Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. They aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used individual screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is therefore important to assess whether general health checks do more good than harm. This is the first update of the review published in 2012.

OBJECTIVES

To quantify the benefits and harms of general health checks.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers on 31 January 2018. Two review authors independently screened titles and abstracts, assessed papers for eligibility and read reference lists. One review author used citation tracking (Web of Knowledge) and asked trial authors about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the trials. We contacted trial authors for additional outcomes or trial details when necessary. When possible, we analysed the results with a random-effects model meta-analysis; otherwise, we did a narrative synthesis.

MAIN RESULTS

We included 17 trials, 15 of which reported outcome data (251,891 participants). Risk of bias was generally low for our primary outcomes. Health checks have little or no effect on total mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.97 to 1.03; 11 trials; 233,298 participants and 21,535 deaths; high-certainty evidence, I² = 0%), or cancer mortality (RR 1.01, 95% CI 0.92 to 1.12; 8 trials; 139,290 participants and 3663 deaths; high-certainty evidence, I² = 33%), and probably have little or no effect on cardiovascular mortality (RR 1.05, 95% CI 0.94 to 1.16; 9 trials; 170,227 participants and 6237 deaths; moderate-certainty evidence; I² = 65%). Health checks have little or no effect on fatal and non-fatal ischaemic heart disease (RR 0.98, 95% CI 0.94 to 1.03; 4 trials; 164,881 persons, 10,325 events; high-certainty evidence; I² = 11%), and probably have little or no effect on fatal and non-fatal stroke (RR 1.05 95% CI 0.95 to 1.17; 3 trials; 107,421 persons, 4543 events; moderate-certainty evidence, I² = 53%).

AUTHORS' CONCLUSIONS

General health checks are unlikely to be beneficial.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

A neglected opportunity for China's tobacco control? Shift in smoking behavior during and after wives' pregnancy

Background

Although observational data suggest that men’s attempts and behavior at quitting smoking are often stimulated during their spouses’ pregnancy, few studies have systematically examined this phenomenon.

Methods

This was a cross-sectional study which examined Chinese men’s smoking behaviors during and after their wives’ pregnancy. Women who visited community health centers for routine immunization of their children were approached. Information was mainly collected on men’s tobacco use before, during and after pregnancy in July to August 2011. Individual and socio-environmental factors were examined by non-conditional logistical regression analysis to find potential reasons behind men’s quitting during pregnancy and maintained this change till the post-partum period.

Results

Totally 765 of 811 eligible women (94.3%) completed the interview. Prior to pregnancy, 42.9% of husbands smoked; this decreased to 36.34% during pregnancy, a reduction of 6.53%. Although the rate increased to a higher level (43.79%) after delivery, positive changes in men’s smoking behavior were detected. One-third (29.88%) reduced the daily number of cigarettes smoked, and nearly half (45.12%) relocated themselves to smoke when their pregnant wives were nearby. Noticeably, those who quit were most likely occasional smokers (Odds Ratio(OR) = 4.83, 95%CI [2.22, 10.48]), smoking less than ten years (OR = 2.80, 95%CI [1.19, 6.58]), not smoking at home (OR = 4.48, 95%CI [1.94, 10.39]), not smoking for social use (OR = 4.05, 95%CI [1.74, 9.41]), under lower financial pressure after the birth of child (OR = 5.28, 95%CI [2.14, 13.02]) and influenced by family members (OR = 2.82, 95%CI [1.25, 6.38]). However, only 22% of spontaneous cessation was maintained postpartum. Most relapses occurred within 6 months after delivery.

Conclusions

Pregnancy offers an opportunity to decrease smoking amongst Chinese males. Intervention programs involving expectant fathers may be effective to further reduce prevalence of smoking among men in China.

Electrochemical skin conductance to detect sudomotor dysfunction, peripheral neuropathy and the risk of foot ulceration among Saudi patients with diabetes mellitus

BACKGROUND

Sudomotor dysfunction is manifested clinically as abnormal sweating leading to dryness of feet skin and increased risk of foot ulceration. The aim of this study was to test the performance of foot electrochemical skin conductance (ESC) to detect diabetic peripheral neuropathy and the risk of foot ulceration against traditional methods in Saudi patients with diabetes mellitus.

METHODS

This cross-sectional study was conducted on 296 Saudi patients with diabetes mellitus. Painful neuropathic symptoms were evaluated using the neuropathy symptom score (NSS). The risk of foot ulceration and diabetic peripheral neuropathy were determined using the neuropathy disability score (NDS). Vibration perception threshold (VPT) was assessed using neurothesiometer. Neurophysiological assessment of the right and left sural, peroneal and tibial nerves was performed in 222 participants. Diabetic peripheral neuropathy was defined according to the definition of the American Academy of Neurology. ESC was measured with Sudoscan.

