Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice.

OBJECTIVE: To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care. DESIGN: Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years. SETTING: 124 general practices in The Netherlands. PARTICIPANTS: 185 GPs. MAIN OUTCOME MEASURES: Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs. RESULTS: The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention. CONCLUSIONS: Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development.

Blood pressure control in treated hypertensive patients: clinical performance of general practitioners.

BACKGROUND: The blood pressure of many treated hypertensive patients remains above recommended target levels. This discrepancy may be related to general practitioners' (GPs') actions. AIM: To assess clinical performance of GPs in blood pressure control in treated hypertensive patients and to explore the influence of patient and GP characteristics on clinical performance. DESIGN OF STUDY: Cross-sectional study conducted on 195 GPs with invitations to participate made via bulletins and by letter. SETTING: One hundred and thirty-two practices in the southern half of The Netherlands from November 1996 to April 1997. METHOD: Performance criteria were selected from Dutch national hypertension guidelines for general practice. GPs completed self-report forms immediately after follow-up visits of hypertensive patients treated with antihypertensive medication. RESULTS: The GPs recorded 3526 follow-up visits. In 63% of these consultations the diastolic blood pressure (DBP) was 90 mmHg or above. The median performance rates of the GPs were less than 51% for most of the recommended actions, even at a DBP of > or = 100 mmHg. Performance of non-pharmacological actions increased gradually with increasing DBP; prescribing an increase in antihypertensive medication and making a follow-up appointment scheduled within six weeks rose steeply at a DBP of > or = 100 mmHg. Patient and GP characteristics contributed little to clinical performance. Action performance rates varied considerably between GPs. CONCLUSION: GPs seem to target their actions at a DBP of below 100 mmHg, whereas guidelines recommend targeting at a DBP of below 90 mmHg.

Health perception of patients after cardiovascular risk detection and after intervention in general practice.

BACKGROUND. To explore unfavorable effects, health perception was assessed in patients enrolled in a cardiovascular program in general practice. METHODS. A prospective questionnaire survey was conducted shortly after risk detection and after 1 year of intervention. Patients (n=413) with an elevated risk were selected from 27 practices in The Netherlands. The outcome measure was patients' perceptions of their general health status. RESULTS. The response rate was 62%. Two thirds of the patients did not show any change in general health status at either point in time. Substantially more patients showed improvement after 1 year of intervention. Compared to reference data, no major differences were found. CONCLUSION. Enrollment in a cardiovascular risk detection and intervention program did not lead to unfavorable perceptions of general health status, either shortly after risk detection or after 1 year of intervention. (c) 2001 by CHF, Inc.

Cardiovascular risk detection and intervention in general practice: the patients' views.

OBJECTIVE: To assess patients' views on the organization of (cardiovascular) preventive care. DESIGN: Prospective questionnaire survey with measurements shortly after risk assessment (T1) and after 1 year of risk intervention (T2). SETTING: Twenty-seven general practices participating in a project to enhance systematic cardiovascular disease prevention in two regions in The Netherlands. STUDY PARTICIPANTS: Two-hundred and ninety-eight successive patients aged 30-60 years identified with an elevated cardiovascular risk. MAIN OUTCOME MEASURES: Organizational aspects such as the acceptability of the care provider, practicality of special clinics, accessibility of the practice for routine care. RESULTS: Most of the respondents (74%) had no preference for a care provider in cardiovascular preventive care and only a few patients (3%) reported having little confidence in the expertise of the practice assistant to provide such care. The vast majority (88%) considered special preventive clinics to be practical, especially at T1. Most of the respondents (76%) did not report a decline in the accessibility of their practice for routine care. These outcome measures were not affected by age, sex, educational level or the number of risk factors measured during 1 year of risk intervention. CONCLUSION: Most patients did not have any major objections against the organization of preventive care through opportunistic case finding and risk monitoring in special preventive clinics managed by the practice assistant.

Tailored outreach visits as a method for implementing guidelines and improving preventive care.

