Targeted case finding in the prevention of cardiovascular disease: a stepped wedge cluster randomised controlled trial

Does Adding Training in Shared Decision Making for Home Care Teams to Providing Decision Guides Better Engage Frail Elders and Caregivers in Housing Decisions? :A Stepped-Wedge Cluster Randomized Trial

Background

Frail older adults and caregivers need support from their home care teams in making difficult housing decisions, such as whether to remain at home, with or without assistance, or move into residential care. However, home care teams are often understaffed and busy, and shared decision-making training is costly. Nevertheless, overall awareness of shared decision-making is increasing. We hypothesized that distributing a decision aid could be sufficient for providing decision support without the addition of shared decision-making training for home care teams.

Objective

We evaluated the effectiveness of adding web-based training and workshops for care teams in interprofessional shared decision-making to passive dissemination of a decision guide on the proportion of frail older adults or caregivers of cognitively-impaired frail older adults reporting active roles in housing decision-making.

Methods

We conducted a stepped-wedge cluster randomized trial with home care teams in 9 health centers in Quebec, Canada. Participants were frail older adults or caregivers of cognitively impaired frail older adults facing housing decisions and receiving care from the home care team at one of the participating health centers. The intervention consisted of a 1.5-hour web-based tutorial for the home care teams plus a 3.5-hour interactive workshop in interprofessional shared decision-making using a decision guide that was designed to support frail older adults and caregivers in making housing decisions. The control was passive dissemination of the decision guide. The primary outcome was an active role in decision-making among frail older adults and caregivers, measured using the Control Preferences Scale. Secondary outcomes included decisional conflict and perceptions of how much care teams involved frail older adults and caregivers in decision-making. We performed an intention-to-treat analysis.

Results

A total of 311 frail older adults were included in the analysis, including 208 (66.9%) women, with a mean age of 81.2 (SD 7.5) years. Among 339 caregivers of cognitively-impaired frail older adults, 239 (70.5%) were female and their mean age was 66.4 (SD 11.7) years. The intervention increased the proportion of frail older adults reporting an active role in decision-making by 3.3% (95% CI –5.8% to 12.4%, P=.47) and the proportion of caregivers of cognitively-impaired frail older adults by 6.1% (95% CI -11.2% to 23.4%, P=.49). There was no significant impact on the secondary outcomes. However, the mean score for the frail older adults’ perception of how much health professionals involved them in decision-making increased by 5.4 (95% CI −0.6 to 11.4, P=.07) and the proportion of caregivers who reported decisional conflict decreased by 7.5% (95% CI −16.5% to 1.6%, P=.10).

Conclusions

Although it slightly reduced decisional conflict for caregivers, shared decision-making training did not equip home care teams significantly better than provision of a decision aid for involving frail older adults and their caregivers in decision-making.

Trial Registration

ClinicalTrials.gov NCT02592525; https://clinicaltrials.gov/show/NCT02592525

Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients

BACKGROUND

The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting.

METHODS

Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study.

RESULTS

A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively.

CONCLUSION

The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.

NHS Health Checks: an observational study of equity and outcomes 2009-2017

Background

The NHS Health Check cardiovascular prevention programme is now 10 years old.

Aim

To describe NHS Heath Check attendance, new diagnoses, and treatment in relation to equity indicators.

Design and setting

A nationally representative database derived from 1500 general practices from 2009–2017.

Method

The authors compared NHS Health Check attendance and new diagnoses and treatments by age, sex, ethnic group, and deprivation.

Results

In 2013–2017, 590 218 (16.9%) eligible people aged 40–74 years attended an NHS Health Check and 2 902 598 (83.1%) did not attend. South Asian ethnic groups were most likely to attend compared to others, and females more than males. New diagnoses were more likely in attendees than non-attendees: hypertension 25/1000 in attendees versus 9/1000 in non-attendees; type 2 diabetes 8/1000 versus 3/1000; and chronic kidney disease (CKD) 7/1000 versus 4/1000. In people aged ≥65 years, atrial fibrillation was newly diagnosed in 5/1000 attendees and 3/1000 non-attendees, and for dementia 2/1000 versus 1/1000, respectively. Type 2 diabetes, hypertension, and CKD were more likely in more deprived groups, and in South Asian, Black African, and Black Caribbean ethnic groups. Attendees were more likely to be prescribed statins (26/1000) than non-attendees (8/1000), and antihypertensive medicines (25/1000 versus 13/1000 non-attendees). However, of the 117 963 people with ≥10% CVD risk who were eligible for statins, only 9785 (8.3%) were prescribed them.

Conclusion

Uptake of NHS Health Checks remains low. Attendees were more likely than non-attendees to be diagnosed with type 2 diabetes, hypertension, and CKD, and to receive treatment with statins and antihypertensives. Most attendees received neither treatment nor referral. Of those eligible for statins, <10% were treated. Policy reviews should consider a targeted approach prioritising those at highest CVD risk for face-to-face contact and consider other options for those at lower CVD risk.

Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials

Importance

Statins are a cornerstone medication in cardiovascular disease prevention, but their use in clinical practice remains suboptimal, with less than half of people who are indicated for statins actually taking the medication.

