Sharing risk management: an implementation model for cardiovascular absolute risk assessment and management in Australian general practice

Purpose: Despite considerable work in developing and validating cardiovascular absolute risk (CVAR) algorithms, there has been less work on models for their implementation in assessment and management. The aim of our study was to develop a model for a joint approach to its implementation based on an exploration of views of patients, general practitioners (GPs) and key informants (KIs). Methods: We conducted six focus group (three with GPs and three with patients) and nine KI interviews in Sydney. Thematic analysis was used with comparison to highlight the similarities and differences in perspectives of participants. Results: Conducting CVAR was seen as more acceptable for regular patients rather than new patients for whom GPs had to attract their interest and build rapport before doing so at the next visit. GPs' interest and patients' positive attitude in managing risk were important in implementing CVAR. Long consultations, good communication skills and having a trusting relationship helped overcome the barriers during the process. All the participants supported engaging patients to self-assess their risk before the consultation and sharing decision making with GPs during consultation. Involving practice staff to help with the patient self-assessment, follow-up and referral would be helpful in implementing CVAR assessment and management, but GPs, patients and practices may need more support for this to occur. Conclusions: Multiple strategies are required to promote the better use of CVAR in the extremely busy working environment of Australian general practice. An implementation model has been developed based on our findings and the Chronic Care Model. Further research needs to investigate the effectiveness of the proposed model

Randomized trial evaluating the framing of cardiovascular risk and its impact on blood pressure control [ISRCTN87597585]

BACKGROUND: The format or frame in which the results of randomized trials are presented has been shown to influence health professional's self-reported practice. We sought to investigate the effect of framing cardiovascular risk as two different formats in a randomized trial. METHODS: We recruited 457 patients aged between 60 and 79 years with high blood pressure from 20 family practices in Avon, UK. Patients were randomized to cardiovascular risk presented either as 1) an absolute risk level (AR) or as 2) the number needed to treat to prevent an adverse event (NNT). The main outcome measures were: 1) percentage of patients in each group with a five-year cardiovascular risk ≥ 10%, 2) systolic and diastolic blood pressure, 3) intensity of prescribing of cardiovascular medication. RESULTS: Presenting cardiovascular risk as either an AR or NNT had no impact reducing cardiovascular risk at 12 month follow up, adjusted odds ratio 1.53 (95%CI 0.76 to 3.08). There was no difference between the two groups in systolic (adjusted difference 0.97 mmHg, 95%CI -2.34 mmHg to 4.29 mmHg) or diastolic (adjusted difference 0.70 mmHg, 95%CI -1.05 mmHg to 2.45 mmHg) blood pressure. Intensity of prescribing of blood pressure lowering drugs was not significantly different between the two groups at six months follow up. CONCLUSIONS: Presenting cardiovascular risk in clinical practice guidelines as either an AR or NNT had a similar influence on patient outcome and prescribing intensity. There is no difference in patient outcomes when these alternative formats of risk are used in clinical practice guidelines

Cardiovascular risk evaluation and antiretroviral therapy effects in an HIV cohort: implications for clinical management: the CREATE 1 study

International audienceAims: To determine the cardiovascular disease (CVD) risk profile of a large UK HIV cohort and how highly active antiretroviral therapy (HAART) affects this. Methods: A cross-sectional study within a large inner city Hospital and neighbouring district hospital. 1021 HIV positive outpatients representative of the complete cohort; 990 had no previous CVD. We recorded demographics, highly active antiretroviral therapy (HAART) history and CVD risk factors. CVD and coronary heart disease (CHD) risks were calculated using the Framingham (1991) algorithm adjusted for family history. Results: The non-CVD cohort (n=990) was 74% male, 51% Caucasian and 73.1% were on HAART. Mean age was 41±9 years, systolic blood pressure 120±14mmHg, total cholesterol 4.70±1.05mmol/L, HDL-C 1.32±0.48 mmol/L and 37% smoked. Median CVD risk (n=973) was 4 (0-56)% in men and 1.4(0-37) % in women; CHD risks were 3.5(0-36)% and 0.6(0-16)%. CVD risk was >20% in 6% of men and 1% of women and >10% in 12% of men and 4% of women. CVD risk was higher in Caucasians than other ethnicities; the risk factor contributing most was raised cholesterol. For patients on their first HAART, increased CHD risk (26.2% vs. 6.5%; odds ratio 4.03, p<0.001) was strongly related to duration of therapy. Conclusions: Modifiable risk factors, especially cholesterol, and also duration of HAART, were key determinants of CVD risk. Discussion: Regular CHD and/or CVD risk assessment should be performed on patients with HIV. The effect of different HAART regimens on CHD risk should be considered when selecting therapy. Clinical Trials.gov identifier: NCT010509

The Sandwell Project: A controlled evaluation of a programme of targeted screening for prevention of cardiovascular disease in primary care