RESULTS

Feet-ESC decreased as the scores of sensory and motor function tests increased. Feet-ESC decreased as the NSS, NDS and severity of diabetic peripheral neuropathy increased. Sensitivity of feet-ESC < 50μS to detect diabetic peripheral neuropathy assessed by VPT ≥ 25 V, NDS ≥ 3, NDS ≥ 6 was 90.1, 61 and 63.8 % respectively and specificity 77, 85 and 81.9 % respectively. Sensitivity of feet-ESC < 70μS to detect diabetic peripheral neuropathy assessed by VPT ≥ 25 V, NDS ≥ 3, NDS ≥ 6 was 100, 80.6 and 80.9 % respectively. Sensitivity and specificity of feet-ESC < 70μS to detect confirmed-diabetic peripheral neuropathy were 67.5 and 58.9 % respectively.

CONCLUSION

Sudoscan a simple and objective tool can be used to detect diabetic peripheral neuropathy and the risk of foot ulceration among patients with diabetes mellitus. Prospective studies to confirm our results are warranted.

Meta-analyses involving cluster randomization trials: a review of published literature in health care

Throughout the 1980s and 1990s cluster randomization trials have been increasingly used to evaluate effectivenessof health care intervention. Such trials have raised several methodologic challenges in analysis. Meta-analyses involving cluster randomization trials are becoming common in the area of health care intervention. However, as yet there has been no empirical evidence of current practice in the meta-analyses. Thus a review was performed to identify and examine synthesis approaches of meta-analyses involving cluster randomization trials in the published literature. Electronic databases were searched for meta-analyses involving cluster randomization trials from the earliest date available to 2000. Once a meta-analysis was identified, papers on the relevant cluster randomization trials included were also requested. Each of the original papers of cluster randomization trials included was examined for its randomized design and unit, and adjustment for clustering effect in analysis. Each of the selected meta-analyses was then evaluated as to its synthesis concerning clustering effect. In total, 25 eligible meta-analyses were reviewed. Of these, 15 meta-analyses reported simple conventional methods of the fixed-effect model as method of analysis, while six did not incorporate the cluster randomization trial results in the synthesis methods but described the trial results individually. Three meta-analyses attempted to account for the clustering effect in the synthesis methods but approaches were in arbitrary. Fifteen meta-analyses included more than one cluster randomization trial, each of which included cluster randomization trials with a mixture of randomized designs and units, and units of analysis. These mixture situations might increase heterogeneity, but have not been considered in any meta-analysis. Some methods dealing with a binary outcome for some specific situations have been discussed. In conclusion, some difficulties in the quantitative synthesis procedures were found in the meta-analyses involving cluster randomization trials. Recommendations in the applications of approaches to some specific situations in a binary outcome variable have also been provided. There are still, however, several methodologic issues of the meta-analyses involving cluster randomization trials that need to be investigated further.

Long-term effect of a low-intensity smoking intervention embedded in an adherence program for patients with hypercholesterolemia: Randomized controlled trial

OBJECTIVE

We evaluated the long-term effect of a smoking intervention embedded in an adherence program in patients with an increased risk for cardiovascular disease.

METHOD

Secondary analysis of a randomized controlled trial: In 2002-2004, 8108 patients with hypercholesterolemia were enrolled from general practices in Germany. Patients received a 12-month adherence program and statin medication (intervention) or statin medication only (control). The program aimed to improve adherence to medication and lifestyle by educational material, mailings, and phone calls. Smoking was self-reported at baseline and every 6months during the 3-year follow-up.

RESULTS

In total, 7640 patients were analyzed. At baseline, smoking prevalence was 21.7% in the intervention and 21.5% in the control group. Prevalence decreased in both groups to 16.6% vs. 19.5%, 15.3% vs. 16.8%, and 14.2% vs. 15.6% at the 12-, 24-, and 36-month follow-up. The intervention had a beneficial effect on smoking differing over time (group×time: P=0.005). The effect was largest after 6 and 12months [odds ratios (95% confidence intervals): 0.67 (0.54-0.82) and 0.63 (0.51-0.78)]. The effect decreased until the 18-month follow-up [0.72 (0.58-0.90)] and was not significant after 24months.

CONCLUSION

A low-intensity smoking intervention embedded in an adherence program can contribute to smoking cessation although the intervention effect diminished over time.

TRIAL REGISTRATION

ClinicalTrials.gov (www.clinicaltrials.gov): NCT00379249.

