Risk Factors In Primary Care Research Articles

Prevalence of Risk for Obstructive Sleep Apnea Syndrome and Association With Risk Factors in Primary Care.

BackgroundObstructive sleep apnea syndrome (OSAS) is a chronic, progressive disease with high morbidity and mortality. It is underdiagnosed, especially among women.ObjectiveTo study the prevalence of high risk for OSAS globally and for the Berlin Questionnaire (BQ) categories, and to evaluate the reliability of the BQ use in the population studied.MethodsObservational, cross-sectional study with individuals from the Niterói Family Doctor Program, randomly selected, aged between 45 and 99 years. The visits occurred between August/2011 and December/2012. Variables associated with each BQ category and with high risk for OSAS (global) were included in logistic regression models (p < 0.05).ResultsOf the total (616), 403 individuals (65.4%) reported snoring. The prevalence of high risk for OSA was 42.4%, being 49.7% for category I, 10.2% for category II and 77.6% for category III.Conclusion BQ showed an acceptable reliability after excluding the questions Has anyone noticed that you stop breathing during your sleep? and Have you ever dozed off or fallen asleep while driving?. This should be tested in further studies with samples mostly comprised of women and low educational level individuals. Given the burden of OSAS-related diseases and risks, studies should be conducted to validate new tools and to adapt BQ to better screen OSAS.

Feasibility of automated pre-screening for lifestyle and behavioral health risk factors in primary care.

BackgroundScreening of primary care patients for unhealthy behaviors and mental health issues is recommended by numerous governing bodies internationally, yet evidence suggests that provider-initiated screening is not routine practice. The objective of this study was to implement systematic pre-screening of primary care patients for common preventive health issues on a large scale.MethodsPatients registered for non-acute visits to one of 40 primary care providers from eight clinics in an Academic Medical Center health care network in the United States from May, 2012 to May, 2014 were contacted one- to three-days prior to their visit. Patients were invited to complete a questionnaire using an Interactive Voice Response (IVR) system. Six items assessed pain, smoking, alcohol use, physical activity, concern about weight, and mood.ResultsThe acceptance rate among eligible patients reached by phone was 65.6 %, of which 95.5 % completed the IVR-Screen (N = 8,490; mean age 57; 57 % female). Sample demographics were representative of the overall primary care population from which participants were drawn on gender, race, and insurance status, but participants were slightly older and more likely to be married. Eighty-seven percent of patients screened positive on at least one item, and 59 % endorsed multiple problems. The majority of respondents (64.2 %) reported being never or only somewhat physically active. Weight concern was reported by 43.9 % of respondents, 36.4 % met criteria for unhealthy alcohol use, 23.4 % reported current pain, 19.6 % reported low mood, and 9.4 % reported smoking.ConclusionsThe percent endorsement for each behavioral health concern was generally consistent with studies of screening using other methods, and contrasts starkly with the reported low rates of screening and intervention for such concerns in typical PC practice. Results support the feasibility of IVR-based, large-scale pre-appointment behavioral health/ lifestyle risk factor screening of primary care patients. Pre-screening in this population facilitated participation in a controlled trial of brief treatment for unhealthy drinking, and also could be valuable clinically because it allows for case identification and management during routine care.

68 * TIMED UP AND GO TEST RESULTS IN PATIENTS FOUND THROUGH GENERAL PRACTICE FALLS RISK SCREENING. PRELIMINARY EVALUATION OF THE NORTH TYNESIDE FALLS PREVENTION SERVICE (NTFPS)

