Community programmes for coronary heart disease in Spanish primary care

Authors

  • Eva Frigola-Capell,

    Corresponding author
    1. Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
    2. Avedis Donabedian Research Institute (FAD), Barcelona, Spain
    3. Universitat Autònoma de Barcelona, Barcelona, Spain
    4. Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
    • Correspondence to: E. Frigola-Capell, Instituto Universitario Avedis Donabedian, Universitat Autònoma de Barcelona, C/Provença 293, pral. 08037 Barcelona, Spain. E-mail: fad@fadq.org; eva.frigola@gmail.com

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  • Jan van Lieshout,

    1. Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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  • Miguel A. Muñoz,

    1. Universitat Autònoma de Barcelona, Barcelona, Spain
    2. Unitat de Suport a la Recerca Barcelona ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
    3. Institut Català de la Salut, Barcelona, Spain
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  • Jose Verdú-Rotellar,

    1. Universitat Autònoma de Barcelona, Barcelona, Spain
    2. Institut Català de la Salut, Barcelona, Spain
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  • Francesc Orfila,

    1. Unitat de Suport a la Recerca Barcelona ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
    2. Institut Català de la Salut, Barcelona, Spain
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  • Rosa Suñol,

    1. Avedis Donabedian Research Institute (FAD), Barcelona, Spain
    2. Universitat Autònoma de Barcelona, Barcelona, Spain
    3. Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
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  • Michel Wensing

    1. Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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SUMMARY

Objective

To explore the added value of community-orientated programmes aimed at enhancing healthy lifestyles associated with the key components of cardiovascular risk management (CVRM) in coronary heart disease (CHD) patients.

Methods

Observational study in Spain, including 36 practices, 36 health professionals, and 722 CHD patients (mean (SD) age 72 (11.73)). Our predictor variable of interest was reported deliveries from primary care practices (PCPs) concerning community-orientated programmes such as physical exercise and smoking cessation groups. Data were obtained through structured questionnaires administered to PCP health professionals. Our CVRM outcome measures were as follows: recorded risk factors, drug prescriptions, and intermediate patient outcomes (blood pressure levels, low-density lipoprotein cholesterol, and body mass index).

Results

Thirty practices delivered community programmes: most delivered one [17 (47.2%) practices] or two [11 (30.5%) practices]. These educational programmes aimed to encourage enhanced healthy lifestyles through group counselling sessions, mailed print material, and one-to-one counselling. In PCPs delivering community programmes, more patients received antihypertensives (89.7%), antiplatelet therapy (80.5%), and statins (70.8%) than those PCPs without programmes, although there were no statistically significant differences between them.

Conclusions

No evidence was found for the added value of community-orientated CVRM programmes that could help health professionals refine criteria when including CHD patients in preventive programmes. Copyright © 2014 John Wiley & Sons, Ltd.

Introduction

In spite of recent progress in reducing mortality, coronary heart disease (CHD) remains one of the leading worldwide causes of death (European Society of Cardiology, 2012). Evidence-based recommendations on improving lifestyle (smoking cessation (Critchley and Capewell, 2004), physical exercise (Jolliffe et al., 2000), diet (Hooper et al., 2012), and alcohol intake (Corrao et al., 2000)) and drug treatment (statins (Law et al., 1994, 2003; CTT Collaborators, 2005; Kotseva et al., 2009), antihypertensive therapy (Fourth Joint Task Force of the European Society of Cardiology and Other Societies, 2007; Kotseva et al., 2009) and antiplatelet therapy (European Society of Cardiology, 2007)) have been incorporated as performance measures within a number of health quality frameworks, particularly in primary care, where patients at high cardiovascular risk or with an established cardiovascular disease receive preventive treatment (Bodenheimer et al., 2002). Community management of cardiovascular disease patients can be cost-effective, for instance by avoiding hospitalisation (Frigola Capell et al., 2013). The optimum way to deliver and achieve prevention for targets within this setting is, however, still unclear. Interventions aimed at enhancing healthy lifestyles in the community have been carried out by primary care professionals (Eriksson et al., 2006; Lakerveld et al., 2012) and community providers (Krantz et al., 2013) with mixed results. In addition, the profile of patients that can benefit from referral is yet to be elucidated. Nevertheless, community-based preventive activities, complementing usual care contacts, are employed in the Spanish primary care setting.