The Effectiveness of a General-Practice-Based Physical Activity Intervention on Patient Physical Activity Status

Physical inactivity is a risk factor for a number of chronic diseases, including cardiovascular disease. Interventions designed to reduce the prevalence of physical inactivity have focused primarily on either adoption of physical activity or noncompliance and relapse, and no interventions have been reported which cover adoption, compliance, maintenance, and relapse, particularly within the clinical setting. TheFresh Startprogram, a multiple risk factor intervention program for the reduction of cardiovascular disease risk factors in general practice patients, was developed to cover all aspects of the adoption and maintenance of habitual physical activity, using Prochaska and DiClemente's Transtheoretical model. The evaluation of the program on cardiovascular disease risk factors and behaviours provided the opportunity to evaluate the impact of a staged program on patient physical activity behaviour. The program was evaluated in a randomised controlled trial in Sydney's Western, South-western, and Wentworth regions with 80 volunteer general practitioners and 758 volunteer patients between January 1991 and January 1993. Self-reported physical activity data were used as the basis for estimating energy expenditure due to leisure-time physical activity. The results failed to show any differences between groups over time, as a function of patients' baseline stages of change, and as a function of baseline activity levels. There were some indications, however, that the least active would respond to doctor-based advice to increase their physical activity, and that doctor advice would lead to a progression inintention to changein approximately 20% of patients. Limitations of the study, the program, and physical activity intervention in the clinical setting are discussed.

General Practitioners as Agents of Health Risk Behaviour Change: Opportunities for Behavioural Science in Patient Smoking Cessation

General practitioners have been suggested as occupying a position in the community that offers considerable potential for reducing the prevalence of health risk behaviours. Green, Eriksen, and Schor (1988) have proposed that if general practitioners are to effectively adopt a role in modifying patient health risk behaviours, a number of prerequisite conditions must be met. Using the model proposed by Green et al., this paper reviews the literature to describe the circumstances under which general practitioners currently practise this role. The review focuses on the circumstances relating to practitioner modification of one patient health risk behaviour: smoking. Research detailing the extent of practitioner involvement in the modification of this risk behaviour is also reviewed. The paper concludes by discussing the opportunities available for behavioural scientists to facilitate general practitioners' adoption of a role in patient smoking cessation.

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

BACKGROUND

A recent review concluded that general health checks fail to reduce mortality in adults.

AIM

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

DESIGN AND SETTING

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

METHOD

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

RESULTS

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were -0.13 mmol/l (95% confidence interval [CI] = -0.19 to -0.07), -3.65 mmHg (95% CI = -6.50 to -0.81), -1.79 mmHg (95% CI = -2.93 to -0.64), and -0.45 kg/m(2) (95% CI = -0.66 to -0.24), respectively. The odds of a patient remaining at 'high risk' with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

CONCLUSION

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Effectiveness of a national cardiovascular disease risk assessment program (NHS Health Check): results after one year

OBJECTIVE

We aimed to assess whether the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program, was associated with reduction in CVD risk in attendees after one year.

METHODS

We extracted data from patients aged 40-74 years, with high estimated CVD risk, who were registered with general practices in a deprived, culturally diverse setting in England. We included 4748 patients at baseline (July 2008-November 2009), with 3712 at follow-up (December 2009-March 2011). We used a pre-post study design to assess changes in global CVD risk, individual CVD risk factors and statin prescription in patients with a complete and partial Health Check.

RESULTS

There were significant reductions in mean CVD risk score (28.2%; 95% confidence interval (CI)=27.3-29.1 to 26.2%; 95% CI, 25.4-27.1), diastolic blood pressure, total cholesterol levels and lipid ratios after one year in patients with a complete Health Check. Statin prescription increased from 14.0% (95% CI=11.9-16.0) to 60.6% (95% CI=57.7-63.5).

CONCLUSIONS

The introduction of NHS Health Check was associated with significant but modest reductions in CVD risk among screened high-risk individuals. Further cost-effectiveness analysis and work accounting for uptake is required to assess whether the program can make significant changes to population health.

Layers of complexity in interpreting evidence on effectiveness

There has been growing attention to using evidence on effectiveness to guide public health and health improvement policies, strategies, programmes and actions 'on the ground'. However, there has been insufficient recognition of the complexity attached to interpreting such evidence and translating it into action. In this paper, a randomized controlled trial is used as an illustrative case study to uncover layers of that complexity. It is suggested that these layers should be taken into account in designing, executing, analysing and reporting primary evaluative studies and reviews; formulating recommendations for action; and developing more fully fit-for-purpose approaches to evidence-informed public health and health improvement.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm.

OBJECTIVES

We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.

MAIN RESULTS

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

AUTHORS' CONCLUSIONS

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

Background  Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives  This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy  A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria  This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results  Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions  While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Pharmacogenetics of smoking cessation in general practice: results from the patch II and patch in practice trials

INTRODUCTION

Cigarette smoking remains the leading cause of preventable death worldwide. However, the efficacy of available first-line therapies remains low, particularly in primary care practice where most smokers seek and receive treatment. These observations reinforce the notion that 'one size fits all' smoking cessation therapies may not be optimal. Therefore, a translational research effort was launched by the Imperial Cancer Research Fund (later Cancer Research UK) General Practice Research Group, who led a decade-long research enterprise that examined the influence of pharmacological hypothesis-driven research into genetic influences on drug response for smoking cessation with transdermal nicotine replacement therapy in general practice.

METHODS

New and previously published smoking cessation genetic association results of 30 candidate gene polymorphisms genotyped for participants in two transdermal nicotine replacement clinical trials based in UK general practices, which employed an intention to analyze approach.

