Evidence in action--guidelines directing workload.

OBJECTIVE: To approximate the workload of blood pressure (BP) measurements and lifestyle counselling in primary healthcare when the related guidelines are followed. To evaluate the impact of facilitated guideline implementation with respect to workloads. DESIGN: Modelling study after cross-sectional audit process. SETTING: Thirty-one municipal health stations. Intervention Intrinsic facilitation in implementation of hypertension guideline. MAIN OUTCOME MEASURES: Number and level (normal <140/85 mmHg, slightly 140-160/85-95 mmHg or markedly elevated >160/95 mmHg) of BP measurements at nurses' appointments, approximation of time allocated for measurements and lifestyle counselling before and 1 year after the intervention. RESULTS: A total of 3119 BP measurements were recorded during the audit week in 2002. BP level measurements were "normal" in 1214 (38.9%), slightly elevated in 1371 (44.0%) and markedly elevated in 534 (17.1%). According to the modelling, 12% of a nurse's workday consisted of BP recordings and counselling. After intervention, the corresponding figures were 2330 measurements (828 (35.5%) normal, 990 (42.5%) slightly and 512 (22.0%) markedly elevated) corresponding to 6.3% of the workday. CONCLUSIONS: Through facilitation programmes, it is possible to change working practices according to the related guidelines, agree on the division of tasks and empower patients to engage with their own treatment. These changes can lead to considerable decreases in the workload of health centre personnel with consequent redistribution of personnel resources to patients in true need for services.

Individualised multifactorial lifestyle intervention trial for high-risk cardiovascular patients in primary care.

BACKGROUND: The multiprofessional teams in Finnish health centres are well placed to carry out interventions aimed at the prevention of cardiovascular diseases. AIM: To evaluate the effectiveness of an individually tailored multifactorial lifestyle intervention in primary care for individuals at high risk for cardiovascular disease. DESIGN OF STUDY: A randomised controlled trial was conducted over 24 months with interim assessments at six and 12 months. SETTING: A health centre in Finland with a patient population of 11,000. METHOD: One hundred and fifty adults aged 18 to 65 years old with existing cardiovascular disease or multiple risk factors were randomised to active multiprofessional risk factor intervention or to standard care. The main outcome measure was a change in cardiovascular risk-factor score. Secondary outcomes were changes in blood pressure, weight, body-mass index, serum cholesterol, blood glucose, smoking cessation, and exercise habits. RESULTS: The cardiovascular risk score decreased by 28% in the intervention group (23% in the control group), body weight decreased by 3.7% (2%) and total cholesterol decreased by 10.8% (6.5%), while time engaged in exercise increased by 39% (43%). Differences were not significant. CONCLUSIONS: Cardiovascular risk levels of high-risk individuals decreased in both intervention and control groups. Primary care prevention should be targeted to high-risk persons. Long-term follow-up studies are needed.

Quality improvement programme for cardiovascular disease risk factor recording in primary care.

OBJECTIVES: Evaluation of the effect of a quality improvement programme on cardiovascular disease (CVD) risk factor recording and risk factor levels in a controlled study at two primary health care centres serving 26,000 inhabitants in Northern Helsinki. METHODS: From a random sample of patient records from 1995 (n=1,066), 1996 (n=1,042), and 1997 (n=1,040) the frequency of CVD risk factor recording was measured and the changes in mean levels of total cholesterol, blood glucose, blood pressure, and body weight were monitored during the follow up period. The intervention programme (1995-1996) consisted of lectures and meetings of multiprofessional teams, development of local guidelines, and introduction of a structured risk factor recording sheet as part of the patient records. RESULTS: After the quality improvement period all risk factors were better recorded at the intervention station than at the control station (p<0.001). More high risk CVD patients were detected from the general population at the intervention station. The mean values of most measured risk factors changed during the intervention. During the follow up period differences were observed between the two health stations in the time trends for body weight, body mass index (BMI), total cholesterol, and glucose levels. Risk factor levels of high risk patients receiving CVD treatment decreased during the intervention. CONCLUSIONS: A simple quality improvement programme improved the practice of recording risk factors for CVD which resulted in earlier detection of patients with a high risk of developing the disease.

Effectiveness of individual lifestyle interventions in reducing cardiovascular disease and risk factors.

In order to assess the effectiveness of lifestyle interventions in reducing cardiovascular disease risk factors, morbidity and mortality among working-age adults, we undertook a systematic review of randomized controlled trials of various lifestyle interventions (diet, exercise, smoking cessation, alcohol intake reduction) in adults followed for 1 year or longer. Twenty-one single-factor and 21 multifactorial interventions were analysed by outcome. Changes in cardiovascular morbidity and mortality and total mortality were considered as main outcomes. Changes in weight, total cholesterol, blood pressure, sodium excretion, smoking and alcohol consumption were also analysed, and numbers needed to treat were calculated for smoking, morbidity and mortality. In secondary prevention, both single and multifactorial lifestyle interventions were shown to reduce morbidity and mortality, and multifactorial approaches reduced cholesterol levels. Primary prevention was found to reduce risk factors efficiently, especially when the intervention is multifactorial. Effect sizes were heterogeneous with wide confidence intervals. Standardized ways of describing interventions, measuring their effects and reporting outcomes systematically would facilitate effect-size evaluations. Interventions should optimally be multifactorial and targeted at high-risk patients with multiple risk factors for cardiovascular disease.

Computer-assisted telephone interview (CATI) in primary care.

OBJECTIVES: We aimed to study the prevalence of cardiovascular disease (CVD) risk factors among 11,000 inhabitants in Northern Helsinki, and to identify high-risk individuals in the area and direct them to the local primary-health-care-centred CVD-risk-factor prevention programme. METHOD: We conducted a computer-assisted telephone interview (CATI), a descriptive survey and primary care unit searching for CVD risk factors within the population under its responsibility. Six hundred and sixty-seven individuals aged 18-65 years out of 1000 randomly chosen inhabitants were interviewed using CATI. We measured the prevalence of self-reported CVD risk factors: smoking, blood pressure, last measured total serum cholesterol, body mass index (BMI), alcohol consumption, diabetes, physical exercise habits, positive family history of CVD/diabetes and personal history of CVD. RESULTS: Sixty-seven per cent of the sample was interviewed. Nineteen per cent did not have a telephone and 3% refused to be interviewed. Eleven per cent did not respond. Persons with high cardiovascular risk scores were observed mainly in the oldest age group. In the total sample, 23% of women and 28% of men were estimated to be at high risk of coronary artery disease. Gender differences were seen only in one age-group: 45-54-year-old men reporting higher risk-factor scores. The results were analysed using the Statistical Analysis System (SAS). CONCLUSIONS: The CATI-method is a useful tool in screening of high-CVD-risk patients and in guiding them to local CVD primary prevention programmes.