Clients and professionals elicit long-term care preferences by using 'What matters to me': A process evaluation in the Netherlands.

BACKGROUND: 'What matters to me' is a five-category preference elicitation tool to assist clients and professionals in choosing long-term care. This study aimed to evaluate the use of and experiences with this tool. METHODS: A mixed-method process evaluation was applied. Participants were 71 clients or relatives, and 12 professionals. They were all involved in decision-making on long-term care. Data collection comprised online user activity logs (N = 71), questionnaires (N = 38) and interviews (N = 20). Descriptive statistics was used for quantitative data, and a thematic analysis for qualitative data. RESULTS: Sixty-nine per cent of participants completed one or more categories in an average time of 6.9 (±0.03) minutes. The tool was rated 6.63 (±0.88) of 7 in the Post-Study System Usability Questionnaire (PSSUQ). Ninety-five per cent experienced the tool as useful in practice. Suggestions for improvement included a separate version for relatives and a non-digital version. Although professionals thought the potentially extended consultation time could be problematic, all participants would recommend the tool to others. CONCLUSION: 'What matters to me' seems useful to assist clients and professionals with preference elicitation in long-term care. Evaluation of the impact on consultations between clients and professionals by using 'What matters to me' is needed.

Proposal for a Framework to Enable Elicitation of Preferences for Clients in Need of Long-Term Care.

PURPOSE: Collaborative deliberation comprises personal engagement, recognition of alternative actions, comparative learning, preference elicitation, and preference integration. Collaborative deliberation may be improved by assisting preference elicitation during shared decision-making. This study proposes a framework for preference elicitation to facilitate collaborative deliberation in long-term care consultations. METHODS: First, a literature overview was conducted comprising current models for the elicitation of preferences in health and social care settings. The models were reviewed and compared. Second, qualitative research was applied to explore those issues that matter most to clients in long-term care. Data were collected from clients in long-term care, comprising 16 interviews, 3 focus groups, 79 client records, and 200 online client reports. The qualitative analysis followed a deductive approach. The results of the literature overview and qualitative research were combined. RESULTS: Based on the literature overview, five overarching domains of preferences were described: "Health", "Daily life", "Family and friends", "Living conditions", and "Finances". The credibility of these domains was confirmed by qualitative data analysis. During interviews, clients addressed issues that matter in their lives, including a "click" with their care professional, safety, contact with loved ones, and assistance with daily structure and activities. These data were used to determine the content of the domains. CONCLUSION: A framework for preference elicitation in long-term care is proposed. This framework could be useful for clients and professionals in preference elicitation during collaborative deliberation.

What matters to me - a web-based preference elicitation tool for clients in long-term care: a user-centred design.

BACKGROUND: During the process of decision-making for long-term care, clients are often dependent on informal support and available information about quality ratings of care services. However, clients do not take ratings into account when considering preferred care, and need assistance to understand their preferences. A tool to elicit preferences for long-term care could be beneficial. Therefore, the aim of this qualitative descriptive study is to understand the user requirements and develop a web-based preference elicitation tool for clients in need of long-term care. METHODS: We applied a user-centred design in which end-users influence the development of the tool. The included end-users were clients, relatives, and healthcare professionals. Data collection took place between November 2017 and March 2018 by means of meetings with the development team consisting of four users, walkthrough interviews with 21 individual users, video-audio recordings, field notes, and observations during the use of the tool. Data were collected during three phases of iteration: Look and feel, Navigation, and Content. A deductive and inductive content analysis approach was used for data analysis. RESULTS: The layout was considered accessible and easy during the Look and feel phase, and users asked for neutral images. Users found navigation easy, and expressed the need for concise and shorter text blocks. Users reached consensus about the categories of preferences, wished to adjust the content with propositions about well-being, and discussed linguistic difficulties. CONCLUSION: By incorporating the requirements of end-users, the user-centred design proved to be useful in progressing from the prototype to the finalized tool 'What matters to me'. This tool may assist the elicitation of client's preferences in their search for long-term care.

Getting to grips with the process of decision-making in long-term care. Descriptive cases illustrate the chaotic reality of the construction of preferences.

