Secondary prevention of cardiovascular disease in different primary healthcare systems with and without pay-for-performance

Performance-Based Pay System and Job Stress Related to Depression/Anxiety in Korea: Analysis of Korea Working Condition Survey

The adoption rate of performance-based pay systems has increased in recent years, and the adverse effects of systems have been emphasized. However, no study has analyzed the increase in the risk of depression/anxiety symptoms caused by the pay system in Korea. This study aimed to reveal the association between performance-based pay systems and symptoms of depression/anxiety, using data from the fifth Korean Working Conditions Survey. Depressive/anxiety symptoms were assessed using "yes" or "no" questions regarding medical problems related to depression/anxiety. The performance-based pay system and job stress were estimated using self-response answers. Logistic regression analyses were conducted to determine the association between performance-based pay systems, job stress, and symptoms of depression/anxiety using data from 27,793 participants. The performance-based pay system significantly increased the risk of the symptoms. Additionally, risk increments were calculated after grouping by pay system and job stress. Workers with two risk factors had the highest risk of symptoms of depression/anxiety for both sexes (male: OR 3.05; 95% CI 1.70-5.45; female: OR 2.15; 95% CI 1.32-3.50), implying synergistic effect of performance-based pay system and job stress on depression/anxiety symptoms. Based on these findings, policies should be established for early detection and protection against the risk of depression/anxiety.

The multimorbidity collaborative medication review and decision making (MyComrade) study: a pilot cluster randomised trial in two healthcare systems

Background

While international guidelines recommend medication reviews as part of the management of multimorbidity, evidence on how to implement reviews in practice in primary care is lacking. The MyComrade (MultimorbiditY Collaborative Medication Review And Decision Making) intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care.

Aim

The pilot study aimed to assess the feasibility of a definitive trial of the MyComrade intervention across two healthcare systems (Republic of Ireland (ROI) and Northern Ireland (NI)).

Design

A pilot cluster-randomised controlled trial was conducted (clustered at general practice level), using specific progression criteria and a process evaluation framework.

Setting

General practices in the ROI and NI.

Participants

Eligible practices were those in defined geographical areas who had GP’s and Practice Based Pharmacists (PBP’s) (in NI) willing to conduct medication reviews. Eligible patients were those aged 18 years and over, with multi morbidity and on ten or more medications.

Intervention

The MyComrade intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care, using a planned collaborative approach guided by an agreed checklist, within a specified timeframe.

Outcome measures

Feasibility outcomes, using pre-determined progression criteria, assessed practice and patient recruitment and retention and intervention acceptability and fidelity. Anonymised patient-related quantitative data, from practice medical records and patient questionnaires were collected at baseline, 4 and 8 months, to inform potential outcome measures for a definitive trial. These included (i) practice outcomes—completion of medication reviews; (ii) patient outcomes—treatment burden and quality of life; (iii) prescribing outcomes—number and changes of prescribed medications and incidents of potentially inappropriate prescribing; and (iv) economic cost analysis. The framework Decision-making after Pilot and feasibility Trials (ADePT) in conjunction with a priori progression criteria and process evaluation was used to guide the collection and analysis of quantitative and qualitative data.

Results

The recruitment of practices (n = 15) and patients (n = 121, mean age 73 years and 51% female), representing 94% and 38% of a priori targets respectively, was more complex and took longer than anticipated; impacted by the global COVID-19 pandemic. Retention rates of 100% of practices and 85% of patients were achieved. Both practice staff and patients found the intervention acceptable and reported strong fidelity to the My Comrade intervention components. Some practice staff highlighted concerns such as poor communication of the reviews to patients, dissatisfaction regarding incentivisation and in ROI the sustainability of two GPs collaboratively conducting the medication reviews. Assessing outcomes from the collected data was found feasible and appropriate for a definitive trial. Two progression criteria met the ‘Go’ criterion (practice and patient retention), two met the ‘Amend’ criterion (practice recruitment and intervention implementation) and one indicated a ‘Stop – unless changes possible’ (patient recruitment).

Conclusion

The MyComrade intervention was found to be feasible to conduct within two different healthcare systems. Recruitment of participants requires significant time and effort given the nature of this population and the pairing of GP and pharmacist may be more sustainable to implement in routine practice.

Trial registration

Registry: ISRCTN, ISRCTN80017020; date of confirmation 4/11/2019; retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01107-y.