Primary care in Spain is organised as a network of large practices that functions as geographical and administrative units. They are staffed by full-time equivalent (FTE) family physicians (FPs) (from 4 to 36) together with nurses, dentists, paediatricians, and social and ancillary workers. Patients are registered at their corresponding practice. FPs can refer patients and act as gatekeepers to other care providers (Bolíbar et al., 2008). Primary care practices (PCPs) are responsible for delivering the health promotion and preventive activities programme (PAPPS) (Gofin and Foz, 2008) developed by the Spanish Society of Family Medicine (SemFYC), which integrates international guidelines on cardiovascular prevention. There is, however, some variability among PCPs with respect to strategies (individual contacts with FPs/nurses and complementary community interventions) employed to implement preventive activities in the community for cardiovascular disease patients. Theoretical frameworks for quality improvement in chronic diseases, such as in the Chronic Care Model (CCM), have included the community approach. The CCM emphasises the fact that chronic diseases require the integration of several aspects into a health system (Wagner et al., 1996) and identifies six essential elements: healthcare organisation, delivery system design, decision support, clinical information systems, self-management support, and community resources and policies (Bodenheimer et al., 2002). Mixed results have been reported concerning the contribution of each domain to patient outcomes. Self-management support, clinical information systems, and decision support have been found to be associated with better outcomes and processes (Tsai et al., 2005; van Lieshout et al., 2012a, 2012b). Less research has been performed, however, on the implementation of community resources in order to evaluate their relative effectiveness (Tsai et al., 2005). Evidence on how PCPs delivered community interventions influence patients' performance can contribute to a better understanding of primary healthcare competence and management.

Our aim was to examine whether the delivery of community-orientated programmes to enhance healthy lifestyles was associated with the quality of cardiovascular risk management (CVRM) in patients with CHD.

Methods

This study was part of the European Practice Assessment (EPA) Cardio project, an international observational study on CVRM performed in 10 European countries (Wensing et al., 2009). Study design, participant inclusion, and outcome measures have been previously described (van Lieshout et al., 2012a, 2012b). Briefly, an exploratory cross-sectional study, including a random sample of 36 practices representing rural and urban settings (cut-off 100 000 inhabitants) in Catalunya (a Spanish region with a population of 7 210 508 (B.O.E., 2007)), was carried out. Each practice provided data for patients with prevalent CHD (I20–I25) registered with their FPs. Patients with diabetes were excluded. On the basis of the statistical accuracy of the estimates for each participant country in the EPA Cardio project (Wensing et al., 2009), we aimed for a minimum of 15 randomly selected CHD patients per practice. Approval was obtained from The Catalan Primary Care Research Institute IDIAP Jordi Gol ethics committee, overseen by the Spanish Ministry of Health.

Our CVRM outcome measures were based on European guidelines (European Society of Cardiology, 2007) for the prevention and management of CHD and the validated EPA instrument (Engels et al., 2006) composed of indicators measuring quality performance in primary care. Data on the prescription of antihypertensive and antiplatelet therapy, and statins, according to the Anatomical Therapeutic Chemical Classification System, were collected. Intermediate patient outcomes included systolic and diastolic blood pressure, total cholesterol and low-density lipoprotein cholesterol (LDL), and weight and body mass index (BMI). We also collected information on age, gender, region (rural/ urban), and diagnosis of hypercholesterolemia (E78) and hypertension (I10) according to the International Classification of Diseases, Tenth Revision. Data were extracted from electronic medical records. None of the individuals responsible for data collection was involved in the subsequent analysis.

As a predictor variable in the post hoc analysis (van Lieshout et al., 2010), items from the validated EPA instrument were employed to collect information on the participation of the PCPs in community programmes to enhance healthy lifestyles. Structured questionnaires, to be completed by the FP or nurse participating in the study, asked the following: (1) Has there been a public health project concerning cardiovascular risk in your practice in the last 2 years? (e.g. physical exercise and smoking cessation)?; (2) did nurses take part in educational activities about cardiovascular disease risk factors (e.g. diet, exercise, and smoking) in schools?; (3) did FPs participate in local/community campaigns or activities concerning cardiovascular disease risk prevention (e.g. smoking cessation campaigns and fun-runs)?; and (4) did nurses take part in local/community campaigns or activities concerning cardiovascular disease risk prevention (e.g. smoking cessation campaigns and fun-runs)?

