A randomized, controlled trial for risk factor reduction in patients with symptomatic vascular disease: the multidisciplinary Vascular Prevention by Nurses Study (VENUS).

BACKGROUND: Patients with manifest vascular disease are at high risk of a new vascular event or death. Modification of classical risk factors is often not successful. We determined whether the extra care of a nurse practitioner could be beneficial to the cardiovascular risk profile of high-risk patients. DESIGN: We conducted a randomized, controlled trial based on the Zelen design. METHODS: Two hundred and thirty-six patients with manifestations of a vascular disease and who had two or more modifiable vascular risk factors were pre-randomized to receive treatment by a nurse practitioner plus usual care or usual care alone. After 1 year, risk factors were remeasured. The primary endpoint was achievement of treatment goals for blood pressure, lipid, glucose and homocysteine levels, body mass index, and smoking. RESULTS: Of the pre-randomized patients, 95 of 119 (80%) in the intervention group and 80 of 117 (68%) in the control group participated in the study. After a mean follow-up of 14 months, the patients in the intervention group achieved significantly more treatment goals than did the patients in the control group (systolic blood pressure 63 versus 37%, total cholesterol 79 versus 61%, low density lipoprotein-cholesterol 88 versus 67%, and body mass index 38 versus 24%). Medication use was increased in both groups and no differences were found in patients' quality of life (SF-36) at follow-up. CONCLUSION: Treatment delivered by nurse practitioners, in addition to a vascular risk factor screening and prevention program, resulted in a better management of vascular risk factors than usual care alone in vascular patients after 1-year follow-up.     

Effectiveness of a quality improvement intervention in reducing cardiovascular risk in hypertensive patients

INTRODUCTION AND OBJECTIVES: To evaluate the effect of a quality improvement intervention on the reduction of cardiovascular risk in patients with hypertension. PATIENTS AND METHOD: Quasi-experimental study involving two primary care centres. One centre was assigned to implement a quality improvement intervention (n = 482 patients), while at the other center "usual care" procedures were followed (control group, n = 360 patients). The quality improvement intervention consisted of a combined program designed for the medical staff and comprising audit, feedback, training sessions and implementation of clinical practice guidelines during 6 months. The main outcome measures were blood pressure, lipid levels, diabetes, smoking and cardiovascular risk. These values were compared before the intervention and after one year. RESULTS: The baseline characteristics of the patients were similar in both groups. Absolute cardiovascular risk decreased from 15.85% to 14.36% (P< .05) in the intervention group, and no significant change was observed in the control group (15.17% to 15.76%). The intervention led to a 2.07% decrease in cardiovascular risk (95%CI, 1.21-2.93; P< .05). The percentage of patients with high cardiovascular risk (> 20% at 10 years) decreased in the intervention group from 30% to 25%, and increased in the control group from 28% to 30%. Relative cardiovascular risk decreased from 2.03 to 1.75 (P< .05) in the intervention group, and from 1.98 to 1.92 (P> .05) in the control group. The intervention thus led to a 0.25 decrease in relative risk (95%CI: 0.14-0.35). CONCLUSIONS: Absolute and relative cardiovascular risk in patients with hypertension was reduced by a quality improvement intervention. The percentage of patients with high cardiovascular risk was also reduced.     

Physical performance is associated with markers of vascular inflammation in patients with coronary heart disease.

BACKGROUND: Coronary heart disease as well as major cardiovascular risk factors are associated with elevated levels of pro-inflammatory markers. There is, however, limited information about how changes in lifestyle improving the cardiovascular risk profile influence these levels. The aim of the study was to evaluate whether changes in lifestyle measures with special attention to physical activity, were associated with the levels of such markers. DESIGN: Coronary heart disease patients (n = 197) were randomized to either a comprehensive lifestyle intervention programme comprising regular physical activity, low fat diet and smoking cessation, or usual care with routine follow-up in the outpatient clinic for 6 months. An exercise test and fasting blood samples analysed for soluble cell adhesion molecules, C reactive protein and pro-inflammatory cytokines were evaluated before and at the end of the study. RESULTS: Improved diet, physical performance and reduction in smoking were obtained in the intervention programme when compared with usual care patients, but no significant group differences in levels of inflammatory markers were observed. In the total population, however, physical performance significantly and inversely predicted levels of soluble cell adhesion molecule 1, (P < 0.001), C-reactive protein (P < 0.001) and interleukin-6 (P = 0.01) at 6 months. Smokers had elevated levels of soluble cell adhesion molecule 1 when compared with non-smokers (P = 0.011). CONCLUSIONS: We demonstrated that physical performance is inversely correlated with levels of pro-inflammatory markers in coronary heart disease patients, possibly retarding the process of atherosclerosis. No effect on inflammatory markers was obtained with a 6-month lifestyle intervention programme when compared with patients who received usual care follow-up.     

