Lewis D Ritchie

Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care

Abstract Objectives: To evaluate the effects of nurse led clinics in primary care on secondary prevention, total mortality, and coronary event rates after four years. Design: Follow up of a randomised controlled trial by postal questionnaires and review of case notes and national datasets. Setting: Stratified, random sample of 19 general practices in north east Scotland. Participants: 1343 patients (673 intervention and 670 control) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound. Intervention: Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year. Main outcome measures: Components of secondary prevention (aspirin, blood pressure management, lipid management, healthy diet, exercise, non-smoking), total mortality, and coronary events (non-fatal myocardial infarctions and coronary deaths). Results: Mean follow up was at 4.7 years. Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year, and these were sustained after four years except for exercise. The control group, most of whom attended clinics after the initial year, caught up before final follow up, and differences between groups were no longer significant. At 4.7 years, 100 patients in the intervention group and 128 in the control group had died: cumulative death rates were 14.5% and 18.9%, respectively (P=0.038). 100 coronary events occurred in the intervention group and 125 in the control group: cumulative event rates were 14.2% and 18.2%, respectively (P=0.052). Adjusting for age, sex, general practice, and baseline secondary prevention, proportional hazard ratios were 0.75 for all deaths (95% confidence intervals 0.58 to 0.98; P=0.036) and 0.76 for coronary events (0.58 to 1.00; P=0.049) Conclusions: Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events. Secondary prevention clinics should be started sooner rather than later. What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease, but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary events

Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care

Objective To evaluate whether nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease. Design Randomised controlled trial. Setting A random sample of 19 general practices in northeast Scotland. Patients 1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease, but without terminal illness or dementia and not housebound. Intervention Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up. Main outcome measures Components of secondary prevention assessed at baseline and one year were: aspirin use; blood pressure management; lipid management; physical activity; dietary fat; and smoking status. A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient. Results There were significant improvements in aspirin management (odds ratio 3.22, 95% confidence interval 2.15 to 4.80), blood pressure management (5.32, 3.01 to 9.41), lipid management (3.19, 2.39 to 4.26), physical activity (1.67, 1.23 to 2.26) and diet (1.47, 1.10 to 1.96). There was no effect on smoking cessation (0.78, 0.47 to 1.28). Of six possible components of secondary prevention, the baseline mean was 3.27. The adjusted mean improvement attributable to intervention was 0.55 of a component (0.44 to 0.67). Improvement was found regardless of practice baseline performance. Conclusions Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease. Most patients gained at least one effective component of secondary prevention and, for them, future cardiovascular events and mortality could be reduced by up to a third.

Secondary prevention in coronary heart disease: baseline survey of provision in general practice

Abstract Objective: To determine secondary preventive treatment and habits among patients with coronary heart disease in general practice. Design: Process of care data on a random sample of patients were collected from medical records. Health and lifestyle data were collected by postal questionnaire (response rate 71%). Setting: Stratified, random sample of general practices in Grampian. Subjects: 1921 patients aged under 80 years with coronary heart disease identified from pre-existing registers of coronary heart disease and nitrate prescriptions. Main outcome measures: Treatment with aspirin, β blockers, and angiotensin converting enzyme inhibitors. Management of lipid concentrations and hypertension according to local guidelines. Dietary habits (dietary instrument for nutritional evaluation score), physical activity (health practice indices), smoking, and body mass index. Results: 825/1319 (63%) patients took aspirin. Of 414 patients with recent myocardial infarction, 131 (32%) took β blockers, and of 257 with heart failure, 102 (40%) took angiotensin converting enzyme inhibitors. Blood pressure was managed according to current guidelines for 1566 (82%) patients but lipid concentrations for only 133 (17%). 673 of 1327 patients (51%) took little or no exercise, 245 of 1333 (18%) were current smokers, 808 of 1264 (64%) were overweight, and 627 of 1213 (52%) ate more fat than recommended. Conclusion: In terms of secondary prevention, half of patients had at least two aspects of their medical management that were suboptimal and nearly two thirds had at least two aspects of their health behaviour that would benefit from change. There seems to be considerable potential to increase secondary prevention of coronary heart disease in general practice. Key messages Patients with coronary heart disease can benefit from both medical and lifestyle secondary prevention measures This study found that half of patients with coronary heart disease in general practice had at least two missed opportunities for effective medical interventions Nearly two thirds of patients with coronary heart disease in general practice had two or more high risk lifestyle factors that would benefit from change There seems to be plenty of opportunity for improving secondary prevention of coronary heart disease in general practice