Descriptive data for age, gender, and prevalence of relevant variables were calculated for all patients. Chi-square and Student's t-test for categorical and continuous variables were used in bivariate analysis to compare patients registered in PCPs with and without delivery of cardiovascular risk reduction programmes. Question 1 of the structured questionnaire reported information on programmes to enhance healthy lifestyles delivered at the PCPs. Questions 2, 3, and 4 provided descriptive information about PCP involvement in community activities related to cardiovascular disease. Multilevel analysis was performed establishing PCPs as random units in order to control variability associated with clinical practice in primary care. Descriptive and bivariate analyses were carried out with SPSS Inc. v18 software. Multilevel analysis was performed with Stata/IC 11.0.

Results

Sixty-six potentially eligible PCPs from the urban setting (population 558 515) and 37 rural ones (population 480 827) were initially identified. In order to accurately reflect the Spanish primary care system in our region, 36 PCPs (with 490 FTE FPs) were randomly included. They were composed of 21 from rural areas (269.35 FTE FPs) and 15 from urban ones (220.7 FTE FPs). Each PCP provided an FP as a research contact.

Community programmes to enhance healthy lifestyles

Approximately 90% of the PCPs participated in public healthcare programmes on lifestyle and in local/community campaigns or activities concerning cardiovascular disease risk prevention. The participation of nurse practitioners was higher (88.8%) than FPs (66.7%). Thirty (83%) practices delivered educational community programmes to enhance healthy lifestyles, the majority implemented either one [17 (47.2%) practices] or two [11 (30.5%) practices] simultaneous programmes (Table 1). The CVRM programmes were offered in group counselling sessions with supplementary mailed print material. Motivation for an active lifestyle was promoted through exercise sessions consisting of walks adapted to recruited patients. The sessions were held by PCP staff, usually nurse practitioners or allied health professionals. They were available for any patient registered at the practice who fulfilled the inclusion criteria.

Table 1. Description of programmes to enhance healthy lifestyles
Name of interventionGoalType of interventionPractices (n = 36)Patients (n = 722)
High Blood pressure reduction programmeEducation/motivation to reduce blood pressureGroup counselling sessions; mailed print material8 (22.2%)159
Obesity reduction programmeEducation/motivation to reduce weightGroup counselling sessions; mailed print material2 (5.6%)30
Exercise promotion programmeEducation/motivation to an active lifestyleGroup counselling sessions; mailed print material22 (61.1%)435
Diet education programmeEducation/motivation to change diet habits.Group counselling sessions; mailed print material4 (11.1%)118
Smoking cessation programmeEducation/motivation to stop smokingOne-to-one counselling/group counselling sessions; mailed print material9 (25%)218

Cardiovascular risk management provided to patients

Data were collected from 722 patients registered at the participating PCPs, 282 from rural settings and 440 from urban ones. PCPs from urban settings delivered significantly (p < 0.001) more programmes to enhance healthy lifestyles than rural areas (Table 2). Mean age for our sample was 72 years (SD 12) with 50.7% of patients ≥ 60 years and 37% women (Table 2). With respect to age, gender, prevalence of hypercholesterolemia, smoking, and hypertension, there were no significant differences between patients registered in PCPs with and without programmes to enhance healthy lifestyles. In the overall sample, drug prescription was high for antihypertensive (88.9%) and antiplatelet therapy (80.2%) and somewhat lower for statins (69.5%).

Table 2. Patient characteristics
N patients = 722; N practices = 36
  • *

    Primary care practices from urban settings significantly (p < 0.001) implement more risk reduction programmes.

