Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

Increasing uptake of National Health Service Health Checks in primary care: a pragmatic randomized controlled trial of enhanced invitation letters in Northamptonshire, England

BACKGROUND

Uptake of NHS Health Checks (NHSHCs) is sub-optimal. This study aimed to increase their uptake using behaviourally informed invitation letters.

METHOD

Patients registered with 6 general practices in Northamptonshire, England who were eligible for an NHSHC between 10 February 2014 and 31 January 2015 were randomized monthly, using a random number generator, to three trial arms: control (standard invitation), sunk costs (resources already allocated) and counterargument (against common barriers to attendance). The outcome measure was uptake of NHSHC by 12 weeks after 31 January.

RESULTS

In total, 6331 patients were randomized. After exclusions, due to ineligibility for the NHSHC, data were analysed for N = 6313 patients: N = 2123 control; N = 2085 counterargument; N = 2105 sunk costs. Overall, 2364 (37.45%) patients attended an NHSHC. Both intervention letters increased uptake compared to control, by 5.46% using counterargument (adjusted odds ratio (AOR) 1.32, CI 1.162-1.51, p < 0.001) and 4.33% using sunk costs (AOR 1.246, CI 1.10-1.42, p < 0.001), with no significant difference between the two.

CONCLUSION

Behaviourally informed invitation letters, containing sunk costs or counterargument messages, can improve the uptake of NHSHCs. The trial was registered with the International Standard Randomised Controlled Trial Registration Number Scheme (ISRCTN57110614).

Unwillingness to participate in health checks for cardiometabolic diseases: A survey among primary health care patients in five European countries

BACKGROUND AND AIMS

Since cardiometabolic diseases (CMD) are a frequent cause of death worldwide, preventive strategies are needed. Recruiting adults for a health check could facilitate the identification of individuals at risk for CMD. For successful results, participation is crucial. We aimed to identify factors related to unwillingness to participate in CMD health checks.

METHODS

We performed a cross-sectional study in the Czech Republic, Denmark, Greece, the Netherlands, and Sweden. A questionnaire was distributed among persons without known CMD consulting general practice between January and July 2017 within the framework of the SPIMEU study.

RESULTS

In total, 1354 persons responded. Nine percent was unwilling to participate in a CMD health check. Male gender, smoking, higher self-rated health, never been invited before, and not willing to pay were related to unwillingness to participate. The most mentioned reason for unwillingness to participate was "I think that I am healthy" (57%). Among the respondents who were willing to participate, 94% preferred an invitation by the general practitioner and 66% was willing to pay.

CONCLUSION

A minority of the respondents was unwilling to participate in a CMD health check with consistent results within the five countries. This provides a promising starting point to increase participation in CMD health checks in primary care.

Characteristics and motives of non-responders in a stepwise cardiometabolic disease prevention program in primary care

BACKGROUND

A high response rate is an important condition for effective prevention programs. We aimed at gaining insight into the characteristics and motives of non-responders in different stages of a stepwise prevention program for cardiometabolic diseases (CMD) in primary care.

METHODS

We performed a non-response analysis within a randomized controlled trial assessing the effectiveness of a stepwise CMD prevention program in the Netherlands. Patients between 45 and 70 years without known CMD were invited for stage 1 of the program, completing a CMD risk score. Patients with an increased risk were advised to visit their general practice for additional measurements, stage 2 of the program. We analyzed determinants of non-response using data from the risk score, electronic medical records, questionnaires and Statistics Netherlands.

RESULTS

Non-response in stage 1 was associated with a younger age, male sex, a migration background, a low prosperity score, self-employment, being single and having lower consultations rates in general practice. Non-response in stage 2 was associated with a low prosperity score, being employed, having no chronic illness, smoking, a normal waist circumference, a negative family history for cardiovascular disease or diabetes and having a lower consultation rate. More than half of the non-responders in stage 2 reported not visiting the GP because they did not expect to have any CMD, despite their increased risk.

CONCLUSIONS

To achieve a larger and more equal uptake of prevention programs for CMD, we should use methods adapted to characteristics of non-responders, such as targeted invitation methods and improved risk communication.

