Effects of a brief cardiovascular prevention program by a health advisor in primary care; the 'Hartslag Limburg' project, a cluster randomized trial.

OBJECTIVE: To determine in primary care patients at high risk for a cardiovascular event, the effects on biomedical risk factors for and incidence of cardiovascular events, of a brief cardiovascular prevention program executed by a health advisor. DESIGN: cluster randomized controlled trial with 1275 patients (24 general practices) in and around Maastricht, the Netherlands (1999-2004). INTERVENTION: health advisors were to complete computerized cardiovascular risk profiles, provide multi-factorial tailored health education and advice, and communicate with GP's to optimize treatment. OUTCOME: differences in changes in risk factors between baseline and follow up at 6, 18, and 36 months and incidence of cardiovascular events at 36 months. PROCESS: Because of logistic reasons risk profiles were put on paper instead of in the computerized patient files. On average patients attended 2.3 counseling sessions. Interaction with GPs was less productive than expected. OUTCOME: Effect after six months on BMI (-0.20 kg/m(2) (95% CI -0.38 to -0.01, p=0.039), Cohen's d: -0.18), and after 18 months on HDL-cholesterol (+0.05 mmol/l (95% CI +0.01 to +0.09, p=0.014), Cohen's d: 0.14). No other (subgroup) effects were found. CONCLUSION: Given the lack of clinically meaningful effects, implementation of this intervention in its present form is not justified.

Experiences of doctors and nurses implementing nurse-delivered cardiovascular prevention in primary care: a qualitative study.

AIM: This paper reports on a study of the experiences of general practitioners and practice nurses implementing nurse-delivered cardiovascular prevention to high risk patients in primary care. BACKGROUND: Difficulties may arise when innovations are introduced into routine daily practice. Whether or not implementation is successful is determined by different factors related to caregivers, patients, type of innovation and context. METHODS: A qualitative study nested in a randomized trial (2006-2008) to evaluate the effectiveness of nurse-delivered cardiovascular prevention. Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses) participated in the trial. Interviews were held on two occasions: at 3 and at 18 months after commencement of consultation. The first occasion was a group interview with six practice nurses. The second consisted of semi-structured interviews with one general practitioner and one practice nurse from each centre. FINDINGS: Main barriers to the implementation included: lack of knowledge about the guideline, attitudes towards treatment targets, lack of communication, insufficient coaching by doctors, content of life style advice. At the start of the consultation project, practice nurses expressed concern of losing nursing tasks. Other barriers were related to patients (lack of motivation), the guideline (target population) and organizational issues (insufficient patient recording and computer systems). CONCLUSIONS: Both general practitioners and practice nurses were positive about nurse-delivered cardiovascular prevention in primary care. Nurses could play an important role in successive removal of barriers to implementation of cardiovascular prevention. Mutual confidence between care providers in the healthcare team is necessary.

Adherence to a guideline on cardiovascular prevention: a comparison between general practitioners and practice nurses.

BACKGROUND: Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver. OBJECTIVE: To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners. SETTING: Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses). METHODS: 701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire. RESULTS: Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found. CONCLUSION: Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.

Patient perceptions of nurse-delivered cardiovascular prevention: cross-sectional survey within a randomised trial.

BACKGROUND: Studies have shown that in general patients are positive about cardiovascular prevention delivered by general practitioners. Further, it has been found that care by nurses for the chronically ill leads to even greater patient satisfaction. OBJECTIVE: The aim of this survey was to answer the following questions: How do patients perceive cardiovascular prevention delivered by the practice nurse? Are patient characteristics and personal health status associated with experiences of received nurse-led care? DESIGN: A cross-sectional survey after completion of a randomised trial. SETTING: Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses, 30,000 patients). PARTICIPANTS: Included in the randomised trial were 701 patients with at least a 10% risk of fatal cardiovascular disease within 10 years. Patients who visited a cardiovascular specialist more often than once a year and patients with diabetes were excluded from the study. In 90% of the patients it concerned secondary prevention. Half of the patients received nurse-delivered care and half received care by the general practitioner. METHOD: A questionnaire was sent by post to all patients after having received one year of cardiovascular prevention. A dual moderator focus group study was held for the development of the questionnaire. FINDINGS: The response rate was 69%. Patients were more satisfied with nurse-delivered cardiovascular prevention compared to standard care by general practitioners. The majority of patients agreed with positive statements regarding received nurse-led care. Patient characteristics such as age, educational level and gender were significantly associated with patients experiences. Furthermore, a significant association between experiences and personal health status was found. In comparison with patients who did not smoke, smokers would recommend the practice nurse less to others (X(2)=4.0, p=0.047), felt more 'rapped on their knuckles' (X(2)=11.5, p=0.003), found the consultation more 'awkward' (X(2)=8.3, p=0.016) and thought the nurse less understanding of their personal situation (X(2)=6.4, p=0.041) and less able to explain clearly (X(2)=6.5, p=0.039). CONCLUSIONS: The majority of patients responded positively to nurse-delivered cardiovascular prevention. Further improvement could be gained by paying more attention to motivational interviewing. Nurses should approach high risk patients more specifically according to the type of risk factor to be treated.

Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial.

BACKGROUND: A substantial part of cardiovascular disease prevention is delivered in primary care. Special attention should be paid to the assessment of cardiovascular risk factors. According to the Dutch guideline for cardiovascular risk management, the heavy workload of cardiovascular risk management for GPs could be shared with advanced practice nurses. AIM: To investigate the clinical effectiveness of practice nurses acting as substitutes for GPs in cardiovascular risk management after 1 year of follow-up. DESIGN OF STUDY: Prospective pragmatic randomised trial. SETTING: Primary care in the south of the Netherlands. Six centres (25 GPs, six nurses) participated. METHOD: A total of 1626 potentially eligible patients at high risk for cardiovascular disease were randomised to a practice nurse group (n = 808) or a GP group (n = 818) in 2006. In total, 701 patients were included in the trial. The Dutch guideline for cardiovascular risk management was used as the protocol, with standardised techniques for risk assessment. Changes in the following risk factors after 1 year were measured: lipids, systolic blood pressure, and body mass index. In addition, patients in the GP group received a brief questionnaire. RESULTS: A larger decrease in the mean level of risk factors was observed in the practice nurse group compared with the GP group. After controlling for confounders, only the larger decrease in total cholesterol in the practice nurse group was statistically significant (P = 0.01, two-sided). CONCLUSION: Advanced practice nurses are achieving results, equal to or better than GPs for the management of risk factors. The findings of this study support the involvement of practice nurses in cardiovascular risk management in Dutch primary care.

Fielding incognito standardised patients as 'known' patients in a controlled trial in general practice.

BACKGROUND: Incognito standardised patients (SPs) have only been used to represent new patients so far. The few trials with incognito SPs provide little detail on the method used for fielding them. OBJECTIVE: To establish the feasibility of introducing SPs as 'known' patients (i.e. patients who have previously visited the practice) into practices, to indicate the required practice preparations, and to describe the various aspects of using SPs in a pretest/post-test design. METHODS: We used incognito SPs as known patients in a controlled trial to assess the practice behaviour of 49 trainees. The SPs received a 2-day training in role playing and completing checklists. We compiled comprehensive practice information folders of each practice to be visited. Real personal data and faked medical data of SPs were inserted in the filing system of each practice to be visited. Apart from SP roles with slightly different reasons-for-encounter and different SPs, the same training protocol, checklists and practice information folders were used in the post-test. RESULTS: The SPs carried out 287 visits in 50 practices. All practices prepared the patient records for the SP visits in a fairly authentic practice style. Trainees detected the SP in 74 visits. The main reasons for detection were imperfections in patient records and aspects of SP roles or role playing. CONCLUSION: Fielding incognito SP visits as known patients was feasible but labour-intensive. Preparing the SP patient records and familiarising SPs with the interior of practices represented new elements in the use of SPs. The pretest/post-test format made their use more efficient instead of complicating it.

GPs' needs for practice-oriented nutrition education; a Delphi study among Dutch GPs.