Age (mean, SD)72 (12)
Gender (female)267 (37)
Smoking, N (%)54 (7.5)
Men over 60 years old (%)366 (50.7)
Hypercholesterolemia (%)230 (31.9)
High blood pressure (%)442 (61.2)
Patients from urban/rural setting440 (60.9)/282 (39.1)*
Systolic blood pressure (mean, SD)131.09 (16.14)
Diastolic blood pressure (mean, SD)72.56 (10.05)
Total cholesterol (mean, SD)182.69 (36.51)
LDL (mean, SD)104.04 (28.64)
Weight (mean, SD in kg)74.06 (14.47)
BMI (mean, SD)28.38 (4.6)
Prescription of statins (%)502 (69.5)
Antihypertensive therapy (%)642 (88.9)
Antiplatelet therapy (%)579 (80.2)

In practices delivering programmes to enhance healthy lifestyles, patients received more antihypertensive therapy (89.7%), antiplatelet therapy (80.5%), and statins (70.8%; Table 3). Nonetheless, the bivariate analyses showed no significant differences for drug prescription, risk factor registration, and intermediate patient outcomes. Differences were found for the prescriptions of statins, although after adjusting for random differences between PCPs, this effect was no longer significant. Registration of BMI was low in both groups.

Table 3. Management of patients listed in practices with and without delivery of programmes to enhance healthy lifestyles
 Delivery of programmes to enhance healthy lifestyles
WithWithoutp-value
N patients = 650N patients = 72
N practices = 30N practices = 6
  • *

    Multilevel analysis showed no significant difference in statin prescription (p = 0.084).

Risk factor registration
Blood pressure484 (74.5)58 (80.6)0.31
Total cholesterol, N (%)394 (60.6)48 (66.7)0.37
BMI, N (%)212 (32.6)27 (37.5)0.43
Risk factor management
Systolic blood pressure, mmHg (mean, SD)130.77 (15.77)133.81 (18.99)0.18
Diastolic blood pressure, mmHg (mean, SD)72.64 (9.85)71.93 (11.62)0.61
Total cholesterol, mg/dl (mean, SD)183.20 (37.18)178.52 (30.59)0.40
LDL (mean, SD)104.28 (29.48)102.29 (21.98)0.67
Weight, kg (mean, SD)73.79 (14.32)76.40 (15.72)0.33
BMI (mean, SD)28.33 (4.61)28.80 (4.74)0.62
Risk factor control
Blood pressure: % patients with BPSYS and BPDIAS < 140/90 mmHg352 (54.2)37 (51.4)0.71
BMI: % patients with BMI <25 kg/m245 (6.9)4 (5.6)0.81
% patients with total cholesterol < 175 mg/dl170 (26.2)20 (27.8)0.78
LDL: % patients with LDL < 100 mg/dl151 (23.2)19 (26.4)0.56
Drug prescription
Statins (%)460 (70.8)42 (58.3)0.04*
Antihypertensive therapy (%)583 (89.7)59 (81.9)0.07
Antiplatelet therapy (%)523 (80.5)56 (77.8)0.64

Discussion

In our sample of PCPs, the delivery of community-orientated programmes to enhance healthy lifestyle was not associated with improved CVRM in CHD patients, although the prescription of preventive medication tended to be greater.

The CCM emphasises that implementation of the six components of the model is required to achieve high-quality healthcare for patients with chronic diseases because of its supporting synergistic effects. The advantages, however, of implementing these multiple components rather than a single one have yet to be elucidated (Tsai et al., 2005). In the literature, self-management, decision support, and clinical information systems have been found to be associated with better outcomes and processes (Tsai et al., 2005; van Lieshout et al., 2012a, 2012b). In contrast, there has been less research focused on the relationship between community resources and patients with chronic illness. Our results appear to suggest that community resources were not linked to the quality of clinical process and intermediate patient outcomes in CHD patients. This finding may be related to the wide implementation in Spain of most of the CCM elements (van Lieshout et al., 2010) and the fact that patients with established cardiovascular disease probably already received a relatively high amount of support and counselling.

Community programmes for enhancing healthy lifestyles in primary care have not been uniformly successful (Ebrahim and Smith, 1997). For instance, in Europe, two primary care-based community interventions aimed at lifestyle improvement for patients at cardiovascular risk found contrasting results. One, a Dutch study (Lakerveld et al., 2012), reported no effects on determinants of behavioural change. The other, however, a Swedish trial, observed positive effects (decreased body weight, waist and hip circumference, BMI, waist–hip ratio, systolic and diastolic blood pressure, triglycerides, and glycosylated haemoglobin) (Eriksson et al., 2006). In an Australian study, no clear benefits were reported for blood lipids, diet, or BMI from patients at cardiovascular risk participating in an intensive programme that required considerable time commitment from nurse/counsellors with respect to the routine care provided by concerned FPs (Woollard et al., 2003). On the other hand, in the USA, a community health worker-based programme was successful in reducing 10-year CHD risk and improving dietary patterns, weight, blood pressure, and cholesterol levels (Krantz et al., 2013).