Introduction: Falls are a major health and health economic burden but case ascertainment remains inadequate. The NTFPS was developed to proactively screen for falls risk factors in primary care. We present data from the Service's strength and balance training classes run with Age UK North-Tyneside. Methods: General practice case notes of those >60 years are screened for falls risk factors and syncope. Patients excluded if known to existing services. Screening questionnaire sent and those at risk invited to attend comprehensive multidisciplinary assessment per NICE guidelines. All given advice on exercise and falls prevention and supplied with relevant literature. Where significant gait and balance problems identified per senior physiotherapy musculoskeletal and falls assessment (including Timed-up and Go Test[TUG], Short Physical Performance Battery), patients may receive: • Targeted home exercises, leaflets • Referral to associated Age UK strength and balance classes depending on mobility, ability, TUG (>13.5 sec high risk of falling) • Community physiotherapy, day hospital referral • Suggestions for referral for orthopaedic review Strength and balance training classes: Ten x weekly, 1 hour sessions of targeted, individualised exercises in small group setting (up to 10 participants) delivered by personal trainer. We report on the first consecutive 187 individuals to complete the strength and balance training programme. Results: Total 187 Mean age 76.6 years (range 60-89), 129(69%) female TUG results as below: Conclusion: This novel approach identifies patients with significant gait and balance abnormalities otherwise not coming to the attention of services. Appropriate triage and referral results in highly significant reductions in TUG results, with concomitant benefits in terms of falls risk reduction. Longer follow up data are needed to examine the longevity of these benefits.

Primary Prevention Research in Suicide

At the American Association of Suicidology’s (AAS) 46th Annual Conference in Austin, Texas (http://www.suicidology.org/web/guest/education-and-training/annualconference), participants were challenged to address why there has not been more progress in reducing the rates of completed suicides (Berman, 2013). A draft of recommendations from the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force was presented at the meeting and subsequently published in this journal (National Action Alliance for Suicide Prevention [NAASP], 2013a, 2013b). The purpose of this commentary is to address this challenge by emphasizing the importance of employing a disease etiology strategy that integrates molecular data with clinical data, environmental data, and health outcomes in a dynamic, iterative fashion. The recommendations of the Research Prioritization Task Force tackle important public health program issues and are embedded within seven key questions, summarized as: 1. Why do people become suicidal? 2. How do we better detect/predict risk? 3. What interventions prevent suicidal behavior? 4. What are the effective services for treating suicidal persons and preventing suicidal behavior? 5. How do we reduce stigma? 6. What are the suicide prevention interventions outside of health-care settings? 7. Which existing and new infrastructure needs are required to further reduce suicidal behavior? (NAASP, 2013b; Silverman et al., 2013)

Care manager to control cardiovascular risk factors in primary care: The Raffaello cluster randomized trial

Background and aimThis cluster randomized trial evaluated the efficacy of a disease and care management (D&CM) model in cardiovascular (CVD) prevention in primary care. Methods and resultsEligible subjects had ≥1 among: blood pressure ≥ 140/90 mmHg; glycated hemoglobin ≥ 7%; LDL-cholesterol ≥ 160 or ≥100 mg/dL (primary or secondary prevention, respectively); BMI ≥ 30; current smoking. The D&CM intervention included a teamwork including nurses as care managers for the implementation of tailored care plans. Control group was allocated to usual-care. The main outcome was the proportion of subjects achieving recommended clinical targets for ≥1 of uncontrolled CVD risk factors at 12-month. During 2008–2009 we enrolled 920 subjects in the Abruzzo/Marche regions, Italy. Following the exclusion of L'Aquila due to 2009 earthquake, final analyses included 762 subjects. The primary outcome was achieved by 39.1% (95%CI: 34.2–44.2) and 25.2% (95%CI: 20.9–29.9) of subjects in the intervention and usual-care group, respectively (p < 0.001). The D&CM intervention significantly increased the proportion of subjects who achieved clinical targets for both diabetes and hypertension, with no differences in hypercholesterolemia, smoking status and obesity. ConclusionsThe D&CM intervention was effective in controlling cardiovascular risk factors, in particular hypertension and diabetes. Numbers needed to treat were small. Such intervention may deserve further consideration in clinical practice.Registration number: ACTRN12611000813987.