RESULTS

By this high bar, one of the polymorphisms (COMT rs4680) was robust to correction for multiple comparisons. Moreover, future research directions are outlined; and lessons learned as well as best-practice models for designing, analyzing, and translating results into clinical practice are proposed.

CONCLUSIONS

The results and lessons learned from this general practice-based pharmacogenetic research programme provide transportable insights at the transition to the second generation of pharmacogenetic and genomic investigations of smoking cessation and its translation to primary care.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Multiple risk factor interventions using counselling and educational methods assumed to be efficacious and cost-effective in reducing coronary heart disease (CHD) mortality and morbidity and that they should be expanded. Trials examining risk factor changes have cast doubt on the effectiveness of these interventions.

OBJECTIVES

To assess the effects of multiple risk factor interventions for reducing total mortality, fatal and non-fatal events from CHD and cardiovascular risk factors among adults assumed to be without prior clinical evidence CHD..

SEARCH STRATEGY

We updated the original search BY SEARCHING CENTRAL (2006, Issue 2), MEDLINE (2000 to June 2006) and EMBASE (1998 to June 2006), and checking bibliographies.

SELECTION CRITERIA

Randomised controlled trials of more than six months duration using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups or specific risk factors (i.e. diabetes, hypertension, hyperlipidaemia, obesity).

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. We expressed categorical variables as odds ratios (OR) with 95% confidence intervals (CI). Where studies published subsequent follow-up data on mortality and event rates, we updated these data.

MAIN RESULTS

We found 55 trials (163,471 participants) with a median duration of 12 month follow up. Fourteen trials (139,256 participants) with reported clinical event endpoints, the pooled ORs for total and CHD mortality were 1.00 (95% CI 0.96 to 1.05) and 0.99 (95% CI 0.92 to 1.07), respectively. Total mortality and combined fatal and non-fatal cardiovascular events showed benefits from intervention when confined to trials involving people with hypertension (16 trials) and diabetes (5 trials): OR 0.78 (95% CI 0.68 to 0.89) and OR 0.71 (95% CI 0.61 to 0.83), respectively. Net changes (weighted mean differences) in systolic and diastolic blood pressure (53 trials) and blood cholesterol (50 trials) were -2.71 mmHg (95% CI -3.49 to -1.93), -2.13 mmHg (95% CI -2.67 to -1.58 ) and -0.24 mmol/l (95% CI -0.32 to -0.16), respectively. The OR for reduction in smoking prevalence (20 trials) was 0.87 (95% CI 0.75 to 1.00). Marked heterogeneity (I(2) > 85%) for all risk factor analyses was not explained by co-morbidities, allocation concealment, use of antihypertensive or cholesterol-lowering drugs, or by age of trial.

AUTHORS' CONCLUSIONS

Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.

Impact of informed-choice invitations on diabetes screening knowledge, attitude and intentions: an analogue study

Background

Despite concerns that facilitating informed choice would decrease diabetes screening uptake, 'informed choice' invitations that increased knowledge did not affect attendance (the DICISION trial). We explored possible reasons using data from an experimental analogue study undertaken to develop the invitations. We tested a model of the impact on knowledge, attitude and intentions of a diabetes screening invitation designed to facilitate informed choices.

Methods

417 men and women aged 40-69 recruited from town centres in the UK were randomised to receive either an invitation for diabetes screening designed to facilitate informed choice or a standard type of invitation. Knowledge of the invitation, attitude towards diabetes screening, and intention to attend for diabetes screening were assessed two weeks later.

Results

Attitude was a strong predictor of screening intentions (β = .64, p = .001). Knowledge added to the model but was a weak predictor of intentions (β = .13, p = .005). However, invitation type did not predict attitudes towards screening but did predict knowledge (β = -.45, p = .001), which mediated a small effect of invitation type on intention (indirect β = -.06, p = .017).

Conclusions

These findings may explain why information about the benefits and harms of screening did not reduce diabetes screening attendance in the DICISION trial.

Quit in general practice: a cluster randomised trial of enhanced in-practice support for smoking cessation

BACKGROUND

This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients.

METHODS/DESIGN

This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches.Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs.The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. Analysis of qualitative data on process outcomes will be based on thematic analysis.

DISCUSSION

High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice.

TRIAL REGISTRATION

ACTRN12609001040257.

Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): trial protocol

Background

Screening invitations have traditionally been brief, providing information only about population benefits. Presenting information about the limited individual benefits and potential harms of screening to inform choice may reduce attendance, particularly in the more socially deprived. At the same time, amongst those who attend, it might increase motivation to change behavior to reduce risks. This trial assesses the impact on attendance and motivation to change behavior of an invitation that facilitates informed choices about participating in diabetes screening in general practice. Three hypotheses are tested:

1. Attendance at screening for diabetes is lower following an informed choice compared with a standard invitation.

2. There is an interaction between the type of invitation and social deprivation: attendance following an informed choice compared with a standard invitation is lower in those who are more rather than less socially deprived.