BACKGROUND: Clients facing decision-making for long-term care are in need of support and accessible information. Construction of preferences, including context and calculations, for clients in long-term care is challenging because of the variability in supply and demand. This study considers clients in four different sectors of long-term care: the nursing and care of the elderly, mental health care, care of people with disabilities, and social care. The aim is to understand the construction of preferences in real-life situations. METHOD: Client choices were investigated by qualitative descriptive research. Data were collected from 16 in-depth interviews and 79 client records. Interviews were conducted with clients and relatives or informal caregivers from different care sectors. The original client records were explored, containing texts, letters, and comments of clients and caregivers. All data were analyzed using thematic analysis. RESULTS: Four cases showed how preferences were constructed during the decision-making process. Clients discussed a wide range of challenging aspects that have an impact on the construction of preferences, e.g. previous experiences, current treatment or family situation. This study describes two main characteristics of the construction of preferences: context and calculation. CONCLUSION: Clients face diverse challenges during the decision-making process on long-term care and their construction of preferences is variable. A well-designed tool to support the elicitation of preferences seems beneficial.

Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial.

BACKGROUND: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. METHODS: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. RESULTS: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. CONCLUSIONS: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners' attitudes, their actual behaviour and care improvement strategies to enhance implementation science. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01501552.

Describing patients' needs in the context of research priorities in patients with multiple myeloma or Waldenstrom's disease: A truly patient-driven study.

BACKGROUND: To ensure true patient-centered care, the urgency of patient participation in research is increasingly recognized. This study takes this one step further and reports on patient participation in describing patients' needs for improving quality of care in the context of research priorities - a challenging partnership with patients in research as we yet lack experience in the Netherlands. OBJECTIVES: 1) To illustrate the process of describing patients' needs in the context of research priorities for patients with blood cancer (multiple myeloma or Waldenstrom's disease) with the purpose to improve the quality of health care. 2) To describe the experienced needs in the context of research priorities in the patients. METHODS: Following the Dialogue Model, we first established a balanced project group and agreed on the study protocol, followed by the actual data collection of which the most important steps included: individual interviews and focus groups with purposeful samples of patients, a questionnaire that was sent to all members of the patient organization (n=1,782), and a dialogue meeting with patients to prioritize the final issues. RESULTS: 1) Ten interviews and two focus groups were successfully conducted. Response rate on the questionnaire averaged 44%. 2) Main research topics: improved information on all aspects of disease and treatment, involving patients in decision making, organization of care and the burden of neuropathy. DISCUSSION: Given the process of data collection we believe that the patients' needs for quality of care improvements in the context of research priorities that were described are valid and representative. The novelty of this approach was that patients themselves contacted researchers to assess the patients' priorities in a scientific and reliable way.

Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial.

AIM: To test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers. DESIGN: Cluster randomized factorial trial with 12-week implementation and measurement period. SETTING: Primary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden. PARTICIPANTS: A total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden. INTERVENTIONS: PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI. MEASUREMENTS: The primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period. FINDINGS: During a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI = 1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI = 1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI = 1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI = 1.11-2.53). CONCLUSIONS: Providing primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study.

AIMS: To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS: Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS: The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION: The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Disease or no disease? Disagreement on diagnoses between self-reports and medical records of adult patients.

BACKGROUND: Previous studies reported moderate to good agreement between patients' self-reported diseases and physicians' registered diseases. Disagreement might hamper a good doctor-patient relationship and hamper good quality of care. Disagreement can be associated with demographic and psychosocial patient characteristics. OBJECTIVES: To evaluate the level of agreement on reported chronic diseases between patients and their general practitioners (GPs); to assess whether disagreement relates to patient characteristics. METHODS: This study is embedded in a large GP based prospective cohort. Questionnaires of 2893 patients reporting on 14 chronic diseases are used. The agreement (percentage) between self-reported chronic diseases and the medical records was assessed first by descriptive statistics. To control for agreement by chance alone Cohen's kappa value was calculated. Type of (dis) agreement was further evaluated and associated with patient characteristics. RESULTS: Despite high agreement on diseases between patients and GPs, kappa's varied from 0.17 (inflammatory joint diseases and rheumatoid arthritis) to 0.86 (diabetes mellitus). Most often under-reporting and over-reporting was related to a decreased physical and mental quality of life and higher age. CONCLUSION: kappa values between patients and GPs appeared to be low in this study.

The challenge of transferring an implementation strategy from academia to the field: a process evaluation of local quality improvement collaboratives in Dutch primary care using the normalization process theory.

RATIONALE, AIMS AND OBJECTIVES: A quality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process. METHODS: In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory. RESULTS: The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it. CONCLUSION: Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.

The balanced incomplete block design is not suitable for the evaluation of complex interventions.

