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Keywords:

  • atherosclerosis;
  • cardiovascular risk;
  • risk factors;
  • secondary prevention;
  • type 2 diabetes;
  • vascular disease

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

Abstract.  Brouwer BG, Visseren FLJ, Algra A, van Bockel JH, Bollen ELEM, Doevendans PA, Greving JP, Kappelle LJ, Moll FL, Pijl H, Romijn JA, van der Wall EE, van der Graaf Y (University Medical Center Utrecht, Utrecht; and Leiden University Medical Center, Leiden; the Netherlands). Effectiveness of a hospital-based vascular screening programme (SMART) for risk factor management in patients with established vascular disease or type 2 diabetes: a parallel-group comparative study. J Intern Med 2010; 268:83–93.

Aims.  Modification of vascular risk factors is effective in reducing mortality and morbidity in patients with symptomatic atherosclerosis; however, it is difficult to achieve and maintain. The aim of the Risk management in Utrecht and Leiden Evaluation (RULE) study was to assess risk factor status after referral in patients with established vascular disease or type 2 diabetes who took part in the multidisciplinary hospital-based vascular screening programme, Second Manifestations of ARTerial disease, compared with a group who did not participate in such a programme.

Methods and results.  Patients with type 2 diabetes, coronary artery disease, cerebrovascular disease or peripheral arterial disease referred by general practitioners to the medical specialist at the University Medical Center (UMC) Utrecht (a setting with a vascular screening programme of systematic screening of risk factors followed by treatment advice) and the Leiden UMC (a setting without such a screening programme), were enrolled in the study. Blood pressure, levels of lipids, glucose and creatinine, weight, waist circumference and smoking status were measured in patients 12–18 months after referral to the two hospitals.

A total of 604 patients were treated in the setting with a vascular screening programme and 566 in the setting without such a programme; 70% of all patients were male, with a mean age of 61 ± 10 years. Amongst screened patients, systolic blood pressure [2.5 mmHg, 95% confidence interval (CI) 0.3–4.6] and the level of LDL cholesterol (0.3 mmol L−1, 95% CI 0.2–0.4) were lower compared with the group that received usual care, after a median of 16 months from referral.

Conclusion.  Systematic screening of risk factors, followed by evidence-based, tailored treatment advice contributed to slightly better risk factor reduction in patients with established vascular disease or type 2 diabetes. However, a large proportion of patients did not reach the treatment goals according to (inter)national guidelines. Systematic screening of vascular risk factors alone is not enough for adequate risk factor management in high-risk patients.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

After the first clinical manifestation of atherosclerotic vascular disease, patients are at a considerably increased risk of another vascular event at the same or at a different location in the vascular system [1]. Therefore, interventions aimed at secondary prevention are warranted. Several risk factors predispose towards atherosclerosis, including hypertension, hypercholesterolaemia, smoking, hyperglycaemia and obesity. Modification of these risk factors is effective in reducing total mortality and vascular morbidity in patients with symptomatic atherosclerosis [2–4]. However, reduction of risk factors is difficult to achieve and maintain in clinical practice, leaving patients at increased risk [5–10].

Treatment of vascular risk factors in high-risk patients is usually managed by the general practitioner or medical specialists such as internists, cardiologists, vascular surgeons and neurologists. Treatment of vascular risk starts with an assessment of all relevant risk factors. Individual risk factors are then evaluated against current (inter)national guidelines on vascular prevention and, if necessary, lifestyle changes or pharmacological treatments are initiated and monitored.

There are (inter)national guidelines on cardiovascular disease prevention to assist vascular risk factor management [8, 11, 12]. In addition, several programmes for risk assessment and treatment have been developed [13–19]. However, the clinical reality is that not all relevant vascular risk factors are measured in individual patients [20]. At the University Medical Center (UMC) Utrecht, patients are invited to participate in the multidisciplinary vascular screening and prevention programme, Second Manifestations of ARTerial disease (SMART) together with usual care (see Methods for more details). The aim of the Risk management in Utrecht and Leiden Evaluation (RULE) study was to assess risk factor status approximately 1.5 years after referral in patients who took part in the multidisciplinary hospital-based vascular screening programme SMART, compared with patients with established vascular disease or type 2 diabetes who did not participate in such a programme.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

Study design

The RULE study is a two-centre, parallel-group, comparative investigation. The risk profile of high-risk cardiovascular patients, 1.5 years after their referral to one of the two participating hospitals, was determined to investigate the effectiveness of the risk-factor evaluation approach in the two hospitals. Patients in the study were referred by their general practitioner to either the UMC Utrecht or the Leiden UMC. In the UMC Utrecht, most patients with established vascular disease or type 2 diabetes were entered in the prevention programme SMART. There was no such formalised programme at Leiden UMC.