<p>Abstract</p> <p>Background</p> <p>A pilot cardiovascular disease prevention project was implemented in the inner-city West Midlands. It was evaluated by comparing its effectiveness to a control group where full implementation was delayed by a year.</p> <p>Methods</p> <p>Cardiovascular risk factor data were extracted on all untreated patients 35 to 74 years old from electronic medical databases in six general practices. A best estimate of ten-year CVD risk cardiovascular risk was calculated on all patients using the extracted risk factor data. Default risk-factor values were used for all missing risk factor data. High risk patients were thus identified. In four practices a project nurse systematically invited, assessed and referred high risk patients for treatment. Two control practices were provided with a list of their high risk patients. The outcomes were the proportions of untreated high-risk patients who were assessed, identified as eligible for treatment and treated under two strategies for identifying and treating such patients in primary care.</p> <p>Results</p> <p>Of all high-risk patients suitable for inclusion in the project, 40.6% (95% CI: 36.7 to 45.7%) of patients in intervention practices were started on treatment were started on at least one treatment, compared to 12.7% (95% CI: 9.8% to 16.1%) in control practices.</p> <p>Conclusion</p> <p>A strategy using electronic primary care records to identify high risk patients for CVD prevention works best with a process for acting on information, ensuring patients are invited, assessed and treated.</p

A study in high-risk, maximally pretreated patients to determine the potential use of PCSK9 inhibitors at various thresholds of total and LDL cholesterol levels

PURPOSE OF THE STUDY: Statins and ezetimibe reduce low-density lipoprotein cholesterol (LDL-c) and cardiovascular disease (CVD) risk. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors lower LDL-c by 50%-70% and might be useful in refractory patients. The National Institute for Health and Care Excellence (NICE) technology appraisal guidance (TAG) recommends use of these drugs in secondary prevention and familial hypercholesterolaemia (FH) at differing LDL-c thresholds. We have estimated the proportion of patients in whom this third-line drug might be useful. STUDY DESIGN: We used data from a lipid-lowering audit programme to study 72 with FH and/or CVD of 271 patients referred over 12 months who failed to achieve target total cholesterol (TC) and LDL-c levels. All 72 patients were treated with ezetimibe, and 69 cases also received statins. We used LDL-c thresholds 1.5-5.5 mmol/L to estimate how many of these refractory patients could benefit from PCSK9 inhibitors. RESULTS: In 72 patients, TC and LDL-c targets were not met by 64 and 53 patients, respectively. We judged using the NICE TAG that only one patient (1.4% ezetimibe requiring and 0.4% total referrals) required a PCSK9 inhibitor. CONCLUSIONS: We determined that the proportion of patients eligible for a PCSK9 inhibitor at various TC and LDL-c levels is modest. This may reflect the use of all available statins in UK lipid clinics often at non-daily frequency. We suggest that cost-effective use of PCSK9 inhibitors requires prescribing being restricted to clinicians working in specialised lipid clinics

The joint effects of apolipoprotein B, apolipoprotein A1, LDL cholesterol, and HDL cholesterol on risk: 3510 cases of acute myocardial infarction and 9805 controls†

AIMS: Plasma levels of apolipoprotein B (apoB), the main surface protein on LDL particles, and LDL-C, the amount of cholesterol in those particles, are closely correlated and, considered separately, are positive risk factors. Plasma levels of apolipoprotein A(1), the main surface protein on HDL particles, and HDL-C, the amount of cholesterol in those particles, are also closely correlated with each other and, considered separately, are negative risk factors. The interdependence of these four risk factors is unclear. METHODS AND RESULTS: Case-control study among 3510 acute myocardial infarction patients (without prior vascular disease, diabetes, or statin use) in UK hospitals and 9805 controls. Relative risks (age, sex, smoking, and obesity-adjusted) were more strongly related to apoB than to LDL-C and, given apoB, more strongly negatively related to apoA(1) than to HDL-C. The ratio apoB/apoA(1) was uncorrelated with time since symptom onset in cases, was reproducible in samples collected a few years apart in controls (correlation 0.81), and encapsulated almost all the predictive power of these four measurements. Its effect was continuous, substantial throughout the UK normal range [relative risk, top vs. bottom decile of this ratio, 7.3 (95% CI 5.8-9.2)] and varied little with age. The ratio apoB/apoA(1) was substantially more informative about risk (chi(1)(2) = 550) than were commonly used measures such as LDL-C/HDL-C, total/HDL cholesterol, non-HDL cholesterol, and total cholesterol (chi(1)(2) = 407, 334, 204, and 105, respectively). Given apoB and apoA(1), the relationship with risk of LDL-C was reversed, and this reversal was strengthened by appropriate allowance for random measurement errors in two correlated variables. Given usual apoB, lower LDL-C (consistent with smaller LDL particles) was associated with higher risk (P &lt; 0.0001). During the first 8 h after symptom onset HDL-C increased by about 10%, precluding reliable assessment of the joint relationship of apoA(1) and pre-onset HDL-C with risk in such retrospective case-control studies. CONCLUSION: Apolipoprotein ratios are more informative about risk than lipid fractions are. This suggests that, among lipoprotein particles of a particular type (LDL or HDL), some smaller and larger subtypes differ in their effects on risk. Direct measurements of even more specific subtypes of lipoprotein particles may be even more informative about risk

"Waste the Waist": The development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk.