Prognostic value of NT-pro-BNP and hs-CRP for risk stratification in primary care: results from the population-based DETECT study

There is continuous debate to the use of biomarkers in the general practitioners office and to what degree the established biomarkers N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and high-sensitive C-reactive protein (hs-CRP) might contribute to improved prediction of incident cardiovascular events. To evaluate the utility and 5-year predictive value of a single measurement of NT-pro-BNP and hs-CRP for incident cardiovascular events, and its added value beyond the contribution of conventional risk factors in primary care. Five year prospective longitudinal clinical epidemiological study in a nationwide sample of 4,775 primary care subjects (mean age 55.8 years, 62 % women) without coronary artery disease at baseline. Main outcome measures were incident major cardiovascular events and all-cause death. During the 5 years of follow-up, 188 subjects (3.9 %) died or experienced a first major cardiovascular event. The addition of NT-pro-BNP, but not of hs-CRP to a prediction model with established cardiovascular risk factors improved the prediction of major cardiovascular events (increase in C statistic by 0.009; p = 0.008), and was associated with a significant improvement in net reclassification improvement (NRI = 23.6 %; p = 0.003). In a primary care setting, one single measurement of NT-pro-BNP, but not of hs-CRP significantly improves the prediction of incident cardiovascular events.

Developing a 'traffic light' test with potential for rational early diagnosis of liver fibrosis and cirrhosis in the community.

Liver disease develops silently and presents late, with often fatal complications. To develop a 'traffic light' test for liver disease suitable for community use that could enhance assessment of liver risk and allow rational referral of more severe disease to specialist care. Two cohorts from Southampton University Hospital Trust Liver Unit: model development and a validation cohort to evaluate prognosis. A total of 1038 consecutive liver patients (inpatient and outpatient) (development n = 397, validation n = 641) for whom the relevant blood tests had been performed, were followed for a mean of 46 months (range 13-89 months). Blood tests for: hyaluronic acid (HA), procollagen-3 N-terminal peptide (P3NP), and platelet count were combined in a diagnostic algorithm to stage liver disease. A simple clinical rule combined: HA, P3NP, and platelet count into a 'traffic light' algorithm, grading the results red--high risk, amber--intermediate risk, and green--low risk. In the validation cohort, no green subjects died or developed varices or ascites (n = 202); in the amber group, 9/267 (3.3%) died, 0/267 developed varices, and 2/267 (0.7%) developed ascites; in the red group, 24/172 died (14%), 24/172 (14%) developed varices, and 20/172 developed (11.6%) ascites. Survival was reduced in red (P<0.001) and amber (P<0.012) groups compared with green. A simple blood test triages liver disease into three prognostic groups; used in the community, it could enhance the management of risk factors in primary care and rationalise secondary care referrals, including the many patients with fatty liver and relatively minor elevations in alanine transaminase.

Efforts to close the evidence-practice gap in the management of cardiovascular risk factors in general practice: strategic or haphazard?

Rational, aims and objectives: Guidelines for best practice management of cardiovascular disease (CVD) risk factors such as smoking, high blood pressure, high cholesterol, risky alcohol consumption, diabetes and obesity are in place in the primary care setting, yet many of these risk factors remain uncontrolled. This review examined: a) trends in the number of published provider-focussed intervention studies which aimed to improve the identification and management of modifiable CVD risk factors in primary care; b) the proportion of primary care research effort directed toward improving provider management of each CVD risk factor compared to the mortality burden associated with each risk factor in high income countries. Methods: An electronic database search of Medline, Cinahl and PsychInfo was conducted for the time period January 1 st 1999 to 31 st December 2010 to identify relevant articles. Results: There was a trend toward an increase in the number of provider-focussed interventions to improve the management of CVD risk factors in general practice over time. The proportion of research effort directed to risk factors varied between 6% for alcohol and obesity to 32% for high blood pressure. High blood pressure and smoking had the highest and second highest proportion of research effort and were ranked second and first, respectively, in terms of mortality burden. Conclusions: The allocation of research effort appears somewhat consistent with the health burden associated with the risk factors examined in this review, although an increase in smoking-related research may be needed.

P1-28 Linkage of primary and secondary care data to identify risk factors for emergency hospital admission for COPD: negotiating the legal and ethical hurdles

IntroductionWe aimed to identify modifiable risk factors in primary care associated with emergency hospital admissions with Chronic Obstructive Pulmonary Disease in Lothian, Scotland. We sought permission to obtain data from...