Study population

All patients aged 18–80 years referred by their general practitioner to the UMC Utrecht or the Leiden UMC because of transient ischaemic attack (TIA), minor ischaemic stroke, peripheral arterial disease (PAD), type 2 diabetes mellitus or referred for elective percutaneous transluminal coronary angioplasty because of angina pectoris or myocardial infarction, were invited to participate in the RULE study approximately 1.5 years after their referral date. Patients were enrolled between May 2005 and August 2007. The ethics committees of the two institutions approved the study and written informed consent was obtained from all participants.

Selection of patients

At the UMC Utrecht, patients who were enrolled in the vascular screening programme or those who were identified through the hospital registration system [diagnosis-related group (DRG) registration] were potential participants in the RULE study. DRG typing is the basic registration method of all hospitals in the Netherlands and all patients who are referred to a hospital are registered. Not all patients at the UMC Utrecht participated in the vascular screening programme; some received usual care alone. These patients fulfilled the inclusion criteria but were not enrolled into the SMART screening programme for logistical reasons, the physician did not propose the screening programme or because the patient refused to participate. A total of 80% of the included patients at the UMC Utrecht followed the vascular screening programme in addition to usual care; the remaining 20% of patients were included in the RULE study but did not undergo the vascular screening.

At the Leiden UMC, patients were also identified through the DRG registration and received usual care for vascular risk factor management by their vascular specialist or general practitioner.

Risk factor treatment at the UMC Utrecht

In addition to usual care, patients were offered the opportunity to participate in the multidisciplinary vascular screening and prevention programme SMART, which started in 1996. This two-step programme is offered to patients with recently diagnosed vascular disease or diabetes mellitus and is now part of usual care at the UMC Utrecht. In the first step, patients are screened for risk factors. In the second step, evidence-based, tailored treatment advice is given to the treating physicians. Participating patients completed questionnaires on medical history, family history, symptoms of cardiovascular disease and risk factors, lifestyle habits and quality of life [21]. The following measurements were performed to formulate an individualized treatment plan: blood pressure, body mass index (BMI), waist and hip circumference, blood levels of glucose, creatinine, total cholesterol, triglycerides, homocysteine and HDL cholesterol and LDL cholesterol, and albumin and creatinine concentrations from an early-morning urine sample.

The results of the screening programme for each patient were discussed at a weekly multidisciplinary team meeting with an internist, a vascular surgeon, a cardiologist, a neurologist and a nurse practitioner, and individualized treatment advice regarding vascular risk factors was proposed for each patient. The results of the screening programme together with the treatment advice were reported in writing to the treating vascular specialist and general practitioner. Treatment recommendations were made, according to the Dutch guidelines for cardiovascular risk management [12] (based on the European guidelines for cardiovascular disease prevention [11]), for the management of risk factors, in particular hypertension, hyperlipidaemia, diabetes mellitus, obesity and smoking. The actual treatment was left to the discretion of the general practitioner and the treating vascular specialist. At the time of the RULE study, risk factor treatment of patients was not undertaken by nurse practitioners at this hospital.

Risk factor treatment at the Leiden UMC

Patients at the Leiden UMC received usual care from their medical specialist (internist, cardiologist, neurologist or vascular surgeon) or from their general practitioner. Risk factor assessment was made according to the Dutch guidelines for cardiovascular risk management 2006 [11, 12]. Risk factor management was organized by each physician, vascular specialist and/or general practitioner, for each individual patient. There was no overall screening or prevention programme. At the time of the RULE study, risk factor treatment was not undertaken by nurse practitioners at this hospital.

