Effectiveness of a clinical practice guideline implementation strategy for patients with anxiety disorders in primary care: cluster randomized trial.

BACKGROUND: Anxiety is a common mental health problem seen in primary care. However, its management in clinical practice varies greatly. Clinical practice guidelines (CPGs) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit. However, uptake and adherence to their recommendations can be low. METHOD/DESIGN: This study involves a community based on cluster randomized trial in primary healthcare centres in the Madrid Region (Spain). The project aims to determine whether the use of implementation strategy (including training session, information, opinion leader, reminders, audit, and feed-back) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion. The number of patients required is 296 (148 in each arm), all older than 18 years and diagnosed with generalized anxiety disorder, panic disorder, and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). They are chosen by consecutive sampling. The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months. Secondary outcome variables include quality of life (EuroQol 5D), and degree of compliance with the CPG recommendations on treatment, information, and referrals to mental health services. Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. DISCUSSION: There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care. Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive. TRIAL REGISTRATION: ISRCTN: ISRCTN83365316.

[Cardiovascular risk stratification using the score scale on the European cardiovascular prevention risk day in health centres in the Madrid region]. / Estratificación del riesgo cardiovascular, según tabla SCORE, en el Día Europeo de la Prevención del Riesgo Cardiovascular en centros de salud de la comunidad de Madrid.

OBJECTIVE: To quantify the cardiovascular risk in a Primary Health Care population using the SCORE chart. METHOD: Multicenter, observational, descriptive study including 1324 health professionals (nurses, physicians, students, etc) employees of any of the eleven Madrid Region Health Areas in order to determinate the cardiovascular risk by the SCORE chart in subjects between 40 and 65 years that attended to their health centre in a voluntary way because of the European Day of Prevention of Cardiovascular Risk. RESULTS: A total of 5025 questionnaires were collected from 142 health centres, with 69.6% being completed by women. Mean age was 53.1 years (SD 7.4). A high SCORE was found in 4.1% of the population, a medium one in 3.9%, and low in 92.4%.. There were significant differences in the mean SCORE between men and women, with men having higher ones, P<.001 (95% CI, 0.9-1.1). The probability of men of having a medium/high SCORE was 10% higher than that of women P<.001 (95% CI, 6.2-12.3). Those with higher educational levels had lower SCORE results, P<.001 (95% CI, 1.1-0.5). Obese and over weight people had a 2.6 higher risk than those of normal weight, P<.001 (95% CI: 1.7-3.9). CONCLUSIONS: Cardiovascular risk is generally low in people who visit health centres. A Medium-high SCORE is more probable in men. Low educational level and overweight and obesity could be associated with a higher risk of being affected by a cardiovascular adverse event.

Effectiveness of an implementation strategy for a breastfeeding guideline in Primary Care: cluster randomised trial.

BACKGROUND: The protection and promotion of breastfeeding is considered a priority in Europe where only 22% of infants less than 6 months old are exclusively breastfed. In Spain this percentage reaches 24.8% but in our city it falls to 18.26%. Various studies emphasise that the improvement of these results should be based upon the training of health professionals. Following the recommendations of a breastfeeding guide can modify the practice of health professionals and improve results with respect to exclusively or predominatly breastfed children at 6 months of age. METHOD/DESIGN: This study involves a community based cluster randomized trial in primary healthcare centres in Leganés (Madrid, Spain). The project aims to determine whether the use of an implementation strategy (including training session, information distribution, opinion leader) of a breastfeeding guideline in primary care is more effective than usual diffusion. The number of patients required will be 240 (120 in each arm). It will be included all the mothers of infants born during the study period (6 months) who come to the health centre on the first visit of the child care programme and who give their consent to participate. The main outcome variable is the exclusive o predominant breastfeeding at 6 moths of age..Main effectiveness will be analyzed by comparing the percentage of infants with exclusive or predominant breastfeeding at 6 months between the intervention group and the control group. All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis. DISCUSSION: Strategies need to be found which facilitate the giving of effective advice on breastfeeding by professionals and which provide support to women during the breastfeeding period. By applying the guide's recommendations, clinical variability can be reduced and the care received by patients can be improved. TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov, number NCT01474096.