Such a variability of findings in the literature could be explained by a range of factors, including patient selection, targeted population, type of intervention (individual or group counselling), health policies, service provider (primary care or community-based), and the quality of the intervention itself (calibre of the counselling techniques, targeted barriers, and professional skills). A number of factors hindering lifestyle behavioural changes have been associated with both primary care professionals and patients. With respect to the former, issues such as time constraints, costs, and lack of counselling skills (Hobbs and Erhardt, 2002; Peterson, 2007) may play a role, whereas in patients, dissatisfaction with the quality of counselling received in primary care (Moore et al., 2000), lack of will power (Wiles, 1998; Rustveld et al., 2009), reluctance to change culturally rooted behaviour (Rustveld et al., 2009), and fatalism regarding the course of their disease in terms of that no action would guarantee protection (Wiles, 1998; Rustveld et al., 2009) have been observed.

The role of the FPs in providing benefits for patients at cardiovascular risk can be crucial (Woollard et al., 2003). There is evidence that primary care professionals can be encouraged, through a number of strategies, to increase the amount of lifestyle advice they offer (Anderson, 2008). Outside this setting, specialised community-based providers have been shown to be able to overcome patients' barriers by focusing on education and improving quality of care and health outcomes. In addition, providers have addressed community-level factors hindering the adoption of healthy habits (Jilcott et al., 2006; Krantz et al., 2013).

In the Spanish environment, previous experience has shown that within the context of a national target or research agenda, PCPs are capable of delivering successful public health programmes. For instance, the ISTAPS smoking cessation programme involved 176 PCPs around Spain in a 6-month intervention. It consisted of implementing recommendations from an evidence-based clinical practice guideline to targeted patients and achieved positive outcome results (Cabezas et al., 2011). The individuals who benefited from this intervention, however, were younger (mean age 42 years) and comorbidity-free compared with those in our study. The structural organisation of Spanish primary care allows population-based prevention at community level. Nevertheless, the constraints of resources may require the redefinition of criteria to include patients in preventive programmes or the re-adaptation of these programmes. When compared with the international literature, Spanish health professionals perform well. For instance, in contrast to other European countries, high levels of control for systolic and diastolic blood pressure have been reported, although levels of risk factor registration are one of the lowest (van Lieshout et al., 2012a, 2012b).

The optimum way to deliver prevention in the community is still unclear, and further research is required, particularly with respect to cost-effectiveness. Regardless the health provider in charge of delivering care at community level, evidence suggests that the role motivated FPs could play in changing patients' behaviour, both at individual and community levels, is a key factor to take into account. All of which suggest that care needs to be considered as a continuum in order to achieve effective interventions.

Our study has some limitations; its design, patient selection, and measures may have had an effect on the results, in particular, the lack of power of our sample due to the low variability of the predictor variable. The wide implementation of community programmes at PCP level may have been responsible for the fact that the trends we found did not reach significance. For instance, the positive trends identified in the prescription of preventive medicines in those practices delivering programmes to enhance healthy lifestyles. We lacked access to detailed information such as inclusion criteria, quality of the counselling provided, and patient attendance rate. Nevertheless, our aim was not to evaluate the effectiveness of these programmes but rather to examine the added value of community interventions in quality CVRM in patients with an established cardiovascular disease.

Conclusions

The delivery of community-orientated programmes to enhance healthy lifestyles by primary care was not associated with better CVRM in CHD patients. Our findings can help health professionals refine criteria when including patients in preventive programmes.

Acknowledgements

We gratefully acknowledge researchers from the EPA Cardio project in Spain: Josep Davins, Rafel Ramos, Clara Pareja, and Concepció Morera for their aid with the study design and fund raising. We thank Jordi Real for his help and advice on multilevel analysis. We are particularly grateful to Conxa Castell for her fund raising assistance,and to the Primary Health Care University Research Institute Jordi Gol (IDIAP Jordi Gol) for their administrative support. This work was supported by the Bertelsmann Stiftung Foundation and the Ministry of Health of the Government of Catalonia, Spain.

The authors have no competing interests.

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