BACKGROUND: Published guidelines and lists of topics in nutrition education for GPs are affected by practical drawbacks, which prevent them from being easily implemented in vocational training curricula. OBJECTIVE: Our aim was to draw up a concise priority list of disease-related nutrition topics reflecting the needs among Dutch GPs for nutrition education geared to everyday practice, which can be used to decide on the main topics and educational content of computer-based instruction. METHODS: This was a two-round Delphi study, using pilot-tested questionnaires carried out among 41 GPs who attended a national CME meeting on nutrition in The Netherlands. Sum scores of, and summarized comments on nutrition topics and their frequencies in top-10 lists drawn up by respondents were the main outcome measures. RESULTS: The response in both Delphi rounds was high (93 and 95%). Analysis of questionnaires in both rounds yielded a priority list of disease-related nutrition topics, with the 14 highest ranking topics identical in both rounds. A fifteenth topic, only found in the second questionnaire, completed the priority list. A group of experts assessed this list as fully acceptable. CONCLUSION: It was possible to compile a priority list of disease-related nutrition topics reflecting the needs of GPs for nutrition education. Based on the results of the Delphi study, we generated the following list of five priority topics: weight problems; diabetes mellitus; hypercholesterolaemia; intestinal complaints; and hypertension. This list of five and the summarized comments of respondents will determine the main topics and educational content of a computer-based instruction we are currently developing.

Quality of care in stroke prevention: results of an audit study among general practitioners.

BACKGROUND: In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke. METHODS: Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel. RESULTS: A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) (n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment. CONCLUSIONS: A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.

Controlled trial of effect of computer-based nutrition course on knowledge and practice of general practitioner trainees.

BACKGROUND: Nutrition education is not an integral part of either undergraduate or postgraduate medical education. Computer-based instruction on nutrition might be an attractive and appropriate tool to fill this gap. OBJECTIVE: The study objective was to assess the degree to which computer-based instruction on nutrition improves factual knowledge and practice behavior of general practitioner (GP) trainees. DESIGN: We carried out a controlled experimental study, using a 79-item knowledge test and 3 incognito standardized patients' visits in a pre- and posttest design with 49 first-year GP trainees. The experimental group (n = 25) received an average of 6 h of a newly developed computer-based instruction on nutrition. The control subjects (n = 24) took the standard vocational training program. RESULTS: The percentage of correct answers on the knowledge test increased from 30% at pretest to 42% at posttest in the experimental group, and from 36% to 37% in the control group. Analysis of covariance, with the pretest scores as covariate, showed a significant experimental versus control group difference at posttest: 9.2% (P = 0.002). The mean percentage of correctly performed items during the 3 standardized patients' visits (assessed by checklists) showed an increase in the experimental group from 20% at pretest to 36% at posttest, whereas the control group changed from 20% to 22%. Analysis of covariance, with the pretest scores as covariate, revealed a significant group difference at posttest: 13.7% (P < 0.001). CONCLUSION: The computer-based instruction proved its effectiveness, both by increasing factual knowledge and by substantially enhancing GP trainees' practice behavior on the subject of nutrition.

Peripheral arterial occlusive disease: prognostic value of signs, symptoms, and the ankle-brachial pressure index.

OBJECTIVES: To determine whether different levels of the ankle-brachial pressure index (ABPI) are associated with an increased risk for progressive limb ischemia, nonfatal and fatal cardiovascular events. To investigate the prognostic value of signs and symptoms associated with peripheral arterial occlusive disease (PAOD). DESIGN: Prospective follow-up study. SETTING: Eighteen general practice centers in the Netherlands. PARTICIPANTS: Three thousand six hundred forty-nine participants (53% female) with a mean age of 59 years (range: 40-78 years). MAIN OUTCOME MEASURES: Progressive limb ischemia, cardiovascular morbidity and mortality. RESULTS: At baseline, 458 participants had PAOD, defined as an ABPI < 0.95. Among these, 148 (32.2%) had an ABPI < 0.70. Cox proportional hazards models showed that after a mean follow-up period of 7.2 years, PAOD patients with an ABPI < 0.70 were at higher risk for cardiovascular death, compared with participants with a moderately reduced ABPI (< 0.95 - > or = 0.70): HR 2.3 versus 1.2. Older age, complaints of intermittent claudication, abnormal pedal pulses, elevated blood pressure, and coexisting cardiovascular disease at baseline were also significant independent prognostic factors for one or more of the adverse outcome events in these patients. CONCLUSION: The ABPI is inversely associated with cardiovascular mortality in PAOD patients. A low ABPI is an independent predictor for cardiovascular mortality in PAOD patients.