Feasibility and success rates of response enhancing strategies in a stepwise prevention program for cardiometabolic diseases in primary care

Background

Prevention programs for cardiometabolic diseases (CMD), including cardiovascular disease, diabetes mellitus and chronic kidney disease are feasible, but evidence for the cost-effectiveness of selective CMD prevention programs is lacking. Response rates have an important role in effectiveness, but methods to increase response rates have received insufficient attention. The aim of the current study is to determine the feasibility and the success rate of a variety of response enhancing strategies to increase the participation in a selective prevention program for CMD.

Methods

The INTEGRATE study is a Dutch randomised controlled trial to assess the effectiveness and cost-effectiveness of a stepwise program for CMD prevention. During the INTEGRATE study we developed ten different response enhancing strategies targeted at different stages of non-response and different patient populations and evaluated these in 29 general practices.

Results

A face-to-face reminder by the GP increased the response significantly. Digital reminders targeted at patients with an increased CMD risk showed a positive trend towards participation. Sending invitations and reminders by e-mail generated similar response rates, but at lower costs and time investment than the standard way of dissemination. Translated materials, information gatherings at the practice, self-management toolkits, reminders by telephone, information letters, local media attention and SMS text reminders did not increase the response to our program.

Conclusions

Inviting or reminding patients by e-mail or during GPs consultation may enhance response rates in a selective prevention program for CMD. Different response-enhancing strategies have different patient target populations and implementation issues, therefore practice characteristics need to be taken into account when implementing such strategies.

Trial registration

Dutch trial Register number NTR4277. Registered 26 November 2013.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12875-020-01293-9.

Mapping non-response in a prevention program for cardiometabolic diseases in primary care: How to improve participation?

•

Non-response in prevention programs for CMD in primary care is often overlooked.

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Willingness to participate amongst non-responders is high.

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There are response enhancing strategies that show potential.

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We should be able to boost response rates of prevention programs for CMD.

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A next logical step is to test potential response enhancing strategies.

Non-response in prevention programs for cardiometabolic diseases (CMD) in primary care is often overlooked. The aim for this study was to define factors that influence the primary response to a selective CMD prevention program and to determine response-enhancing strategies that influence the willingness to participate. We conducted a non-response analysis within a randomized controlled trial evaluating a selective CMD prevention program, the study was conducted from 2013 to 2018 in Netherlands. A random sample of 5616 patients from 15 general practices were invited to complete a risk score (RS) as initial step of the program. Non-responders received an additional questionnaire. The response on the risk score was 51% (n = 2872). From the 3558 non-response questionnaires sent, 786 (22%) were returned. In a multivariable multilevel regression analysis smoking was independently associated with non-response. Of all reported reasons for non-response ‘forgot/no time’ accounted for 45%. In total, 73% of the non-responders indicated to reconsider participation when approached differently. A personal approach by the patients’ own GP, using advertisements and informative campaigns are potentially the best methods to enhance the response. Although a relatively high proportion did not respond to the invitation for the risk score, the majority of them indicated to be willing to participate if a different invitation strategy would be used. With more time and energy, response rates for CMD prevention programs could possibly increase substantially. A next logical step in this process is to test potential response enhancing strategies in research setting.

Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: a factorial randomised controlled trial

Background

The NHS Health Check (NHS HC) is a cardiovascular risk assessment to prevent cardiovascular disease. Public Health England (PHE) wants to increase uptake.

Methods

We explored the impact of behaviourally informed invitation letters and pre-notification and reminder SMS on uptake of NHS HCs. Patients at 28 General Practices in the London Borough of Southwark who were eligible to receive an NHS HC between 1st November 2013 and 31st December 2014 were included. A double-blind randomised controlled trial with a mixed 2 (pre-notification SMS – yes or no) × 4 (letter – national template control, open-ended, time-limited, social norm) × 2 (reminder SMS – yes or no) factorial design was used. The open-ended letter used simplification, behavioural instruction and a personalised planning prompt for patients to record the date and time of their NHS HC. The time-limited letter was similar but stated the NHS HC was due in a named forthcoming month. The social norms letter was similar to the open-ended letter but included a descriptive social norms message and testimonials from local residents and no planning prompt. The outcome measure was attendance at an NHS HC.