3. Amongst those who attend for screening, intentions to change behavior to reduce risks of complications in those subsequently diagnosed with diabetes are stronger following an informed choice invitation compared with a standard invitation.

Method/Design

1500 people aged 40–69 years without known diabetes but at high risk are identified from four general practice registers in the east of England. 1200 participants are randomized by households to receive one of two invitations to attend for diabetes screening at their general practices. The intervention invitation is designed to facilitate informed choices, and comprises detailed information and a decision aid. A comparison invitation is based on those currently in use. Screening involves a finger-prick blood glucose test. The primary outcome is attendance for diabetes screening. The secondary outcome is intention to change health related behaviors in those attenders diagnosed with diabetes. A sample size of 1200 ensures 90% power to detect a 10% difference in attendance between arms, and in an estimated 780 attenders, 80% power to detect a 0.2 sd difference in intention between arms.

Discussion

The DICISION trial is a rigorous pragmatic denominator based clinical trial of an informed choice invitation to diabetes screening, which addresses some key limitations of previous trials.

Trial registration

Current Controlled Trials ISRCTN73125647

Health tests and health consultations reduced cardiovascular risk without psychological strain, increased healthcare utilization or increased costs. An overview of the results from a 5-year randomized trial in primary care. The Ebeltoft Health Promotion Project (EHPP)

BACKGROUND

Few randomized controlled trials (RCT) have evaluated health tests and health consultations in primary care with a long follow-up period. The Ebeltoft Health Promotion Project (EHPP) evaluated health tests and health consultations over a period of 5 years in the frame of a health technology assessment.

OBJECTIVE

To review the results of EHPP.

DESIGN

RCT with a control group answering questionnaires and two intervention groups having questionnaires, a comprehensive health test with written advice followed by either a normal consultation on demand or a planned 45 minutes patient-centred consultation.

SETTING

Primary care.

PARTICIPANTS

The target population was all 30-49 year old persons in the municipality of Ebeltoft, Denmark. Invitations were received by 2000 randomly selected persons.

INTERVENTION

A comprehensive biomedical health test including a cardiovascular risk score (CVRS) followed by written advice and health consultations.

MAIN OUTCOME MEASURES

Biomedical measures, psychological measures, healthcare contacts, life years gained, direct and total health costs.

RESULTS

At baseline 75% participated. During the 5 years 85% participated at least once. Elevated CVRS was found in 19% in the control group compared to 10% in the intervention groups (p<0.01) after 5 years. There were no measurable long term psychological reactions. Numbers of contacts to the healthcare system were not increased. Significantly better life expectancy was found without extra direct and total costs.

CONCLUSIONS

An offer of health tests and patient-centred health consultations to the middle-aged population can be cost-effective and may be considered in the fight against the increasing burden of lifestyle diseases.

Evaluation of an informed choice invitation for type 2 diabetes screening

OBJECTIVE

To evaluate an innovative invitation designed to facilitate informed choices for undergoing screening for type 2 diabetes.

METHODS

Four hundred and seventeen people aged 40-69 years (sex: F 53%/M 47%), without known diabetes, recruited from street locations. Participants were randomised to receive one of two hypothetical invitations for screening for type 2 diabetes; one based on General Medical Council guidelines and combined with a decisional balance sheet, the other a brief traditional invitation. Informed choice was assessed immediately after the invitation and 3 weeks later using measures of knowledge, attitudes and intentions.

RESULTS

Two weeks after receipt of the invitation, the proportion of informed choices was significantly higher among participants who received the informed choice invitation compared with those who received the traditional invitation (42.9% versus 11.2%; difference=31.7%, 95% CI: 22.5-40.5%; p<0.001). Mean knowledge scores were significantly higher after the receipt of the invitation designed to facilitate informed choices than after the traditional invitation (5.49 versus 3.90; t(405)=10.106, p<0.001). Intentions to participate in screening were unaffected by receipt of the informed choice invitation.

CONCLUSION

Compared with a traditional invitation, receipt of the invitation designed to facilitate informed choices increased the proportion of informed choices about type 2 diabetes screening attendance.

PRACTICE IMPLICATIONS

: Although the new invitation was associated with better knowledge of screening it had no differential effect on intention and its effect on attendance still requires evaluation.

Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature

BACKGROUND

Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms.

METHODS

We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers.

RESULTS

11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions.

CONCLUSION

Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in July 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed effect model and reported the outcome as a risk ratio (RR) with 95% confidence interval (CI).

MAIN RESULTS

Forty-two studies met the inclusion criteria. Thirty-one studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the likelihood of quitting (RR 1.28, 95% CI 1.18 to 1.38). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. In a subgroup analysis there was weaker evidence that lower intensity interventions were effective (RR 1.27, 95% CI 0.99 to 1.62). There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Nine studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow up.