Risk factor evaluation after referral of patients with established vascular disease or type 2 diabetes to the two UMCs

For all patients at the UMC Utrecht and Leiden UMC, risk factor data recorded immediately after their referral for coronary heart disease (CHD), cerebrovascular disease, PAD or type 2 diabetes were retrieved from the DRG system and medical records by independent physician assistants. Data recorded included the modified Rankin grade for cerebrovascular disease [22], the Fontaine classification for PAD [23], the number of stenotic (>70%) or occluded coronary arteries for CHD and the duration of the disease for type 2 diabetes. For all patients, we recorded age, sex, medical history in addition to the inclusion diagnosis, vascular interventions, blood pressure, weight, waist circumference, plasma concentrations of glucose, creatinine, homocysteine, LDL cholesterol, HDL cholesterol, total cholesterol and triglycerides, smoking status and use of medication.

Vascular risk factor measurement in the RULE study

All patients were invited to participate in the RULE study, for assessment of their risk factor profile, between 12 and 18 months after their initial diagnosis at the UMC Utrecht or Leiden UMC. All measurements were performed by physician assistants. A sample of fasting blood was collected to determine concentrations of total cholesterol, HDL cholesterol, triglycerides, serum glucose, homocysteine and creatinine. LDL cholesterol was calculated using Friedewald’s formula. Fasting urine was collected to determine creatinine and albumin concentrations. Height, weight and waist circumference were measured and BMI was calculated. Medical history, medication use, smoking status and alcohol use were determined using a questionnaire.

Treating physicians (specialists and/or general practitioners) were informed about the results of the RULE study (risk factors) in writing, together with treatment recommendations.

Statistical analysis

We compared the prevalence of various risk factors measured 1.5 years after diagnosis of vascular disease or type 2 diabetes between the study groups, where all patients from the UMC Utrecht were taken together – those who did take part in the vascular screening programme and those we did not. For each risk factor, continuous variables are presented as mean with standard deviation (SD) or as median with interquartile range (IQR), and dichotomous variables as percentages.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

Study population

A total of 2348 patients were invited for atherosclerotic risk factor measurement (1123 in the UMC Utrecht and 1225 in Leiden UMC) of whom 1170 patients participated in the RULE study (604 patients in the UMC Utrecht and 566 patients in Leiden UMC) (Fig. 1). A total of 519 patients treated at the UMC Utrecht and 659 patients at Leiden UMC did not give informed consent to participate because of other co-morbidity, no interest in the study or distance from home to the hospital. In the intervention group, 136 (23%) patients did not participate in the vascular screening programme after their initial diagnosis at the UMC Utrecht.

image

Figure 1. Flowchart of the RULE study. UMC, University Medical Center; CHD, coronary heart disease; TIA/minor stroke, transient ischaemic attack or minor ischaemic stroke; PAD, peripheral arterial disease; DM2, type 2 diabetes; GP, general practitioner.

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Of the total study population (n = 1170), 70% was male, with a mean age of 61 ± 10 years. The four disease categories (CHD, cerebrovascular disease, PAD and type 2 diabetes) were equally represented in the two study groups. Characteristics of the patients in the four inclusion categories at time of diagnosis at the UMC Utrecht and Leiden UMC are shown in Table 1. There were small differences between the total group of UMC Utrecht patients and those from the Leiden UMC with regard to CHD and type 2 diabetes.

Table 1. Disease severity of patients at time of diagnosis in UMC Utrecht or Leiden UMC (n = 1170)
 UMC UtrechtLeiden UMC
TotalVascular screeningUsual careUsual care
  1. UMC, University Medical Center; HDL, high-density lipoprotein; LDL, low-density lipoprotein; BMI, body mass index.