Intensified preventive care to reduce cardiovascular risk in healthcare centres located in deprived neighbourhoods: a randomized controlled trial

BACKGROUND: We examined the effectiveness of a structured collaboration in general practice between a practice nurse, a peer health educator, the general practitioner (GP) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases. DESIGN: A randomized controlled trial in three healthcare centres (18 GPs) in deprived neighbourhoods of two major Dutch cities. METHODS: Two hundred seventy-five high-risk patients (30-70 years) from various ethnic groups were randomized to intervention (n=137) or usual care group (n=138). We determined group differences in outcomes [10-year absolute risk (Framingham risk equation), blood pressure, lipids and body mass index] at 12-month follow-up. RESULTS: The 10-year absolute risk was reduced by 1.76% (standard error: 0.81) in intervention and by 2.27% (standard error: 0.69) in usual care group; the difference in mean change was 0.88% [95% confidence interval: -1.16 to 2.93]. In both groups significant reductions were observed in the following individual risk factors: total cholesterol, total cholesterol/high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol, with no relevance between group differences. CONCLUSION: The cardiovascular risk profile of intervention and control patients improved after 1-year follow-up. However, no extra effect of the structured preventive care on the risk for cardiovascular diseases was achieved.     

The effect of older-person centered and integrated health management model on multiple lifestyle behaviors: A randomized controlled trial from China

ObjectiveTo investigate the effectiveness of the older-centered Integrated Health Management Model Project (OPCHMP) for multiple lifestyle behaviours in the elderly.MethodsA 2-arm, parallel, randomized controlled trial was conducted in Nanjing. The elderly were recruited from multiple community health service centres. The intervention group was intervened and received a personalized, 2-year OPCHMP. The control group only received usual care. Adherence to healthy lifestyle behaviours (ATHLBS) is the primary outcome, obtained through a self-reported composite health behaviour score. The secondary outcomes were health indicators. General estimating equation models were performed to analyse longitudinal dichotomous data and continuous data.Results637 (intervention = 323; control = 314) participants were included in the study. The participants mean age was 70.53 ± 6.07 years. Significant ATHLBS correction was achieved after 24-month follow-up in the intervention group, comparing to controls. And the intervention group reported significantly better health indicators.ConclusionOPCHMP had positive effect on multiple lifestyle habits in elderly population, which is very encouraging.     

Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review

Nurses in primary health care (PHC) provide an increasing proportion of chronic disease management and preventive lifestyle advice. The databases MEDLINE, CINAHL, EMBASE and PsychINFO were searched and the articles were systematically reviewed for articles describing controlled adult lifestyle intervention studies delivered by a PHC nurse, in a PHC setting. Thirty‐one articles describing 28 studies were analysed by comparison group which revealed: (i) no difference of effect when the same intervention was delivered by a PHC nurse compared to other health professionals in PHC (n = 2); (ii) the provision of counselling delivered by a PHC nurse was more effective than health screening (n = 10); (iii) counselling based on behaviour change theory was more effective than the same dose of non‐behavioural counselling when at least three counselling sessions were delivered (n = 3). The evidence supports the effectiveness of lifestyle interventions delivered by nurses in PHC to affect positive changes on outcomes associated with the prevention of chronic disease including: weight, blood pressure, cholesterol, dietary and physical activity behaviours, patient satisfaction, readiness for change and quality of life. The strength of recommendations is limited by the small number of studies within each comparison group and the high risk of bias of the majority of studies.     

