A systematic review of the effectiveness of promoting lifestyle change in general practice

BACKGROUND: There is increasing evidence that particular lifestyle behaviours increase the risk of disease and it is widely argued that GPs are ideally placed to encourage patients to modify their behaviour in these areas and thereby reduce their disease risk. There is therefore a need for evidence that GP-based lifestyle interventions are effective in eliciting behaviour change. As there has been no comprehensive attempt to review the literature on this subject, we chose to conduct a systematic review, incorporating meta-analytic techniques where possible, to address this need. OBJECTIVES: This study aimed to examine how effective lifestyle advice provided by GPs is in changing patient behaviour. The following four areas of behaviour were examined: smoking, alcohol consumption, diet, and exercise. METHOD: The review was restricted to English-language reports of trials which investigated the effectiveness of lifestyle advice provided in a general practice setting. Studies were included where it could be established that subjects were randomly allocated to experimental groups and where a comparison was made between either a "no intervention' or "usual care' control group, or between advice of differing intensities. Six electronic databases were searched and a total of 37 trials were selected for inclusion in the review. Meta- analytic techniques were employed to analyse the data from the smoking advice trials. The results form the trials concerned with the other three behaviours did not lend themselves to this form of analysis. Outcome data were extracted from these trials and summarized in tabular form. RESULTS: The results of this review suggest that whilst many of the general practice-based lifestyle interventions show promise in effecting small changes in behaviour, none appears to produce substantial changes. CONCLUSION: There is a need for more extensive and rigorous research in this area before substantial public funds are committed to general practice-based health promotion. Furthermore, it is clear that if general practice-based interventions are to be effective in a public health sense, a greater number of GPs will need to become involved in promoting behaviour change than the literature suggests is currently occurring.      

Assessment of coronary risk in general practice in relation to the use of guidelines: a survey in Denmark

BACKGROUND: There is a considerable gap between recommended and actually conducted preventive cardiology in general practice. The effect of guidelines is not fully evaluated. METHODS: A questionnaire containing 10 questions on preventive cardiology, including the use of clinical guidelines, together with four case stories for cardiovascular risk estimation was mailed to 205 general practitioners (GPs). RESULTS: Response rate was 81%. Twenty-five percent of the GPs had consultations in preventive cardiology at least once a day and 60% of the GPs thought lifestyle intervention had significant effect on cardiovascular risk. Approximately two-thirds of the GPs were regular users of national guidelines on prevention of cardiovascular disease. While the majority of GPs correctly assigned a patient with multiple risk factors to the high-risk category there was a much larger variation in risk estimations if fewer risk factors were present. GPs who reported use of guidelines overestimated coronary risk twice as frequently as nonusers of guidelines. CONCLUSION: Preventive cardiology in general practice is common and the effect of lifestyle intervention is well accepted. Poor discrimination between high- and low-risk patients may, however, lead to suboptimal preventive care. The use of guidelines does not seem to improve risk estimation and further dissemination of better tools for risk estimation is needed.     

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.     

Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups -primary care patients in Sweden

Background

Clinical trials have indicated that lifestyle interventions for patients with lifestyle-related cardiovascular and diabetes risk factors (the metabolic syndrome) are cost-effective. However, patient characteristics in primary care practice vary considerably, i.e. they exhibit heterogeneity in risk factors. The cost-effectiveness of lifestyle interventions is likely to differ over heterogeneous patient groups.

Methods

Patients (62 men, 80 women) in the Kalmar Metabolic Syndrome Program (KMSP) in primary care (Kalmar regional healthcare area, Sweden) were divided into three groups reflecting different profiles of metabolic risk factors (low, middle and high risk) and gender. A Markov model was used to predict future cardiovascular disease and diabetes, including complications (until age 85 years or death), with health effects measured as QALYs and costs from a societal perspective in Euro (EUR) 2012, discounted 3%. Simulations with risk factor levels at start and at 12 months follow-up were performed for each group, with an assumed 4-year sustainability of intervention effects.

Results

The program was estimated cost-saving for middle and high risk men, while the incremental cost vs. do-nothing varied between EUR 3,500 – 18,000 per QALY for other groups. There is heterogeneity in the cost-effectiveness over the risk groups but this does not affect the overall conclusion on the cost-effectiveness of the KMSP. Even the highest ICER (for high risk women) is considered moderately cost-effective in Sweden. The base case result was not sensitive to alternative data and methodology but considerably affected by sustainability assumptions. Alternative risk stratifications did not change the overall conclusion that KMSP is cost-effective. However, simple grouping with average risk factor levels over gender groups overestimate the cost-effectiveness.

