Patient cardiovascular risk self-management: results from a randomized trial of motivational interviewing delivered by practice nurses.

BACKGROUND: To enhance cardiovascular risk management and patients' self-management, a tailored programme to improve cardiovascular risk management was tested in a randomized trial. The presented study concerned secondary analysis. OBJECTIVES: To explore the correlations of practice nurses' counselling skills at baseline on chronic illness care (measured with Patient Assessment of Chronic Illness Care questionnaire) and patients' self-management (assessed with Patient Activation Measure) at follow-up and to examine the effect of the tailored implementation programme on chronic illness care and patients' self-management. METHODS: A two-arm cluster randomized trial was conducted in 34 general practices in the Netherlands. Counselling skills of practice nurses at baseline were abstracted from audio-taped consultations, which were assessed by Motivational Interviewing Treatment Integrity. Data of 2184 patients with established cardiovascular disease or at high cardiovascular risk were gathered at inclusion and at 6 months follow-up by a composite questionnaire. Multilevel regression analysis was applied, controlling for patient characteristics. RESULTS: Counselling skills of practice nurses were not associated with chronic illness care and patients' self-management scores. At follow-up, patients in the intervention group experienced less chronic illness care and were less activated in disease management than patients in the control group. The most important predictors were patients' age, gender and education level. CONCLUSIONS: The logic model underlying the implementation programme needs to be reconsidered, because patient perceptions were neither influenced by nurses' counselling skills nor by other components of the implementation programme.

Tailored implementation of cardiovascular risk management in general practice: a cluster randomized trial.

BACKGROUND: Counselling on health-related lifestyles is key to the prevention and management of chronic diseases. After comprehensive study of determinants of its delivery in general practice and strategies to improve, we composed a tailored improvement program, which included communication skills training, online patient information, and a clinical protocol for managing depressive symptoms. Our aim was to assess the effectiveness of this program on professional performance and outcomes in cardiovascular patients. METHODS: A two-arm cluster randomized trial in 34 general practices involving 34 nurses was conducted. The primary outcome was an aggregated score of a positive score on lifestyle counselling delivered and an appropriate action on depressive symptoms. Secondary outcomes included the various elements of the primary outcome, vascular risk factors (extracted from patient records), and patient-reported lifestyle behaviors. Data were collected from medical records and a written survey among included patients. RESULTS: A sample of 1782 patients with recorded cardiovascular disease or high cardiovascular risk was available at follow-up at 6 months. No impact on the primary outcome was found; lifestyle counselling was recorded in a minority of patients (11.4 % in the intervention group and 10.3 % in the control group). An effect was found on a secondary outcome: patients' physical activity level increased (B 0.18; 95 % CI 0.02-0.35) on a seven-point scale. CONCLUSIONS: The tailored improvement program showed no effect on the primary outcome. This challenges the methodology of tailoring. More involvement of the targeted health care professionals might offer ways to develop more effective implementation programs. Physical activity might be the lifestyle issue that can be more easily changed than smoking or dietary habits. TRIAL REGISTRATION: Nederlands Trial register NTR4069.

Stakeholders' contributions to tailored implementation programs: an observational study of group interview methods.

BACKGROUND: Tailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases. METHODS: Participants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs. RESULTS: In total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers. CONCLUSIONS: Group interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories.

Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods.

BACKGROUND: The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown. METHODS: The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease--COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants). RESULTS: A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming. CONCLUSIONS: Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects.

Tailored implementation of evidence-based practice for patients with chronic diseases.

BACKGROUND: When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries. METHODS: A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain. RESULTS: The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries. CONCLUSION: The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial.

BACKGROUND: Cardiovascular disease (CVD) is an important worldwide cause of mortality. In The Netherlands, CVD is the leading cause of death for women and the second cause of death for men. Recommendations for diagnosis and treatment of CVD are not well implemented in primary care. In this study, we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with (high risk for) CVD. METHODS/DESIGN: A two-arm cluster randomized trial is planned. We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values, risk profiling and lifestyle advice. Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management (CVRM). They are also advised to screen for the presence and severity of depressive symptoms in patients. We also advise practice nurses to use selected E-health options (selected websites and Twitter-consult) in patients without symptoms of depression. Patients with mild depressive symptoms are referred to a physical exercise group. We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM. Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practices in several geographical areas in The Netherlands. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients. Patients' health-related lifestyles (physical exercise, diet and smoking status) will be measured with validated questionnaires and medical record audit will be performed to document estimated CVD risk. Additionally, we will survey and interview participating healthcare professionals for exploration of processes of change. The control practices will provide usual care. DISCUSSION: Tailored interventions can improve healthcare. An understanding of the methods to reach the improved healthcare can be improved. This research contributes a share of it. Identification of the determinants of practice and developing implementation interventions were two steps which were completed. The subsequent step was implementation of the tailored intervention program. TRIAL REGISTRATION: Name trial register: Nederlands trial register. Web address of trial register: http://www.trialregister.nl. Data of registration: 11 July 2013. Number of registration: NTR4069.