Results

Data for 12, 244 invites were analysed. Uptake increased in almost all letter and SMS combinations compared to the control letter without SMS (Uptake 18%), with increases of up to 12 percentage points for the time-limited letter with pre-notification and reminder (Uptake 30%; Adjusted Odds Ratio AOR 1.86; 95% CI 1.45–2.83; p < 0.00); 10 percentage points for the open-ended letter with reminder (Uptake 27%; AOR 1.68; 95% CI 1.31–2.17; p < 0.00) and a 9 percentage point increase using the time-limited letter with reminder (Uptake 27%; AOR 1.61; 95% CI 1.25–2.10; p < 0.00). The reminder SMS increased uptake for all intervention letters. The pre-notification did not add to this effect.

Conclusions

This large randomised controlled trial adds support to the evidence that small, low cost behaviourally informed changes to letter-based invitations can increase uptake of NHS HCs. It also provides novel evidence on the effect of SMS reminders and pre-notification on NHS HC attendance.

Trial registration

Retrospectively Registered (24/01/2014) ISRCTN36027094.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7476-8) contains supplementary material, which is available to authorized users.

Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: A systematic review

Background

Health checks for cardiometabolic diseases could play a role in the identification of persons at high risk for disease. To improve the uptake of these health checks in primary care, we need to know what barriers and facilitators determine participation.

Methods

We used an iterative search strategy consisting of three steps: (a) identification of key-articles; (b) systematic literature search in PubMed, Medline and Embase based on keywords; (c) screening of titles and abstracts and subsequently full-text screening. We summarised the results into four categories: characteristics, attitudes, practical reasons and healthcare provider-related factors.

Results

Thirty-nine studies were included. Attitudes such as wanting to know of cardiometabolic disease risk, feeling responsible for, and concerns about one’s own health were facilitators for participation. Younger age, smoking, low education and attitudes such as not wanting to be, or being, worried about the outcome, low perceived severity or susceptibility, and negative attitude towards health checks or prevention in general were barriers. Furthermore, practical issues such as information and the ease of access to appointments could influence participation.

Conclusion

Barriers and facilitators to participation in health checks for cardiometabolic diseases were heterogeneous. Hence, it is not possible to develop a ‘one size fits all’ approach to maximise the uptake. For optimal implementation we suggest a multifactorial approach adapted to the national context with special attention to people who might be more difficult to reach. Increasing the uptake of health checks could contribute to identifying the people at risk to be able to start preventive interventions.

Impact of socioeconomic deprivation on screening for cardiovascular disease risk in a primary prevention population: a cross-sectional study

OBJECTIVES

Investigate the association between socioeconomic deprivation and completeness of cardiovascular disease (CVD) risk factor recording in primary care, uptake of screening in people with incomplete risk factor recording and with actual CVD risk within the screened subgroup.

DESIGN

Cross-sectional study.

SETTING

Nine UK general practices.

PARTICIPANTS

7987 people aged 50-74 years with no CVD diagnosis.

METHODS

CVD risk was estimated using the Framingham equation from data extracted from primary care electronic health records. Where there was insufficient information to calculate risk, patients were invited to attend a screening assessment.

ANALYSIS

Proportion of patients for whom clinical data were sufficiently complete to enable CVD risk to be calculated; proportion of patients invited to screening who attended; proportion of patients who attended screening whose 10-year risk of a cardiovascular event was high (>20%). For each outcome, a set of logistic regression models were run. Crude and adjusted ORs were estimated for person-level deprivation, age, gender and smoking status. We included practice-level deprivation as a continuous variable and practice as a random effect to account for clustering.

RESULTS

People who had lower Indices of Multiple Deprivation (IMD) scores (less deprived) had significantly worse routine CVD risk factor recording (adjusted OR 0.97 (0.95 to 1.00) per IMD decile; p=0.042). Screening attendance was poorer in those with more deprivation (adjusted OR 0.89 (0.86 to 0.91) per IMD decile; p<0.001). Among those who attended screening, the most deprived were more likely to have CVD risk >20% (OR 1.09 (1.03 to 1.15) per IMD decile; p=0.004).

