C.M. Lobo

Perceptions of cardiovascular risk among patients with hypertension or diabetes

We aimed to examine risk perceptions among patients at moderate to high cardiovascular risk. A questionnaire about perceived absolute risk of myocardial infarction and stroke was sent to 2424 patients with hypertension or diabetes. Response rate was 86.3% and 1557 patients without atherosclerotic disease were included. Actual cardiovascular risk was calculated by using Framingham risk functions. A total of 363 (23.3%) of the 1557 patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. The remaining 1194 patients tended to overestimate their risk. In 42.3% (497/1174) and 46.8% (541/1155) of the cases, patients overestimated their actual 10-year risk for myocardial infarction and stroke, respectively, by more than 20%. Older age, smoking, familial history of cardiovascular disease (CVD), and actual absolute risk predicted higher levels of perceived absolute risk. Male sex, higher scores for an internal health locus of control, lower scores for a physician locus of control, and self-rated excellent or (very) good health were positively related to higher accuracy. In conclusion, patients showed inadequate perceptions of their absolute risk of cardiovascular events and physicians should thus provide greater information about absolute risk when offering preventive therapy.

Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice

Aims To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners (GPs) for patients with diabetes. To identify practice characteristics which predict success.

Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice

Objective: To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care. Design: Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years. Setting: 124 general practices in The Netherlands. Participants: 185 GPs. Main outcome measures: Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs. Results: The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention. Conclusions: Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development.

Provision of information and advice in cardiovascular care: clinical performance of general practitioners.

The aim of this study was to assess the provision of information and advice by general practitioners (GPs) with respect to patients with hypertension, hypercholesterolaemia, or cardiovascular disease. The study relied on the prospective recording of patient encounters by GPs. Performance indicators were selected from the Dutch national guidelines for general practice. The GPs (n=195) completed 5330 encounter forms. High levels of performance were found with regard to advice on smoking cessation and the provision of information (e.g. information about alarm symptoms or the aim of treatment). Low levels of performance were found with regard to advice on salt consumption, alcohol consumption, weight reduction and physical exercise for patients with hypertension. Discussion of compliance with the therapy in case of hypercholesterolaemia, advice on physical exercise in case of angina pectoris and advice on foot care in case of peripheral arterial disease also showed a substantial gap between recommended and actual care. Performance rates varied considerably across GPs. The patient and GP characteristics examined in this study contributed very little to the clinical performance.

Effect of a comprehensive intervention program targeting general practice staff on quality of life in patients at high cardiovascular risk: a randomized controlled trial.

Background: We implemented a comprehensive intervention program targeting general practice staff, that proved successful in optimizing practice organization and clinical decision-making. In this paper, health-related quality of life (HRQL) is investigated as a clinical outcome. Objective: To evaluate the effect of the implementation of an intervention program on the HRQL in patients at high cardiovascular risk. Research design: Randomized controlled trial. Intervention practices (n = 62) received a comprehensive intervention program (by means of outreach visitors) lasting 21 months. HRQL of patients at high cardiovascular risk was assessed by the MOS 36-Item Short-Form Health Survey (SF-36), at baseline and after intervention. Three patient categories were distinguished: diabetes mellitus, cardiovascular disease and hypertension. Results: HRQL deteriorated in all respondents, but more pronounced in the control group. In diabetes patients the differences between intervention and control group were significant for the Vitality and Mental Health scales, with mean difference in change of 3.93 (95% CI: 1.08–6.78) and 3.71 (95% CI: 0.73–6.68), respectively. Patients with cardiovascular disease had significantly different changes on three scales: physical functioning (3.57, 95% CI: 0.71–6.43), vitality (3.01, 95% CI: 0.72–5.30) and social functioning (3.96, 95% CI: 0.50–7.42). In patients with hypertension, there were no differences between the intervention and control group. Conclusion: Our comprehensive intervention program resulted in changes in HRQL on several domains, particularly in patients with diabetes and cardiovascular disease.

Organisational determinants of cardiovascular prevention in general practice.

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objective r - r To assess organisational determinants in the prevention of cardiovascular disease. Design r - r A cross-sectional study. Setting and subjects r - r 130 general practices in The Netherlands. Data were collected using questionnaires. A causal model was designed and analysed by path analysis. Main outcome measures r - r Relationships between preventive activities, practice management and practice characteristics. Results r - r Important differences between adequacy of equipment and practice organisation were found. Record-keeping was significantly better when working experience of the GPs was less than 15 years, when the practice consisted only of female GPs, and when the practice had written protocols for cardiovascular disease management and the staff held regular scheduled meetings (teamwork). Teamwork also showed a significant relation with follow-up activities. The influence of non-measured variables in the model was considerable. Conclusion r - r In exploring the organisational setting as a barrier to prevention and disease management, the designed model showed no major effects. Despite the wide variety of practice organisational items investigated, a strong influence of non-measured variables was evident. Teamwork in the practices proved to be related to both follow-up and record-keeping. Younger and female GPs were further predictors of adequate record-keeping.

Process evaluation of a multifaceted intervention to improve cardiovascular disease prevention in general practice.

Objectives: To perform a process evaluation of a multifaceted intervention to improve cardiovascular and diabetes care in general practice. Methods: The feasibility of the intervention, carried out by outreach visitors in 62 practices, was addressed by evaluating whether the intervention programme was performed as planned and the extent to which it was accepted by the practice team. In addition, the costs of the programme were determined. Results: The intervention was largely carried out as planned, although the intervention period had to be extended by three months. Of the 18 topics that could be addressed during the intervention period, 12 (mean) were addressed. The number of outreach visits per practice was 15.2 (mean), each visit lasted about one hour. Most practice members endorsed both the key recommendations for clinical decision-making and car — diovascular risk profiling. The majority of GPs (range 63-98%) agreed with the guidelines for clinical decision-making, and 29-97% had a positive opinion about the guidelines for practice organisation. According to practice staff members, the outreach visitor had sufficient knowledge and skills to support them in changing the practice organisation. GPs were less positive about the outreach visitors knowledge and skills in optimising clinical decision — making; however 78% believed that the outreach visitor contributed to effecting change in their clinical decision-making. The total costs of the intervention per practice were 4317. Conclusions: This process evaluation demonstrated that the intervention was usually carried out as planned and achieved a high satisfaction rating from the participating practice members.