Molly Byrne

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial.

Objective To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease. Design Cluster randomised controlled multicentre trial. Setting General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems. Participants 903 patients with established coronary heart disease registered with one of 48 practices. Intervention Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care. Main outcome measures The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12). Results At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03). Conclusions Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease. Trial registration Current Controlled Trials ISRCTN24081411.

Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners A Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

Sexual counseling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

Selection bias resulting from the requirement for prior consent in observational research: a community cohort of people with ischaemic heart disease.

Objective: To evaluate differences between adults who consent to participate in observational research and those who do not. Design: Prospective, population-based cohort study. Setting: 35 randomised Irish general practices. Participants: 1609 adults with ischaemic heart disease identified in 2000–1. Intervention: Medical records search, postal questionnaire and consent form in 2005–6. Main outcome measures: Differences in demographic and prognostic risk factors between consenters and non-consenters. Results: At follow-up, charts were located for 1592 patients (98.9%). Questionnaires were sent to 1269 patients and 876 were returned (69%). Of these, 574 (65.5%) gave consent for participation in further research. Logistic regression identified four characteristics as independently positively predictive of consent to participation in further research among questionnaire responders: having undergone percutaneous transluminal coronary angioplasty was associated with an increased odds of consent, with an odds ratio (OR) of 1.77 (95% CI 1.09 to 2.86), as was a last recorded blood pressure <140/90 mm Hg (OR = 1.45 (1.00 to 2.09)), a last recorded total cholesterol level <5 mmol/l (OR = 1.71 (1.16 to 2.54)) and being an ex-smoker rather than a current smoker or non-smoker (OR = 1.73 (1.17 to 2.57)). Conclusions: This research demonstrates the potential impact of consent bias in observational research on ischaemic heart disease, a disease of everyday clinical importance in Europe. It demonstrates that clinically important prognostic variables may be associated with consent preferences. Future cohorts, dependent upon prior written consent, may contain disproportionate numbers of those who have made healthy lifestyle decisions, have previously benefited from treatment or whose clinical risk factors are already well managed. As a result, the generalisability of such research may be diminished and the effects of treatments over- or underestimated.

Predicting donation among an Irish sample of donors and nondonors: extending the theory of planned behavior.

BACKGROUND: Research has indicated the ability of the Theory of Planned Behavior to predict blood donation. This study tested an extended version of the Theory of Planned Behavior (attitude, subjective norm, and perceived behavioral control with the addition of past behavior, moral norm, self‐identity, and anticipated regret) in predicting donation intention and behavior among donors and nondonors and if forming implementation intentions improved attendance at a mobile blood donation clinic.

Cardiac rehabilitation staff views about discussing sexual issues with coronary heart disease patients: a national survey in Ireland.

Background: While a healthy sexual life is regarded as an important aspect of quality of life, sexual counselling from healthcare providers for cardiac patients has received little attention in the literature. Aim: To document current practice and assess the needs of cardiac rehabilitation service providers in Ireland with regard to sexual assessment and management for patients. Methods: Cardiac rehabilitation staff in all relevant centres in Ireland responded to a postal questionnaire. Sexual health management was assessed by a series of questions on current practice, staff attitudes, beliefs and perceived barriers to discussing sexual problems. Results: Staff (N = 60; 61% response rate) reported a lack of assessment and counselling protocols for addressing sexual health problems, with little or no onward referral system available. Results also suggest staff believe that patients do not expect them to ask about their sexual concerns. Barriers reported included an overall lack of confidence (45%), knowledge (58%) and training (85%). Conclusion: Development of guidelines, assessment protocols and training for cardiac rehabilitation staff are essential in the area of sexual health problems in order to improve the quality of services for patients with coronary heart disease.

The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

BackgroundThe aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.MethodsSPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions.The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires.The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

OBJECTIVES The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. METHODS Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. RESULTS The intervention strategy resulted in mean cost savings per patient of euro512.77 (95 percent confidence interval [CI], -1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, -0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay euro45,000 per additional QALY. CONCLUSIONS Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice.