CONCLUSIONS

Our data suggest that those who had the most to gain from screening were least likely to attend, potentially exacerbating existing health inequalities. Future research should focus on tailoring the delivery of CVD screening to ensure engagement of socioeconomically deprived groups.

Implementation of NHS Health Checks in general practice: variation in delivery between practices and practitioners

Aim To evaluate NHS Health Check implementation in terms of frequency of data recording, advice provided, referrals to community-based lifestyle support services, statin prescribing and new diagnoses, and to assess variation in these aspects between practices and health professionals involved in delivery.

BACKGROUND

Most NHS Health Checks are delivered by general practices, but little detail is known about the extent of variation in how they are delivered in different practices and by different health professionals.

METHODS

This was an observational study conducted in a purposively selected sample of 13 practices in Sefton, North West England. Practices used previously recorded information from their clinical management systems to identify patients with cardiovascular disease (CVD) risk ⩾20%, a potentially cost-effective approach. The evaluation was conducted during the first year of delivery in Sefton. Data were extracted from medical records of all patients identified, regardless of Health Check attendance. Findings Of the 2892 patients identified by the 13 practices, 1070 had received an NHS Health Check at the time of the study. Of these, only 936 (87.5%) had a recorded CVD risk score, with risk ⩾20% confirmed in 92.0%. Estimated risk category was correct in 456/677 (67.4%) of patients with estimated and actual risk scores. Significant variation was found between practices and health professionals in parameters recorded, tests requested, advice given and referrals for lifestyle support. Only 45.3% of patients had body mass index, smoking, alcohol, exercise, blood pressure and cholesterol all recorded. Lifestyle advice and referral into lifestyle services were documented in 80.6% and 6.4% of attenders, respectively, again with significant variation between practices and professionals. Statin prescribing rose in attenders from 19.6% to 34.6%. A similar proportion of attenders and non-attenders received new diagnoses.

CONCLUSION

Effort is required to reduce variation in how practices deliver and follow-up NHS Health Checks, to ensure the consistency of the programme.

Patients' attitudes towards screening for diabetes and other medical conditions in the dental setting

AIM

To determine the attitudes of patients attending routine appointments at primary care dental clinics and general dental practices towards the possibility of chair-side screening for medical conditions, including diabetes, in the dental setting.

METHODS

A brief, anonymous, self-administered questionnaire distributed to adult patients (≥18 years) attending 2 primary care dental clinics and 16 general dental practices in South-West England.

RESULTS

One hundred and ninety-seven completed questionnaires were received from patients at primary care dental clinics and 429 from general dental practice patients. Overall, 87% of respondents thought that it was important or very important that dentists screened patients for medical conditions such as diabetes; 79% were very willing to let a dental team member carry out screening. The majority indicated willingness to be screened for various medical conditions during a visit to the dentist, with significantly higher proportions of respondents in the primary care clinics indicating willingness (hypertension: 83% vs 74%; heart disease: 77% vs 66%; diabetes 82% vs 72% [all p <0.02]). Nearly two thirds of primary care clinic respondents and over half of general practice patients indicated that they would be willing to discuss test results with the dental team. Overall, 61% had never knowingly been screened or tested for diabetes; 20% reported that they had been tested within the previous 12 months.

CONCLUSION

The majority of respondents supported the concept of medical screening in a dental setting and were willing both to have screening tests and discuss their results with the dental team. Patient acceptance is paramount for successful implementation of such screening programmes.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A process evaluation of the NHS Health Check care pathway in a primary care setting

BACKGROUND

More evidence is needed concerning the implementation of the NHS Health Check programme in order to identify areas for improvement. The aim of the study was to investigate the way in which the Gloucestershire NHS Health Check programme care pathway was followed and interpreted compared with national programme indicators.

METHODS

A cross sectional review of Gloucestershire's Health Checks was undertaken to assess programme performance via a primary care audit of key indicators within a cohort of 83 GP practices and an eligible population of 210 513. Data were assessed to compare differences between practices and to compare county data with national indicators.