Diabetes status modifies the efficacy of home-based kidney care for Zuni Indians in a randomized controlled trial

BackgroundHome-Based Kidney Care (HBKC) is a pragmatic treatment approach that addresses patient preferences and cultural barriers to healthcare. We previously reported the results of a clinical trial of HBKC vs. usual care in a cohort of Zuni Indians in New Mexico. This study investigated the potential for differential efficacy of HBKC vs. usual care according to type 2 diabetes (T2DM) status.MethodsWe analyzed the data from all individuals who participated in a randomized clinical trial that compared HBKC to usual care among patients with CKD, and assessed whether the effect of the HBKC intervention affected the subset of patients with T2DM differently than those individuals without T2DM. We used linear regression models to estimate the effect of HBKC on improvement in Patient Activation Measure (PAM) total scores within the groups of participants defined by T2DM status, and to compare the effects between these two groups. We used generalized estimating equations (GEE) to account for household clustering.ResultsThe original study enrolled 63 participants into the HBKC group, and 62 into the usual care. Ninety-eight of these individuals completed the 12-month intervention, 50 in the HBKC group and 48 in the usual care group. The present study compared the intervention effect in the 56 participants with T2DM (24 participants in the HBKC group and 32 in usual care) to the intervention effect in the 42 participants without T2DM (26 participants in the HBKC group and 16 in usual care). Those with T2DM who received the HBKC intervention experienced an average increase in PAM total scores of 16.0 points (95% Confidence Interval: 8.8–23.1) more than those with T2DM who were in the usual care group. For those without T2DM, the intervention had essentially no effect, with those who received the HBKC intervention having an average PAM total scores that was 1.4 points (95% C.I.: ?12.4 to 9.6) lower than those who received usual care. There was a significantly different HBKC treatment effect by T2DM status (p = 0.02).ConclusionThis secondary analysis suggests that the effectiveness of this HBKC intervention on increasing patient activation is most notable among those CKD patients who also have T2DM.     

The Extensive Lifestyle Management Intervention (ELMI) following cardiac rehabilitation trial.

AIM: Previous studies have reported lifestyle and risk factor deterioration following completion of a cardiac rehabilitation program (CRP). We report the results of a one-year Extensive Lifestyle Management Intervention (ELMI) aimed at preventing these adverse changes. METHODS AND RESULTS: A total of 302 men and women with ischaemic heart disease were recruited following completion of a CRP and randomized to either the ELMI (consisting of exercise sessions, telephone follow-ups and risk factor and lifestyle counselling) or usual care. The primary outcome was global cardiovascular risk using the Framingham and Procam risk scores. Secondary outcomes included risk factors and lifestyle behaviours. Baseline characteristics were similar between the two groups. Adherence to the ELMI was high. There was a non-significant trend in favour of the ELMI between for both the Framingham (6.6+/-3.1 to 6.2+/-2.9 vs 6.6+/-3.2 to 6.7+/-3.2, P=0.138) and Procam (20.0+/-20.0 to 20.6+/-19.5 vs 19.1+/-18.7 to 21.8+/-19.1, P=0.089) scores. There were no differences in secondary outcomes. CONCLUSIONS: A one-year multi-factorial post-CRP intervention results in modest, non-significant benefits to global risk compared to usual care. The absence of deterioration in the usual care group may be due to improved practices in usual care.     

The Italian Diabetes and Exercise Study (IDES): design and methods for a prospective Italian multicentre trial of intensive lifestyle intervention in people with type 2 diabetes and the metabolic syndrome

Background and aimsThe IDES is a prospective Italian multicentre randomized controlled trial to evaluate the efficacy of an intensive lifestyle intervention on modifiable cardiovascular disease (CVD) risk factors in a large cohort of people with type 2 diabetes and the metabolic syndrome.Methods and resultsWe recruited 606 subjects with type 2 diabetes and waist circumference >94 cm (M) and >80 cm (F), plus >1 other metabolic syndrome trait (IDF criteria) for both sexes, aged 40–75 years, BMI 27–40 kg/m², diabetes duration >1 year with a sedentary lifestyle of >6 months. Patients were randomized into two groups: a control group, receiving conventional care including exercise counselling and an intervention group, treated with a mixed (aerobic and resistance) exercise programme (150 min/week) prescribed and supervised for 12 months. Primary outcome is HbA1c reduction. Secondary outcomes include other traditional and non-traditional risk factors and their relationship to exercise volume/intensity and fitness; dosage of glucose, lipid and blood pressure-lowering drugs; global CVD 10-year risk; patient well-being; and costs.ConclusionThis trial verifies whether a prescribed and supervised exercise programme, including both aerobic and resistance training, is more effective than conventional exercise counselling in reducing modifiable CVD risk factors in type 2 diabetic subjects with the metabolic syndrome.     

