[A different cardiovascular epidemiology]

BACKGROUND

Cardiovascular diseases constitute the leading cause of sickness and death in Western countries. They are therefore embraced with much attention in medical research, treatment and preventive programmes for which quantifiable biological risk factors comprise the common conceptual basis. We want to demonstrate that the current narrow biological focus may prohibit a deeper understanding of the sickness expressions. THEORY, MATERIAL AND METHOD: The present paper is grounded in a theory of human beings as self-reflecting and capable of creating and conveying meaning affected by culture, time and relationships with others. From such a perspective, the human body is seen as a lived body, a centre for expression of experience. Two cases are interpreted in light of more recent epidemiological evidence of associations between traumatic experiences and cardiovascular disease.

RESULTS

Research shows that traumatic experiences in general and early trauma in particular are potent pathogens. Different types of trauma are, however, not consistently related to specific diseases, but rather to complex patterns of so called co-morbidity. These patterns blur the mind-body-distinction and thereby the classification systems for somatic and mental diseases. When such patterns are interpreted as expressions of embodied life, insight is provided into how traumatic experience informs the lived body.

INTERPRETATION

Correlations between traumatic experience and cardiovascular disease challenge the dominating biological framework of cardiovascular epidemiology. An analysis of the evidence by means of two cases opens up new perspectives. Knowledge about the path from particular and painful experience to particular and painful disease is an inevitable premise for an adequate treatment of the individual. It is also a prerequisite for development of adequate preventive measures.

Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study

OBJECTIVE

To estimate the high risk group for cardiovascular disease in a well defined Norwegian population according to European guidelines and the systematic coronary risk evaluation system.

DESIGN

Modelling study.

SETTING

Nord-Tröndelag health study 1995-7 (HUNT 2), Norway.

PARTICIPANTS

5548 participants of the Nord-Tröndelag health study 1995-7, aged 40, 50, 55, 60, and 65.

MAIN OUTCOME MEASURES

Distribution of risk categories for cardiovascular disease, with emphasis on the high risk group.

MAIN RESULTS

At age 40, 22.5% (95% confidence interval 19.3% to 25.7%) of women and 85.9% (83.2% to 88.6%) of men were at high risk of cardiovascular disease. Corresponding numbers at age 50 were 39.5% (35.9% to 43.1%) and 88.7% (86.3% to 91.0%) and at age 65 were 84.0% (80.6% to 87.4%) and 91.6% (88.6% to 94.1%). At age 40, one out of 10 women and no men would be classified at low risk for cardiovascular disease.

CONCLUSION

Implementation of the 2003 European guidelines on prevention of cardiovascular disease in clinical practice would classify most adult Norwegians at high risk for fatal cardiovascular disease.

Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. A descriptive epidemiological study

OBJECTIVE

Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97.

MAIN OUTCOME MEASURES

Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication.

MAIN RESULTS

In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women.

CONCLUSIONS AND IMPLICATIONS

Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.

Evidence-based medicine in general practice: a hindrance to optimal medical care?

This article is the second part of a "pro et contra session" about evidence-based medicine at the 13th Nordic Congress in General Practice 2003 in Helsinki. Marjukka Mäkelä's arguments in favour of evidence-based medicine may be found in the preceding article.

Is opportunistic disease prevention in the consultation ethically justifiable?

Medical resources are increasingly shifting from making patients better to preventing them from becoming ill. Genetic testing is likely to extend the list of conditions that can be screened for. Is it time to stop and consider whom we screen and how we approach it?

A matter of heart: the general practitioner consultation in an evidence-based world

This article is based on a keynote presentation at the 12th Nordic Congress in General Practice in Trondheim, Norway in September 2002. The aim was to demonstrate the strengths and limitations of evidence-based medicine (EBM) in a primary healthcare setting. The presentation comprised two separate lectures discussing an authentic case history from everyday practice that had been presented to the authors by the congress organisers. Initially, Peter Nilsson overviews the correct approach to the situation as described according to EBM. Subsequently, Linn Getz questions whether we can be sure that application of EBM is necessarily in this particular patient's best interests. The title of the presentation, 'A matter of heart', has a double meaning. On the one hand it indicates an update on preventive cardiology, on the other it addresses the importance of academic courage (coeur = heart) among members of the medical community. The general practitioner is in a unique position to observe the interaction between the scientific paradigm of biomedicine and individuals, whether suffering from ill health or considering themselves healthy. It is our privilege and professional duty to reflect upon clinical experience and be open to critical debate.