The MultimorbiditY COllaborative Medication Review And DEcision Making (MyComrade) study: a protocol for a cross-border pilot cluster randomised controlled trial

Background

While international guidelines recommend medication reviews as part of the management of multimorbidity, evidence on how to implement reviews in practice in primary care is lacking. The MultimorbiditY Collaborative Medication Review And Decision Making (MyComrade) intervention is an evidence-based, theoretically informed novel intervention which aims to support the conduct of medication reviews for patients with multimorbidity in primary care. Our aim in this pilot study is to evaluate the feasibility of a trial of the intervention with unique modifications accounting for contextual variations in two neighbouring health systems (Republic of Ireland (ROI) and Northern Ireland (NI)).

Methods

A pilot cluster randomised controlled trial will be conducted, using a mixed-methods process evaluation to investigate the feasibility of a trial of the MyComrade intervention based on pre-defined progression criteria. A total of 16 practices will be recruited (eight in ROI; eight in NI), and four practices in each jurisdiction will be randomly allocated to intervention or control. Twenty people living with multimorbidity and prescribed ≥ 10 repeat medications will be recruited from each practice prior to practice randomisation. In intervention practices, the MyComrade intervention will be delivered by pairs of general practitioners (GPs) in ROI, and a GP and practice-based pharmacist (PBP) in NI. The GPs/GP and PBP will schedule the time to review the medications together using a checklist. Usual care will proceed in practices in the control arm. Data will be collected via electronic health records and postal questionnaires at recruitment and 4 and 8 months after randomisation. Qualitative interviews to assess the feasibility and acceptability of the intervention and explore experiences related to multimorbidity management will be conducted with a purposive sample of GPs, PBPs, practice administration staff and patients in intervention and control practices. The feasibility of conducting a health economic evaluation as part of a future definitive trial will be assessed.

Discussion

The findings of this pilot study will assess the feasibility of a trial of the MyComrade intervention in two different health systems. Evaluation of the progression criteria will guide the decision to progress to a definitive trial and inform trial design. The findings will also contribute to the growing evidence-base related to intervention development and feasibility studies.

Trial registration

ISRCTN Registry, ISRCTN80017020. Date of confirmation is 4/11/2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01018-y.

An external pilot cluster randomised controlled trial of a theory-based intervention to improve appropriate polypharmacy in older people in primary care (PolyPrime): study protocol

BACKGROUND

The use of multiple medications (polypharmacy) is a concern in older people (≥65 years) and is associated with negative health outcomes. For older populations with multimorbidity, polypharmacy is the reality and the key challenge is ensuring appropriate polypharmacy (as opposed to inappropriate polypharmacy). This external pilot cluster randomised controlled trial (cRCT) aims to further test a theory-based intervention to improve appropriate polypharmacy in older people in primary care in two jurisdictions, Northern Ireland (NI) and the Republic of Ireland (ROI).

METHODS

Twelve GP practices across NI (n=6) and the six counties in the ROI that border NI will be randomised to either the intervention or usual care group. Members of the research team have developed an intervention to improve appropriate polypharmacy in older people in primary care using the Theoretical Domains Framework of behaviour change. The intervention consists of two components: (1) an online video which demonstrates how a GP may prescribe appropriate polypharmacy during a consultation with an older patient and (2) a patient recall process, whereby patients are invited to scheduled medication review consultations with GPs. Ten older patients receiving polypharmacy (≥4 medications) will be recruited per GP practice (n=120). GP practices allocated to the intervention arm will be asked to watch the online video and schedule medication reviews with patients on two occasions; an initial and a 6-month follow-up appointment. GP practices allocated to the control arm will continue to provide usual care to patients. The study will assess the feasibility of recruitment, retention and study procedures including collecting data on medication appropriateness (from GP records), quality of life and health service use (i.e. hospitalisations). An embedded process evaluation will assess intervention fidelity (i.e. was the intervention delivered as intended), acceptability of the intervention and potential mechanisms of action.

DISCUSSION

This pilot cRCT will provide evidence of the feasibility of a range of study parameters such as recruitment and retention, data collection procedures and the acceptability of the intervention. Pre-specified progression criteria will also be used to determine whether or not to proceed to a definitive cRCT.

TRIAL REGISTRATION

ISRCTN, ISRCTN41009897 . Registered 19 November 2019. ClinicalTrials.gov, NCT04181879 . Registered 02 December 2019.