Objective

To perform a systematic review and synthesis of the literature on patient-oriented and physician-oriented interventions aimed at increasing statin-prescribing rates in adults without a history of cardiovascular disease.

Evidence Review

PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials published between January 2000 and May 2019. Data abstraction was performed using the Cochrane Public Health Review Group's data collection template, and a narrative synthesis of study results was conducted. The risk of bias in each study was qualitatively assessed, and a funnel plot was created to further evaluate the risk of publication bias.

Findings

Among 7948 citations and 128 full-text articles reviewed, 20 studies (of 109 807 patients) were included in the review. Eight trials reported a statistically significant increases in statin-prescribing rates. Among the effective trials, absolute effect sizes ranged from 4.2% (95% CI, 2.2%-6.4%) to 23% (95% CI, 7.3%-38.9%) and odds ratios from 1.29 (95% CI, 1.01-1.66) to 11.8 (95% CI, 8.8-15.9). Patient-education initiatives were the most commonly effective intervention, with 4 of 7 trials indicating increases in statin-prescribing rates. Two trials combined electronic decision-support tools with audit-and-feedback systems, both of which were effective overall. Physician-education programs without dynamic input regarding patient risk or updated treatment recommendations were generally found to be less effective.

Conclusions and Relevance

While heterogeneous in their interventions and outcomes, a number of interventions have demonstrated increases in statin-prescribing rates, with patient-education initiatives demonstrating more promising results than those focused on physician education alone. As opposed to more education about generic recommendations, tailored patient-focused and physician-focused interventions were more effective when they provided personalized cardiovascular risk information, dynamic decision-support tools, or audit-and-feedback reports in a multicomponent program. There are a number of modestly successful approaches to implement increases in rates of statin prescribing, a proven yet underused cardiovascular disease prevention class of therapy.

GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care

BACKGROUND

Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects.

AIM

To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols.

DESIGN AND SETTING

A controlled before-after study comparing surgery performance measures in UK primary care.

METHOD

This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England.

RESULTS

There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001.

CONCLUSION

This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.

Evaluation of the clinical effectiveness of a work-based mentoring programme to develop clinical reasoning on patient outcome: A stepped wedge cluster randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of clinical mentoring on postgraduate physiotherapists have been explored, but its impact on patient outcomes is unknown. The objective of this trial was to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes.

METHODS

In a stepped-wedge cluster RCT in the musculoskeletal physiotherapy outpatient departments of a large NHS organisation, 16 physiotherapists were randomised by cluster to receive the intervention-150 hours of mentored clinical practice-at one of 3 time periods; control was usual training. 441 patients submitted outcome measures: Patient-Specific Functional Scale (PSFS) (primary outcome measure), EQ-5D-5L, patient activation and patient satisfaction (secondary outcome measures). A further secondary outcome measure of physiotherapist performance was collected by an independent assessor observing the physiotherapists practice.

RESULTS

80.0% of intervention patients achieved clinically significant PSFS scores compared with 63.8% of control patients. Binary logistic regression analysis modelling for time, cluster and patient characteristics showed strong statistical evidence for this difference (p = 0.023; odds ratio 4.24, 95%CI 1.22, 14.79). Physiotherapist performance scores improved from a mean of 47.8% (SD 3.60) pre-intervention to a mean of 56.0% (SD 4.24) (p<0.001). There was no statistical evidence for differences between groups on other secondary outcomes.

CONCLUSION

This is the first study that we aware of that provides patient outcomes measurement of an established educational intervention in physiotherapy, providing evidence that this type of intervention positively impacts patient outcomes and physiotherapist performance. This provides a basis for further research in education across other healthcare disciplines and outcome measures.

Risk work or resilience work? A qualitative study with community health workers negotiating the tensions between biomedical and community-based forms of health promotion in the United Kingdom

Emplaced health promotion interventions, delivered by community health workers are increasingly being used internationally. However, the application of epidemiological risk knowledge to individuals within such communities is not straightforward and creates tensions for community health workers who are part of the communities that they are serving. Situated qualitative interview data were co-produced with community health workers employed in a superdiverse, deprived, post-industrial region of the United Kingdom, using photo-voice methods, to develop an account of how they made sense of the challenges of their work. The analysis draws on and develops theories of risk work and resilience work, which draw on practice theory. The key findings were that, first, being a critical insider enabled community health workers to make sense of the diverse constraints on health and lifestyles within their community. Second, they understood their own public health role as limited by operating within this context, so they articulated their occupational identity as focused on supporting clients to make small but sustainable changes to their own and their families’ lifestyles. Third, the uncertainties of translating population based risk information to individual clients were (at least partially) resolved at an embodied level, with the community health workers identifying as accessible and trusted role models for the value of changed lifestyles. The article is important for policy and practice as it provides a critique of a rapidly evolving new mode of delivery of public health services, and insights on the development of this new public health workforce.

Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size

OBJECTIVE

To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design.

STUDY DESIGN AND SETTING

We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment.

RESULTS

Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention.

CONCLUSION

About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.