Long-term outcomes of lifestyle intervention to prevent type 2 diabetes in people at high risk in primary health care

AimsThe Finnish National Diabetes Prevention Program (FIN-D2D) was the first large-scale diabetes prevention program in a primary health care setting in the world. The risk reduction of type 2 diabetes was 69% after one-year intervention in high-risk individuals who were able to lose 5% of their weight. We investigated long-term effects of one-year weight change on the incidence of type 2 diabetes, cardiovascular events, and all-cause mortality.MethodsA total of 10,149 high-risk individuals for type 2 diabetes were identified in primary health care centers and they were offered lifestyle intervention to prevent diabetes. Of these individuals who participated in the baseline screening, 8353 had an oral glucose tolerance test (OGTT). Complete follow-up data during one-year intervention were available for 2730 individuals and those were included in the follow-up analysis. The long-term outcome events were collected from national health registers after the median follow-up of 7.4 years.ResultsAmong individuals who lost weight 2.5?4.9% and 5% or more during the first year, the hazard ratio for the incidence of drug-treated diabetes was 0.63 (95% CI 0.49?0.81, p = 0.0001), and 0.71 (95% CI 0.56?0.90, p = 0.004), respectively, compared with those with stable weight. There were no significant differences in cardiovascular events or all-cause mortality among study participants according to one-year weight changes.ConclusionsHigh-risk individuals for type 2 diabetes who achieved a moderate weight loss by one-year lifestyle counseling in primary health care had a long-term reduction in the incidence of drug-treated type 2 diabetes. The observed moderate weight loss was not associated with a reduction in cardiovascular events.     

Impact of diabetes education teams in primary care on processes of care indicators

AimsTo evaluate the impact of the integration of onsite diabetes education teams in primary care on processes of care indicators according to practice guidelines.MethodsTeams of nurse and dietitian educators delivered individualized self-management education counseling in 11 Ontario primary care sites. Of the 771 adult patients with HbA1c ≥7% who were recruited in a prospective cohort study, 487 patients attended appointments with the education teams, while the remaining 284 patients did not (usual care group). Baseline demographic, clinical information, and patient care processes (diabetes medical visit, HbA1c test, lipid profile, estimated glomerular filtration rate, and albumin-to-creatinine ratio, measuring blood pressure, performing foot exams, provision of flu vaccine, and referral for dilated retinal exam) were collected from patient charts one year before (pre period) and after (post period) the integration began. A multi-level random effects model was used to analyze the effect of group and period on whether the process indicators were met based on practice guidelines.ResultsCompared to the usual care group, patients seen by the education teams had significant improvements on indicators for semi-annual medical visit and annual foot exam. No significant improvements were found for other process of care indicators.ConclusionsOnsite education teams in primary care settings can potentially improve diabetes management as shown in two process of care indicators: medical visits and foot exams. The results support the benefits of having education teams in primary care settings to increase adherence to practice guidelines.     

Efficacy of dietary intervention or in combination with exercise on primary prevention of cardiovascular disease: A systematic review

Background and aimLifestyle factors heavily influence the development of cardiovascular disease (CVD); therefore, interventions delivering adequate lifestyle changes may improve the prognosis among patients at cardiovascular (CV) risk. Recently published research on the effectiveness of dietary and exercise intervention programmes, alone or combined, on reducing risk factors associated with CVD as well as preventing CV events have been now assessed.Methods and resultsUsing the Medline database via PubMed, we searched for prospective studies published between January 2000 and January 2020 assessing the efficacy of dietary interventions alone or in combination with exercise on reducing CV risk factors or events in human adults at risk. Study quality was assessed using the American Dietetic Association Quality Criteria Checklist.From 934 articles, 21 prospective experimental design studies (15 randomized controlled trials (RCTs), one cluster RCT, and five quasi-experimental intervention studies with a control group) met inclusion and exclusion criteria. Most interventions improved at least some markers of CV risk and the most improvement was time devoted to physical activity increased. A low-fat intervention diet seemed to be effective only when coupled with moderate intensity exercise and weight loss, while a Mediterranean diet (MedDiet) intervention without physical activity, decreased both systolic and diastolic blood pressure, major CV events rate and risk of developing type 2 diabetes.ConclusionThe MedDiet appears to have the most beneficial effect on CV events and increased hours of physical training are strongly related to greater improvement of risk factors; nevertheless, adherence to intervention is fundamental as it directly relates to health outcomes.     