RESULTS

The annual programme uptake was 49.8% and a total of 1031 patients were diagnosed with cardiovascular disease (CVD). Variations in the detection of modifiable risk factors in relation to the NHS Ready Reckoner were identified: diabetes (-0.04%), CKD (-0.9%), hypertension (-19.9%); obesity (-7.1%); low physical activity (-57.7%) and smoking (-14.3%).

CONCLUSIONS

Disparities in uptake and implementation of the care pathway demonstrate inconsistencies in the application of processes and knowledge. There appears to be an overestimation of CVD risk by the Ready Reckoner tool likely to be attributable to a failure to adjust for existing local early identification efforts in primary care and prevention.

Patients' willingness to attend the NHS cardiovascular health checks in primary care: a qualitative interview study

BACKGROUND

The NHS Cardiovascular Health Check (NHSHC) programme was introduced in England in 2009 to reduce cardiovascular disease mortality and morbidity for all patients aged 40 to 74 years old. Programme cost-effectiveness was based on an assumed uptake of 75% but current estimates of uptake in primary care are less than 50%. The purpose of this study was to identify factors influencing patients' willingness to attend an NHSHC. For those who attended, their views, experiences and their future willingness to engage in the programme were explored.

METHOD

Telephone or face-to-face interviews were conducted with patients who had recently been invited for an NHSHC by a letter from four general practices in Torbay, England. Patients were purposefully sampled (by gender, age, attendance status). Interviews were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

17 attendees and 10 non-attendees were interviewed. Patients who attended an NHSHC viewed it as worthwhile. Proactive attitudes towards their health, a desire to prevent disease before they developed symptoms, and a willingness to accept screening and health check invitations motivated many individuals to attend. Non-attendees cited not seeing the NHSHC as a priority, or how it differed from regular monitoring already received for other conditions as barriers to attendance. Some non-attendees actively avoided GP practices when feeling well, while others did not want to waste health professionals' time. Misunderstandings of what the NHSHC involved and negative views of what the likely outcome might be were common.

CONCLUSION

While a minority of non-attendees simply had made an informed choice not to have an NHSHC, improving the clarity and brevity of invitational materials, better advertising, and simple administrative interventions such as sending reminder letters, have considerable potential to improve NHSHC uptake.

Willingness to participate in prevention programs for cardiometabolic diseases

Background

Cardiometabolic diseases are the leading cause of death worldwide and result in decreased quality of life for patients and increased healthcare costs. Population-based prevention programs may prevent the onset and development of cardiometabolic diseases. The effectiveness of these programs depends on participation rates. This study identified factors related to willingness to participate in health checks and lifestyle intervention programs to prevent cardiometabolic diseases.

Methods

A questionnaire was sent to 1,500 Dutch adults, participating in the Dutch Health Care Consumer Panel of NIVEL. The questionnaire was developed by NIVEL. Predictors of willingness to participate were identified with logistic regression analyses. Predictors investigated were socio-demographic variables, risk factors for cardiometabolic diseases and motivational aspects.

Results

The response rate was 63%. 56% of the participants in our study were willing to participate in a health check. Higher age was associated with increased willingness to participate, as was the desire to know the actual risk for cardiometabolic diseases (OR = 4.6). Becoming unnecessarily worried was identified as a barrier (OR = 0.3). 47% were willing to participate in a lifestyle intervention program. People aged 39–65 were most willing to participate. Attention for prevention relapse behavior (OR = 3.3), informing the general practitioner about results (OR = 2.6) and conducting the program in a group (OR = 2.0) were positively associated with willingness to participate in lifestyle interventions.

Conclusions

Willingness to participate in a health check depended on personal beliefs, whereas social aspects contributed most to willingness to participate in a lifestyle intervention program. This information can be used to optimize and tailor the promotion of prevention programs.

Screening for increased cardiometabolic risk in primary care: a systematic review

BACKGROUND

Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear.

AIM

To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy.

DESIGN AND SETTING

Systematic review of studies performed in primary care in Western countries.

METHOD

MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities.

RESULTS

The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods.

CONCLUSION

The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.