NHS health checks: a cross- sectional observational study on equity of uptake and outcomes

BACKGROUND

The National Health Checks programme aims to reduce the incidence of cardiovascular diseases and health inequalities in England. We assessed equity of uptake and outcomes from NHS Health Checks in general practices in Bristol, UK.

METHODS

A cross-sectional study using patient-level data, from 38 general practices. We descriptively analysed the socioeconomic status (SES) of patients invited and the SES and ethnicity of those attending. Logistic regression was used to test associations between invitation and attendance, with population characteristics.

RESULTS

Between June 2010 to October 2014, 31,881 patients were invited, and 13,733 NHS Health Checks completed. 47% of patients invited from the three least and 39% from the two most-deprived index of multiple deprivation quintiles, completed a Check. Proportions of invited patients, by ethnicity were 64% non-black and Asian and 31% black and Asian. Men were less likely to attend than women (OR 0.73, 95% confidence interval 0.67 to 0.80), as were patients ≤ 49 compared to ≥ 70 years (OR 0.40, 95% confidence interval 0.65 to 0.83). After controlling for SES and population characteristics, compared to patients with low CVD risk, high risk patients were more likely to be prescribed cardiovascular drugs (OR 6.2, 95% confidence interval 4.51 to 8.40). Compared to men, women (OR 01.18, 95% confidence interval 1.03 to 1.35) were more likely to be prescribed cardiovascular drugs, as were those ≤ 49 years (50-59 years, OR 1.42, 95% confidence intervals 1.13-1.79, 60-69 years, OR 1.60, 95% confidence intervals, 1.22-2.10, ≥ 70 years, OR 1.64, 95% confidence intervals, 1.14 to 2.35). Controlling for population characteristics, the following groups were most likely to be referred to lifestyle services: younger women (OR 2.22, 95% CI 1.69 to 2.94), those in the most deprived IMD quintile (OR 3.22, 95% CI 1.63 to 6.36) and those at highest risk of CVD (OR, 2.77, 95% CI 1.91 to 4.02).

CONCLUSIONS

We found no statistically significant evidence of inequity in attendance for an NHS Health Check by SES. Being older or a woman were associated with better attendance. Targeting men, younger patients and ethnic minority groups may improve equity in uptake for NHS Health Checks.

Levels of detection of hypertension in primary medical care and interventions to improve detection: a systematic review of the evidence since 2000

OBJECTIVES

In England, many hypertensives are not detected by primary medical care. Higher detection is associated with lower premature mortality. We aimed to summarise recent evidence on detection and interventions to improve detection in order to inform policies to improve care.

DESIGN

Data sources: systematic review of articles published since 2000. Searches of Medline and Embase were undertaken. Eligibility criteria: published in English, any study design, the setting was general practice and studies included patients aged 18 or over.

EXCLUSION CRITERIA

screening schemes, studies in primary care settings other than general practice, discussion or comment pieces.

PARTICIPANTS

adult patients of primary medical care services.

SYNTHESIS

study heterogeneity precluded a statistical synthesis, and papers were described in summary tables.

RESULTS

Seventeen quantitative and one qualitative studies were included. Detection rates varied by gender and ethnic group, but longitudinal studies indicated an improvement in detection over time. Patient socioeconomic factors did not influence detection, but living alone was associated with lower detection. Few health system factors were associated with detection, but in two studies higher numbers of general practitioners per 1000 population were associated with higher detection. Three studies investigated interventions to improve detection, but none showed evidence of effectiveness.

LIMITATIONS

The search was limited to studies published from 2000, in English. There were few studies of interventions to improve detection, and a meta-analysis was not possible.

CONCLUSIONS AND IMPLICATIONS

Levels of detection of hypertension by general practices may be improving, but large numbers of people with hypertension remain undetected. Improvement in detection is therefore required, but guidance for primary medical care is not provided by the few studies of interventions included in this review. Primary care teams should continue to use low-cost, practical approaches to detecting hypertension until evidence from new studies of interventions to improve detection is available.

Street-level diplomacy? Communicative and adaptive work at the front line of implementing public health policies in primary care

Public services are increasingly operating through network governance, requiring those at all levels of the system to build collaborations and adapt their practice. Agent-focused implementation theories, such as 'street-level bureaucracy', tend to focus on decision-making and the potential of actors to subvert national policy at a local level. While it is acknowledged that network leaders need to be adaptable and to build trust, much less consideration has been given to the requirement for skills of 'diplomacy' needed by those at the front line of delivering public services. In this article, drawing on theoretical insights from international relations about the principles of 'multi-track diplomacy', we propose the concept of street level diplomacy, offer illustrative empirical evidence to support it in the context of the implementation of public health (preventative) policies within primary care (a traditionally responsive and curative service) in the English NHS and discuss the contribution and potential limitations of the new concept. The article draws on qualitative data from interviews conducted with those implementing case finding programmes for cardiovascular disease in the West Midlands. The importance of communication and adaptation in the everyday work of professionals, health workers and service managers emerged from the data. Using abductive reasoning, the theory of multi-track diplomacy was used to aid interpretation of the 'street-level' work that was being accomplished.