  2. Data are mean ± standard deviation or percentages.

Total (n)604468136566
 Age (years)60.2 ± 9.760.0 ± 9.861.0 ± 9.461.1 ± 10.0
 Male (%)73747066
Coronary heart disease (n)20217032171
 Age (years)60.4 ± 9.160.9 ± 8.957.8 ± 9.861.8 ± 9.9
 Male (%)84829171
 No. of stenotic (>70%) coronary arteries
  1 (%)41433365
  2 (%)31294328
  3 (%)2728237
Cerebrovascular disease (n)14910841166
 Age (years)60.2 ± 10.359.6 ± 10.662.0 ± 9.363.1 ± 10.2
 Male (%)66696161
 Rankin grade
  0 (%)43463238
  1 (%)37383535
  2 (%)13131419
  3 (%)62165
  4 (%)1035
Peripheral arterial disease (n)1329537135
 Age (years)62.5 ± 8.861.3 ± 8.965.4 ± 7.961.7 ± 9.5
 Male (%)71687669
 Fontaine classification
  1–2 (%)941008187
  3–4(%)601913
 Ankle brachial index0.70 ± 0.210.73 ± 0.210.63 ± 0.210.70 ± 0.16
Type 2 diabetes mellitus (n)121952694
 Age (years)57.5 ± 10.357.6 ± 10.757.3 ± 8.655.4 ± 8.8
 Male (%)68715460
 Diagnosis of DM2 (years ago)5.5 ± 7.96.0 ± 8.43.5 ± 4.96.3 ± 6.0
Risk factors
 Systolic blood pressure (mmHg)144 ± 21144 ± 21148 ± 24145 ± 22
 Diastolic blood pressure (mmHg)83 ± 1183 ± 1183 ± 1282 ± 12
 Glucose (mmol L−1)6.6 ± 2.36.5 ±  .2.06.8 ±  .3.57.8 ±  .3.5
 Total cholesterol (mmol L−1)4.9 ± 1.24.8 ± 1.25.1 ± 1.15.0 ± 1.4
 HDL cholesterol (mmol L−1)1.3 ± 0.41.3 ± 0.41.3 ± 0.41.4 ± 0.7
 LDL cholesterol (mmol L−1)2.8 ± 1.02.7 ± 1.03.0 ± 1.02.9 ± 1.2
 Triglycerides (mmol L−1)1.8 ± 1.11.7 ± 1.12.1 ± 1.42.4 ± 2.2
 Creatinine (μmol L−1)93 ± 3993 ± 3695 ± 5291 ± 48
 Creatinine clearance (Cockroft)79 ± 2479 ± 2378 ± 2979 ± 23
 Microproteinuria (mg mmol−1)8.0 ± 16.17.3 ± 11.413.8 ± 40.77.6 ± 22.1
 BMI (kg m−2)27.4 ± 4.227.4 ± 4.227.6 ± 4.527.5 ± 5.6
 Waist circumference (cm)95 ± 1195 ± 11105103 ± 14
 Current smokers (%)21193233

Differences in risk factors between the intervention and reference groups

In the total group of patients from the UMC Utrecht compared with those from the Leiden UMC there were statistically significant differences in systolic blood pressure (139 ± 19 mmHg vs. 142 ± 20 mmHg; age- and sex-adjusted difference: −2.5 mmHg [95% confidence interval (CI): −4.6 to −0.3] and diastolic blood pressure [82 ± 10 mmHg vs. 85 ± 11 mmHg; age- and sex-adjusted difference: −3.2 mmHg (95% CI:−4.4 to −1.9)], and in the levels of LDL cholesterol [2.4 ± 0.8 mmol L−1 vs. 2.7 ± 1.0 mmol L−1; age- and sex-adjusted difference: −0.3 mmol L−1 (95% CI: −0.4 to −0.2)], HDL cholesterol [1.3 ± 0.4 mmol L−1 vs. 1.5 ± 0.4 mmol L−1; age- and sex-adjusted difference: −0.1 mmol L−1 (95% CI: −0.2 to −0.05)] and homocysteine [11.3 ± 4.3 μmol L−1 vs. 13.2 ± 5.0 μmol L−1; age- and sex-adjusted difference: −1.9 mmol L−1 (95% CI: −2.4 to −1.3)]. Amongst the total group of UMC Utrecht patients, the most important risk factors were lower compared with the patients who received usual care in the Leiden UMC (Table 2). Similar patterns were observed for the four disease categories (Table S1A–D).

Table 2. Risk factors measurements in three groups of patients with established vascular disease or type 2 diabetes (n = 1170)
 UMC UtrechtLeiden UMC
TotalVascular screeningUsual careUsual careMean difference (95% CI)a
n = 604n = 468n = 136n = 566
  1. UMC, University Medical Center; HDL, high-density lipoprotein; LDL, low-density lipoprotein; BMI, body mass index; CI, confidence interval.

  2. All data are means ± standard deviation.

  3. aMean difference adjusted for age and sex (95% confidence interval): value of UMC Utrecht – value of Leiden UMC.

