Ruth Chambers

Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent

Background As part of national policy to manage the increasing burden of chronic diseases, the Department of Health in England has launched the NHS Health Checks programme, which aims to reduce the burden of the major vascular diseases on the health service. Methods A cross-sectional review of response, attendance and treatment uptake over the first year of the programme in Stoke on Trent was carried out. Patients aged between 32 and 74 years and estimated to be at ≥20% risk of developing cardiovascular disease were identified from electronic medical records. Multi-level regression modelling was used to evaluate the influence of individual- and practice-level factors on health check outcomes. Results Overall 63.3% of patients responded, 43.7% attended and 29.8% took up a treatment following their health check invitation. The response was higher for older age and more affluent areas; attendance and treatment uptake were higher for males and older age. Variance between practices was significant (P < 0.001) for response (13.4%), attendance (12.7%) and uptake (23%). Conclusions The attendance rate of 43.7% following invitation to a health check was considerably lower than the benchmark of 75%. The lack of public interest and the prevalence of significant comorbidity are challenges to this national policy innovation.

NHS health checks through general practice: randomised trial of population cardiovascular risk reduction

BackgroundThe global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century. The Department of Health in England has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk. The aims of this study were to monitor population changes in cardiovascular disease (CVD) risk factors over the first year of the new service and to assess the value of tailored lifestyle support, including motivational interview with ongoing support and referral to other services.MethodsRandomised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent, England. Thirty eight general practices and 601 (365 usual care, 236 additional lifestyle support) patients were recruited and randomised independently between September 2009 and February 2010. Changes in population CVD risk between baseline and one year follow-up were compared, using intention-to-treat analysis. The primary outcome was the Framingham 10 year CVD risk score. Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories. Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for: weight management, physical activity, cook and eat and positive thinking.ResultsAverage population CVD risk decreased from 32.9% to 29.4% (p <0.001) in the NHS Health Check only group and from 31.9% to 29.2% (p <0.001) in the NHS Health Check plus additional lifestyle support group. There was no significant difference between the two groups at either measurement point. Prevalence of high blood pressure, high cholesterol and smoking were reduced significantly (p <0.01) in both groups. Prevalence of central obesity was reduced significantly (p <0.01) in the group receiving additional lifestyle support but not in the NHS Health Check only group.ConclusionsThe NHS Health Check service in Stoke on Trent resulted in significant reduction in estimated population CVD risk. There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction.

Using simple telehealth in primary care to reduce blood pressure: a service evaluation

Objectives This service evaluation examines how efficiently an innovative, simple and interactive blood pressure (BP) management intervention improves BP control in general practice. Design Prospective service evaluation. Setting Ten volunteer general practitioner (GP) practices in Stoke on Trent, UK. Participants Practice staff identified 124 intervention patients and invited them to participate based on two inclusion criteria: (1) patient has chronic kidney disease (CKD) stages 3 or 4 with BP persistently >130/85 mm Hg or (2) patient is >50 years-old (without CKD stages 3–5) with BP persistently >140/90 mm Hg despite prescribed antihypertensive medication. Three selected hypertensive control patients per intervention patient underwent usual clinical care (n=364). Interventions Intervention patients used ‘Florence’, a simple, interactive mobile phone texting service with BP management intervention for 3 months, or for less time if their BP became controlled. Patients measured their BP, text their readings to Florence, received an immediate automatic response and had results reviewed by their GP/practice nurse at least weekly. Main outcome measures Baseline data including recent BP readings and medications were collected; similar information was obtained for 6 months for both control and intervention patients. Average BP readings and medication usage were determined. Results At final data collection, five intervention patients had not yet completed the full programme. Control and intervention patients were well matched except that intervention patients had significantly greater baseline BP. Greatest BP reductions were among hypertensive intervention patients without CKD stages 3–5. Intervention patients had significantly more BP readings and more changes in medication over the 3-month data collection period. Conclusions Simple telehealth is acceptable and effective in reducing patients’ BP. In future, poorly controlled patients could be targeted to maximise BP reductions or broader use could improve diagnostic accuracy and accessibility for patients who struggle to regularly attend their GP surgery.