OBJECTIVES: In quality of care research, the balanced incomplete block (BIB) design is regularly claimed to have been used when evaluating complex interventions. In this article, we reflect on the appropriateness of using this design for evaluating complex interventions. STUDY DESIGN AND SETTING: Literature study using PubMed and handbooks. RESULTS: After studying various articles on health services research that claim to have applied the BIB and the original methodological literature on this design, it became clear that the applied method is in fact not a BIB design. CONCLUSION: We conclude that the use of this design is not suited for evaluating complex interventions. We stress that, to prevent improper use of terms, more attention should be paid to proper referencing of the original methodological literature.

Managing alcohol problems in general practice in Europe: results from the European ODHIN survey of general practitioners.

AIMS: To document the attitudes of general practitioners (GPs) from eight European countries to alcohol and alcohol problems and how these attitudes are associated with self-reported activity in managing patients with alcohol and alcohol problems. METHODS: A total of 2345 GPs were surveyed. The questionnaire included questions on the GP's demographics, reported education and training on alcohol, attitudes towards managing alcohol problems and self-reported estimates of numbers of patients managed for alcohol and alcohol problems during the previous year. RESULTS: The estimated mean number of patients managed for alcohol and alcohol problems during the previous year ranged from 5 to 21 across the eight countries. GPs who reported higher levels of education for alcohol problems and GPs who felt more secure in managing patients with such problems reported managing a higher number of patients. GPs who reported that doctors tended to have a disease model of alcohol problems and those who felt that drinking was a personal rather than a medical responsibility reported managing a lower number of patients. CONCLUSION: The extent of alcohol education and GPs' attitudes towards alcohol were associated with the reported number of patients managed. Thus, it is worth exploring the extent to which improved education, using pharmacotherapy in primary health care and a shift to personalized health care in which individual patients are facilitated to undertake their own assessment and management (individual responsibility) might increase the number of heavy drinkers who receive feedback on their drinking and support to reduce their drinking.

Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study.

BACKGROUND: Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent. AIM: To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners' electronic medical records. METHODS: We applied the existing model (N = 3,045, 2003-2005) to a later time frame (2009-2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007-2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests. RESULTS: The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65). CONCLUSION: This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients' electronic medical records.

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial.

BACKGROUND: The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers. METHODS/DESIGN: In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals' role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling. DISCUSSION: Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.

Small but important errors in cardiovascular risk calculation by practice nurses: a cross-sectional study in randomised trial setting.

BACKGROUND: Practice nurses play an increasingly important role in the prevention of cardiovascular diseases but we do not have evidence about the accuracy of their cardiovascular risk assessments during real practice consultations. OBJECTIVES: To examine how nurses perform with regard to absolute 10-year cardiovascular risk assessment in actual practice. DESIGN: Cross-sectional study. SETTING: This study was nested in the IMPALA study, a clustered randomised controlled trial involving 24 general practices in The Netherlands. PARTICIPANTS: 24 practice nurses, trained in 10-year cardiovascular risk assessment, calculated the risk of a total of 421 patients without established cardiovascular diseases but eligible for cardiovascular risk assessment. METHODS: The main outcome measure was the accuracy of risk assessments, defined as (1) the difference between the 10-year cardiovascular risk percentage calculated by nurses and an independent assessor, and (2) the agreement between the treatment categories assigned by the nurses (low, moderate or high risk) and those assigned by the independent assessor. RESULTS: Thirty-one (7.4%) of the calculated risk percentages differed by more than our preset limits, 25 (81%) being underestimations. Elderly patients (OR 1.1, 95% CI 1.0-1.1), male patients (vs. female OR 3.1, 95% CI 1.2-7.3), and smoking patients (vs. non-smoking OR 3.8, 95% CI 1.7-8.9) were more likely to have their cardiovascular risk miscalculated. Ten (28%) of the 36 patients who should be assigned to the high-risk treatment category according to the independent calculation, were missed as high-risk patients by the practice nurses. CONCLUSIONS: The overall standard of accuracy of cardiovascular risk assessment by trained practice nurses in actual practice is high. However, a significant number of high-risk patients were misclassified, with the probability that it led to missed opportunities for risk-reducing interventions. As cardiovascular risk assessments are frequently done by nurses in general practice, further specific training should be considered to prevent undertreatment.

Degree of solidarity with lifestyle and old age among citizens in the Netherlands: cross-sectional results from the longitudinal SMILE study.