This is the accepted version of the article which has been published in final form in the British Journal of Health Psychology, which can be accessed via the DOI in this record.Objectives. To identify an evidence-based intervention to promote changes in diet and physical activity and adapt it for a UK primary care setting for people with high cardiovascular risk. Design. A three-stage mixed-methods design was used to facilitate a strategic approach to programme selection and adaptation. Method. Stage 1: Criteria for scientific quality and local appropriateness were developed for the selection/adaptation of an intervention to promote lifestyle change in people of high cardiovascular risk through (1) patient interviews, (2) a literature search to extract evidence-based criteria for behavioural interventions, and (3) stakeholder consultation. Stage 2: Potential interventions for adaptation were identified and ranked according to their performance against the criteria developed in Stage 1. Stage 3: Intervention mapping (IM) techniques were used to (1) specify the behavioural objectives that participants would need to reach in order to attain programme outcomes, and (2) adapt the selected intervention to ensure that evidence-based strategies to target all identified behavioural objectives were included. Results. Four of 23 potential interventions identified met the 11 essential criteria agreed by a multi-disciplinary stakeholder committee. Of these, the Greater Green Triangle programme (Laatikainen et al., 2007) was ranked highest and selected for adaptation. The IM process identified 13 additional behaviour change strategies that were used to adapt the intervention for the local context. Conclusions. IM provided a useful set of techniques for the systematic adaptation of an existing lifestyle intervention to a new population and context, and facilitated transparent working processes for a multi-disciplinary team.Department of Healt

"Waste the Waist": The development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk.

This is the accepted version of the article which has been published in final form in the British Journal of Health Psychology, which can be accessed via the DOI in this record.Objectives. To identify an evidence-based intervention to promote changes in diet and physical activity and adapt it for a UK primary care setting for people with high cardiovascular risk. Design. A three-stage mixed-methods design was used to facilitate a strategic approach to programme selection and adaptation. Method. Stage 1: Criteria for scientific quality and local appropriateness were developed for the selection/adaptation of an intervention to promote lifestyle change in people of high cardiovascular risk through (1) patient interviews, (2) a literature search to extract evidence-based criteria for behavioural interventions, and (3) stakeholder consultation. Stage 2: Potential interventions for adaptation were identified and ranked according to their performance against the criteria developed in Stage 1. Stage 3: Intervention mapping (IM) techniques were used to (1) specify the behavioural objectives that participants would need to reach in order to attain programme outcomes, and (2) adapt the selected intervention to ensure that evidence-based strategies to target all identified behavioural objectives were included. Results. Four of 23 potential interventions identified met the 11 essential criteria agreed by a multi-disciplinary stakeholder committee. Of these, the Greater Green Triangle programme (Laatikainen et al., 2007) was ranked highest and selected for adaptation. The IM process identified 13 additional behaviour change strategies that were used to adapt the intervention for the local context. Conclusions. IM provided a useful set of techniques for the systematic adaptation of an existing lifestyle intervention to a new population and context, and facilitated transparent working processes for a multi-disciplinary team.Department of Healt

Outcomes of a community-based weight management programme for morbidly obese populations

Background: Morbid obesity is an ongoing concern worldwide. There is a paucity of research reporting primary care outcomes focussed on complex and morbidly obese populations. The National Institute for Health and Care Excellence (NICE) recommends a specialist, multidisciplinary weight management team for the successful management of such populations. This is the first service evaluation reporting both primary (weight change) and secondary [body mass index (BMI), waist circumference, physical activity levels, fruit and vegetable intake, Rosenberg self-esteem score] outcomes in these patients. Methods: The present study comprised a prospective observational study of a cohort data set for patients (n = 288) attending their 3-month and 6-month (n = 115) assessment appointments at a specialist community weight management programme. Results: Patients had a mean (SD) initial BMI of 45.5 (6.6) kg m–²; 66% were females. Over 80% of patients attending the service lost some weight by 3 months. Average absolute weight loss was 4.11 (4.95) kg at 3 months and 6.30 (8.41) kg at 6 months, equating to 3.28% (3.82%) and 4.90% (6.26%), respectively, demonstrating a statistically significant weight change at both time points (P < 0.001). This meets NICE best practice guidelines for the commissioning of services leading to a minimum of 3% average weight loss, with at least 30% of patients losing at ≥5% of their initial weight. Waist measurement and BMI were reduced significantly at 3 months. Improvements were also seen in physical activity levels, fruit and vegetable consumption, and self-esteem levels (P < 0.001). Conclusions: This service was successful in aiding weight loss in morbidly obese populations. The findings of the present study support the view that weight-loss targets of 3% are realistic