Conclusions

Lifestyle counseling to prevent metabolic diseases is cost-effective in Swedish standard primary care settings. The use of risk stratification in the cost-effectiveness analysis established that the program was cost-effective for all patient groups, even for those with very high levels of lifestyle-related risk factors for the metabolic syndrome diseases. Heterogeneity in the cost-effectiveness of lifestyle interventions in primary care patients is expected, and should be considered in health policy decisions.

     

Implementation of a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention delivery

ABSTRACT: BACKGROUND: As in clinical practice resources may be limited compared to experimental settings, translation of evidence-based lifestyle interventions into daily life settings is challenging. In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care. Based on this evaluation we discuss opportunities for refining intervention delivery. METHODS: A 2.5-year intervention was performed in 14 general practices in the Netherlands among individuals at high risk for type 2 diabetes (FINDRISC-score [greater than or equal to] 13) (n = 479) and was compared to usual care (n = 446). Intervention consisted of individual lifestyle counselling by nurse practitioners (n = 24) and GPs (n = 48) and group-consultations. Drop-out and attendance were registered during the programme. After the intervention, satisfaction with the programme and perceived implementation barriers were assessed with questionnaires. RESULTS: Drop-out was modest (intervention: 14.6 %; usual care: 13.2 %) and attendance at individual consultations was high (intervention: 80-97 %; usual care: 86-94 %). Providers were confident about diabetes prevention by lifestyle intervention in primary care. Participants were more satisfied with counselling from nurse practitioners than from GPs. A major part of the GPs reported low self-efficacy regarding dietary guidance. Lack of counselling time (60 %), participant motivation (12 %), and financial reimbursement (11 %) were regarded by providers as important barriers for intervention implementation. CONCLUSIONS: High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling. Results support a role for the nurse practitioner as the key player in guiding lifestyle modification. Further research is needed on strategies that could increase cost-effectiveness, such as more stringent criteria for participant inclusion, group-counselling, more tailor-made counselling and integration of screening and / or interventions for different disorders.     

Women's evaluation of abuse and violence care in general practice: a cluster randomised controlled trial (weave)

Background  

Intimate partner abuse (IPA) is a major public health problem with serious implications for the physical and psychosocial wellbeing of women, particularly women of child-bearing age. It is a common, hidden problem in general practice and has been under-researched in this setting. Opportunities for early intervention and support in primary care need to be investigated given the frequency of contact women have with general practice. Despite the high prevalence and health consequences of abuse, there is insufficient evidence for screening in primary care settings. Furthermore, there is little rigorous evidence to guide general practitioners (GPs) in responding to women identified as experiencing partner abuse. This paper describes the design of a trial of a general practice-based intervention consisting of screening for fear of partner with feedback to GPs, training for GPs, brief counselling for women and minimal practice organisational change. It examines the effect on women's quality of life, mental health and safety behaviours.     

Shared care in gastroenterology: GPs' views of open access to out-patient follow-up for patients with inflammatory bowel disease

OBJECTIVE: The aim of this study was to ascertain GPs' views about open access to out-patient follow-up for patients with inflammatory bowel disease (IBD). METHODS: Semi-structured interviews and a postal survey were carried out in general practices in West Glamorgan UK, each with at least one IBD patient taking part in a randomized trial of open access versus routine follow-up, which has been reported elsewhere. A total of 112 GPs from 53 general practices who referred the 180 study patients to specialist gastroenterological care in Neath or Swansea were included in the study. Main outcome measures were GPs' experience of the trial; preferences between methods of out-patient follow-up; and their views about enhancing open access follow-up. RESULTS: Sixty-nine GPs from 40 practices took part in the practice-specific data collection and 91 returned 156 patient-specific questionnaires. They expressed a strong preference for open access follow-up, for both specific patients (108/156 patients) and IBD patients in general (47/69 GPs). Preference for extending open access follow-up to other chronic conditions was not so strong (21/69 GPs). A substantial number of GPs considered their experience of the trial limited (30/69), and few GPs were aware of the shared care guideline distributed before the trial started (8/69). Few GPs encountered any problems in the management of the study patients (9/69) and <50% of the GPs used a Cumulative Encounter Form (29/69) developed for the study. Most GPs were supportive of giving patients written guidelines (56/69) and establishing a gastroenterological (GI) nurse practitioner (45/69). CONCLUSIONS: Open access follow-up of patients with IBD is supported by GPs. The approach would probably be improved by the distribution of written information to patients, the establishment of a GI nurse practitioner and an integrated approach between the nurse, hospital specialist, GP and patient.     

Cardiovascular risk education and social support (CaRESS): report of a randomized controlled trial from the Kentucky Ambulatory Network (KAN)

PURPOSE: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. METHODS: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters. RESULTS: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high. CONCLUSION: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.     