A comparison, for older people with diabetes, of health and health care utilisation in two different health systems on the island of Ireland

Background

There are social and economic differences between Northern Ireland (NI) and the Republic of Ireland (ROI). There are also differences in the health care systems in the two jurisdictions. The aims of this study are to compare health (prevalence of diabetes and related complications) and health care utilisation (general practitioner, outpatient or accident and emergency utilisation) among older people with diabetes in the NI and ROI.

Methods

Large scale comparable surveys of people over 50 years of age in Northern Ireland (NICOLA, wave 1) and the Republic of Ireland (TILDA, wave 1) are used to compare people with diabetes (type I and type II) in the two jurisdictions. The combined data set comprises 1536 people with diabetes. A coarsened exact matching approach is used to compare health care utilisation among people with diabetes in NI and ROI with equivalent demographic, lifestyle and illness characteristics (age, gender, education, smoking status and self-related health, number of other chronic diseases and number of diabetic complications).

Results

The overall prevalence of diabetes in the 50 to 84 years old age group is 3.4 percentage points higher in NI (11.1% in NI, 7.7% ROI, p-value < 0.01). The diabetic population in NI appear sicker – with more diabetic complications and more chronic illnesses. Comparing people with diabetes in the two jurisdictions with similar levels of illness we find that there are no statistically significant differences in GP, outpatient or A&E utilisation.

Conclusion

Despite the proximity of NI and ROI there are substantial differences in the prevalence of diabetes and its related complications. Despite differences in the health services in the two jurisdictions the differences in health care utilisation for an equivalent cohort are small.

The effectiveness of a pay for performance program on diabetes care in Taiwan: A nationwide population-based longitudinal study

Over the past two decades, studies have widely examined the effectiveness of pay-for-performance (P4P) programs by conducting biochemical tests and assessing complications; however, the reported effectiveness of such programs among participants selected through purposeful sampling is controversial. Therefore, the objective of the current study was to analyze the effectiveness of a P4P program on patients' prognoses, including hospitalization for chronic diabetic complications, and all-cause mortality during specific follow-up years by using a nationwide population-based database in Taiwan. Based on 125,315 newly diagnosed type 2 diabetes patient cohort during 2002-2006, two control sets were designed by propensity-score-matching strategy according to participation of P4P program and followed up to 2012. The results indicated that full participants demonstrated the lowest risks of developing complications and all-cause mortality compared with nonparticipants. These findings confirm the long-term effect of P4P programs on full participants and reveal that this effect is not due to confounding variables. The results indicate the importance of performance management and adherence to interventions for patients with chronic diseases in a long-term observation. Comprehensive and continuous care is suggested to improve patient prognosis and quality of care.

Long-Term and Interactive Effects of Pay-For-Performance Interventions among Diabetic Nephropathy Patients at the Early Chronic Kidney Disease Stage

Chronic kidney disease (CKD) is a major health problem worldwide because of the aging population and lifestyle changes. One of the important etiologies of CKD is diabetes mellitus (DM). The long-term effects of pay-for-performance (P4P) on disease progression have not been thoroughly examined.This study is a retrospective population-based patient cohort design to examine the continuous effects of diabetes and CKD P4P interventions. This study used the health insurance claims database to conduct a longitudinal analysis. A total of 32,084 early CKD patients with diabetes were extracted from the outpatient claims database from January 2011 to December 2012, and the follow-up period was extended to August 2014. A 4-group matching design, including both diabetes and early CKD P4P interventions, with only diabetes P4P intervention, with only early CKD P4P intervention, and without any P4P interventions, was performed according to their descending intensity. The primary outcome of this study was all-cause mortality and the causes of death. The statistical methods included a Chi-squared test, ANOVA, and multi-variable Cox regression models.A dose-response relationship between the intervention groups and all-cause mortality was observed as follows: comparing to both diabetes and early CKD P4P interventions (reference), hazard ratio (HR) was 1.22 (95% confidence interval [CI], 1.00-1.50) for patients with only a diabetes P4P intervention; HR was 2.00 (95% CI, 1.66-2.42) for patients with only an early CKD P4P intervention; and HR was 2.42 (95% CI, 2.02-2.91) for patients without any P4P interventions. The leading cause of death of the total diabetic nephropathy patient cohort was infectious diseases (34.32%) followed by cardiovascular diseases (17.12%), acute renal failure (1.50%), and malignant neoplasm of liver (1.40%).Because the earlier interventions have lasting long-term effects on the patient's prognosis regardless of disease course, an integrated early intervention plan is suggested in future care plan designs. The mechanisms regarding the effects of P4P intervention, such as health education on diet control, continuity of care, and practice guidelines and adherence, are the primary components of disease management programs.

