To help reduce the burden of stroke on individuals and the population a new app, the Stroke Riskometer™, has been developed. We aim to explore the validity of the app for predicting the risk of stroke compared with current best methods.

Methods

752 stroke outcomes from a sample of 9501 individuals across three countries (New Zealand, Russia and the Netherlands) were utilized to investigate the performance of a novel stroke risk prediction tool algorithm (Stroke Riskometer™) compared with two established stroke risk score prediction algorithms (Framingham Stroke Risk Score [FSRS] and QStroke). We calculated the receiver operating characteristics (ROC) curves and area under the ROC curve (AUROC) with 95% confidence intervals, Harrels C-statistic and D-statistics for measure of discrimination, R² statistics to indicate level of variability accounted for by each prediction algorithm, the Hosmer-Lemeshow statistic for calibration, and the sensitivity and specificity of each algorithm.

Results

The Stroke Riskometer™ performed well against the FSRS five-year AUROC for both males (FSRS = 75·0% (95% CI 72·3%–77·6%), Stroke Riskometer™ = 74·0(95% CI 71·3%–76·7%) and females [FSRS = 70·3% (95% CI 67·9%–72·8%, Stroke Riskometer™ = 71·5% (95% CI 69·0%–73·9%)], and better than QStroke [males – 59·7% (95% CI 57·3%–62·0%) and comparable to females = 71·1% (95% CI 69·0%–73·1%)]. Discriminative ability of all algorithms was low (C-statistic ranging from 0·51–0·56, D-statistic ranging from 0·01–0·12). Hosmer-Lemeshow illustrated that all of the predicted risk scores were not well calibrated with the observed event data (P < 0·006).

Conclusions

The Stroke Riskometer™ is comparable in performance for stroke prediction with FSRS and QStroke. All three algorithms performed equally poorly in predicting stroke events. The Stroke Riskometer™ will be continually developed and validated to address the need to improve the current stroke risk scoring systems to more accurately predict stroke, particularly by identifying robust ethnic/race ethnicity group and country specific risk factors.

Improving bone mineral density reporting to patients with an illustration of personal fracture risk

Background

To determine patients’ preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations.

Methods

Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration.

Results

Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most “clear,” “clean,” and “easy to read”. The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category.

Conclusions

Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference.

Trial Registration

ClinicalTrials.gov Identifier: NCT01507662

Web search behavior and information needs of people with multiple sclerosis: focus group study and analysis of online postings

BACKGROUND

Multiple sclerosis (MS) patients and their family members increasingly seek health information on the Internet. There has been little exploration of how MS patients integrate health information with their needs, preferences, and values for decision making. The INtegrating and Deriving Evidence, Experiences, and Preferences (IN-DEEP) project is a collaboration between Italian and Australian researchers and MS patients, aimed to make high-quality evidence accessible and meaningful to MS patients and families, developing a Web-based resource of evidence-based information starting from their information needs.

OBJECTIVE

The objective of this study was to analyze MS patients and their family members' experience about the Web-based health information, to evaluate how they asses this information, and how they integrate health information with personal values.

METHODS

We organized 6 focus groups, 3 with MS patients and 3 with family members, in the Northern, Central, and Southern parts of Italy (April-June 2011). They included 40 MS patients aged between 18 and 60, diagnosed as having MS at least 3 months earlier, and 20 family members aged 18 and over, being relatives of a person with at least a 3-months MS diagnosis. The focus groups were audio-recorded and transcribed verbatim (Atlas software, V 6.0). Data were analyzed from a conceptual point of view through a coding system. An online forum was hosted by the Italian MS society on its Web platform to widen the collection of information. Nine questions were posted covering searching behavior, use of Web-based information, truthfulness of Web information. At the end, posts were downloaded and transcribed.

RESULTS

Information needs covered a comprehensive communication of diagnosis, prognosis, and adverse events of treatments, MS causes or risk factors, new drugs, practical, and lifestyle-related information. The Internet is considered useful by MS patients, however, at the beginning or in a later stage of the disease a refusal to actively search for information could occur. Participants used to search on the Web before or after their neurologist's visit or when a new therapy was proposed. Social networks are widely used to read others' stories and retrieve information about daily management. A critical issue was the difficulty of recognizing reliable information on the Web. Many sources were used but the neurologist was mostly the final source of treatment decisions.

CONCLUSIONS

MS patients used the Internet as a tool to integrate information about the illness. Information needs covered a wide spectrum, the searched topics changed with progression of the disease. Criteria for evaluating Internet accuracy and credibility of information were often lacking or generic. This may limit the empowerment of patients in health care choices.