Effects of therapeutic lifestyle changes on peripheral artery tonometry in patients with abdominal obesity

Background and aimsAbdominal obesity (AO) is associated with endothelial function (EF) alteration and increased global cardiovascular (CV) risk. Therapeutic lifestyle changes (TLSC) reduce CV risk, but the impact on EF assessed by peripheral artery tonometry (PAT) is unknown. In this study, we aimed to prospectively assess the effects of TLSC on EF measured by PAT in increased CV risk patients with AO.Methods and results150 patients with AO and moderate CV risk were randomized to groups receiving a one-year intervention of either conventional medical care (control group, CG) or an intensive TLSC program (intervention group, IG). Vascular studies (EF by PAT, intima-media thickness (IMT)) and lifestyle (LS) assessment were performed before and after intervention. The PAT ratio improved in the IG and worsened in the CG. The global CV risk was reduced (P = 0.017) in the IG due to a significant decrease in systolic blood pressure (P < 0.001), increase in HDL cholesterol and ApolipoproteinA1 (P = 0.013). More individuals in the IG than in the CG quit smoking (P = 0.001) and increased their physical activity (P = 0.014). The improvement in at least two LS components was associated with a PAT ratio increase (2.44 IC: 95% 0.99–6.00, P = 0.051). The PAT ratio increase determined less IMT progression (?1.1 IC: 95% 0.91–1.00, P = 0.053).ConclusionsGood adherence to a TLSC program reduces global CV risk and determines PAT ratio improvement. The PAT ratio increase is the main determinant of lower IMT progression.     

Low-doses aspirin in the primary prevention of cardiovascular disease in patients with diabetes: Meta-analysis stratified by baseline cardiovascular risk

Background and aimThe aim of this meta-analysis was to analyze the risks and benefits of low-dose aspirin in patients with T2D without cardiovascular conditions according to the baseline cardiovascular risk.MethodsWe performed a meta-analysis including randomized clinical trials that evaluated the use of low-dose aspirin (75–100 mg/day) versus placebo/usual care in patients with T2D. Studies were classified as low, moderate and high risk based on the number of events in the placebo/control arms or by cardiovascular risk score when reported. The incidence of MACE, cardiovascular mortality and bleeding were evaluated.ResultsTen eligible trials (34069 patients) were considered eligible for the analyses. According to the stratified analysis, low-dose aspirin use was associated with reduced risk for MACE in the moderate/high-risk group (OR: 0.88; 95% CI, 0.80–0.97; I² = 0%) but not in the low-risk group (OR: 0.89; 95% CI, 0.77–1.01; I² = 0%). Likewise, low-dose aspirin use was associated with more bleeding in the low-risk group, showing a non-significant trend in the moderate/high-risk group. There was no reduction in cardiovascular mortality in either group. Beyond the different findings in each stratum, the differences between the subgroups were not statistically significant.ConclusionThis study showed that low-dose aspirin in patients with T2D reduces MACE and increases bleeding. Based on the within-subgroups results, the baseline cardiovascular risk does not modify the effect of aspirin therapy. However, few studies were included and the comparison between subgroups showed a trend in favor to the highest risk group, these results should be confirmed in future studies.     

Reducing metabolic syndrome through a community-based lifestyle intervention in African American women