A cross-sectional survey and service evaluation of simple telehealth in primary care: what do patients think?

Objective To determine the patient experience of using a simple telehealth strategy to manage hypertension in adults. Design As part of a pragmatic service evaluation, the acceptability of, satisfaction with and ease of use of a simple telehealth strategy was determined via text, cross-sectional questionnaire survey administered by telephone, case studies, discussion groups and informal feedback from practices. This simple telehealth approach required patients to take home blood pressure (BP) readings and text them to a secure server (‘Florence’) for immediate automatic analysis and individual healthcare professional review. Participants 124 intervention patients who used the Florence system. Setting 10 volunteer general practitioners (GP) practices in Stoke on Trent, UK, with poor health and high levels of material deprivation took part. Results Patient satisfaction was high. In particular, patients found the system easy to use, were very satisfied about the feedback from their GP regarding their BP readings, found the advice sent via Florence useful and preferred to send BP readings using Florence rather than having to go to the practice monthly to get BP checked. Overall satisfaction with the system was 4.81/5.00 at week 13 of the programme. Other advantages of being enrolled with Florence were improved education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur at a time that suited the patient rather than their practice. Conclusions This simple telehealth strategy for managing hypertension in the community was met with high levels of patient satisfaction and feelings of control and support. This management approach should thus be considered for widespread implementation for clinical management of hypertension and other long-term conditions involving monitoring of patients’ bodily measurements and symptoms as a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.

Equality for people with disabilities in medicine

Time for action and partnerships As a result of our advances in medical science and technology more lives are being saved than ever before, although many people who are saved from death are left disabled. Add to this the expansion of the ageing population, in whom the prevalence of physical impairments is highest, and disability emerges as a major facet of modern society–one in four people in the United Kingdom has a disability or is closely associated with someone who has.1 Disability has become part and parcel of our human experience. By definition, therefore, the challenges facing citizens with disabilities are now a major “mainstream issue,” both for society in general and for the medical profession in particular. Yet several reports and studies indicate that doctors commonly fail to identify and tackle disability issues.2–6 Why is it that health professionals often seem unwilling or unable to engage with people with disabilities? One reason may be the poor record that the medical profession in the United Kingdom has in treating people with disabilities as equal within its own ranks. We recently organised a two day conference to …

Patient and professional user experiences of simple telehealth for hypertension, medication reminders and smoking cessation: a service evaluation

Objectives To establish patient and professional user satisfaction with the Advice & Interactive Messaging (AIM) for Health programme delivered using a mobile phone-based, simple telehealth intervention, ‘Florence’. Design A service evaluation using data extracted from Florence and from a professional user electronic survey. Setting 425 primary care practices across 31 Clinical Commissioning Groups in England. Participants 3381 patients registered on 1 of 10 AIM protocols between March 2013 and January 2014 and 77 professional users. Intervention The AIM programme offered 10 clinical protocols, in three broad groups: (1) hypertension diagnosis/monitoring, (2) medication reminders and (3) smoking cessation. Florence sent patients prompts to submit clinical information, educational messages and user satisfaction questions. Patient responses were reviewed by their primary healthcare providers. Primary outcome measures Patients and professional user experiences of using AIM, and within this, Florence. Results Patient activity using Florence was generally good at month 1 for the hypertension protocols (71–80%), but reduced over 2–3 months (31–60%). For the other protocols, patient activity was 0–39% at 3 months. Minimum target days of texting were met for half the hypertension protocols. 1707/2304 (74%) patients sent evaluative texts responded at least once. Among responders, agreement with the adapted friends and family statement generally exceeded preproject aspirations. Professional responders were generally positive or equivocal about the programme. Conclusions Satisfaction with AIM appeared optimal when patients were carefully selected for the protocol; professional users were familiar with the system, the programme addressed a problem with the previous service delivery that was identified by users and users took an active approach to achieve clinical goals. However, there was a significant decrease in patients’ use of Florence over time. Future applications may be optimised by identifying and addressing reasons for the waning use of the service and enhancing support during implementation of the service.