P80– Quality of care in the management of cardiovascular risk factors in primary care of the Basque Country before the implementation of three clinical practice guidelines

P80– Quality of care in the management of cardiovascular risk factors in primary care of the Basque Country before the implementation of three clinical practice guidelines

Abdominal obesity is associated with ineffective control of cardiovascular risk factors in primary care in France

Aim Insufficient control of cardiovascular risk factors is observed in primary care. The goal of the present study was to evaluate the association of abdominal obesity with achievement of treatment targets for HbA 1c, LDL cholesterol, triglycerides, HDL cholesterol and blood pressure in primary care. Methods In this cross-sectional observational epidemiological study, primary-care practitioners completed a questionnaire covering demographic and socioeconomic data, medical history, drug treatment, and clinical and biological characteristics for 3351 patients (1630 men and 1721 women). Therapeutic targets were HbA 1c < 7%, LDL cholesterol < 1.6 g/L, triglycerides < 1.5 g/L and SBP/DBP < 140/90 mmHg. Multivariate analyses were performed to assess the relationship between waist circumference and a lack of cardiovascular risk-factor control. Results The patients’ mean ages were 58 ± 14 years and 55 ± 16 years for men and women, respectively. A large waist circumference was positively and significantly ( P < 0.0001 for all) associated with diabetes, hypercholesterolaemia, hypertriglyceridaemia, low HDL cholesterol and hypertension. The prevalence of patients not achieving therapeutic targets increased across waist-circumference quartiles. For treated patients, the odds ratios (95% CI) (adjusted for age, gender, education, smoking status and medical specialty) for not achieving treatment targets were 17.6 (2.2–142) for triglycerides, 2.8 (1.3–6.1) for HbA 1c and 1.4 (0.9–2.0) for blood pressure on comparisons with extreme quartiles of waist-circumference distribution. Conclusion In primary care, a lack of control of triglycerides, HbA 1c and, to a lesser extent, blood pressure increases with waist circumference independently of confounders. This suggests that abdominal obesity is associated of poor results in the treatment of diabetes and hypertriglyceridaemia.

The covariation of multiple risk factors in primary care: a latent class analysis

There is a need to advance the quality of healthcare by increasing knowledge about multiple risk factors and how to intervene to improve health outcomes. In an effort to better describe the presentation of multiple risks, this study involved a database review to describe the prevalence and covariation of multiple risk factors in individuals presenting to primary care. Patients with a primary care encounter from January 1, 2005 to June 30, 2005 (N = 10,043) were identified from the Department of Veteran's Affair's medical database and information about the following risk factors was extracted: alcohol use, psychiatric distress, body mass, smoking status, blood pressure, and posttraumatic stress. Exploratory and confirmatory latent class analyses identified three classes of individuals. Class 1 consisted of individuals with an overall lower level of risk for health problems, but a moderately high likelihood of elevated blood pressure. Individuals in Class 2 appeared to have the greatest need for intervention because they had a moderate to high likelihood of reporting at risk alcohol use, smoking, depression, and posttraumatic stress. Class 3 consisted of individuals reporting the co-occurrence of at risk alcohol use, smoking, and elevated blood pressure. Similar to past research, the findings highlight the need for addressing multiple risk factors in primary care. In addition, this study expands on the literature by identifying specific patterns of covariation among different risk factors that suggest avenues for research and program development.

Missed Opportunities for Coronary Heart Disease Diagnoses: Primary Care Experience – Whose Experience Is It?

To the Editor: I have read the article by Turkay et al (1) with great interest. The authors studied the missed opportunities for detection of coronary heart disease and related risk factors in primary care. The number of missed diagnoses shows that there is something missing. So, why have they missed them and what was missed?

