Improving cardiovascular health in the German CINDI area: Methods and results of the practice-based ‘Three-Level Strategy’ (CINDI equals; Countrywide Integrated Noncommunicable Diseases Intervention programme of the WHO)

Abstract

Objectives: To evaluate the German intervention model of ‘Three-Level Strategy’ especially in reducing cardiovascular risk during a major prevention study (study phase I) and to investigate the feasibility and efficiency of a new system that provides continuous ‘self-evaluation’ of general practitioners cooperating in intervention (study phase II).

Methods: Primary care setting in the CINDI intervention area with a population of about 45,000 and a control town in phase I, subsequently (phase II) in a smaller part of this area. Cross-sectional investigations by means of random sampling on the population level (phase I) and in practices (phase II). Intervention with the ‘Three-Level Strategy of General Practitioners’ method comprising individual health consultation (1st level), supplemented by groupwork with the patients (2nd level) and community-oriented influencing of lifestyle by GPs at the 3rd level. Evaluation of this intervention strategy within the German Cardiovascular Prevention Study (GCP, 1985–1992) in phase I; since 1992, intervention, monitoring, and evaluation in seven practices in one community (phase II).

Main outcome measures were besides assessing health behaviour by a questionnaire, reduction of the four CVD risk factors, namely smoking, obesity (BMI ≥30), hypertension (WHO criteria), and hypercholesterolaemia (≥250 mg/dl).

Results: In the intervention town of phase I (GCP evaluation), in contrast to the control town, the cardiovascular risk factors were reduced: smoking (-9.4%), obesity (-17.1%), hypertension (-51.4%) and hypercholesterolaemia (-12.8%). In the practices of the smaller area, from 1992 to 1994, (phase II), the prevalence of smoking (-23.2%, p <0.01) as well as hypertension (-22.1%, p<0.01) decreased too; there was no further reduction of hypercholesterolaemia and obesity. Special health groups improved health behaviour.

Conclusions: The practice-based intervention model of general practitioners proved to be effective (GCP, phase I). Close cooperation of GPs enables the setting up of a continuous monitoring and evaluation system and facilitates further success without noticeable costs (phase II). The annual determination and analysis of medical data and health services give information on the health-related behaviour in the GP clientele and approximate information on the local population.