Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams

Background: People with severe mental illnesses (SMI) are at increased risk of cardiovascular disease (CVD). Clinical guidelines recommend regular screening for CVD risk factors. We evaluated a nurse led intervention to improve screening rates across the primary-secondary care interface.Methods: Six community mental health teams (CMHTs) were randomised to receive either the nurse led intervention plus education pack (n = 3) or education pack only (n = 3). Intervention (6 months): The nurse promoted CVD screening in primary care and then in CMHTs. Patients who remained unscreened were offered screening by the nurse. After the intervention participants with SMI were recruited from each CMHT to collect outcome data. Main outcome: Numbers screened during the six months, confirmed in General Practice notes.Results: All six CMHTs approached agreed to randomisation. 121 people with SMI participated in outcome interviews during two waves of recruitment (intervention arm n = 59, control arm n = 62). Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year, with less than 20% having been screened for each risk factor. After the trial, CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure (96% vs 68%; adjusted Odds Ratio (OR) 13.6; 95% CI: 3.5-38.4), cholesterol (66.7% vs 26.9%, OR 6.1; 3.2-11.5), glucose (66.7% vs 36.5% OR 4.4; 2.7-7.1), BMI (92.5% vs 65.2% OR 6.5; 2.1-19.6), and smoking status (88.2% vs 57.8% OR 5.5; 3.2-9.5) and have a 10 year CVD risk score calculated (38.2% vs 10.9%) OR 5.2 1.8-15.3). Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse.Conclusions: The nurse-led intervention was superior, resulting in an absolute increase of approximately 30% more people with SMI receiving screening for each CVD risk factor. The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention, but the response rate for outcome collection was disappointing; possibly a result of the cluster design. The trial was not large or long enough to detect changes in risk factors.Trial Registration: International Standard Randomised Controlled Trial Registration Number (ISRCTRN) 58625025

Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia

Background: Despite multiple guidelines for management of community-acquired pneumonia (CAP), barriers to guideline use are rarely evaluated. Methods: We performed quantitative and qualitative surveys of junior doctors before implementation of a CAP management pathway. After implementation, we identified patient-related determinants of pathway adherence by multivariate analysis. Results: We surveyed 83 (77%) of the 108 junior doctors working in acute medicine between August 2001 and July 2002 and selected 8 for in-depth interview. We identified five main themes that influence pathway adherence. First, education (recognized to be insufficient on antimicrobial therapy) and experience: increasing clinical experience was associated with greater knowledge of pathway content, but decreasing likelihood of consulting the pathway. Second, attitudes to CAP: doctors recognized that they had not treated CAP with respect early on. Third, work intensity and lack of senior support were barriers to good practice. Fourth, guideline factors: they need to be simple enough to be easy to use while containing enough information to be useful. Fifth, CAP is sometimes difficult to diagnose on admission. Notably, when given three clinical scenarios only six (7%) of respondents assessed CAP severity correctly. In the intervention study, early administration of antibiotics was associated (P &lt; 0.05) with indicators of increased severity of illness (pulse, respiratory rate, oxygenation and temperature) in addition to being admitted to the intervention hospital (P &lt; 0.001). Conclusions: Some of the identified barriers could be overcome by undergraduate and postgraduate education. However, equally important are organizational barriers that can only be overcome by systems redesign.</p

Methodological Challenges in Online Trials

Health care and health care services are increasingly being delivered over the Internet. There is a strong argument that interventions delivered online should also be evaluated online to maximize the trial's external validity. Conducting a trial online can help reduce research costs and improve some aspects of internal validity. To date, there are relatively few trials of health interventions that have been conducted entirely online. In this paper we describe the major methodological issues that arise in trials (recruitment, randomization, fidelity of the intervention, retention, and data quality), consider how the online context affects these issues, and use our experience of one online trial evaluating an intervention to help hazardous drinkers drink less (DownYourDrink) to illustrate potential solutions. Further work is needed to develop online trial methodology