Azhar Farooqi

Educational interventions in kidney disease care: a systematic review of randomized trials.

BACKGROUND There is increasing evidence that educational interventions aimed at empowering patients are successful in chronic disease management. Our aim was to conduct a systematic review of the effectiveness of such educational interventions in people with kidney disease. SYSTEMATIC REVIEW: A comprehensive search strategy was applied by using major electronic databases from 1980 to March 2007. Researchers independently reviewed titles and abstracts and extracted data from identified studies. SETTING & POPULATION Patients in any of the following stages of chronic kidney disease: early, predialysis, and dialysis. Kidney transplant recipients were excluded because this group has additional educational needs that are beyond the scope of this review. SELECTION CRITERIA FOR STUDIES Randomized controlled trials. INTERVENTIONS Structured educational interventions (involving informational and psychological components) with usual care. OUTCOMES Clinical, behavioral, psychological, and knowledge outcomes were considered. RESULTS 22 studies were identified involving a wide range of multicomponent interventions with variable aims and outcomes depending on the area of kidney disease care. 18 studies provided significant results for at least 1 of the outcomes. The majority of studies aimed to improve diet and/or fluid concordance in dialysis patients and involved short- and medium-term follow-up. A single major long-term study was a 20-year follow-up of a predialysis educational intervention that showed increased survival rates. No study was found that addressed chronic kidney disease at an earlier stage. LIMITATIONS Meta-analysis was not possible because of study heterogeneity. CONCLUSIONS Multicomponent structured educational interventions were effective in predialysis and dialysis care, but the quality of many studies was suboptimal. Effective frameworks to develop, implement, and evaluate educational interventions are required, especially those that target patients with early stages of chronic kidney disease. This could lead to possible prevention or delay in progression of kidney disease.

Rationale and design of the ADDITION-Leicester study, a systematic screening programme and Randomised Controlled Trial of multi-factorial cardiovascular risk intervention in people with Type 2 Diabetes Mellitus detected by screening

BackgroundEarlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in Type 2 Diabetes Mellitus (T2DM). Latent phase identification through screening requires structured, appropriately targeted population-based approaches. Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from randomised intervention trials in screen-detected T2DM cases. UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM. To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care. Here we describe the rationale and methods of a systematic community screening programme and randomised controlled trial of cardiovascular risk management within a UK multiethnic setting (ADDITION-Leicester).DesignA single-blind cluster randomised, parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care.MethodsADDITION-Leicester consists of community-based screening and intervention phases within 20 general practices coordinated from a single academic research centre. Screening adopts a universal diagnostic approach via repeated 75g-Oral Glucose Tolerance Tests within an eligible non-diabetic population of 66,320 individuals aged 40-75 years (25-75 years South Asian). Volunteers also provide detailed medical and family histories; complete health questionnaires, undergo anthropometric measures, lipid profiling and a proteinuria assessment. Primary outcome is reduction in modelled Coronary Heart Disease (UKPDS CHD) risk at five years. Seven thousand (30% of South Asian ethnic origin) volunteers over three years will be recruited to identify a screen-detected T2DM cohort (n = 285) powered to detected a 6% relative difference (80% power, alpha 0.05) between treatment groups at one year. Randomisation will occur at practice-level with newly diagnosed T2DM cases receiving either conventional (according to current national guidelines) or intensive (algorithmic target-driven multi-factorial cardiovascular risk intervention) treatments.DiscussionADDITION-Leicester is the largest multiethnic (targeting >30% South Asian recruitment) community T2DM and vascular risk screening programme in the UK. By assessing feasibility and efficacy of T2DM screening, it will inform national disease prevention policy and contribute significantly to our understanding of the health care needs of UK South Asians.Trial registrationClinicaltrial.gov (NCT00318032).

Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial

Aims: To evaluate the effect of a disease management programme for patients with coronary heart disease (CHD) and chronic heart failure (CHF) in primary care. Methods: A cluster randomised controlled trial of 1316 patients with CHD and CHF from 20 primary care practices in the UK was carried out. Care in the intervention practices was delivered by specialist nurses trained in the management of patients with CHD and CHF. Usual care was delivered by the primary healthcare team in the control practices. Results: At follow up, significantly more patients with a history of myocardial infarction in the intervention group were prescribed a beta-blocker compared to the control group (adjusted OR 1.43, 95% CI 1.19 to 1.99). Significantly more patients with CHD in the intervention group had adequate management of their blood pressure (<140/85 mm Hg) (OR 1.61, 95% CI 1.22 to 2.13) and their cholesterol (<5 mmol/l) (OR 1.58, 95% CI 1.05 to 2.37) compared to those in the control group. Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed (OR 4.69, 95% CI 1.88 to 11.66) or excluded (OR 3.80, 95% CI 1.50 to 9.64) in the intervention group compared to the control group. There were significant improvements in some quality-of-life measures in patients with CHD in the intervention group. Conclusions: Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care.

Diabetes screening anxiety and beliefs

Aims  This study assesses the impact of screening for diabetes on anxiety levels in an ethnically mixed population in the UK, and explores whether beliefs about Type 2 diabetes account for these anxiety levels.

Intensive multifactorial intervention improves modelled coronary heart disease risk in screen‐detected Type 2 diabetes mellitus: a cluster randomized controlled trial

Diabet. Med. 29, 531–540 (2012)

A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: The Let's Prevent Diabetes cluster randomised controlled trial

OBJECTIVES Prevention of type 2 diabetes (T2DM) is a priority in healthcare, but there is a lack of evidence investigating how to effectively translate prevention research into a UK primary care setting. We assessed whether a structured education programme targeting lifestyle and behaviour change was effective at preventing progression to T2DM in people with pre-diabetes. MATERIALS AND METHODS Forty-four general practices were randomised to receive either standard care or a 6hour group structured education programme with an annual refresher course, and regular phone contact. Participants were followed up for 3years. The primary outcome was progression to T2DM. RESULTS Eight hundred and eighty participants were included (36% female, mean age 64years, 16% ethnic minority group); 131 participants developed T2DM. There was a non-significant 26% reduced risk of developing T2DM in the intervention arm compared to standard care (HR 0.74, 95% CI 0.48, 1.14, p=0.18). The reduction in T2DM risk when excluding those who did not attend the initial education session was also non-significant (HR 0.65, 0.41, 1.03, p=0.07). There were statistically significant improvements in HbA1c (-0.06, -0.11, -0.01), LDL cholesterol (-0.08, -0.15, -0.01), sedentary time (-26.29, -45.26, -7.32) and step count (498.15, 162.10, 834.20) when data were analysed across all time points. CONCLUSIONS This study suggests that a relatively low resource, pragmatic diabetes prevention programme resulted in modest benefits to biomedical, lifestyle and psychosocial outcomes, however the reduction to the risk of T2DM did not reach significance. The findings have important implications for future research and primary care.

Screening for the metabolic syndrome using simple anthropometric measurements in south Asian and white Europeans: A population-based screening study. The Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) Study

AIMS To estimate the prevalence of metabolic syndrome in a general population sample of south Asians and white Europeans and compare predictors of metabolic syndrome, using ethnic specific definitions of obesity. METHODS 3099 participants (71.4% white European, 28.6% south Asian) aged 40-75 years were screened using a 75 g oral glucose tolerance test. Metabolic syndrome was defined using National Cholesterol Education Programme and International Diabetes Federation definitions. We compared sensitivity, specificity and area under the curve of waist circumference, body mass index and waist-hip ratio. RESULTS The prevalence of metabolic syndrome using the definitions above was 29.9% (29.2% south Asian, 30.2% white European), and 34.4% (34.2% south Asian, 34.5% white European), respectively. Using the National Cholesterol Education Programme definition, waist circumference was significantly more predictive of metabolic syndrome than body mass index or waist-hip ratio. The area under the curve for waist circumference was 0.75 (95% CI: 0.69-0.80) and 0.76 (0.72-0.81) for south Asian men and women; 0.83 (0.80-0.85) and 0.80 (0.77-0.82) for white European men and women. CONCLUSIONS The prevalence of metabolic syndrome is high in both south Asian and white European populations. Waist circumference is a simple and effective measure for predicting metabolic syndrome in different populations.