Background and aimsMetabolic syndrome (MetS) increases the risk of cardiovascular disease and type 2 diabetes. Despite a higher prevalence of MetS in African American (AA) women, little is known about the effectiveness of lifestyle interventions in improving metabolic markers in this high-risk group. This study investigated the effectiveness of a community-based lifestyle intervention delivered by lay health coaches in reducing MetS among AA women.Methods and resultsA cluster-randomized diabetes prevention program (DPP) was implemented in 11 churches utilizing a community-based participatory research (CBPR) approach to develop and deliver the interventions. A total of 221 adults, AA women who were overweight or obese, and did not have diabetes were included in this study. The prevalence of MetS was 42.08% before receiving the DPP intervention and 31.22% after the intervention that represented a 10.86% absolute reduction and a 25.81% relative reduction from baseline. The adjusted odds ratio (OR) of being free from MetS at post-intervention in contrast to baseline was 2.14 (p = 0.02). Factors that increased the odds of being free from MetS were younger age, reduction in intake of total calories, total fat, saturated and trans-fat, and dietary sodium.ConclusionA faith adapted lifestyle intervention held in church settings and delivered by minimally trained lay health coaches reduced the prevalence of MetS in AA women who were overweight or obese. Findings from this study can be used to translate evidence into public health programs at the community level for the prevention of type 2 diabetes and cardiovascular disease.Clinical trial registration numberNCT 04082702 (www.clinicaltrials.gov).     

Mortality Rates in Treated Hypertensive Men With Additional Risk Factors Are High But Can Be Reduced: A Randomized Intervention Study

The aim was to examine the feasibility and efficacy of a multifactorial risk factor intervention program in hypertensive patients at high cardiovascular risk. Treated hypertensive men, aged 50 to 72 years, with at least one of the following: serum cholesterol concentration ≥ 6.5 mmol/L, diabetes mellitus, or smoking were randomized to multifactorial risk factor intervention (n = 253) or usual care (n = 255). The specific intervention was based on group meetings to encourage a lipid lowering diet and smoking cessation. Cholestyramine, nicotinic acid, fibrates, and later statins were used either as single drug therapy or in combination, following agreed guidelines in patients in whom the nonpharmacological intervention was judged to be insufficient. Usual care was given according to clinical practice. The median follow-up time was 6.6 years. Sixty-four patients (25.1%) died in the usual care group, compared with 41 patients (16.2%) in the intervention group (P = .016; 95% confidence interval, relative risk 0.42 to 0.92). The overall risk for fatal and nonfatal cardiovascular events was 29% lower in the intervention group than in the usual care group (P = .041). Relative to usual care, the intervention program lowered mean in-trial serum concentrations of total cholesterol (6.3%, P < .0001), LDL cholesterol (9.1%, P < .0001), and blood glucose (0.2 mmol/L, P < .05). Among smokers, at entry, cotinine-adjusted quit rates were 28% in the intervention group and 11% in the usual care group (P = .012) after 3 years.This study illustrates the very high cardiovascular risk in hypertensive patients 50 to 72 years of age with additional risk factors. The results indicate, however, that the gloomy prognosis may be improved by a dedicated risk factor intervention program.     

Telemedicine Intervention to Improve Long-Term Risk Factor Control and Body Composition in Persons with High Cardiovascular Risk: Results from a Randomized Trial: Telehealth strategies may offer an advantage over standard institutional based interventions for improvement of cardiovascular risk in high-risk patients long-term

Background:Telehealth strategies are increasingly used to support people at high cardiovascular risk long-term, but is it unclear if these interventions are effective at improving cardiovascular risk.Objective:To evaluate the effects of a telemedicine technology-based program on risk factor control and body composition in patients at high cardiovascular risk.Methods:This is a population based randomized controlled trial. 100 patients at high and very high cardiovascular risk were randomly assigned to a telemedicine technology-based program consisting of: Comprehensive counseling on risk factors delivered by a physician; biweekly remote support via phone delivered by a trained nurse during the first three months after enrollment; and a control group receiving routine care with individual single-session counseling on patients’ current risk factors without further support. The follow-up period was 1 year.Results:Mean age of participants was 59.9 ± 4.5 years, 80% were women. Weight (–0.582; p < 0.001), waist circumference (–0.429; p = 0.01), body mass index (–0.216; p < 0.001) diastolic blood pressure (–0.881; p = 0.04), total cholesterol (–0.149; p = 0.01) and LDL cholesterol (–0.123; p = 0.003) were lower in the intervention group compared to the control group after 12-month. Body fat mass was also lower (–0.352; p = 0.01) and lean mass was higher (0.92; p = 0.03) in the intervention group. Anxiety scores (–2.5; p < 0.002) and depression scores (–2.6; p < 0.001) were also lower in the intervention group.Conclusions:Among older people at high cardiovascular risk, the addition of telehealth strategies using remote support by phone calls over a period of 3 month resulted in small but significant improvements of cardiovascular risk factors, body composition, anxiety, and depression which are maintained long-term. Such telehealth strategies may offer an advantage over standard institution-based interventions.     