Systolic blood pressure (mmHg)139 ± 19138 ± 18142 ± 21142 ± 20−2.5 (−4.6 to −0.3)
Diastolic blood pressure (mmHg)82 ± 1081 ± 1083 ± 1085 ± 11−3.2 (−4.4 to −1.9)
Glucose (mmol L−1)6.5 ± 1.96.5 ± 1.86.6 ± 2.26.6 ± 3.0−0.2 (−0.5 to 0.1)
Total cholesterol (mmol L−1)4.4 ± 1.04.4 ± 1.04.7 ± 1.14.5 ± 1.1−0.02 (−0.14 to 0.10)
HDL cholesterol (mmol L−1)1.3 ± 0.41.3 ± 0.41.4 ± 0.41.5 ± 0.4−0.1 (−0.2 to −0.05)
LDL cholesterol (mmol L−1)2.4 ± 0.82.4 ± 0.82.5 ± 0.92.7 ± 1.0−0.3 (−0.4 to −0.2)
Triglycerides (mmol L−1)1.6 ± 1.11.5 ± 1.01.7 ± 1.21.6 ± 1.1−0.1 (−0.2 to 0.1)
Creatinine clearance (Cockroft)75 ± 2276 ± 2274 ± 2376 ± 23−2.0 (−4.1 to 0.1)
Homocysteine (μmol L−1)11.3 ± 4.311.2 ± 4.411.7 ± 4.013.2 ± 5.0−1.9 (−2.4 to −1.3)
BMI (kg m−2)27.9 ± 4.627.8 ± 4.528.2 ± 4.628.0 ± 4.7−0.1 (−0.6 to 0.4)
Waist circumference (cm)99 ± 1299 ± 1199 ± 1299 ± 14−0.4 (−1.8 to 1.0)
Current smoking (%)20192322−3 (−8 to 1)

Proportion of patients achieving treatment goals of risk factors

More patients in the UMC Utrecht group achieved their treatment goals, compared with those treated at the Leiden UMC, for the most important risk factors [systolic blood pressure (55% vs. 51%), diastolic blood pressure (78% vs. 69%), LDL cholesterol (59% vs. 48%), BMI<30 kg m−2 (75% vs. 72%)] (Table 3). The patterns in the four subgroups were similar to those in the total group (Table S2A–D).

Table 3. Proportion of patients who achieved treatment goals (n = 1170)
Achieved targetsUMC UtrechtLeiden UMC
TotalVascular screeningUsual careUsual care
n = 604n = 468n = 136n = 566
  1. UMC, University Medical Center; HDL, high-density lipoprotein; LDL, low-density lipoprotein; BMI, body mass index.

  2. All data are percentages.

Systolic blood pressure <140 mmHg55574851
Diastolic blood pressure <90 mmHg78797369
Total cholesterol <4.5 mmol L−156584956
HDL cholesterol: men >1.0, women 1.2 mmol L−177768186
LDL cholesterol <2.5 mmol L−159605448
Triglycerides <1.7 mmol L−167686367
Glucose <7.0 mmol L−178788175
Patients with diabetes: glucose <7.0 mmol L−139393935
Patients without diabetes: glucose <7.0 mmol L−196969995
BMI <25 kg m−223242427
BMI <30 kg m−275767172
Waist circumference men <102, women <88 cm51505246
No smoking80817776

Use of medication

In patients with vascular disease, there were no differences in the proportion of those on medication at the two hospitals (Table 4). Patients with type 2 diabetes in the Leiden UMC used more glucose-lowering agents compared with the UMC Utrecht group (96% vs. 88%) due to more frequent use of insulin in the Leiden UMC group (61% vs. 29%).

Table 4. Medication in patients with established vascular disease or type 2 diabetes, according to study group and treatment
MedicationPatients with type 2 diabetesPatients with established vascular disease
UMC UtrechtLeiden UMCUMC UtrechtLeiden UMC
TotalVascular screeningUsual careUsual careTotalVascular screeningUsual careUsual care
n = 121n = 96n = 25n = 94n = 483n = 372n = 111n = 472
  1. ACE, angiotensin converting enzyme; AII antagonist, angiotensin II.

