Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice

Abstract

Objective: To evaluate the effects of feedback reports combined with outreach visits from trained nonphysicians 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.

Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: A systematic review

“…Ten studies implemented national guidelines [11,12,23,25,27,[30][31][32][33]36,37], while four studies adapted national guidelines to be used locally [13,14,21,22,29,34]. In four studies local guidelines were developed by multidisciplinary teams [15][16][17][18]26,28].…”

“…Only significant results: decrease in the prescriptions of inhaled corticosteroids for newly diagnosed COPD patients older than 40 years: GI 0.0 (95% CI: 0.0-0.1), GC 0.5 (95% CI: 0.3-0.9), p = 0.00. Seven studies assessed the implementation of more than one guideline [13,14,26,32,33,36,37]. In total, two studies assessed the implementation of guidelines on osteoarthritis [19,20,37], four on COPD [13,14,25,33,34], four on hypertension [24,32,36,37], six on coronary heart disease [17,18,23,26,32,36,37], six on asthma [13,14,26,27,30,33,34] and finally seven on type two diabetes mellitus [11,12,15,16,21,22,28,29,31,35].…”

“…One study for each Member State was performed in Finland [23], France [24], Germany [19,20], Italy [15,16], Spain [25] and Sweden [17,18], three studies were performed in the UK [26][27][28] and in Denmark [11,12,29,30], while nine studies were performed in the Netherlands [13,14,21,22,[31][32][33][34][35][36][37]. GPs with access to a specific medical information system were included.…”

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

“…Strategies used in these initiatives have included passive dissemination of educational information to health care providers and patients, computerized order sets, automatically generated suggestions for care interventions, automated reminders attached to echocardiography results, as well as intensive education, direct feedback and care support from expert clinicians (161)(162)(163)(164)(165)(166)(167)(168)(169)(170)(171). Strategies that rely on passive dissemination of information to health care providers are, at best, modestly effective (162,167,168).…”

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme

“…Multi-faceted interventions that target practice systems are more effective than single interventions (Grimshaw et al, 2001;Frijling et al, 2003;Margolis et al, 2004;Welschen et al, 2004). Furthermore, the adoption of evidence-based approaches to weight management using an interactive model of communication is critical to empowering patients.…”