[Blood pressure records in general practice--expectations and reality]

BACKGROUND

The effect of antihypertensive medication on cardiovascular diseases is based on results achieved in prospective and controlled clinical studies. Comparable results in clinical practice can be achieved only when the quality of management for subjects with high blood pressure is comparable with the quality achieved in clinical studies.

MATERIAL AND METHODS

This study consists of two parts; an attempt to implement an computer-based clinical decision support system for management of hypertension in primary health care in two counties in Norway, and a questionnaire survey among doctors in primary care and specialists in internal medicine in hospitals in other counties. We asked what they expected would be the result of the specific implementation strategy for the computer-based program. The objectives were to evaluate the results of the implementation strategy and to compare these results with expectations expressed in the filled-in questionnaires by doctors without any obligations to the main study.

RESULTS

A total of 175 doctors were invited to implement the clinical decision support system. 85% responded; 44% of these, or 37% of the invited doctors, were willing to participate. After 12 months with recurrent visits by one of the authors, only six out of 74 doctors participating in the intervention study still used the program. The questionnaire were completed and returned by 203 doctors, who expected that 55% of the invited doctors would accept the invitation following the implementation strategy used. In general the validity of the information given by the questionnaire was poor and unreliable.

INTERPRETATION

We conclude that introduction of a computer-based clinical decision support system is difficult in a busy primary care setting. Availability and simplicity are crucial requirements, and doctors would need financial compensation if they were to use such a system.

[Pharmacological prevention of cardiovascular diseases in general practice]

BACKGROUND

In this paper the Norwegian College of General Practitioners, Working Group on Hypertension report recommendations for primary preventive drug treatment of elevated cardiovascular risk.

MATERIAL AND METHODS

Updated metaanalyses and randomised controlled trials are the main basis for the recommendations. The purpose of treating hypertension is prevention of cardiovascular diseases. Drug treatment with documented effect on morbidity and mortality is therefore recommended. We have also evaluated the cost effectiveness of drug treatment.

RESULTS

An estimate of the total risk of future cardiovascular disease is a necessary basis for treatment decisions. This paper presents tools for estimating total cardiovascular risk. Drug treatment is recommended if ten-year risk exceeds 20% or blood pressure equals or exceeds 170/100 mmHg. Drug treatments include antihypertensive, antithrombotic, antidiabetic and lipid-lowering drugs with documented effect on hard endpoints. Aspirin, thiazides, betablockers, metformin, calcium blockers, ACE inhibitors and statins are all drugs with documented effects on significant endpoints, but the costs of these treatments differ substantially.

INTERPRETATION

Drug treatment to prevent cardiovascular disease should be recommended for patients at significant risk of cardiovascular disease. Drugs with documented effect on morbidity and mortality should be used. Considerations of costs are important in treatment decisions.

[Life style advice provided by primary health care to prevent cardiovascular diseases]

BACKGROUND

The Working Group on Hypertension of the Norwegian College of General Practitioners reports in this paper on the documentation on behavioural advice in the prevention of cardiovascular disease. Emphasis is given to hypertension.

MATERIAL AND METHODS

The recommendations are mainly based on updated metaanalyses and randomised controlled trials. Hypertension is treated to prevent cardiovascular disease; that is why we put emphasis on documentation with significant end points. The validity of the documentation for general practice is assessed. We have also assessed whether certain methods or theories for behavioural change could be helpful to the general practitioner.

RESULTS

The value of advice against smoking, dietary advice (increased intake of grain products, vegetables, fruit, poultry and fish), and advice about exercise are well documented and applicable in general practice. Respect for the patient's autonomy and interest in the patients and their health-related habits seem to be important factors for improving doctor's chances of influencing patient behaviour.

INTERPRETATION

The value of life-style advice is well documented and should play an important role in clinical strategies to prevent cardiovascular disease in high-risk patients.

Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system

OBJECTIVES

To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention.

METHODS

Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation).

RESULTS

Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5).

CONCLUSIONS

Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system

OBJECTIVE

To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system (CDSS) and a specific implementation strategy. Evaluation of patient outcome.

DESIGN

Randomised study with health centres as units. The intervention group had the CDSS installed and made ready for use, doctors and assistants were trained and received a user-manual, the doctors were offered telephone repetitions, a seminar in risk intervention and, at the same seminar, further demonstration of the CDSS. The doctors received baseline registrations with information of how they treated their own hypertensive patients, and use of the CDSS was checked repeatedly.

SETTING

General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.

PARTICIPANTS

Seventeen health centres with 24 doctors and 984 patients in the intervention group. Data from 879 patients used in the final analyses. Twelve health centres with 29 doctors and 1255 patients in the control group. Data from 1119 patients used in the final analyses.

MAIN OUTCOME MEASURES

After an intervention period of 18 months, group differences in level of systolic and diastolic blood pressure, serum cholesterol, body mass index, and risk score for myocardial infarction were calculated, as well as group differences in fractions of smokers.

RESULTS

Significant group difference in favour of intervention group: diastolic blood pressure 1 mmHg (95% CI -1.89, -0.17). However, a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg (95% CI 1.0, 4.5) had been reduced to 1.2 mmHg (95% CI -0.6, 3.0) after intervention.

CONCLUSION

Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinically significant way.

Implementing clinical guidelines in the treatment of hypertension in general practice

Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures.

[Drugs in the treatment of asymptomatic risk conditions--better documentation is required]

This paper points to the dilemmas posed by the lack of longitudinal studies of morbidity and mortality, or of side-effects, of several drugs widely used in treatment of asymptomatic risk factors. New drugs and new indications make large groups eligible for treatment, i.e. for mildly elevated blood pressure or cholesterol levels, impaired glucose tolerance and risk of osteoporosis. The treatment of people with asymptomatic elevated risk factors differs in point of principle from the treatment of diseases, symptoms or complaints: The patient has no subjective feeling about his or her condition; the health risk is usually lower; there are no good evaluation measures for the treatment; and the risk that side-effects outweigh the benefits is greater. This makes high quality treatment and good information to patients even more important than in ordinary practice. More knowledge about effects with regard to morbidity and mortality and about long-term side-effects is necessary. Doctors should prefer drugs for which the effects are documented, and give patients with the highest health risk top priority.

Treatment of diabetes mellitus--physicians' adherence to clinical guidelines in Norway

OBJECTIVE

To assess general practitioners' current adherence to the Norwegian clinical guidelines for the treatment of diabetes mellitus.

DESIGN

Descriptive, retrospective registration of information from patient records of one year; 7 November 1993 to 7 November 1994. In addition, mailed questionnaire to examine the representativeness of the participating doctors.

SETTING

General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.

PARTICIPANTS

In one year 1119 patients were registered with the diagnosis of diabetes mellitus in the records of 56 general practitioners. The patients were 53% women and 47% men; 51% were 70 years or older.

MAIN OUTCOME MEASURES

Levels of HbA1c and blood pressure in accordance with the recommendations of the Norwegian clinical guidelines for diabetes mellitus. Fractions of patients with a measured HbA1c, blood pressure, and serum cholesterol in one year.

RESULTS

At least one HbA1c was recorded in 77% of the diabetic patients during the specified year. In patients under 70 years of age, 56% had HbA1c above the recommended treatment level of 7.5%. In patients 70 years of age or older, 36% were above the recommended limit of 8.5%. At least one blood pressure was recorded in 79% of the patients during the specified year. In patients under 70 years of age, 53% had a systolic blood pressure above the recommendations of 140 mmHg, and 22% had a diastolic blood pressure above the recommendations of 90 mmHg. Serum cholesterol was not recorded during the specified year in 75% of the patients.

CONCLUSION

There are still major discrepancies between current practice and the intentions laid down in the Norwegian clinical guidelines. A discussion of alternative methods for implementation and evaluation of the efficacy of clinical guidelines is needed.