Literature review of nursing practice in managing obesity in primary care: developments in the UK

AIMS AND OBJECTIVES

To review empirical studies reporting primary care nursing practice in relation to obesity management for adults in the UK; to place these in the context of policy and professional developments.

BACKGROUND

Obesity is recognized as a public health problem in many parts of the world. The UK has a well-developed system of primary care nursing with experience of initiatives to tackle obesity.

METHODS

Searches of electronic databases supplemented by hand-searching of identified leads and key journals. Data extracted and analysed following methods for an integrative literature review.

FINDINGS

Eleven empirical studies were reviewed. Obesity management developed as part of the role of general practice nurses after 1990. Nurses' role has been mainly in providing one-to-one support to within surgery or clinic consultations; and to a lesser extent group based support sessions. The interventions could be characterized as general oral advice about nutrition and lifestyle. There was no evidence of positive outcomes for patients from these interventions. In some contexts, oral advice extended to calorie deficit diets and more developed referral options about physical activity. Two studies examined outcomes of practice following attempts to implement evidence-based protocols. The evidence of outcomes from these is mixed. At best, perhaps 10% of patients entering a nurse led support programme may achieve a clinically significant weight loss.

CONCLUSIONS

There is potential in primary care nursing to help patients manage obesity but caution is needed. Despite practice developments in the UK the outcomes for patients remain unclear. RELEVANCE TO CLINICAL PRACTICE. It is important to follow a structured programme in supporting patients with weight loss within an holistic assessment of their needs.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Motivating for cancer prevention

Effective habit change usually requires a combination of psycho-educational, behavioural, and social learning strategies. Motivational interview and shared decision making are likely to be the most efficient approaches. Assessing the current motivation can be based on the transtheoretical model of change (TTM) with the goal to move from one behaviour to another healthier one. In a daily busy clinical practice, brief counselling interventions of one to three visits can substantially help patients change problematic behaviours, particularly in the areas of smoking cessation and exercise. The acronym FRAMES has been used to define the elements of an effective brief intervention which helps to trigger the patient motivation to change; giving Feedback based on a thorough assessment; helping the patient take Responsibility for changing; giving clear Advice on what behaviour must change; offering a Menu of options for making the change; expressing Empathy for the ambivalence and difficulty in making changes; enhancing Self-efficacy to foster commitment and confidence. This chapter reviews relevant aspects of clinician-patient communication with regard to cancer prevention, especially smoking cessation and exercise.

Nursing intervention and smoking cessation: meta-analysis update

OBJECTIVE

The study objective was to determine through meta-analysis the effects of nursing-delivered smoking-cessation interventions.

RESULTS

Thirty-four studies met inclusion criteria in this updated meta-analysis. Twenty-six studies compared a nursing intervention with a control or usual care group of adults and found interventions of high and low intensity to modestly increase the odds of quitting (1.36, 95% confidence interval 1.22-1.51). The study results demonstrated heterogeneity; using a random effects model did not make a difference. There was evidence that interventions were most effective for hospital inpatients with cardiovascular disease than for patients with other conditions (odds ratio 2.14, confidence interval 1.39-3.31). Interventions in nonhospitalized adults were beneficial as well; no effect was found for additive intervention components. Counseling during health-screening programs or as part of multifactorial secondary preventions programs was found to be the least effective. The challenge will be to incorporate smoking-cessation interventions into evidence-based nursing practice.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Primary prevention programmes in many countries attempt to reduce mortality and morbidity due to coronary heart disease (CHD) through risk factor modification. It is widely believed that multiple risk factor intervention using counselling and educational methods is efficacious and cost-effective and should be expanded. Recent trials examining risk factor changes have cast considerable doubt on the effectiveness of these multiple risk factor interventions.

OBJECTIVES

To assess the effects of multiple risk factor intervention for reducing cardiovascular risk factors, total mortality, and mortality from CHD among adults without clinical evidence of established cardiovascular disease.

SEARCH STRATEGY

MEDLINE was searched for the original review to 1995. This was updated by searching the Cochrane Central Register of Controlled Trials on The Cochrane Library Issue 3 2001, MEDLINE (2000 to September 2001) and EMBASE (1998 to September 2001).

SELECTION CRITERIA

Intervention studies using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups, or high risk groups. Trials of less than 6 months duration were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently. Investigators were contacted to obtain missing information.

MAIN RESULTS

A total of 39 trials were found of which ten reported clinical event data. In the ten trials with clinical event end-points, the pooled odds ratios for total and CHD mortality were 0.96 (95% confidence intervals (CI) 0.92 to 1.01) and 0.96 (95% CI 0.89 to 1.04) respectively. Net changes in systolic and diastolic blood pressure, and blood cholesterol were (weighted mean differences) -3.6 mmHg (95% CI -3.9 to -3.3 mmHg), -2.8 mmHg (95% CI -2.9 to -2.6 mmHg) and -0.07 mMol/l (95% CI -0.8 to -0.06 mMol/l) respectively. Odds of reduction in smoking prevalence was 20% (95% CI 8% to 31%). Statistical heterogeneity between the studies with respect to mortality and risk factor changes was due to trials focusing on hypertensive participants and those using considerable amounts of drug treatment.