BACKGROUND AND AIM: With the increasing interest in lifestyle, health and consequences of unhealthy lifestyles for the healthcare system, a new kind of solidarity is gaining importance: lifestyle solidarity. While it might not seem fair to let other people pay for the costs arising from an unhealthy lifestyle, it does not seem fair either to punish people for their lifestyle. However, it is not clear how solidarity is assessed by people, when considering disease risks or lifestyle risks. The aim of this study was to investigate the degree of solidarity with lifestyle as well as with other factors that are related to health outcomes-for example, old age-and the relation between this degree of solidarity and various characteristics. METHODS: This cross-sectional study is part of the Dutch longitudinal SMILE study. Data on the degree of solidarity with different lifestyles and old age, and the relation between the degree of solidarity and various demographic and other variables were obtained in a questionnaire survey. RESULTS: Solidarity with smokers and overweight people was moderate, as was solidarity with older people. Respondents were ambivalent about athletes. Respondents who were younger, male and highly educated, and those with a healthy lifestyle, a small social network, high quality of life and an internal locus of control, showed low solidarity. CONCLUSIONS: Solidarity with an unhealthy lifestyle and old age is moderate and the degree of solidarity varies among the different subgroups.

Increased attendance rate: BMI matters, lifestyles don't. Results from the Dutch SMILE study.

INTRODUCTION: a small group of frequent attenders is responsible for a disproportional large percentage of all daytime consultations in general practice. High attendance rates are related to demographic and psychological characteristics. Differences in attendance rates are only partly explained by chronic diseases. Furthermore, lifestyles might be relevant too. The aim of this study was to examine the effect of lifestyle on attendance rates. METHOD: this study is part of the Study of Medical Information and Lifestyles in Eindhoven, the Netherlands (SMILE). Generalized estimated equations were used to determine the relation between attendance rate and the different lifestyle factors (N = 4444). RESULTS: a higher body mass index was related to increased attendance rate in both male [relative risk (RR) 1.02; 95% confidence interval (CI) 1.01-1.03] and female patients (RR 1.01; 95% CI 1.01-1.02). Lifestyles were not related to the attendance rate, except for a sedentary lifestyle in women (RR 1.08; 95% CI 1.04-1.12). DISCUSSION: since half of the Dutch population suffers from overweight or obesity and this number is still increasing, attendance rates will rise further. In order to relieve the GPs, nurse practitioners could play a more prominent role in lifestyle interventions concerning overweight and obesity and its related diseases.

Improving lifestyle and risk perception through patient involvement in nurse-led cardiovascular risk management: a cluster-randomized controlled trial in primary care.

OBJECTIVE: To determine if lifestyle improved at a short term through an intervention to involve patients in cardiovascular risk management by the practice nurse. METHODS: The IMPALA study (2006, the Netherlands) was a cluster-randomised controlled trial involving 25 general practices and 615 patients who were eligible for cardiovascular risk management. The intervention consisted of (1) individual 10-year cardiovascular risk assessment, (2) risk communication, (3) use of a decision aid and (4) adapted motivational interviewing, applied by practice nurses in two consultations. Outcomes were smoking, alcohol, diet, physical activity and the secondary outcomes risk perception, anxiety, confidence about the decision and satisfaction with the communication, measured at baseline and after 12 weeks. RESULTS: Patients of both groups improved their lifestyle, but no relevant significant differences between the groups were found. Intervention group patients improved in terms of the appropriateness of risk perception, although not significantly. Intervention group patients improved significantly in terms of appropriateness of anxiety and were more satisfied with the communication compared to control group patients. CONCLUSION: The intervention seems to have improved the patients' risk perception, anxiety and satisfaction with the communication, which are important conditions for shared decision making. However, we found no additional effect of the intervention on lifestyle.

Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial.

BACKGROUND: Preventive guidelines on cardiovascular risk management recommend lifestyle changes. Support for lifestyle changes may be a useful task for practice nurses, but the effect of such interventions in primary prevention is not clear. We examined the effect of involving patients in nurse-led cardiovascular risk management on lifestyle adherence and cardiovascular risk. METHODS: We performed a cluster randomized controlled trial in 25 practices that included 615 patients. The intervention consisted of nurse-led cardiovascular risk management, including risk assessment, risk communication, a decision aid and adapted motivational interviewing. The control group received a minimal nurse-led intervention. The self-reported outcome measures at one year were smoking, alcohol use, diet and physical activity. Nurses assessed 10-year cardiovascular mortality risk after one year. RESULTS: There were no significant differences between the intervention groups. The effect of the intervention on the consumption of vegetables and physical activity was small, and some differences were only significant for subgroups. The effects of the intervention on the intake of fat, fruit and alcohol and smoking were not significant. We found no effect between the groups for cardiovascular 10-year risk. INTERPRETATION: Nurse-led risk communication, use of a decision aid and adapted motivational interviewing did not lead to relevant differences between the groups in terms of lifestyle changes or cardiovascular risk, despite significant within-group differences.