Randomised controlled trial of additional lifestyle support for the reduction of cardiovascular disease risk through primary care in Stoke-on-Trent, UK ☆

The purpose of this trial is to evaluate the effectiveness of providing additional support in modifying lifestyles and in reducing population cardiovascular disease risk compared with usual primary prevention care. A prospective, individually randomised controlled trial design is used, within which groups of patients are clustered by general practice. Multi-level modelling is proposed to account for clustering effects by practice and a two-stage least squares regression approach to account for expected contamination at the analysis stage. The research is set in Stoke-on-Trent, a mid-sized urban city in central England with a generally poor health profile. Patients included will be those aged between 35 and 74 years who have been identified as being at increased risk of developing cardiovascular disease. Approximately 920 patients will be recruited in each arm of the trial (20 control, 20 treatment in each of 46 practices). Usual primary prevention care (control) will be compared with usual primary prevention care plus bespoke lifestyle support (treatment). The primary outcome measure is the Framingham 10-year cardiovascular disease risk at one year. Intermediate outcomes: weight, physical activity and health-related quality of life, will be determined at six months to monitor progress with treatment. Change in individual risk factors: blood pressure, lipid profile, weight, body mass index, waist circumference, smoking, diabetes and cardiovascular disease status and medications will also be measured at one year to help understand the specific mechanisms by which the primary endpoint was achieved.

Exercise promotion for patients with significant medical problems

The study aimed to determine the effects of three methods of exercise pro motion on the medium-term exercise behaviour and perceived health status (SF-36) of patients with significant medical problems, by a four-arm ran domised controlled trial of unsolicited exercise advice, individual exercise assessments and follow-up exercise sessions. A total of 386 (85 per cent) and 324 (71 per cent) patients responded to initial and follow-up mailings respectively. Fifty per cent of subjects attended for exercise assessment, of which 58 per cent completed four exercise sessions. Results showed encour aging trends for improved exercise behaviour and perceived health status in subjects allocated to the health promotion groups.

Risk matters in healthcare : communicating, explaining and managing risk

Part 1 Understanding and talking about risk: risk - whats it all about then? risk communication. Part 2 Clinical risk management: changing the culture managing common risks in general practice improving the explanation of risk - personal development plan risk management - practice personal and professional development plan. Appendix - sources of further information.

One-year cardiovascular risk and quality of life changes in participants of a health trainer service

Aims: To explore 12-month changes in cardiovascular disease (CVD) risk and health-related quality of life (HRQoL) in participants of a health trainer (HT) programme. Methods: Participants were 994 adults with at least one established CVD risk factor who were referred to a HT programme. The primary outcome was 12-month change in Framingham 10 year CVD risk score. Secondary outcomes included change in individual risk factors and HRQoL. Intention to treat analysis was used to explore 12-month changes for the overall population and those classified ‘high risk’ (≥20% CVD risk) at baseline. Results: At baseline, 33.6% of participants were classified as ‘high CVD risk’ and 95.7% were overweight or obese. There were modest 12-month improvements in most modifiable CVD risk factors, but not overall CVD risk (-0.25±6.50%). In ‘high-risk’ participants significant reductions were evident for overall CVD risk (-2.34±8.13%) and individual risk factors. Small, significant 12-month HRQoL improvements were observed, but these were not associated with CVD risk change. Conclusions: Significant CVD risk reductions in participants in this HT programme with high baseline CVD risk (.20%) in HRQoL in the population as a whole indicated that the programme in its current form should target high-risk patients.