Screening for type 2 diabetes in a multiethnic setting using known risk factors to identify those at high risk: a cross-sectional study.

INTRODUCTION Screening enables the identification of type 2 diabetes mellitus (T2DM) during its asymptomatic stage and therefore allows early intervention which may lead to fewer complications and improve outcomes. A targeted screening program was carried out in a United Kingdom (UK) multiethnic population to identify those with abnormal glucose tolerance. METHODS A sample of individuals aged 25-75 years (40-75 white European) with at least one risk factor for T2DM were invited for screening from 17 Leicestershire (UK) general practices or through a health awareness campaign. All participants received a 75 g oral glucose tolerance test, cardiovascular risk assessment, detailed medical and family histories and anthropometric measurements. RESULTS In the 3,225 participants who were screened. 640 (20%) were found to have some form of abnormal glucose tolerance of whom 4% had T2DM, 3% impaired fasting glucose (IFG), 10% impaired glucose tolerance (IGT) and 3% both IFG and IGT. The odds of detecting IGT was approximately 60% greater (confounder-adjusted odds ratios [OR] 1.67 [1.22-2.29]) in the South Asian population. CONCLUSIONS Around one in five people who had targeted screening have IGT, IFG or T2DM, with a higher prevalence in those of South Asian origin. The prevalence of undetected T2DM is lower in South Asians compared to previously published studies and maybe due to increased awareness of this group being at high risk.

Making use of mortality data to improve quality and safety in general practice: a review of current approaches

Objective: To review studies of the use of mortality data in quality and safety improvement in general practice. Design: Narrative review. Methods: Search of Medline, Embase and CINAHL for articles reporting mortality monitoring or mortality reviews in general practice. The included articles were reported in English and of any study design, excluding case reports and comment pieces. Studies of palliative care and bereavement, and of primary care programmes in developing countries, were excluded. Results: 229 articles were identified in the searches, 65 were identified as potentially relevant and 53 were included in the review. The studies addressed the impact of primary care provision on mortality rates, methods of monitoring mortality, and the role of audit and death registers in quality and safety improvement. General practitioners were interested in using mortality data but reported difficulties in obtaining complete information. There were no experimental studies of the impact of the use of mortality data, and little evidence of long-term systematic initiatives to use mortality data in quality and safety improvement in general practice. Conclusions: Mortality data are not used systematically in general practice although general practitioners appear interested in the potential of this information in improving quality and safety. Improved systems to provide complete data are needed and experimental studies required to determine the effectiveness of use of the data to improve general practice care.

Dietary habits of young people attending secondary schools serving a multiethnic, inner-city community in the UK

Background: Childhood obesity is an escalating health concern with important implications, including increased risk of type 2 diabetes and cardiovascular disease. Although South Asians in the UK have an increased risk of developing these conditions, detailed studies on their lifestyles including the dietary habits of young people are scarce. Methods: As part of an action research project, a food intake questionnaire was used to survey the dietary habits of 11–15-year olds attending five inner-city schools serving a predominantly South Asian population. Food choices were considered in the overall sample and in South Asians compared with white Europeans. Results: 3418 (72% of registered pupils) responses were obtained. A subset of 3018 pupils could be categorised as either South Asian (86%) or white European (14%). Around one fifth of pupils started the school day without eating anything. Responses indicated high consumption of “negative” foods such as sweets, including Asian sweets (63%), but lower rates for “positive” foods such as vegetables (34%). In the full sample, 26% said they had consumed more than one can of sugar-sweetened fizzy drink and 17% reported eating more than one packet of full-fat crisps on the previous day. Poor dietary habits were indicated in both South Asian and white European pupils. Conclusions: Our large-scale survey confirmed poor dietary habits in secondary school pupils from a multiethnic community. Urgent efforts are needed to find ways of encouraging healthy lifestyles, particularly in populations with a high risk of developing cardiovascular disease and type 2 diabetes.