Rural and urban differences in stage at diagnosis of colorectal and lung cancers

There is evidence that patients living in outlying areas have poorer survival from cancer. This study set out to investigate whether they have more advanced disease at diagnosis. Case notes of 1323 patients in north and northeast Scotland who were diagnosed with lung or colorectal cancer in 1995 or 1996 were reviewed. Of patients with lung cancer, 42% (69/164) living 58 km or more from a cancer centre had disseminated disease at diagnosis compared to 33% (71/215) living within 5 km. For colorectal cancer the respective figures were 24% (38/161) and 16% (31/193). For both cancers combined, the adjusted odds ratio for disseminated disease at diagnosis in furthest group compared to the closest group was 1.59 (P = 0.037). Of 198 patients with non-small-cell lung cancer in the closest group, 56 (28%) had limited disease (stage I or II) at diagnosis compared to 23 of 165 (14%) of the furthest group (P = 0.002). The respective figures for Dukes A and B colorectal cancer were 101 of 196 (52%) and 67 of 172 (39%) (P = 0.025). These findings suggest that patients who live remote from cities and the associated cancer centres have poorer chances of survival from lung or colorectal cancer because of more advanced disease at diagnosis. This needs to be taken into account when planning investigation and treatment services.

Rural factors and survival from cancer: analysis of Scottish cancer registrations.

In this survival study 63 976 patients diagnosed with one of six common cancers in Scotland were followed up. Increasing distance from a cancer centre was associated with less chance of diagnosis before death for stomach, breast and colorectal cancers and poorer survival after diagnosis for prostate and lung cancers.

Effective feedback to improve primary care prescribing safety (EFIPPS) a pragmatic three-arm cluster randomised trial: Designing the intervention

BackgroundHigh-risk prescribing in primary care is common and causes considerable harm. Feedback interventions have small/moderate effects on clinical practice, but few trials explicitly compare different forms of feedback. There is growing recognition that intervention development should be theory-informed, and that comprehensive reporting of intervention design is required by potential users of trial findings. The paper describes intervention development for the Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) study, a pragmatic three-arm cluster randomised trial in 262 Scottish general practices.MethodsThe NHS chose to implement a feedback intervention to utilise a new resource, new Prescribing Information System (newPIS). The development phase required selection of high-risk prescribing outcome measures and design of intervention components: (1) educational material (the usual care comparison), (2) feedback of practice rates of high-risk prescribing received by both intervention arms and (3) a theory-informed behaviour change component to be received by one intervention arm. Outcome measures, educational material and feedback design, were developed with a National Health Service Advisory Group. The behaviour change component was informed by the Theory of Planned Behaviour and the Health Action Process Approach. A focus group elicitation study and an email Delphi study with general practitioners (GPs) identified key attitudes and barriers of responding to the prescribing feedback. Behaviour change techniques were mapped to the psychological constructs, and the content was informed by the results of the elicitation and Delphi study.ResultsSix high-risk prescribing measures were selected in a consensus process based on importance and feasibility. Educational material and feedback design were based on current NHS Scotland practice and Advisory Group recommendations. The behaviour change component was resource constrained in development, mirroring what is feasible in an NHS context. Four behaviour change interventions were developed and embedded in five quarterly rounds of feedback targeting attitudes, subjective norms, perceived behavioural control and action planning (2×).ConclusionsThe paper describes a process which is feasible to use in the resource-constrained environment of NHS-led intervention development and documents the intervention to make its design and implementation explicit to potential users of the trial findings.Trial registrationClinicalTrials.gov: NCT01602705

Impact of deprivation and rural residence on treatment of colorectal and lung cancer.

For common cancers, survival is poorer for deprived and outlying, rural patients. This study investigated whether there were differences in treatment of colorectal and lung cancer in these groups. Case notes of 1314 patients in north and northeast Scotland who were diagnosed with lung or colorectal cancer in 1995 or 1996 were reviewed. On univariate analysis, the proportions of patients receiving surgery, chemotherapy and radiotherapy appeared similar in all socio-economic and rural categories. Adjusting for disease stage, age and other factors, there was less chemotherapy among deprived patients with lung cancer (odds ratio 0.39; 95% confidence intervals 0.16 to 0.96) and less radiotherapy among outlying patients with colorectal cancer (0.39; 0.19 to 0.82). The time between first referral and treatment also appeared similar in all socio-economic and rural groups. Adjusting for disease stage and other variables, times to lung cancer treatment remained similar, but colorectal cancer treatment was quicker for outlying patients (adjusted hazard ratio 1.30; 95% confidence intervals 1.03 to 1.64). These findings suggest that socio-economic status and rurality may have a minor impact on modalities of treatment for colorectal and lung cancer, but do not lead to delays between referral and treatment.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study.