Achievement of guideline-defined treatment goals in primary care: the German Coronary Risk Management (CoRiMa) study

The success in achieving treatment goals for cardiovascular risk factors in primary care is largely unknown. Therefore, the goals of this study were (i) to assess whether routinely collected practice data can be used to evaluate treatment in primary care, (ii) to compare current treatment with goals of published guidelines, and (iii) to calculate future risk for cardiovascular events using these real-life data. In 110 physician offices in Germany, data from the patient management systems of all patients seen between January 1998 and June 2005 were extracted and analysed (715 644) with current guidelines used for reference. Of those patents, 284 096 (40% of all patients analysed) had one of the following diseases: 157 101 (55% of 284 096) had hypertension, 83 005 (29%) diabetes, 64 205 (23%) coronary artery disease (CAD), 174 787 (62%) hyperlipidaemia, and 136 360 (48%) had more than one of the listed diagnoses. During the last visit, treatment goals were achieved for total and LDL cholesterol in 9 and 29%, respectively, for blood pressure in 28%, and for HbA1c in 36%. Low achievement of treatment goals was also seen in patients with CAD or diabetes. Using the Framingham risk model and the SCORE Deutschland risk charts, 20 and 22% of patients had a high 10-year risk for a primary cardiovascular event and a fatal cardiovascular event, respectively. Achieving treatment goals for all risk factors would significantly reduce the number of high-risk patients. (i) Routinely collected practice data can be used to evaluate quality of care; (ii) 40% of patients in primary care have cardiovascular disease or diabetes; (iii) even in high-risk patients, the majority does not achieve treatment goals; and (iv) achieving the treatment goals would reduce the proportion of high-risk patients from 20 to <5%.

High time to join hands between family medicine and cardiology!

In many countries there is a steady deterioration of cardiovascular health, leading to cardiovascular disease (CVD), due to an inappropriate lifestyle. Few people achieve the recommended levels of regular physical activity and correct nutritional habits, or succeed in preventing stress and obesity. Smoking still remains one of the prime risk factors. Recently, an alarming first report has been published on the increase of CVD mortality in younger males and an attenuation of the decrease of mortality in younger women.1 In contrast, the World Health Organization (WHO) states that more than half of the CVD mortality could be prevented through simple methods at the population level. At present the prevention challenge is met through both political and medical initiatives. On the political level, the European Heart Health Charter marks an EU cornerstone agreement, which demands the promotion of a heart-healthy lifestyle in all member states.2 On the medical level, the 2007 guidelines of 10 joint European societies on CVD prevention are the recent contributions to prevention in clinical practice.3 The task of the joint society's prevention committee to implement the 2007 document is in full progress, representing engagement of a broad group of experts from family medicine, cardiology, diabetology, and other disciplines. Important initiatives indeed, but will they reach their ambitious targets? The study of Geller et al. 4 provides clear and sobering reading. In this large cohort of German patients with CVD and/or diabetes mellitus, the management of known risk factors in primary care needs urgent improvement: 9–36% … *Corresponding author. Tel: +46 491 782 000; fax: +46 491 782 643. E-mail address : Joep{at}ltkalmar.se

Brief Alcohol Interventions and Multiple Risk Factors in Primary Care

SUMMARY Early identification and intervention of harmful/hazardous drinking in primary care are U.S. healthcare priorities. Traditionally, research has focused on designing interventions for patients in primary care who report hazardous/harmful alcohol use, even though it is likely for a patient to be at risk for multiple problems. This article has three major goals: (1) to present data highlighting the prevalence and co-variation of other risk factors with hazardous/harmful drinking, including data from a small descriptive study; (2) to review the literature on brief alcohol interventions designed to address multiple risk factors; and (3) to provide recommendations for future research. Despite data indicating primary care patients present with multiple risk factors, only a limited number of studies in the literature have investigated brief interventions addressing alcohol use and other risk factors. It is important for future research to expand brief alcohol interventions to include other risk factors as well.

Physicians' estimates of the 10 year cardiovascular risk in hypertensive patients: an evaluation in primary care physicians in training.