Targeted versus universal prevention. a resource allocation model to prioritize cardiovascular prevention

Background

Diabetes mellitus brings an increased risk for cardiovascular complications and patients profit from prevention. This prevention also suits the general population. The question arises what is a better strategy: target the general population or diabetes patients.

Methods

A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed.

Results

Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of ?40 per capita, about ?2,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below ?0,000 per QALY. Low or high budgets (below ? or above ?00 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients.

Conclusions

Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.     

The implementation costs of an electronic prevention programme in Belgian general practice

Abstract

Introduction: Guidelines to prevent cardiovascular (CV) disease are widely available. To implement these guidelines an electronic prevention programme (EPP) with a risk calculator for general practitioners (GPs) was developed. The aim of the present study was to calculate the implementation cost per installation. Methods: This cost study is part of a larger clinical trial, studying the effects of interventions in GP-practice on the management of CV risk factors. Participating GPs were asked to install the EPP. They could take part in a group education session or receive education by e-mail, telephone or at home. After a prospective cost registration, the cost per installation and a sensitivity analysis were calculated. Results: 185 GPs participated in the study. The total implementation cost of the EPP was €83,939. As the EPP was successfully installed by 102 GPs, the mean cost equals €823 per GP. Sensitivity analyses showed a decrease in costs due to a decrease of the costs of group education and/or an increase of installations.

Conclusion: This study showed that it is possible to implement an EPP for cardiovascular prevention with an acceptable cost.     

Why target sedentary adults in primary health care? Baseline results from the Waikato Heart, Health, and Activity Study

BACKGROUND: The question of whether the public health issue of physical inactivity should be addressed in primary health care is a controversial matter. METHODS: Baseline cross-sectional analysis of a physician-based physical activity intervention trial involving sedentary adults was undertaken within 42 rural and urban family practices in New Zealand to examine self-reported levels of physical activity and cardiovascular risk factors. A self-administered single question about physical activity was used to screen 40- to 79-year-old patients from waiting rooms for physical inactivity. RESULTS: The positive predictive value of the screening question was 81%. Participation rates for the study were high, including 74% of family physicians (n = 117) in the region. Eighty-eight percent of consecutive patients in the age group agreed to be screened and 46% were identified as sedentary. Of those eligible, 66% (n = 878) agreed to participate in a study involving a lifestyle intervention from their family physician. Blood pressure and BMI were significantly greater than that in the general population. There were high rates of hypertension (52%), diabetes (10.5%), obesity (43%), previous cardiovascular disease (19%), and risk factors for cardiovascular disease (93%). Decreasing total energy expenditure was associated with increasing cardiovascular risk (P = 0.001). CONCLUSION: Sedentary adults in primary care represent a high cardiovascular risk population. Screening for inactivity in primary care is effective and efficient. Two-thirds of sedentary adults agreed to receive a lifestyle intervention from their family physician.     

Improving referrals for glue ear from primary care: are multiple interventions better than one alone?

OBJECTIVES: To evaluate the effect of a risk factor checklist and training video for general practitioners in reducing inter-practice variation and improving the appropriateness of referrals (assessed by their positive predictive value or PPV) of patients with suspected otitis media with effusion (OME or 'glue ear') to secondary care. METHODS: Fifty general practices (177 practitioners) from the NHS Trent region and the West of Scotland were cluster-randomised either to a control group (n = 12) or to one of three intervention groups (training video (n = 16), checklist (n = 11), or both (n = 11)). Data on all paediatric ear, nose and throat (ENT) referrals and diagnostic results at ENT clinics were collected for a one-year period pre- and post-intervention. Referral rates for OME and for closely related conditions were calculated for children aged 0-15 years, based on each practice's list size. PPV was defined as the proportion of referrals resulting in bilateral hearing loss > or = 20 dB at the ENT outpatient department. RESULTS: There was a significant improvement in the PPV, adjusted for patients' waiting time between general practitioner (GP) referral and being seen at the ENT department. The improvement in PPV pre- and post-intervention was 15% (95% confidence interval, CI: -12.1% to 41.7%) for the practices receiving both interventions, compared with a degradation of 20% pre- and post-intervention (95% CI: -32.9% to -6.4%) for practices receiving only one intervention and a degradation of 34% for those receiving no intervention. CONCLUSIONS: Disseminating a risk factor checklist and training video on glue ear to GPs using a multi-channel approach can improve the quality of referrals to ENT.     

Quality of care in stroke prevention: results of an audit study among general practitioners

BACKGROUND: In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke. METHODS: Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel. RESULTS: A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) (n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment. CONCLUSIONS: A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.     