Objectives: To determine what factors are associated with the time people take to consult with symptoms of lung cancer, with a focus on those from rural and socially deprived areas. Methods: A cross-sectional quantitative interview survey was performed of 360 patients with newly diagnosed primary lung cancer in three Scottish hospitals (two in Glasgow, one in NE Scotland). Supplementary data were obtained from medical case notes. The main outcome measures were the number of days from (1) the date participant defined first symptom until date of presentation to a medical practitioner; and (2) the date of earliest symptom from a symptom checklist (derived from clinical guidelines) until date of presentation to a medical practitioner. Results: 179 participants (50%) had symptoms for more than 14 weeks before presenting to a medical practitioner (median 99 days; interquartile range 31–381). 270 participants (75%) had unrecognised symptoms of lung cancer. There were no significant differences in time taken to consult with symptoms of lung cancer between rural and/or deprived participants compared with urban and/or affluent participants. Factors independently associated with increased time before consulting about symptoms were living alone, a history of chronic obstructive pulmonary disease (COPD) and longer pack years of smoking. Haemoptysis, new onset of shortness of breath, cough and loss of appetite were significantly associated with earlier consulting, as were a history of chest infection and renal failure. Conclusion: For many people with lung cancer, regardless of location and socioeconomic status, the time between symptom onset and consultation was long enough to plausibly affect prognosis. Long-term smokers, those with COPD and/or those living alone are at particular risk of taking longer to consult with symptoms of lung cancer and practitioners should be alert to this.

Vaccine effectiveness in pandemic influenza - primary care reporting (VIPER): an observational study to assess the effectiveness of the pandemic influenza A (H1N1)v vaccine

OBJECTIVES To determine influenza A (H1N1)v vaccine effectiveness (VE) in the Scottish population at an early stage of the 2009-10 H1N1v vaccination programme, using a sentinel surveillance network of 41 general practices contributing to the Practice Team Information (PTI) network. METHODS Retrospective cohort study using record linkage. Using the Community Health Index (CHI) number, general practice patient-level data were extracted and linked to the Scottish Morbidity Record (SMR) catalogue, containing information on all inpatient hospitalisations in Scotland. The Health Protection Scotland (HPS) data set was also used, consisting of laboratory-confirmed cases of influenza A (H1N1)v from the practices. The study involved a longitudinal evaluation of the aspect of the influenza A (H1N1)v vaccination programme implemented through general practice in autumn/winter 2009. RESULTS At 25 December 2009, vaccine uptake estimates for the study population were 12.0% (95% CI 11.9 to 12.1). For those patients in an at-risk group (n = 59,721), the uptake rate was 37.5% (95% CI 37.1 to 37.9). Among the 1492 patients swabbed, 467 were positive for H1N1, giving a positivity rate of 31.3% [95% confidence interval (CI) 29.0 to 33.7]. Among those in a clinical risk group who were not vaccinated, 41.3% (95% CI 35.6 to 46.9) tested positive for influenza A (H1N1)v, a significant difference from the H1N1 positivity percentage among patients with no clinical risk (p < 0.01). Among those vaccinated and in a clinical risk group, only one patient (5%, 95% CI 0.3 to 23.6) tested after vaccination was positive for influenza A (H1N1)v. By comparing postvaccination swabs in those who were vaccinated with swabs taken in those who remained unvaccinated, the VE was found to be 95.0% (95% CI 76.0 to 100.0). In the study population there were 2739 admissions to hospital, of which 1241 were emergency admissions; all 48 emergency hospitalisations for influenza and pneumonia occurred in patients who did not receive the vaccine. VE for single or combined end points of influenza and pneumonia hospitalisation for all patients was estimated at 100.0% (95% CI infinity to 100.0). There were 132 hospitalisations in the unvaccinated group versus five in the vaccinated group for cardiovascular-related conditions. There were 193 hospitalisations in the unvaccinated group versus nine in those vaccinated in the group of patients admitted for influenza, pneumonia, chronic obstructive pulmonary disease (COPD) and cardiovascular-related conditions. VE for cardiovascular-related conditions alone, or in individuals with influenza, pneumonia COPD and cardiovascular-related conditions, was 71.1% (95% CI 11.3 to 90.6) and 64.7% (95% CI 12.0 to 85.8) respectively. CONCLUSIONS Evidence from swabs submitted from patients in the cohort who presented in general practice with influenza-like illness suggests that the introduction of influenza A (H1N1)v vaccine in Scotland during 2009 was associated with a high degree of protection. Influenza A (H1N1)v immunisation in primary health-care settings appears to be both effective and widely acceptable, and should continue to be the mainstay of disease prevention for at-risk patients. A further analysis encompassing the whole influenza season is required to cover more days of vaccination exposure and increase precision.