Screening for increased cardiometabolic risk in primary care: a systematic review.

BACKGROUND: Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear. AIM: To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy. DESIGN AND SETTING: Systematic review of studies performed in primary care in Western countries. METHOD: MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities. RESULTS: The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods. CONCLUSION: The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.

Implementing cardiometabolic health checks in general practice: a qualitative process evaluation.

BACKGROUND: A stepwise screening approach for the detection and management of cardiometabolic disease is proposed in various primary care guidelines. The aim of this study was to explore the implementation of a cardiometabolic health check as perceived by the involved caregivers and patients. METHODS: Qualitative process evaluation of the implementation of a cardiometabolic screening programme in a multidisciplinary primary healthcare centre in Eindhoven, the Netherlands, in which 1270 patients had participated. We explored the caregivers' experiences though focus group discussions and collected patients' experiences through a written questionnaire containing two open-ended questions. We analyzed our data using a thematic content analysis based on grounded theory principles. RESULTS: Five general practitioners, three practice nurses and five medical receptionists participated in the focus groups. Additionally we collected experiences of 657 (52% of 1270) participating patients through an open-ended questionnaire.GPs were enthusiastic about offering a health check and preferred systematic screening over case-finding, both in terms of yield and workload. The level of patient participation was high and most participants were enthusiastic about the health check being offered by their GP. Despite their enthusiasm, the GPs realized that they lacked experience in the design and implementation of a structured, large-scale prevention programme. This resulted in suboptimal instruction of the involved practice nurses and medical receptionists. The recruitment strategy was unnecessarily aggressive. There were shortcomings in communicating the outcomes of the health check to the patients and there was no predefined follow-up programme. Based on our findings we developed a checklist that can be used by designers of similar health checks. CONCLUSIONS: A number of fundamental issues may arise when GPs organize a systematic screening programme in their practice. These issues are related to the preparation of the involved staff, the importance of integration with everyday clinical practice, the approach of healthy patients and the provision of adequate follow-up programmes. The identified challenges and recommendations can be taken into account during future screening programmes.

Why do women prefer home births in Ethiopia?

BACKGROUND: Skilled attendants during labor, delivery, and in the early postpartum period, can prevent up to 75% or more of maternal death. However, in many developing countries, very few mothers make at least one antenatal visit and even less receive delivery care from skilled professionals. The present study reports findings from a region where key challenges related to transportation and availability of obstetric services were addressed by an ongoing project, giving a unique opportunity to understand why women might continue to prefer home delivery even when facility based delivery is available at minimal cost. METHODS: The study took place in Ethiopia using a mixed study design employing a cross sectional household survey among 15-49 year old women combined with in-depth interviews and focus group discussions. RESULTS: Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) for their most recent birth in the one year preceding the survey. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. The most important reasons for not seeking institutional delivery were the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). The group discussions and interviews identified several reasons for the preference of traditional birth attendants over health facilities. Traditional birth attendants were seen as culturally acceptable and competent health workers. Women reported poor quality of care and previous negative experiences with health facilities. In addition, women's low awareness on the advantages of skilled attendance at delivery, little role in making decisions (even when they want), and economic constraints during referral contribute to the low level of service utilization. CONCLUSIONS: The study indicated the crucial role of proper health care provider-client communication and providing a more client centered and culturally sensitive care if utilization of existing health facilities is to be maximized. Implications of findings for maternal health programs and further research are discussed.

Development, implementation and yield of a cardiometabolic health check.

BACKGROUND: Cardiometabolic health checks are currently introduced in several countries in an attempt to reduce the population-wide increase of cardiometabolic disease. OBJECTIVE: Developing and implementing a health check for cardiometabolic disorders in a medium-sized primary health care centre and describing the participation rate and the numbers of disorders requiring treatment that are identified. METHODS: Observational research in Eindhoven, The Netherlands. All registered patients aged 40-75 years without known cardiometabolic disease (i.e. cardiovascular diseases, diabetes and chronic kidney disease) (n = 1704) were sent a written invitation to participate in a health check. A three-step procedure was used to determine whether a participant was at increased risk of developing cardiometabolic disease. Treatment was started if necessary, according to current guidelines. We recorded the numbers of patients proceeding through each step and the numbers of disorders identified. RESULTS: A total of 1270 patients (75%) returned the first screening questionnaire. Based on the information from this questionnaire, 952 were invited to visit the health care centre for further assessment. A total of 145 patients (11% of the 1270) were found to have at least one disorder for which treatment was indicated (e.g. increased cardiovascular risk, isolated systolic hypertension, diabetes mellitus, suspected familial hypercholesterolaemia or kidney disease). CONCLUSIONS: The response rate and the number of cases identified demonstrate that cardiometabolic disorders can be effectively detected at a primary health care centre. Further research is needed to assess the long-term effects and efficacy of health checks in general practice.

[Cardiometabolic risk factors detected with a preventative screening programme]. / Cardiometabole risicofactoren opgespoord met preventieconsult.

OBJECTIVE: Design and implementation of a preventative screening programme for cardiometabolic risk assessment in a medium-sized general practice. Description of the response rate and number of detected diseases to be treated. DESIGN: Questionnaire and observational research. METHOD: All registered patients aged 40 to 75 years without prior cardiometabolic disease (cardiovascular diseases, diabetes and renal disorders) (n=1704) received a written invitation to participate in a preventative screening programme. During a maximum of 3 sequential screening steps the risk for cardiometabolic disease for each participant was determined. Based on their outcome, participants were offered treatment when necessary. The number of patients who completed each of the steps as well as the number of detected disorders were registered. RESULTS: In total 1270 patients (75%) returned an initial screening questionnaire. Based on the information provided in this questionnaire 952 patients were invited for an additional examination at the general practice. In 145 participants (11% of 1270) at least one condition was diagnosed that needed either treatment or follow-up according to the prevailing Dutch practice guidelines, such as elevated risk for cardiovascular diseases, isolated systolic hypertension, diabetes mellitus, suspected familiar hypercholesterolaemia or renal disorders. CONCLUSION: The response-rate as well as the number of newly diagnosed cases demonstrate that it is quite feasible to screen for cardiometabolic disorders in a primary healthcare centre. Follow-up studies are needed to assess the long-term health effects and efficiency of the preventative screening programme.

Students' perceptions about the transition to the clinical phase of a medical curriculum with preclinical patient contacts; a focus group study.

BACKGROUND: Studies have shown that medical students experience the transition between preclinical and clinical training as a stressful period. They are generally frustrated by their inability to apply their knowledge to solve clinical problems in practice. Preclinical patient contacts may offer a solution to this 'shock of practice.' We studied how students who have had preclinical patient contacts perceive the transition from preclinical to clinical training and, more specifically, how they value these early patient contacts as preparation for learning in clinical practice. METHODS: A purposive sample of 21 students participated in three focus groups which met twice during their first weeks of clinical clerkships. The interviews were recorded and transcribed literally. Qualitative content analysis of the transcriptions was performed. RESULTS: According to the students, working in clinical practice was enjoyable, motivated them to study and helped them to develop non-analytical reasoning skills. The students experienced stress due to increased working hours and work load, uncertainty as to what was expected of them and self-perceived lack of knowledge. They did not experience a major gap between the preclinical and clinical phase and felt well prepared for the clerkships. The preclinical patient contacts were considered to be instrumental in this. CONCLUSIONS: Early patient contacts seem to ameliorate the shock of practice and prepare students for clinical work. The problems mentioned by the students in this study are mainly related to the socialisation process. The results of this study have to be validated by quantitative research.