AUTHORS' CONCLUSIONS

The pooled effects suggest multiple risk factor intervention has no effect on mortality. However, a small, but potentially important, benefit of treatment (about a 10% reduction in CHD mortality) may have been missed. Risk factor changes were relatively modest, were related to the amount of pharmacological treatment used, and in some cases may have been over-estimated because of regression to the mean effects, lack of intention to treat analyses, habituation to blood pressure measurement, and use of self-reports of smoking. Interventions using personal or family counselling and education with or without pharmacological treatments appear to be more effective at achieving risk factor reduction and consequent reductions in mortality in high risk hypertensive populations. The evidence suggests that such interventions have limited utility in the general population.

Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness

BACKGROUND

This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely.

METHODS

Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison.

RESULTS

Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service.

CONCLUSIONS

This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.

Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease

Objectives:Obesity and dyslipidemia are risk factors for ischemic heart disease, and prevention and treatment in primary care can reduce these risks. The objective of this cost-effectiveness analysis was to compare the costs and effects (in terms of life years gained) of providing nutritional counseling by a general practitioner (GP) or a dietician.

Methods:A total of 60 GPs, who accepted to participate, were randomized either to give nutritional counseling or to refer patients to a dietician for counseling. The life years gained was estimated using a Cox regression model. Costs were estimated on the basis of registered use of time (dieticians) or agreed salaries (GPs).

Results:The effect of nutritional counseling comparing GPs and dieticians is greatest when counseling is performed by a GP—0.0919 years versus 0.0274 years. These effects appear to be moderate, but they are significant. It is also proven that the GP group was the most cost-effective—the cost of gaining 1 extra life year was estimated to be 8,213 DKK compared with the dietician group, for which the incremental cost-effectiveness ratio was estimated to be 59,987 DKK.

Conclusions:The effects were moderate, but other studies of other patient groups and interventions report effects within the same magnitude. The GP group was the most cost-effective, but it must be concluded that both counseling strategies were relatively cost-effective. Even though the cost of gaining an extra life year was estimated to be 59,987 DKK in the dietician group, this might be an acceptable price.

Substitution of doctors by nurses in primary care

BACKGROUND

Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care.

OBJECTIVES

Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.

SEARCH STRATEGY

The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix).

SELECTION CRITERIA

Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes.

MAIN RESULTS

4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

AUTHORS' CONCLUSIONS

The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.

A randomized non-pharmacological intervention study for prevention of ischaemic heart disease: baseline results Inter99

BACKGROUND

Various strategies have been used to induce lifestyle changes to reduce ischaemic heart disease (IHD) with various successes. The aim of Inter99 is to assess the effect on IHD incidence of individually tailored non-pharmacological intervention on lifestyle using a newly developed computer-based health educational tool. The article describes the study and baseline results.

METHODS

From a population of 61,301 individuals two random samples (high intensity intervention group (A), n = 11,708; low intensity intervention group (B), n = 1308) are screened to assess their absolute risk of IHD. Those at high risk receive individual lifestyle counselling. Individuals in group A are furthermore offered lifestyle counselling in groups on smoking cessation or physical activity/diet over a 6-month period. Individuals in group B are referred to their GP. High-risk persons are re-counselled after 1 and 3 years and the whole group is re-invited after 5 years. The remaining 48,285 (group C) are followed by questionnaire. The total population is followed through central registers. Intermediate end-points are changes in lifestyle, cholesterol, blood pressure and body mass index. Final end-point is reduction in incidence of IHD.

RESULTS

The randomization leads to comparable groups. Participation rate was 52.5%. A total of 60% fulfilled the predetermined criteria for being at high risk for developing IHD. After an individual lifestyle counselling 41% accepted group-based counselling.

CONCLUSION

This large randomized population based trial discloses a noticeable need for and acceptance of lifestyle intervention in the general population.

Multiple behavioral risk factor interventions in primary care. Summary of research evidence

BACKGROUND

An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner.

METHODS

We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature.

RESULTS

There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care.

CONCLUSIONS

We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the "5A's" construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.

Nursing interventions for smoking cessation

BACKGROUND

Health care professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in June 2003.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently.

MAIN RESULTS

Twenty-nine studies met the inclusion criteria. Twenty studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the odds of quitting (Peto Odds Ratio 1.47, 95% CI 1.29 to 1.68). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. There was limited evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Five studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found the nursing intervention to have less effect under these conditions.

REVIEWER'S CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that interventions can be effective. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Lifestyle changes after a health dialogue. Results from the Live for Life health promotion programme

OBJECTIVE

To evaluate the effect of a health dialogue on lifestyle habits, and to relate the lifestyle changes to changes of biological risk markers for ischaemic heart disease.

DESIGN

Cross-sectional study, intervention and follow-up.