Comparison of uptake and predictors of adherence in primary and secondary prevention of cardiovascular disease in a community-based cardiovascular prevention programme (MyAction Westminster)

BACKGROUND

Despite the benefits of cardiac rehabilitation, uptake and adherence remain suboptimal. With the advent of NHS Health Checks, primary prevention programmes have also been advocated, but little is known about uptake and adherence rates. This study examined rates and predictors of adherence amongst patients with cardiovascular disease (CVD) and those at high multifactorial risk (HRI) attending an innovative programme integrating primary and secondary prevention.

METHODS

Comparison of rates of uptake and adherence and also predictors of adherence between 401 CVD patients and 483 HRI. The outcome was the number of sessions attended and predictor variables included clinical and psychosocial variables. Differences between groups were examined using t-tests and non-parametric tests. Multivariable regression analyses examined predictors of adherence.

RESULTS

Uptake to the assessment (CVD: 97%, HRI: 88%) and the programme (CVD: 78%, HRI: 74%) were high for both groups. An average of 8/12 was attended in both groups. Beliefs about treatment predicted adherence for both groups (P < 0.01). The alcohol causal belief also predicted poorer adherence amongst CVD patients (P < 0.02). Older age also predicted better adherence amongst HRI (P < 0.001).

CONCLUSIONS

Rates of uptake and adherence were high for both HRI and CVD patients. Further research is needed to examine whether interventions targeting predictor variables further improve adherence.

The impact of chronic kidney disease and cardiovascular comorbidity on mortality in a multiethnic population: a retrospective cohort study

OBJECTIVE

To assess the impact of chronic kidney disease (CKD) and cardiovascular comorbidity on mortality in a multiethnic primary care population.

DESIGN

Retrospective cohort study.

SETTING

Inner-city primary care trust in West Midlands, UK.

PARTICIPANTS

Individuals aged 40 years and older, of South Asian, black or white ethnicity, registered with a general practice and with their kidney function checked within the last 12 months (n=31 254).

OUTCOME MEASURE

All-cause mortality.

RESULTS

Reduced estimated glomerular filtration rate, higher albuminuria, older age, white ethnicity (vs South Asian or black ethnicity) and increasing cardiovascular comorbidities were independent determinants of a higher mortality risk. In the multivariate model including comorbidities and kidney function, the HR for mortality for South Asians was 0.697 (95% CI 0.56 to 0.868, p=0.001) and for blacks it was 0.533 (95% CI 0.403 to 0.704, p<0.001) compared to whites.

CONCLUSIONS

The HR for death is lower for South Asian and black individuals compared to white individuals. This is, in part, independent of age, gender, socioeconomic status, kidney function and comorbidities. Risk of death is higher in individuals with CKD and with a higher cumulative cardiovascular comorbidity.

Cardiovascular risk assessment of South Asian populations in religious and community settings: a qualitative study

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of mortality, and South Asian groups experience worse outcomes than the general population in the UK. Regular screening for CVD risk factors is recommended, but we do not know the best settings in which to deliver this for ethnically diverse populations. Health promotion in religious and community settings may reduce inequalities in access to cardiovascular preventative health care.

OBJECTIVES

To use stakeholders' and attendees' experiences to explore the feasibility and potential impact of cardiovascular risk assessment targeting South Asian groups at religious and community venues and how health checks in these settings might compare with general practice assessments.

METHOD

Qualitative semi-structured interviews were used. The settings were two Hindu temples, one mosque and one Bangladeshi community centre in central and north-west London. Twenty-four participants (12 stakeholders and 12 attendees) were purposively selected for interview. Interviews were recorded and transcribed verbatim. Themes from the data were generated using thematic framework analysis.

RESULTS

All attendees reported positive experiences of the assessments. All reported making lifestyle changes after the check, particularly to diet and exercise. Barriers to lifestyle change, e.g. resistance to change from family members, were identified. Advantages of implementing assessments in religious and community settings compared with general practice included accessibility and community encouragement. Disadvantages included reduced privacy, organizational difficulties and lack of follow-up care.

CONCLUSION

Cardiovascular risk assessment in religious and community settings has the potential to trigger lifestyle change in younger participants. These venues should be considered for future health promotional activities.

