An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial

Abstract

BackgroundImplementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care.MethodsPEP Intervention practices received education, clinical audit and feedback and practice facilitation.Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires.Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar’s test and multilevel analysis was used to determine the effect of the intervention on follow-up scores.ResultsFive hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes.ConclusionsThe lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures.Trial registrationAustralian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Beliefs and attitudes towards lifestyle change and risks in primary care – a community-based study

“…social cognitive theory [19], the transtheoretical model of change [24], or self-affirmation on health-behavior change [25] may be beneficial in understanding resistance towards beneficial health information and in reducing it. The essential goal is to implement functioning theory-based health promotion in everyday primary care actions [11]. However, the current health promotion strategies do not seem to be beneficial in practice.…”

“…It has been suggested that in order to be more effective, health promotion should be more personalized and adapted more to individual characteristics and readiness for health behavior change [8]. Because of the complexity in the health behavior of the population, there is an evident need for individual assessment and goal setting, educating and training, and following up on the subjects to whom the lifestyle interventions are targeted [11]. The epidemiological evidence or medical knowledge oriented toward risks and dangers alone may not be efficient in health promotion.…”

Promoting physical activity in primary care: a systematic review and meta-analysis

“…All studies except one, 15 which did not show follow-up data, reported data loss. Thirteen studies used an intention-to-treat analysis; 17 , 19 , 21 , 24 , 26 – 28 , 30 , 31 , 34 , 35 , 37 , 38 the other studies did not report how they approached the missing data in the analyses. Further bias might have been introduced in 18 studies either by not reporting fidelity data, or through low fidelity to the intervention.…”

“…In nine studies, the intervention was delivered by primary care physicians, 15 , 17 – 19 , 24 , 32 , 33 , 36 , 38 in 10 by practice nurses, 20 – 22 , 25 – 29 , 30 , 34 and in five by both. 16 , 23 , 31 , 35 , 37 Fourteen studies evaluated a PA intervention 16 – 19 , 23 , 25 , 27 – 29 , 31 , 33 – 36 and 10 a lifestyle intervention. 15 , 20 , 21 , 22 , 24 , 26 , 30 , 32 , 37 , 38 Three studies included a single behaviour change consultation as intervention, 16 – 18 and 10 studies a baseline behaviour change consultation with follow-up visits or phone call.…”

Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors

“…To date, it remains unclear how effective audits and feedback are at improving clinical practice, and which characteristics of audits and feedback have the greatest impact [23,24]. Several studies conducted in the primary care setting have attempted to determine the effects of audit and feedback interventions in cardiovascular health [25,26,27,28,29,30,31]. In an article that evaluated the effects of audit and feedback on secondary prevention in patients with non-acute stroke, blood pressure and metabolic control were considered adequate in 73% of patients with hypertension and 62% of patients with diabetes, respectively [25].…”