  2. Data are percentages of patients.

  3. aAnti-coagulant and anti-platelet agents.

Blood pressure-lowering agents (%)8382857875767379
 1 idem (%)2323233442433936
 2 idem (%)3232324036353837
 3 idem (%)3230362216161522
 ≥4 idem (%)1415956696
 Beta-blocking agents (%)4039423047484448
 Diuretics (%)5352543226252730
 ACE inhibitor or AII antagonist (%)7474736548484650
 Calcium antagonist (%)2323231917162224
Lipid lowering agents (%)7171697086868383
 1 anti-lipid lowering agent (%)90889410093929597
 ≥2 anti-lipid lowering agents (%)1012608863
 Statins (%)6770586983838381
 Fibrates (%)33412200.4
Glucose-lowering agents (%)8889859614151318
 Oral glucose-lowering agents (%)757477731314915
 Insulin (%)293023614367
Anti-thrombotic agents (%)a3942274085868193
 Anti-platelet agents3134193876777080

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

The results of our study show that patients with established vascular disease or type 2 diabetes mellitus treated in a hospital setting with the availability of a vascular screening programme had lower levels of systolic blood pressure and LDL cholesterol compared with patients treated in a similar setting but without access to such a programme. Although our analyses indicated that the programme was effective, with treatment goals for vascular risk factors being achieved more frequently in the setting with a vascular screening programme, at least one-third of patients did not achieve international guideline-recommended targets for systolic blood pressure, LDL cholesterol and other vascular risk factors.

Patients with a history of cardiovascular disease are at high risk for recurrence of a vascular event. The importance of modifying risk factors is supported by previous studies, which showed that a reduction of 5 mmHg in diastolic blood pressure is associated with a one-third lower risk of stroke and 20% reduction in any major coronary event [24–26]. A reduction of 1 mmol L−1 LDL cholesterol is accompanied by a 19% reduction in fatal CHD events, 26% reduction in nonfatal myocardial infarction and 17% reduction in stroke [3]. For patients with diabetes, a 50% reduction in the risk of cardiovascular events during a follow-up period of 8 years was seen in a study with multifactorial treatment of hyperglycaemia, hypertension and dyslipidaemia [18]. Extrapolating the results of previous trials to the expected event reduction in this study would indicate about a 10% lower risk of stroke and about 15% less major ischaemic coronary events based on the observed 2.3 mmHg reduction in systolic blood pressure. The 0.3 mmol L−1 reduction in LDL cholesterol would translate into a 7% risk reduction in CHD events and a 5% risk reduction in stroke for patients treated in a setting with a vascular screening programme compared with those without access to such a programme.

The data from this study indicate that a vascular screening programme adds to better vascular risk factor treatment. However, a large proportion of risk factors are still not treated optimally and, consequently, a single systematic screening of risk factors followed by interdisciplinary treatment advice is not enough for adequate risk reduction in patients with established vascular diseases or type 2 diabetes mellitus.

At the time of the RULE study, patients who underwent the vascular screening programme at the UMC Utrecht did not receive the results of the vascular screening immediately, but were supposed to receive the information from their treating vascular specialist and general practitioner. The efficacy of the programme may be enhanced by active involvement of the patients. This may also reduce the likelihood of patients not consulting their vascular specialist or general practitioner for risk factor management. However, the treatment advice may have stimulated the physician to comply with the guidelines [27] and to take greater responsibility for the treatment plan.

In the group treated in the setting with a vascular screening programme, some of the patients did not in fact participate in this programme. Although the screening programme is presented to all patients referred to the UMC Utrecht, it is not possible to include all patients in the programme for logistical reasons. Some patients do not participate because of co-morbidities, some have no interest in the programme, and the distance from their home to the hospital prevents some patients from participating. Thus, patients who did and did not take part in the programme are probably not comparable. In this study, about 80% participated in the screening programme; the remaining 20% did not. In an on-treatment analysis, reflecting 100% participation, the risk factor levels at follow-up were lower in the patients who participated in the vascular screening than in those who did not.