Impact of pay for performance on behavior of primary care physicians and patient outcomes

BACKGROUND AND OBJECTIVES

Pay-for-performance is a financial incentive which links physicians' income to the quality of their services. Although pay-for-performance is suggested to be an effective payment method in many pilot countries (ie the UK) and enjoys a wide application in primary health care, researches on it are yet to reach an agreement. Thus, a systematic review was conducted on the evidence of impact of pay-for-performance on behavior of primary care physicians and patient outcomes aiming to provide a comprehensive and objective evaluation of pay-for-performance for decision-makers.

METHODS

Studies were identified by searching PubMed, EMbase, and The Cochrane Library. Electronic search was conducted in the fourth week of January 2013. As the included studies had significant clinical heterogeneity, a descriptive analysis was conducted. Quality Index was adopted for quality assessment of evidences.

RESULTS

Database searches yielded 651 candidate articles, of which 44 studies fulfilled the inclusion criteria. An overall positive effect was found on the management of disease, which varied in accordance with the baseline medical quality and the practice size. Meanwhile, it could bring about new problems regarding the inequity, patients' dissatisfaction and increasing medical cost.

CONCLUSIONS

Decision-makers should consider the baseline conditions of medical quality and the practice size before new medical policies are enacted. Furthermore, most studies are retrospective and observational with high level of heterogeneity though, the descriptive analysis is still of significance.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

Impact of pay-for-performance on management of diabetes: a systematic review

OBJECTIVES

To review and synthesize published evidence of pay-for-performance (P4P) effects on management of diabetes.

METHODS

Databases including Ovid MEDLINE, EMbase, PubMed, The Cochrane Library (Issue 3, 2012) were comprehensively searched for the effects of P4P programs in terms of patient outcomes and physician behaviors. Studies covering detailed data were included and synthesized. The quality of the body of evidence for each quality indicator was determined using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Among 742 identified articles, 12 interrupted time series studies, 7 controlled before-after studies, and 2 cross-sectional studies were included. Additionally, 12 studies were further included for quantitative analysis. Results of meta-analysis showed that P4P produced generally positive effects in most indicators (eg, patients with records of total cholesterol or blood pressure). However, these results were inconsistent. The percentage of patients with HbA1c ≤ 7% or 53 mmol/mol showed a pooled odds ratio of 0.98 in patients, but a pooled mean difference of 19.71% in the physician groups. The odds ratios of receiving tests/reaching an outcome level were also diverse in patients (odds ratios ranged from 0.98 to 3.32). Besides, process indicators had higher rates of improvement than outcome indicators.

CONCLUSIONS

P4P programs have variable impacts on patient outcomes of diabetes as well as physician behaviors, with various effects from negligible to strongly beneficial. Considering the low quality of the included studies, this conclusion should be cautiously interpreted.

Modelling Coronary Heart Disease Mortality declines in the Republic of Ireland, 1985-2006

BACKGROUND

Consistent declines in coronary heart disease (CHD) death rates have been previously observed in Ireland since 1985.

AIMS & METHODS

To use the previously validated Irish IMPACT CHD mortality model to further examine the subsequent CHD mortality falls from 1985 through to 2006, and to determine the contribution of risk factor changes and "evidence based" treatments to this decline by age and gender.

RESULTS

CHD mortality rates fell by 68% in men (63% in 65-84 years) and by 69% in women (66% in 65-84 years). This resulted in approximately 6450 fewer CHD deaths than if mortality rates had not changed. Overall, approximately 40% (38% in men; 45% in women) of the CHD mortality decline could be attributed to improvements in treatment uptake, particularly secondary prevention (12%), angina (9%), and heart failure therapies (8%). Approximately 48% of the CHD mortality decline was attributable to risk factor improvements (54% in men; 37% in women); the biggest contributions came from falls in population systolic pressure (28%), cholesterol (24%), and physical inactivity levels (10%). Negative trends in diabetes and obesity levels generated an estimated 17% additional CHD deaths. The largest benefits from improvements in risk factors were seen in men aged 25-64 years, while the greatest treatment benefits occurred in women aged 65-84 years. The model explained approximately 88% of the observed mortality declines.