Designing health communication: Testing the explanations for the impact of communication medium on effectiveness

Objective. The written format has been found consistently to be the most effective medium for communicating relatively complex information (e.g. Furnham, Gunter, & Green, 1990). Looking at the communication of health information, Corston and Colman (1997) accounted for media differences by referring to the facts that reading a written presentation is self-paced (the self-pacing theory) and that a written presentation contains fewer distracting characteristics than either audio-visual or auditory-only presentations (the distraction theory). The present study sought to test these theories. Method. Female students (N = 175) between the ages of 16 and 18 from two secondary schools were exposed to a fictitious health warning and completed a questionnaire immediately afterwards, measuring communication effectiveness via recall. Participants were divided into seven treatment condition groups which varied in the medium of presentation (two written, three audio-visual and three auditory-only) and distraction level inherent to the design of the communication. Results. In line with previous literature, the written format was the most effective way to communicate a piece of health-related information (p < .01). No evidence was provided for the ‘self-pacing theory’. Substantial support, however, was found for the ‘distraction theory’. Conclusions. In general, minimally distracting communication proved maximally effective. A simple distraction effect, however, was not found within the audio-visual medium. Here the presentation where the viewers see a reader conveying the message (the ‘talking head’ condition) proved most effective, even though it was not the least distracting. Being able to see someone reading the message appears to convey a special communication advantage on the presentation.

Barriers and facilitators associated with attendance at hospital diabetes clinics among young adults (15-30 years) with type 1 diabetes mellitus: a systematic review

Regular clinic attendance is recommended to facilitate self‐management of diabetes. Poor attendance is common among young adults with type 1 diabetes mellitus (DM). This systematic review aimed to produce a narrative synthesis of the evidence regarding factors which promote or impede regular attendance at adult diabetes clinics among young adults (15–30 years) with type 1 DM. Studies reporting facilitators and barriers to clinic attendance were identified by searching four electronic databases, checking reference lists, and contacting diabetes research networks. A total of 12 studies (8 quantitative and 4 qualitative) met the inclusion criteria. Young adults experiences transitioning from paediatric to adult diabetes care can influence attendance at the adult clinic positively if there is a comprehensive transition programme in place, or negatively if the two clinics do not communicate and provide adequate support. Post‐transition, relationship development and perceptions of the value of attending the clinic are important for regular attendance. Controlled research is required to better understand decisions to attend or not attend outpatient services among people with chronic conditions. Service delivery must be sensitive to the developmental characteristics of young adults and tailored support may be required by young adults at greatest risk of non‐attendance.

The Irish DAFNE Study Protocol: A cluster randomised trial of group versus individual follow-up after structured education for Type 1 diabetes

BackgroundStructured education programmes for individuals with Type 1 diabetes have become a recognised means of delivering the knowledge and skills necessary for optimal self-management of the condition. The Dose Adjustment for Normal Eating (DAFNE) programme has been shown to improve biomedical (HbA1c and rates of severe hypoglycaemia) and psychosocial outcomes for up to 12 months following course delivery. The optimal way to support DAFNE graduates and maintain the benefits of the programme has not been established. We aimed to compare 2 different methods of follow-up of DAFNE graduates in a pragmatic clinical trial delivered in busy diabetes clinics on the island of Ireland.MethodsSix participating centres were cluster randomised to deliver either group follow-up or a return to traditional one-to-one clinic visits. In the intervention arm group follow-up was delivered at 6 and 12 months post DAFNE training according to a curriculum developed for the study. In the control arm patients were seen individually in diabetes clinics as part of routine care. Study outcomes included HbA1c levels, self-reported rates of severe hypoglycaemia, body weight and measures of diabetes wellbeing and quality of life. These were measured at 6, 12 and 18 months after recruitment. Generalisability (external validity) was maximised by recruiting study participants from existing DAFNE waiting lists in each centre, by using broad inclusion criteria (including HbA1c values less than 13 percent with no lower limit) and by using existing clinic staff to deliver the training and follow-up. Internal validity and treatment fidelity were maximised by quality assuring the training of all DAFNE educators, by external peer review of the group follow-up sessions and by striving for full attendance at follow-up visits. Assays of HbA1c were undertaken in a central laboratory.DiscussionThis pragmatic clinical trial evaluating group follow-up after a structured education programme has been designed to have broad generalisability. The results should inform how best to manage the well educated patient with Type 1 diabetes in the real world of clinical practiceTrial registrationCurrent Controlled Trials ISRCTN79759174