Effects of a general practice-based intervention on diet,body mass index and blood lipids in patients at cardiovascular risk

BACKGROUND: General practice-based health-promotion programmes implemented by nurse-counsellors may reduce cardiovascular risk factors, particularly in patients at increased risk. DESIGN: In a randomized controlled trial, trained nurse-counsellors delivered cognitive behavioural programmes aiming to reduce cardiovascular risk in patients with hypertension, Type 2 diabetes mellitus or coronary heart disease. Of 591 eligible patients from seven general practices in Perth, Western Australia, 212 agreed to participate and were randomized to one of three groups. In the 'Low' intervention (n = 69), monthly telephone contacts for 1 year followed one face-to-face individual counselling session; in the 'High' intervention (n = 74) individual face-to-face counselling continued over 1 year, taking place monthly, for up to 1 h; Controls (n = 69) received usual care only. Participants were assessed at baseline with follow-up 12 and 18 months later. RESULTS: Follow-up assessments were attended by 77, 71 and 65% of the Control, 'Low' and 'High' groups, respectively. Total fat intake fell by 9, 12 and 5% in the 'High', 'Low' and Control groups, respectively, at 12 months and by 2, 10 and 5% at 18 months. Total serum cholesterol fell by 3, 3 and 2% in the 'High', 'Low' and 'Control' groups, respectively, at 12 months and by 7, 5 and 8% at 18 months. Neither change in fat intake nor serum cholesterol differed significantly between groups. Body mass index increased in all groups with no significant changes related to the programme. CONCLUSIONS: Programmes using nurse-counsellors were not significantly more successful than usual care from general practitioners, consistent with reported benefits of lifestyle advice from primary-care physicians.     

Long-term effects of a collaborative care intervention in persistently depressed primary care patients

OBJECTIVE: A previous study described the effect of a collaborative care intervention on improving adherence to antidepressant medications and depressive and functional outcomes of patients with persistent depressive symptoms 8 weeks after the primary care physician initiated treatment. This paper examined the 28-month effect of this intervention on adherence, depressive symptoms, functioning, and health care costs. DESIGN: Randomized trial of stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe and moderate depression groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and a primary care physician. MEASURES AND MAIN RESULTS: The collaborative care intervention was associated with continued improvement in depressive symptoms at 28 months in patients in the moderate-severity group (F1,87 = 8.65; P =.004), but not in patients in the high-severity group (F1,51 = 0.02; P =.88) Improvements in the intervention group in antidepressant adherence were found to occur for the first 6 months (chi2(1) = 8.23; P <.01) and second 6-month period (chi2(1) = 5.98; P <.05) after randomization in the high-severity group and for 6 months after randomization in the moderate-severity group(chi2(1) = 6.10; P <.05). There were no significant differences in total ambulatory costs between intervention and control patients over the 28-month period (F1,180 = 0.77; P =.40). CONCLUSIONS: A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.     

Occupational health care identifies risk for type 2 diabetes and cardiovascular disease

AimsTo assess the risk for type 2 diabetes (T2D) and cardiovascular disease (CVD) among employees of a Finnish airline; to study the association of shift work with T2D and CVD risk; and to test the feasibility of risk screening in occupational health care setting.MethodsAltogether 4169 employees were invited for a health check-up and 2312 participated in this study. The check-up included physical examinations, questionnaires on working hours, sleep, and lifestyle, diabetes risk score FINDRISC, and blood tests. Lifestyle counselling was offered for those with increased T2D risk.ResultsAltogether 15% of participants had a high T2D risk (FINDRISC ≥ 15 and/or elevated, but non-diabetic blood glucose), and a further 15% had a moderate T2D risk (FINDRISC 10–14 and normal blood glucose). Of those 60% agreed to attend lifestyle counselling. Metabolic syndrome was more common, lipid profile more unfavorable and hsCRP higher by increasing FINDRISC score category. Risk factor profiles linked to shift work status were not self-evident.ConclusionsThe renewed health check-up process effectively identified those employees with increased T2D and CVD risk who would benefit from lifestyle intervention. The use of FINDRISC questionnaire was a feasible first-step screening method in occupational health care setting.