Identification of the four conventional cardiovascular disease risk factors by Dutch general practitioners
ABSTRACT Detecting and managing the four major conventional risk factors, smoking, hypertension, diabetes mellitus, and hypercholesterolemia, is pivotal in the primary and secondary prevention of cardiovascular disease (CVD).
To assess the preventive activities of general practitioners (GPs) regarding the four conventional risk factors and the associated measurements for cardiovascular risk factors by GPs in relation to the time of the first clinical presence of CVD.
Large longitudinal general practice research database (the Integrated Primary Care Information database) in the Netherlands from September 1999 to August 2003.
Patients > 18 year of age with newly diagnosed CVD with a valid history of at least 1 year before and after the first clinical diagnosis of CVD. Details on conventional risk factors and associated measurements for the four cardiovascular risk factors were assessed in relation to the first clinical diagnosis of CVD.
In total, 157,716 patients met the study inclusion criteria. Of the 2,594 patients with newly diagnosed CVD, at least one of the four investigated risk factors was observed in 76% of women and 73% of men. In 40% of cases, no risk factor was recorded before the date of the first CVD diagnosis. In 16% of cases, no associated measurements were present before the first CVD diagnosis.
In daily practice, GPs seem to focus on the secondary prevention of CVD. Intervention strategies that aim to influence GPs' case finding behavior should focus on increasing the awareness of physicians in performing risk factor-associated measurements in patients who are eligible for the primary prevention of CVD. Further research will have to show the feasibility and effectiveness of such intervention strategies.
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ABSTRACT: 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. Given the lack of clinically meaningful effects, implementation of this intervention in its present form is not justified.Preventive Medicine 09/2011; 53(6):395-401. DOI:10.1016/j.ypmed.2011.08.031 · 2.93 Impact Factor
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ABSTRACT: Risicovoorspelling en risicoverlaging bij patienten met manifest vaatlijden Engelstalig abstract The number of patients with clinical manifest arterial disease is increasing because of the aging of the population. Patients with manifest arterial disease have an increased risk of a new vascular event in the same or different arterial bed. Medical treatment of vascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) and lifestyle changes (healthy diets, exercise, quit smoking) can reduce the future risk. Studies presented in this thesis not only confirm the high prevalence of vascular risk factors in patients with manifest arterial disease, but also demonstrate the relevance of non-invasive screening on asymptomatic arterial disease. Standard screening for asymptomatic arterial disease identified a limited number of vascular abnormalities that necessitated immediate medical attention. But the screening revealed a high prevalence of peripheral arterial disease and carotid artery stenosis. Furthermore we found that the presence of asymptomatic carotid artery stenosis was associated with a 50% increased risk of recurrent vascular events (hazard ratio (HR) 1.5, 95% CI 1.1 - 2.1) in patients with clinical manifest arterial disease or type 2 diabetes but without a history of cerebral ischemia. Thus, the presence of asymptomatic carotid artery stenosis of ? 50% indicates higher risk in patients already known to be at high risk. We evaluated new strategies aiming at better risk factor-management in order to delay or to prevent progression of atherosclerosis. An additional letter to the treating specialist with medical treatment recommendations in case of new or poorly controlled risk factors resulted in marginal increase in medication use compared with trends in medication use in usual care. The extra care given by a nurse practitioner in addition to usual care and on top of a vascular screening and prevention program resulted in achievement of more treatment goals for systolic blood pressure (odds ratio (OR) 2.7, 95% CI 1.3 - 5.4), total cholesterol (OR 3.3, 95% CI 1.5 - 7.3), LDL-cholesterol (OR 3.5, 95% CI 1.5 - 8.6), and BMI (OR 4.0, 95% CI 1.2 - 13.1) compared to usual care alone. Another way to achieve effective and efficient risk factor-management may be nurse practitioner guided treatment by Internet-communication with individual patients in addition to usual care. Goal setting to change behavior and the online-relationship between a nurse practitioner and a patient can continue for many years because of the repeated episodic nature of the atherosclerotic vascular disease process. The other part of this thesis concerns about risk prediction. The existing prediction models, intended for patients without cardiovascular disease or diabetes, underestimated the predicted risk in our cohort of patients with clinical manifestations of arterial disease. A new prediction model including traditional risk factors, history and extent of atherosclerosis showed that prediction of recurrent vascular events is possible after 1-year of follow-up but not at 3 or 5-years in patients with symptomatic cardiovascular disease. Indicators for a higher cardiovascular risk in patients with symptomatic peripheral arterial disease are older age (HR 1.85, 95% CI 1.48 - 2.30), impaired renal function (HR 0.79, 95% CI 0.69 - 0.91), elevated homocysteine levels (HR 1.03, 95% CI 1.02 - 1.05), and a history of coronary heart disease (HR 2.30, 95% CI 1.51 - 3.51).
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ABSTRACT: Van Wyk JT, Van Wijk MAM, Sturkenboom MCJM, Mosseveld M, Moorman PW, Van der Lei J. Het effect van elektronische herinneringen bij de behandeling van dislipidemie. Huisarts Wet 2009;52(10):490-6. Doel Sommige systemen ter ondersteuning van klinische besluitvorming (Clinical Decision Support Systems, CDSS) genereren automatisch herinneringen voor de gebruiker. Andere systemen moeten actief door de gebruiker worden opgestart. Er zijn geen gerandomiseerde onderzoeken die deze twee werkwijzen in een klinische omgeving vergelijken. We onderzochten het effect van de geautomatiseerde herinneringen en dat van niet-geautomatiseerde ondersteuning (‘op verzoek’). Dat deden we in het kader van de besluitvorming rond de screening en behandeling van dislipidemie, gebaseerd op de richtlijnen van het NHG. Methode We deden een geclusterd gerandomiseerd onderzoek, waaraan 36 Nederlandse huisartsenpraktijken (77 artsen) met 87.886 patiënten (39.433 mannen in de leeftijd van 18 tot 70 jaar, 48.453 vrouwen in de leeftijd van 18 tot 75 jaar) deelnamen. We wezen de praktijken toe aan de herinneringgroep, de op-verzoekgroep of de controlegroep (geen interventie). We berekenden het percentage patiënten dat gescreend en behandeld werd na 12 maanden follow-up. Resultaten In de herinneringgroep werd 65% van de patiënten die gescreend moesten worden, daadwerkelijk gescreend, in de controlegroep lag dat percentage op 25% (RR tegen controle = 1,76; 95%-BI 0,98-1,68). In de herinneringgroep werd 66% van de patiënten die behandeling nodig hadden daadwerkelijk behandeld (RR tegen controle = 1,40; 95%-BI 1,15-1,70) vergeleken met 39% van de patiënten (RR tegen controle = 1,19; 95%-BI 0,94-1,50) in de op-verzoekgroep en 36% van de patiënten in de controlegroep. Conclusie De versie van de CDSS met de herinnering gaf een significante verbetering van de mate van screening en behandeling van dislipidemie door huisartsen. behandeling-onderzoek-automatiseringHuisarts en wetenschap 10/2009; 52(10):490-496. DOI:10.1007/BF03085750