Cost effectiveness analysis of a next generation risk assessment score for cardiovascular disease

OBJECTIVES

The goal of this study is to determine the cost-effectiveness of MIRISK VP, a next generation coronary heart disease risk assessment score, in correctly reclassifying and appropriately treating asymptomatic, intermediate risk patients.

STUDY DESIGN

A Markov model was employed with simulated subjects based on the Multi-Ethnic Study of Atherosclerosis (MESA). This study evaluated three treatment strategies: (i) practice at MESA enrollment, (ii) current guidelines, and (iii) MIRISK VP in MESA.

METHODS

The model assessed patient healthcare costs and outcomes, expressed in terms of life years and quality-adjusted life years (QALYs), over the lifetime of the cohort from the provider and payer perspective. A total of 50,000 hypothetical individuals were used in the model. A sensitivity analysis was conducted (based on the various input parameters) for the entire cohort and also for individuals aged 65 and older.

RESULTS

Guiding treatment with MIRISK VP leads to the highest net monetary benefits when compared to the 'Practice at MESA Enrollment' or to the 'Current Guidelines' strategies. MIRISK VP resulted in a lower mortality rate from any CHD event and a modest increase in QALY of 0.12-0.17 years compared to the other two approaches.

LIMITATIONS

This study has limitations of not comparing performance against strategies other than the FRS, the results are simulated as with all models, the model does not incorporate indirect healthcare costs, and the impact of patient or physician behaviors on outcomes were not taken into account.

CONCLUSIONS

MIRISK VP has the potential to improve patient outcomes compared to the alternative strategies. It is marginally more costly than both the 'Practice at MESA Enrollment' and the 'Current Guidelines' strategies, but it provides increased effectiveness, which leads to positive net monetary benefits over either strategy.

Acceptance and practicability of a visual communication tool in smoking cessation counselling: a randomised controlled trial

BACKGROUND

Smoking cessation advice is important for reducing the worldwide burden of disease resulting from tobacco smoking. Appropriate risk communication formats improve the success of counselling interventions in primary care.

AIMS

To test the feasibility and acceptance of a smoking cessation counselling tool with different cardiovascular risk communication formats including graphs, in comparison with the International Primary Care Respiratory Group (IPCRG) 'quit smoking assistance' tool.

METHODS

GPs were randomised into an intervention group (using our communication tool in addition to the IPCRG sheet) and a control group (using the IPCRG sheet only). We asked participants for socioeconomic data, smoking patterns, understanding of information, motivation, acceptance and feasibility, and measured the duration and frequency of counselling sessions.

RESULTS

Twenty-five GPs performed 2.8 counselling sessions per month in the intervention group and 1.7 in the control group (p=0.3) with 114 patients. The median duration of a session was 10 mins (control group 11 mins, p=0.09 for difference). Median patients' motivation for smoking cessation was 7 on a 10-point visual analogue scale with no significant difference before and after the intervention (p=0.2) or between groups (p=0.73 before and p=0.15 after the intervention). Median patients' ratings of motivation, selfconfidence, understanding of information, and satisfaction with the counselling were 3-5 on a 5-point Likert scale, similar to GPs' ratings of acceptance and feasibility, with no significant difference between groups.

CONCLUSIONS

Among Swiss GPs and patients, both our innovative communication tool and the IPCRG tool were well accepted and both merit further dissemination and application in research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Starting and staying on preventive medication for cardiovascular disease

PURPOSE OF REVIEW

To synthesize the qualitative research literature regarding medication use to prevent cardiovascular disease in order to explain the variation in healthcare professional (HCP) and patient behaviours, and to evaluate the implications for practice.

RECENT FINDINGS

The decision to start preventive medication is affected by the patient-HCP relationship and by the design of the service. Both HCPs and patients are influenced by their understanding of the evidence regarding the value of preventive interventions; their values and preferences; and their sociopolitical context and the organizational structure of their practice environment. The design of their service affects uptake as a consequence of its impact on clinical communication and the extent to which the service is tailored to the needs of the local community. Continuing to take prescribed medication is affected by both contextual and practical factors. Recommendations for practice can be split into those with a clinical focus and those with a patient or community focus. More sophisticated analyses have moved beyond recommendations for patient and HCP education, and address constraints in the organization of clinical services and the social context of evidence translation.

SUMMARY

Qualitative health research provides important insights into the experience of and context for decision making about medication prescription and adherence that can help efforts to prevent cardiovascular disease.

The effect of a patient-oriented treatment decision aid for risk factor management in patients with diabetes (PORTDA-diab): study protocol for a randomised controlled trial

Background

To improve risk factor management in diabetes, we need to support effective interactions between patients and healthcare providers. Our aim is to develop and evaluate a treatment decision aid that offers personalised information on treatment options and outcomes, and is intended to empower patients in taking a proactive role in their disease management. Important features are: (1) involving patients in setting goals together with their provider; (2) encourage them to prioritise on treatments that maximise relevant outcomes; and (3) integration of the decision aid in the practice setting and workflow. As secondary aim, we want to evaluate the impact of different presentation formats, and learn more from the experiences of the healthcare providers and patients with the decision aid.