OBJECTIVES: Authors of successful outreach visit studies stress the importance of tailoring the intervention to the unique attributes and needs of each practice. For a better understanding of the outreach visit method, the tailoring mechanism is explored in this article. The variation among practices in preventive outreach visits to implement guidelines and characteristics that determine the variation (baseline adherence to organizational guidelines, practice and visitor characteristics) are described. We explored whether and how many visits were paid to practices that showed no increase in adherence to guidelines. SETTING AND STUDY PARTICIPANTS: For 18 months, six trained nurse visitors assisted 33 family practices in implementing a set of guidelines to organize a program for cardiovascular disease prevention. MEASURES: Visit and consultative action parameters (number and duration of visits, duration of training and of conferring) and increase in adherence to organizational guidelines after 18 months of assistance compared to baseline adherence. RESULTS: Practices differed considerably concerning the visit and consultative action parameters. Exploratory multiple regression analysis showed that baseline adherence to guidelines, and practice and visitor characteristics were related to the number of visits. Visitor characteristics were strongly related to the total time spent on visits, training, and conferring. DISCUSSION: Our findings confirm that, concerning the number of visits, assistance is primarily adapted to the unique attributes of each clinic. It may be useful, from the viewpoint of cost-effectiveness, to standardize the performance of visitors somewhat more with regard to the visit length. The tailoring mechanism resulted in time well spent in assisting practices. We hope that our results contribute to the further development of the outreach method.

Relationship between practice organization and cardiovascular risk factor recording in general practice.

BACKGROUND: Research findings suggest that the level of cardiovascular risk factor recording in general practice is not yet optimal. Several studies indicate a relation between the organization of cardiovascular disease prevention at practice level and cardiovascular risk factor recording. AIM: To explore the relation between the organization of cardiovascular disease prevention and risk factor recording in general practice. METHOD: A cross-sectional study was conducted using data on adherence to selected practice guidelines and on cardiovascular risk factor recording from 95 general practices. Practice guidelines were developed beforehand in a consensus procedure. Adherence was assessed by means of a questionnaire and practice observations. Risk factor recording was assessed by an audit of 50 medical records per practice. RESULTS: Factor analysis of risk factor recording revealed three dimensions explaining 76% of the variance: recording of health-related behaviour, recording of clinical parameters, and recording of medical background parameters. Adherence to the guideline 'proactively invite patients to attend for assessment of cardiovascular risk' was related to a higher recording level in all three dimensions. Practice characteristics did not show a consistent relationship to the level of risk factor recording. CONCLUSION: This study indicates that the presence of a system of proactive invitation was related to the recording of cardiovascular risk factors in medical records in general practice.

Changing preventive practice: a controlled trial on the effects of outreach visits to organise prevention of cardiovascular disease.

OBJECTIVES: To assess the effects of outreach visits by trained nurse facilitators on the organisation of services used to prevent cardiovascular disease. To identify the characteristics of general practices that determined success. DESIGN: A non-randomised controlled trial of two methods of implementing guidelines to organise prevention of cardiovascular disease: an innovative outreach visit method compared with a feedback method. The results in both groups were compared with data from a control group. SETTING AND SUBJECTS: 95 general practices in two regions in The Netherlands. INTERVENTIONS: Trained nurse facilitators visited practices, focusing on solving problems in the organisation of prevention. They applied a four step model in each practice. The number of visits depended on the needs of the practice team. The feedback method consisted of the provision of a feedback report with advice specific to each practice and standardised instructions. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 different guidelines. Guidelines were on the detection of patients at risk, their follow up, the registration of preventive activities, and teamwork within the practice. RESULTS: Outreach visits were more effective than feedback in implementing guidelines to organise prevention. Within the group with outreach visits, the increase in the number of practices adhering to the guidelines was significant for six out of 10 guidelines. Within the feedback group, a comparison of data before and after intervention showed no significant differences. Partnerships and practices with a computer changed more. CONCLUSION: Outreach visits by trained nurse facilitators proved to be effective in implementing guidelines within general practices, probably because their help was practical and designed for the individual practice, guided by the wishes and capabilities of the practice team.

Barriers to preventive care in general practice: the role of organizational and attitudinal factors.

BACKGROUND: There are numerous barriers to preventive care. In this paper we focus on barriers related to the organization of preventive services and to the general practitioners' (GPs') attitudes and self-efficacy expectations. The prevention of cardiovascular disease was taken as a case study. AIM: To study the organization of cardiovascular services and the attitudes and self-efficacy expectations of GPs, the relationships that exist between these factors, and the influence of practice and provider characteristics. METHOD: A survey was conducted among 95 general practices with 195 GPs. RESULTS: Few practices were sufficiently well-organized to provide effective preventive services. Seventy per cent of the GPs had positive self-efficacy expectations. Thirty to fifty per cent had positive attitudes. Few relationships were found between the organization of services and positive attitudes or expectations. Moreover, few relationships were found between practice and provider characteristics and barriers studied. List size played some role in the presence of barriers. CONCLUSION: Barriers to prevention exist. Even a positive attitude or self-efficacy expectation does not automatically coincide with a practice organization equipped for prevention. Changing attitudes is probably not enough. Efforts have to be directed at the organization of services.