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

ABSTRACT: BACKGROUND: People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes. METHODS: Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor. The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review. RESULTS: 52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71 %, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity. Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients. CONCLUSION: Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change.This has implications for workforce development and the organisation of primary health care.     

Cardiovascular health check in the elderly in one general practice: does it offer new information and lead to interventions?

BACKGROUND: Prevention of cardiovascular disease in the elderly is becoming increasingly important. GPs are in a unique position to initiate preventive interventions in this age group. However, it is not clear which strategy a GP should follow to identify patients at increased cardiovascular risk-case finding or screening. OBJECTIVE: We aimed to assess the value of a single cardiovascular health check compared with a normal care case finding and to investigate the diagnostic or therapeutic consequences of detecting new cardiovascular risk indicators. METHODS: In 1991, 1002 persons aged 60 years and over, enlisted in one general practice, were invited. Of the 805 subjects who responded (80%), the cardiovascular risk profile was determined by a research physician. The proportion of newly detected cardiovascular risk indicators was the main outcome measure. A risk indicator was considered newly detected when it was not mentioned in the GP's summary of the patient record, which had been checked by the patient for its completeness. The patient records of participants with newly detected hypertension, diabetes or hypercholesterolaemia were systematically reviewed to detect diagnostic and therapeutic interventions by the GP. RESULTS: In 25.1% of the participants, one or more cardiovascular risk indicators were found which were previously unknown to the GP, including 38 (4.7%) cases of hypertension, 82 (10%) cases of isolated systolic hypertension, 14 (1.7%) cases of diabetes mellitus and 63 (7.8%) cases of hypercholesterolaemia. On the basis of these findings, the GP initiated therapeutic interventions in almost all subjects with newly detected diabetes. However, reports of newly detected hypertension or high cholesterol levels were usually not followed by an intervention. CONCLUSION: A single cardiovascular health check in the elderly can detect a considerable number of risk indicators that are unknown to a patient's GP. In most cases, however, the detection of hypertension or cholesterol > or = 6.5 mmol/l did not lead to interventions by the GP. More efforts are needed to ensure that the beneficial effects of these interventions are not limited to participants in clinical trials but can be extended to patients in general practice.     

Deprivation and systematic stroke prevention in general practice: an audit among general practitioners in the Rotterdam region, The Netherlands

BACKGROUND: To investigate differences in quality of preventive care provided by general practitioners (GPs) to patients at risk of stroke living in deprived and non-deprived neighbourhoods in the Rotterdam region. METHODS: A 'deprivation score' was used to categorize neighbourhoods according to their deprivation status. Data on the process of patient care were collected by means of chart review and interviews with GPs. Cases of stroke (n=188) were retrospectively audited by an expert panel with guideline-based review criteria. To measure differences in quality of patient care between neighbourhoods, deprivation scores were related to scores for sub-optimal care. RESULTS: After adjustment for socio-demographic characteristics, patients in deprived neighbourhoods had an increased risk (OR 1.95 (95% CI: 0.98-3.90)) of having received sub-optimal preventive care if compared with patients in non-deprived neighbourhoods. This excess risk was limited to women (OR 3.57 (95% CI: 1.39-9.16) vs OR 1.01 (95% CI: 0.41-2.48) in men). Adjustment for socio-demographic characteristics and risk factor distribution did not change the OR for women to receive sub-optimal care significantly (OR 3.21 (95% CI: 1.24-8.31)). Sub-optimal care originated mainly from deficiencies in follow-up of treated hypertensive and diabetes patients and evaluation of patients' cardiovascular risk profile. Among treated hypertensive women in deprived neighbourhoods who received sub-optimal care, the mean number of deficiencies related to follow-up was almost double that of the corresponding group in non-deprived neighbourhoods. CONCLUSION: Quality of care to prevent stroke in general practice differs considerably between deprived and non-deprived neighbourhoods. Patients in deprived neighbourhoods, and women in particular, have almost twice the risk of receiving sub-optimal preventive care.     

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.

     

Screening risks for intimate partner violence and primary care settings: implications for future abuse

Most health care intervention models for intimate partner violence (IPV) are crisis driven and targeted to survivors of injury following episodes of physical violence. Knowledge about anticipatory and preventive approaches with women who are at risk for abuse is scarce, limiting professionals' ability to respond fully and effectively to this problem. This paper describes a retrospective, practice-based research study of social work interventions in two hospital-based primary care practices. A total of 431 female patients completed a self-administered questionnaire developed for the early detection of IPV risk factors during routine health care visits. The study showed surprisingly high rates of multiple risk markers in an urban primary care population whose medical presentations ordinarily would not raise provider suspicion about abuse. Findings confirmed the willingness of primary care populations to freely partake in routine screening and support the value of early identification and intervention with populations at risk. Practice implications are discussed.