Methods and design

We will conduct a randomised trial comparing four formats of the decision aid in a 2×2 factorial design with a control group. Patients with type 2 diabetes managed in 18 to 20 primary care practices in The Netherlands will be recruited. Excluded are patients with a recent myocardial infarction, stroke, heart failure, angina pectoris, terminal illness, cognitive deficits, >65 years at diagnosis, or not able to read Dutch. The decision aid is offered to the patients immediately before their quarterly practice consultation. The same decision information will be available to the healthcare provider for use during consultation. In addition, the providers receive a set of treatment cards, which they can use to discuss the benefits and risks of different options. Patients in the control group will receive care as usual. We will measure the effect of the intervention on patient empowerment, satisfaction with care, beliefs about medication, negative emotions, health status, prescribed medication, and predicted cardiovascular risk. Data will be collected with questionnaires and automated extraction from medical records in 6 months before and after the intervention.

Discussion

This decision aid is innovative in supporting patients and their healthcare providers to make shared decisions about multiple treatments, using the patient’s data from electronic medical records. The results can contribute to the further development and implementation of electronic decision support tools for the management of chronic diseases.

Trial registration

Dutch Trial register NTR1942.

Coronary risk assessment among intermediate risk patients using a clinical and biomarker based algorithm developed and validated in two population cohorts

BACKGROUND

Many coronary heart disease (CHD) events occur in individuals classified as intermediate risk by commonly used assessment tools. Over half the individuals presenting with a severe cardiac event, such as myocardial infarction (MI), have at most one risk factor as included in the widely used Framingham risk assessment. Individuals classified as intermediate risk, who are actually at high risk, may not receive guideline recommended treatments. A clinically useful method for accurately predicting 5-year CHD risk among intermediate risk patients remains an unmet medical need.

OBJECTIVE

This study sought to develop a CHD Risk Assessment (CHDRA) model that improves 5-year risk stratification among intermediate risk individuals.

METHODS

Assay panels for biomarkers associated with atherosclerosis biology (inflammation, angiogenesis, apoptosis, chemotaxis, etc.) were optimized for measuring baseline serum samples from 1084 initially CHD-free Marshfield Clinic Personalized Medicine Research Project (PMRP) individuals. A multivariable Cox regression model was fit using the most powerful risk predictors within the clinical and protein variables identified by repeated cross-validation. The resulting CHDRA algorithm was validated in a Multiple-Ethnic Study of Atherosclerosis (MESA) case-cohort sample.

RESULTS

A CHDRA algorithm of age, sex, diabetes, and family history of MI, combined with serum levels of seven biomarkers (CTACK, Eotaxin, Fas Ligand, HGF, IL-16, MCP-3, and sFas) yielded a clinical net reclassification index of 42.7% (p < 0.001) for MESA patients with a recalibrated Framingham 5-year intermediate risk level. Across all patients, the model predicted acute coronary events (hazard ratio = 2.17, p < 0.001), and remained an independent predictor after Framingham risk factor adjustments.

LIMITATIONS

These include the slightly different event definition with the MESA samples and inability to include PMRP fatal CHD events.

CONCLUSIONS

A novel risk score of serum protein levels plus clinical risk factors, developed and validated in independent cohorts, demonstrated clinical utility for assessing the true risk of CHD events in intermediate risk patients. Improved accuracy in cardiovascular risk classification could lead to improved preventive care and fewer deaths.

Cardiovascular risk

Cardiovascular disease is a major, growing, worldwide problem. It is important that individuals at risk of developing cardiovascular disease can be effectively identified and appropriately stratified according to risk. This review examines what we understand by the term risk, traditional and novel risk factors, clinical scoring systems, and the use of risk for informing prescribing decisions. Many different cardiovascular risk factors have been identified. Established, traditional factors such as ageing are powerful predictors of adverse outcome, and in the case of hypertension and dyslipidaemia are the major targets for therapeutic intervention. Numerous novel biomarkers have also been described, such as inflammatory and genetic markers. These have yet to be shown to be of value in improving risk prediction, but may represent potential therapeutic targets and facilitate more targeted use of existing therapies. Risk factors have been incorporated into several cardiovascular disease prediction algorithms, such as the Framingham equation, SCORE and QRISK. These have relatively poor predictive power, and uncertainties remain with regards to aspects such as choice of equation, different risk thresholds and the roles of relative risk, lifetime risk and reversible factors in identifying and treating at-risk individuals. Nonetheless, such scores provide objective and transparent means of quantifying risk and their integration into therapeutic guidelines enables equitable and cost-effective distribution of health service resources and improves the consistency and quality of clinical decision making.