To evaluate how young physicians in training perceive their patients' cardiovascular risk based on the medical charts and their clinical judgment. Cross sectional observational study. University outpatient clinic, Lausanne, Switzerland. Two hundred hypertensive patients and 50 non-hypertensive patients with at least one cardiovascular risk factor. Comparison of the absolute 10-year cardiovascular risk calculated by a computer program based on the Framingham score and adapted for physicians by the WHO/ISH with the perceived risk as assessed clinically by the physicians. Physicians underestimated the 10-year cardiovascular risk of their patients compared to that calculated with the Framingham score. Concordance between methods was 39% for hypertensive patients and 30% for non-hypertensive patients. Underestimation of cardiovascular risks for hypertensive patients was related to the fact they had a stabilized systolic blood pressure under 140 mm Hg (OR = 2.1 [1.1; 4.1]). These data show that young physicians in training often have an incorrect perception of the cardiovascular risk of their patients with a tendency to underestimate the risk. However, the calculated risk could also be slightly overestimated when applying the Framingham Heart Study model to a Swiss population. To implement a systematic evaluation of risk factors in primary care a greater emphasis should be placed on the teaching of cardiovascular risk evaluation and on the implementation of quality improvement programs.

Physicians' estimates of the 10 year cardiovascular risk in hypertensive patients: an evaluation in primary care physicians in training.

To evaluate how young physicians in training perceive their patients' cardiovascular risk based on the medical charts and their clinical judgment. Cross sectional observational study. University outpatient clinic, Lausanne, Switzerland. Two hundred hypertensive patients and 50 non-hypertensive patients with at least one cardiovascular risk factor. Comparison of the absolute 10-year cardiovascular risk calculated by a computer program based on the Framingham score and adapted for physicians by the WHO/ISH with the perceived risk as assessed clinically by the physicians. Physicians underestimated the 10-year cardiovascular risk of their patients compared to that calculated with the Framingham score. Concordance between methods was 39% for hypertensive patients and 30% for non-hypertensive patients. Underestimation of cardiovascular risks for hypertensive patients was related to the fact they had a stabilized systolic blood pressure under 140 mm Hg (OR = 2.1 [1.1; 4.1]). These data show that young physicians in training often have an incorrect perception of the cardiovascular risk of their patients with a tendency to underestimate the risk. However, the calculated risk could also be slightly overestimated when applying the Framingham Heart Study model to a Swiss population. To implement a systematic evaluation of risk factors in primary care a greater emphasis should be placed on the teaching of cardiovascular risk evaluation and on the implementation of quality improvement programs.

Mo-P5:308 Specific units for assessing cardiovascular risk factors in primary care. Can the medical resources used in these patients be optimized?

Mo-P5:308 Specific units for assessing cardiovascular risk factors in primary care. Can the medical resources used in these patients be optimized?

Cardiovascular risk factors in primary care: methods and baseline prevalence rates – the DETECT program

ABSTRACTObjectives: DETECT is an epidemiological study in primary care to examine (a) the prevalence rates and comorbidity of diabetes mellitus, hypertension, hyperlipidaemia and coronary heart disease (CHD), and associated conditions; (b) the frequency of behavioural and clinical risk factors for onset and progression; (c) the 12-month course and outcome; and (d) the met and unmet needs for these patients.Methods: Three-stage, cross-sectional clinical-epidemiological study with a prospective-longitudinal component in a nationally representative sample of N = 3795 primary care settings [response rate (RR): 60.2%] and N = 55 518 patients (RR: 95.5%). Patients completed a standardized assessment, including questionnaires for patients and the physician and diagnostic screening measures (i.e. blood pressure, heart rate, body mass index and waist circumference assessments). A subsample of patients (N = 7519) also completed a standardized laboratory screening program and was followed-up after 12 months. Data were weighted to adjust for non-response, regional distribution and attrition.Results: (1) Doctors and patients sample can be regarded as representative for primary care settings in Germany. (2) The clinician-rated point prevalence of hypertension is highest (35.5%), followed by hyperlipidaemia (29.1%), diabetes (14.1%) and CHD (12.1%); prevalence rates of each disorder as well as their co-incidence rates increase markedly with age. (3) The vast majority (78%) of all patients revealed multiple (3+) behavioural and clinical risk factors.Conclusion: The findings of DETECT underline the considerable burden for primary care doctors in managing a highly morbid patient population, with predominantly complex risk factor constellations, in routine care. Our data provide, in unprecedented detail, a basis for calculating age-, gender- and risk-group-adjusted risk-factor profiles in routine care.