Uptake of the NHS Health Check programme in an urban setting

BACKGROUND

The NHS Health Check programme aims to improve prevention, early diagnosis and management of cardiovascular disease (CVD) in England. High and equitable uptake is essential for the programme to effectively reduce the CVD burden.

OBJECTIVES

Assessing the impact of a local financial incentive scheme on uptake and statin prescribing in the first 2 years of the programme.

METHODS

Cross-sectional study using data from electronic medical records of general practices in Hammersmith and Fulham, London on all patients aged 40-74 years. We assessed uptake of complete Health Check, exclusion of patients from the programme (exception reporting) and statin prescriptions in patients confirmed with high CVD risk.

RESULTS

The Health Check uptake was 32.7% in Year 1 and 20.0% in Year 2. Older patients had higher uptake of Health Check than younger (65- to 74-year-old patients: Year 1 adjusted odds ratio (AOR) 2.05 (1.67-2.52) & Year 2 AOR 2.79 (2.49-3.12) compared with 40- to 54-year-old patients). The percentage of confirmed high risk patients prescribed a statin was 17.7% before and 52.9% after the programme. There was a marked variation in Health Check uptake, exception reporting and statin prescribing between practices.

CONCLUSIONS

Uptake of the Health Check was low in the first year in patients with estimated high risk despite financial incentives to general practices; although this matched the national required rate in second year. Further evaluations for cost and clinical effectiveness of the programme are needed to clarify whether this spending is appropriate, and to assess the impact of financial incentives on programme performance.

Primary care and population factors associated with NHS Health Check coverage: a national cross-sectional study

INTRODUCTION

High and equitable coverage of systematic cardiovascular disease (CVD) prevention programmes, such as the NHS Health Check programme in England, is essential if they are to effectively reduce the population CVD burden.

METHODS

We conducted a cross-sectional study using data from 151 English primary care trusts (PCTs) on NHS Health Check coverage during 2011-12. We examined the associations between programme coverage and primary care and population factors, including patient demographics, primary care workforce and cardiovascular health need.

RESULTS

Median coverage of NHS Health Checks was 8.2%, with wide PCT-level variation (range = 0-29.8%). Coverage was significantly higher in PCTs in the most deprived areas compared with the least deprived (P = 0.035), adjusting for covariates. Significant negative associations between coverage and a higher proportion of PCT population aged 40-74 years-the eligible Health Check age group, a larger total population size and higher practice staffing levels were found in the unadjusted analyses.

CONCLUSIONS

NHS Health Check coverage during 2011-12 was lower than the government projection of 18% coverage. Coverage must be increased through concerted multi-disciplinary strategies, for the programme to improve cardiovascular health in England. Considerable variation in participation between PCTs warrants attention, with enhanced support for poor performers.

Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent

BACKGROUND

As part of national policy to manage the increasing burden of chronic diseases, the Department of Health in England has launched the NHS Health Checks programme, which aims to reduce the burden of the major vascular diseases on the health service.

METHODS

A cross-sectional review of response, attendance and treatment uptake over the first year of the programme in Stoke on Trent was carried out. Patients aged between 32 and 74 years and estimated to be at ≥20% risk of developing cardiovascular disease were identified from electronic medical records. Multi-level regression modelling was used to evaluate the influence of individual- and practice-level factors on health check outcomes.

RESULTS

Overall 63.3% of patients responded, 43.7% attended and 29.8% took up a treatment following their health check invitation. The response was higher for older age and more affluent areas; attendance and treatment uptake were higher for males and older age. Variance between practices was significant (P < 0.001) for response (13.4%), attendance (12.7%) and uptake (23%).

CONCLUSIONS

The attendance rate of 43.7% following invitation to a health check was considerably lower than the benchmark of 75%. The lack of public interest and the prevalence of significant comorbidity are challenges to this national policy innovation.

Non-participation in population-based disease prevention programs in general practice

BACKGROUND

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

METHODS

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

RESULTS

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

CONCLUSIONS

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Non-participation in population-based disease prevention programs in general practice

Background

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

Methods

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

Results

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

Conclusions

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.