CONCLUSION

Falls in CHD mortality have continued in both sexes in Ireland, but with notable gender and age differences. The continued increase in diabetes and obesity levels is particularly worrying.

Predictors of adherence to performance measures in patients with acute myocardial infarction

BACKGROUND

There have been substantial improvements in the use of evidence-based, guideline-recommended therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine those factors associated with lessened adherence to guideline-based care.

METHODS

The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for all measures, in eligible patients.

RESULTS

We identified 10 variables that were associated significantly with either greater adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model. Age, sex, and calendar year were significant in all models.

CONCLUSIONS

Use of evidence-based acute myocardial infarction treatments remains less than ideal for certain high-risk populations. The close correlations among factors associated with underperformance highlights the potential for specifically targeting and tailoring quality improvement interventions.

Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review

PURPOSE

Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care.

METHODS

Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review.

RESULTS

Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience.

CONCLUSIONS

Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.

Modelling coronary heart disease mortality in Northern Ireland between 1987 and 2007: broader lessons for prevention

AIMS

To quantify how much of the coronary heart disease (CHD) mortality decline in Northern Ireland between 1987 and 2007 could be attributed to medical and surgical treatments and how much to changes in population cardiovascular risk factors.

METHODS AND RESULTS

The IMPACT mortality model was used to integrate data on uptake and effectiveness of cardiological treatments and risk factor trends in the Northern Ireland population between 1987 and 2007. The main data sources were official population and mortality statistics, hospital administration systems, primary care datasets, published trials and meta-analyses, clinical audits, and national surveys. Between 1987 and 2007, CHD mortality rates in Northern Ireland decreased by 52% in men and 60% in women aged 25-84 years. This resulted in 3180 fewer deaths in 2007 than expected if 1987 mortality rates had persisted. Approximately 35% of this decrease was attributed to increased uptake of treatments in individuals and 60% to population risk factor reductions (principally blood pressure, total cholesterol, and smoking); however, these reductions were partially offset by adverse trends in diabetes, physical inactivity, and obesity.

CONCLUSION

Approximately 60% of the substantial CHD mortality decline in Northern Ireland between 1987 and 2007 was attributable to major cardiovascular risk factor changes and approximately 35% was attributable to treatments. However, adverse trends in diabetes, obesity, and physical inactivity are of major concern.

Translating policy into practice: a case study in the secondary prevention of coronary heart disease

BACKGROUND

This paper focuses on the relationships between health 'policy' as it is embodied in official documentation, and health 'practice' as reported and reflected on in the talk of policy-makers, health professionals and patients. The specific context for the study involves a comparison of policies relating to the secondary prevention of coronary heart disease (CHD) in the two jurisdictions of Ireland - involving as they do a predominantly state funded (National Health Service) system in the north and a mixed health-care economy in the south. The key question is to determine how the detail of health policy as contained in policy documents connects to and gets translated into practice and action.

METHODS

The data sources for the study include relevant health-care policy documents (N=5) and progress reports (N=6) in the two Irish jurisdictions, and semi-structured interviews with a range of policy-makers (N=28), practice nurses (14), general practitioners (12) and patients (13) to explore their awareness of the documents' contents and how they saw the impact of 'policy' on primary care practice.

RESULTS

The findings suggest that although strategic policy documents can be useful for highlighting and channelling attention to health issues that require concerted action, they have little impact on what either professionals or lay people do.

CONCLUSION

To influence the latter and to encourage a systematic approach to the delivery of health care it seems likely that contractual arrangements - specifying tasks to be undertaken and methods for monitoring and reporting on activity - are required.

Confidence and quality in managing CKD compared with other cardiovascular diseases and diabetes mellitus: a linked study of questionnaire and routine primary care data

Background

Much of chronic disease is managed in primary care and chronic kidney disease (CKD) is a recent addition. We are conducting a cluster randomised study of quality improvement interventions in CKD (QICKD) - Clinical Trials Registration: ISRCTN56023731. CKD registers have a lower than expected prevalence and an initial focus group study suggested variable levels of confidence in managing CKD.

Our objective is to compare practitioner confidence and achievement of quality indicators for CKD with hypertension and diabetes.

Method

We validated a new questionnaire to test confidence. We compared confidence with achievement of pay-for-performance indicators (P4P) and implementation of evidence-based guidance. We achieved a 74% (148/201) response rate.