The difference in risk factors between the settings of the two UMCs were not explained by the number of drugs used by the patients; however, an increased dose, the prescription of a more potent drug or the use of combination therapy may explain this difference [28–31]. Furthermore, physicians of patients with access to a vascular screening programme may have been more motivated to achieve optimal treatment of risk factors by nonpharmacological means (e.g. advice regarding exercise, salt intake, smoking) and patients participating in a prevention programme may have been more likely to adhere to medication. Unfortunately, compliance could not be measured; polypharmacy is common to reduce multiple cardiovascular risk factors in patients with cardiovascular disease, and adherence decreases with each additionally prescribed drug [32, 33].

Our results indicate that the two-step approach of systematic screening of risk factors followed by multidisciplinary treatment advice is not enough to achieve adequate risk factor management but should be followed by treatment and prevention [10]. The question remains how this should be done. Treatment of vascular risk factors by nurse practitioners has proven to be more effective than usual care, although the effect is rather modest [14, 16, 17, 34]. An internet-based treatment programme may also be an effective and efficient way to improve risk factor treatment [15, 35, 36]. In other studies, time constraints were identified as the largest single barrier to risk factor and lifestyle treatment by physicians [27, 37]. In patients, lack of awareness of the importance of risk factors is one of the most crucial factors [27]. Therefore, active involvement of patients in risk reduction programmes may be important to start self-management programmes of vascular risk factors reduction.

A strength of this study is that patients with various types of arterial diseases and referred by general practitioners were included, suggesting that these findings may have a broad generalizability. We did not attempt to impose specific treatments but we evaluated risk factor management as a complete strategy. Behaviour of the physicians may differ between the two hospitals but we consider this to be part of the integral strategy with which the patients were approached in the two hospitals.

This is a nonrandomized study and hence the comparability of the two groups may be compromised. In our opinion, this study design was the only feasible option to assess the efficacy of a hospital-based risk factor-management strategy. Individual randomization is hard to realize because it is unlikely that a physician would practice both strategies simultaneously in different patients. Mortality rates for vascular disease, CHD and stroke are comparable between the catchments areas of the two hospitals (see Table S3), indicating that comparability of prognosis of patients in the two areas was not an issue in our study. The severity, extent and duration of diseases were similar in the two study groups. It is therefore unlikely that referral patterns by general practitioners were different in the two regions. Furthermore, the behaviour of the doctors may differ between the two hospitals; however, we consider this to be part of the integral strategy with which the patients were approached in the two hospitals. Hence, we would not label such differences as ‘bias’, but rather consider them as part of the two different strategies.

We acknowledge some limitations of our study. It was not possible to confirm the self-reported medication use by checking pharmacy records. Neither patient diaries nor pharmacy records can be considered as the gold standard with regard to true pharmacotherapy [38]. Furthermore, the study population might be viewed as complex high-risk patients because the patients were referred to UMCs. However, patients were referred by general practitioners, were not tertiary referrals and were able to visit the outpatient clinics, indicating that they were in reasonably good physical health.

In conclusion, systematic screening of risk factors contributed to slightly better risk factor reduction in patients with established vascular disease or type 2 diabetes. In spite of screening, a large proportion of these patients did not reach the treatment goals according to (inter)national treatment guidelines. Systematic screening of risk factors in a hospital-based programme alone is not enough for adequate risk factor management in high-risk patients.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

The help of C. van der Mark, E.C. Willems of Brilman-Tuinhof de Moed, M.M. Monteban, U. Dasrath, Iris de Kruijf, Martijn van Beijnen and Annelot Krediet for data collection is greatly acknowledged.

We gratefully acknowledge the support by The Netherlands Organization for Scientific Research (ZonMw 945.04.256).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conflict of interest
  8. Acknowledgements
  9. References
  10. Supporting Information

Table S1. Risk factor measurements in three groups of patients (A) with coronary heart disease (n = 373), (B) with cerebrovascular disease (n = 315), (C) with peripheral arterial disease (n = 267), (D) with type 2 diabetes (n = 215).

Table S2. (A) Proportion of coronary heart disease patients who achieved treatment goals (n = 373), (B) proportion of cerebrovascular disease patients who achieved treatment goals (n = 315), (C) proportion of peripheral arterial disease patients who achieved treatment goals (n = 267), (D) proportion of type 2 diabetes patients who achieved treatment goals (n = 215).

Table S3. Mortality rate per 10 000 adjusted for age and sex between 2001 and 2004. Source: statistics Netherlands.

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Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.