SETTING

The community of Habo, population 9500, located in Skaraborg, Sweden.

PATIENTS

All 35-year-old inhabitants in Habo were invited to a health examination during a study period between 1989 and 1992. A community intervention programme was combined with a health examination consisting of a health dialogue with a specially trained nurse and use of a "health curve" as an educational tool. The effect of the health examination was examined by comparing baseline characteristics of participants in 1989-1992 with their follow-up data in 1993.

RESULTS

Participants in the health dialogue who were re-examined reported lifestyle improvements including less smoking, decreased dietary fat intake and increased physical activity. Those who reported improved dietary intake and increased physical activity improved their biological risk markers correspondingly (body mass index, waist to hip ratio, serum cholesterol concentration).

CONCLUSIONS

The combination of a community and an individually based health programme can be effective with respect to lifestyle variables and, in those improving their lifestyle, in biological risk markers.

Is there a role for nurse-led blood pressure management in primary care?

Adequate treatment of high blood pressure reduces the risk of strokes and other cardiovascular events, but current treatment in UK general practice is often inadequate. Nurse-led management of people with high blood pressure could lead to improvements due to strict adherence to protocols, agreed target blood pressure, better prescribing and compliance, and regular follow-up. However, a review of the literature shows a lack of robust evidence of the effectiveness of nurse-led hypertension management in primary care. There is a clear need for randomized controlled trials to see if nurse-led management is associated with better blood pressure control than routine care.

Prevention and follow-up of cardiovascular disease among patients without a personal GP

OBJECTIVE

This paper describes the characteristics of Belgian people who declare that they have a personal GP (PGP) compared with those who do not. Furthermore, patterns of cardiovascular prevention and care are described for these two groups.

METHODS

The data are derived from the 1997 Belgian Health Interview Survey (HIS) in which a representative sample (n = 10 221) of the Belgian population was questioned. The HIS data about physical activity, food, blood pressure, cholesterol, cardiovascular diseases, diabetes and stroke are analysed.

RESULTS

After standardization for age and gender, 7.0% of the subjects declared that they did not have a PGP. The mean age of patients without a PGP (33.2 +/- 20.4 years) is significantly lower than for those with a PGP (40.4 +/- 22.7 years) (P < 0.001). More smokers (38.5% compared with 28.5%) were reported among the subjects without a PGP (P < 0.001). For 14.8% of the subjects without a PGP, their blood pressure had never been measured, and for 51.1% their cholesterol had never been measured (6.7% and 35.7%, respectively in subjects with a PGP). Among the subjects without a PGP, 3.8% had high blood pressure and 1.5% had a coronary heart disease. Among the hypertensive patients without a PGP, 43.6% are not treated by any physician.

CONCLUSION

Subjects without a PGP were less likely to have a healthy way of life. Having a PGP seemed to have a beneficial influence on the screening for and the follow-up of cardiovascular risk factors. However, it has never been confirmed that providing people who do not have a PGP with one would result in health improvements. In particular, cardiac patients without a PGP sought their medical treatment directly from specialists.

Assessment of analysis by gender in the Cochrane reviews as related to treatment of cardiovascular disease

BACKGROUND

Cardiovascular disease (CVD) is the leading killer of women in the United States, yet medical care is often based on evidence from clinical trials performed predominantly with men. Numerous studies show that CVD risk factors, clinical presentation, treatment, and treatment outcomes can vary between men and women.

METHODS

The Cochrane Library maintains a large database of critically appraised evidence including meta-analyses of clinical trials, called Systematic Reviews. There were 30 Systematic Reviews pertaining to the treatment of CVD published collectively by the Cochrane Heart Group, Hypertension Group, and Peripheral Vascular Diseases Groups at the time of our study. We examined these 30 Systematic Reviews and the great majority of the clinical trials used for their meta-analyses for inclusion of women and gender-based data analyses. Women comprised only 27% of the pooled population of 258 clinical trials.

RESULTS

Of those trials that included both men and women (n = 196), only 33% examined outcomes by gender. In trials that performed a gender-based analysis, 20% reported significant (p < 0.05) differences in cardiovascular-related outcomes by gender.

CONCLUSIONS

We conclude that (1) there are not enough large-scale clinical trials or meta-analyses concerning CVD in women to determine if their medical treatment should differ from that of men, (2) all clinical trials relating to CVD treatment should have significantly more female participants, and gender-based analyses should be performed, as currently recommended for National Institutes of Health (NIH)-sponsored research by the NIH Revitalization Act of 1993, and (3) the Cochrane Library would be a more useful tool for the evidence-based healthcare of women if the Systematic Reviews used all available gender-specific information in their analyses.

Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force

OBJECTIVE

The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings.

DESIGN AND DATA SOURCES

We conducted a MEDLINE search from 1966 to December 2001.

STUDY SELECTION

We included randomized controlled trials of at least 3 months' duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease.

DATA EXTRACTION

One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques.

DATA SYNTHESIS

We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes.

CONCLUSIONS

Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.