Decision boxes for clinicians to support evidence-based practice and shared decision making: the user experience

BACKGROUND

This project engages patients and physicians in the development of Decision Boxes, short clinical topic summaries covering medical questions that have no single best answer. Decision Boxes aim to prepare the clinician to communicate the risks and benefits of the available options to the patient so they can make an informed decision together.

METHODS

Seven researchers (including four practicing family physicians) selected 10 clinical topics relevant to primary care practice through a Delphi survey. We then developed two one-page prototypes on two of these topics: prostate cancer screening with the prostate-specific antigen test, and prenatal screening for trisomy 21 with the serum integrated test. We presented the prototypes to purposeful samples of family physicians distributed in two focus groups, and patients distributed in four focus groups. We used the User Experience Honeycomb to explore barriers and facilitators to the communication design used in Decision Boxes. All discussions were transcribed, and three researchers proceeded to thematic content analysis of the transcriptions. The coding scheme was first developed from the Honeycomb's seven themes (valuable, usable, credible, useful, desirable, accessible, and findable), and included new themes suggested by the data. Prototypes were modified in light of our findings.

RESULTS

Three rounds were necessary for a majority of researchers to select 10 clinical topics. Fifteen physicians and 33 patients participated in the focus groups. Following analyses, three sections were added to the Decision Boxes: introduction, patient counseling, and references. The information was spread to two pages to try to make the Decision Boxes less busy and improve users' first impression. To try to improve credibility, we gave more visibility to the research institutions involved in development. A statement on the boxes' purpose and a flow chart representing the shared decision-making process were added with the intent of clarifying the tool's purpose. Information about the risks and benefits according to risk levels was added to the Decision Boxes, to try to ease the adaptation of the information to individual patients.

CONCLUSION

Results will guide the development of the eight remaining Decision Boxes. A future study will evaluate the effect of Decision Boxes on the integration of evidence-based and shared decision making principles in clinical practice.

Examining the impact of genetic testing for type 2 diabetes on health behaviors: study protocol for a randomized controlled trial

Background

We describe the study design, procedures, and development of the risk counseling protocol used in a randomized controlled trial to evaluate the impact of genetic testing for diabetes mellitus (DM) on psychological, health behavior, and clinical outcomes.

Methods/Design

Eligible patients are aged 21 to 65 years with body mass index (BMI) ≥27 kg/m² and no prior diagnosis of DM. At baseline, conventional DM risk factors are assessed, and blood is drawn for possible genetic testing. Participants are randomized to receive conventional risk counseling for DM with eye disease counseling or with genetic test results. The counseling protocol was pilot tested to identify an acceptable graphical format for conveying risk estimates and match the length of the eye disease to genetic counseling. Risk estimates are presented with a vertical bar graph denoting risk level with colors and descriptors. After receiving either genetic counseling regarding risk for DM or control counseling on eye disease, brief lifestyle counseling for prevention of DM is provided to all participants.

Discussion

A standardized risk counseling protocol is being used in a randomized trial of 600 participants. Results of this trial will inform policy about whether risk counseling should include genetic counseling.

Trial registration

ClinicalTrials.gov Identifier NCT01060540

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

Background

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

Methods

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

Results

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

Conclusions

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

Press coverage of hormone replacement therapy and menopause

OBJECTIVE

To evaluate the information reported by Italian press articles about hormone replacement therapy (HRT) and menopause, in terms of completeness, clarity of language and transparency.

STUDY DESIGN

In the framework of the Consensus Conference Informing women about hormone replacement therapy, 225 articles published from 2000 to 2007 in Italian lay press were evaluated. Health magazines, weekly news magazines, newspapers, women's magazines and medical practitioners' journals were selected. A form covering graphic layout, completeness of information, clarity of language and transparency was applied to each article by a reviewer. The form was tested in a pilot phase.

RESULTS

HRT was recommended to treat menopausal symptoms in more than half of articles (56%) and was described as a preventive measure in almost half (48%). Risks related to HRT were under-reported (58% of the articles). Information on conflicts of interest was lacking (88%). Opinions of experts were the main source of information cited in the articles (66%).

CONCLUSIONS

The information reported by the articles is lacking in several aspects. Many women are likely to receive unbalanced information from the press. Qualified sources of information delivered on the scientific knowledge available are needed, reporting advantages and disadvantages of HRT, pharmacological and non-pharmacological alternative treatments and their effectiveness. Scientific journalism needs to grow through training. The role of researchers and clinicians is discussed.