Results

87% (n = 128) of respondents are confident in managing hypertension (HT) compared with 59% (n = 87) in managing HT in CKD (HT+CKD); and with 61% (n = 90) in HT, CKD and diabetes (CKD+HT+DM).

85.2% (P4P) and 62.5% (National targets) of patients with hypertension are at target; in patients with HT and CKD 65.1% and 53.3%; in patients with HT, CKD and DM 67.8% and 29.6%.

Confidence in managing proteinuria in CKD is low (42%, n = 62). 87% of respondents knew BP treatment thresholds in CKD, but only 53% when proteinuria is factored in. Male GPs, younger (< 35 yrs), and older (> 54 yrs) clinicians are more confident than females and 35 to 54 year olds in managing CKD.

84% of patients with hypertension treated with angiotensin modulating drugs achieve achieved P4P targets compared to 67% of patients with CKD.

Conclusions

Practitioners are less likely to achieve management targets where their confidence is low.

Cardiac rehabilitation uptake following myocardial infarction: cross-sectional study in primary care

BACKGROUND

Policies suggest that primary care should be more involved in delivering cardiac rehabilitation. However, there is a lack of information about what is known in primary care regarding patients' invitation or attendance.

AIM

To determine, within primary care, how many patients are invited to and attend rehabilitation after myocardial infarction (MI), examine sociodemographic factors related to invitation, and compare quality of life between those who do and do not attend.

DESIGN OF STUDY

Review of primary care paper and computer records; cross-sectional questionnaire.

SETTING

Northern Ireland general practices (38); stratified sample, based on practice size and health board area.

METHOD

Patients, identified from primary care records, 12-16 weeks after a confirmed diagnosis of MI, were posted questionnaires, including a validated MacNew post-MI quality-of-life questionnaire. Practices returned anonymised data for non-responders.

RESULTS

Information about rehabilitation was available for 332 of the 432 patients identified (76.9%): 162 (37.5%) returned questionnaires. Of the total sample, 54.4% (235/432) were invited and 37.0% (160/432) attended; of those invited, 68.1% (160/235) attended. Invited patients were younger than those not invited (mean age 63 years [standard deviation SD 16] versus 68.5 years [SD 16]); mean difference 5.5 years (95% confidence interval [CI] = 1.7 to 9.3). Among questionnaire responders, those who attended were younger and reported better emotional, physical, and social functioning than non-attenders (P = 0.01; mean differences 0.44 (95% CI = 0.11 to 0.77), 0.48 (95% CI = 0.10 to 0.85) and 0.54 (95% CI = 0.15 to 0.94) respectively).

CONCLUSION

Innovative strategies are needed to improve cardiac rehabilitation uptake, integration of hospital and primary care services, and healthcare professionals' awareness of patients' potential for health gain after MI.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

Objectives: The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland.

Methods: Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care.

Results: The intervention strategy resulted in mean cost savings per patient of €512.77 (95 percent confidence interval [CI], −1086.46–91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, −0.0101–0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay €45,000 per additional QALY.

Conclusions: Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice.

[Costs of health. Costs-effectiveness in case of lifestyle changes]

Economical burden for the individuals and for the national budgets of chronic cardio-vasculo-metabolic diseases is high and is rapidly increasing. Costs of treatments and prevention are very different in countries of diverse culture, ethnicity, social-economical situations, but prevention with healthy foods and with adequate physical activity are cheaper than medicines anywhere in the world. A great couple of studies approved cost-effectiveness of interventions directed to the change of life style factors. Cheaper is to influence the whole, yet healthy population, but interventions on people with high risk are more target-specific and usually more expensive. Enhanced physical activity (minimum 30 minutes five times per week with low-medium intensity, plus resistance exercises for maintain the muscle mass and force, plus stretching and calisthenics to maintain joints motility) can be promoted by few hundred-few ten hundred euros or dollars. Price of gain in Quality/Disability-Adjusted Life Years expressed as Incremental Cost Effectiveness/Utility Ratio is known, estimated or modelled, and offers a good value of money.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.

OBJECTIVES

To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.

SEARCH STRATEGY

For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.

MAIN RESULTS

We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

OBJECTIVE

To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease.

DESIGN

Cluster randomised controlled multicentre trial.

SETTING

General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems.

PARTICIPANTS

903 patients with established coronary heart disease registered with one of 48 practices.

INTERVENTION

Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care.

MAIN OUTCOME MEASURES

The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12).

RESULTS

At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03).

CONCLUSIONS

Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24081411.