Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Figures & data

Table 1 Types of intervention, listed according to EPOCa

Professional interventions	Financial interventions	Organizational interventions	Regulatory interventions
Distribution of educational materials	Provider interventions	Provider oriented interventions	Changes in medical liability
Educational meetings.	Fee-for-service	Revision of professional roles	Management of patient complaints
Local consensus processes	Prepaid	Clinical multidisciplinary teams	Peer review
Educational outreach visits	Capitation	Formal integration of services	Licensure
Local opinion leaders	Provider salaried service	Skill mix changes
Patient-mediated interventions	Prospective payment	Continuity of care
Audit and feedback	Provider incentives	Arrangements for follow-up
(Computerized) reminders	Institution incentives	Case management (including co-ordination of assessment, treatment and arrangements for referrals).
Marketing	Provider grant/allowance	Satisfaction of providers with the conditions of work and the material and psychological rewards
Mass media	Institution grant/allowance	Communication and case discussion between distant health professionals
	Provider penalty	Patient oriented interventions
	Institution penalty	Mail order pharmacies
	Formulary	Presence and functioning of adequate mechanisms for dealing with patients’ suggestions and complaints.
	Patient interventions	Consumer participation in governance of health care organizations
	Premium	Structural interventions
	Co-payment	Changes to the setting/site of service delivery
	User-free	Changes in physical structure, facilities and equipment
	Patient incentives	Changes in medical record systems
	Patient grant/allowance	Changes in scope and nature of benefits and services.
	Patient penalty	Presence and organization of quality monitoring mechanisms.
		Ownership, accreditation, and affiliation status of hospitals and other facilities.
		Staff organization

a Notes: Other categories to be agreed in consultation with the EPOC editorial team.

Table 2 Medline search terms and strategy

Basic search strategy (Brindle)
#1 chd risk assessment$	#37 risk calculation$	#72 (busselton adj2 score$)
#2 cvd risk assessment$	#38 risk calculator$	#73 erica risk score$
#3 heart disease risk assessment$	#39 risk factor$ calculator$	#74 framingham scor$
#4 coronary disease risk assessment$	#40 risk factor$ calculation$	#75 dundee scor$
#5 cardiovascular disease risk assessment$	#41 risk engine$	#76 brhs scor$
#6 cardiovascular risk assessment$	#42 risk equation$	#77 British Regional Heart study risk scor$
#7 cv risk assessment$	#43 risk table$	#78 brhs risk scor$
#8 cardiovascular disease$ risk assessment$	#44 risk threshold$	#79 dundee risk scor$
#9 coronary risk assessment$	#45 risk disc?	#80 framingham guideline$
#10 coronary risk scor$	#46 risk disk?	#81 framingham risk?
#11 heart disease risk scor$	#47 risk scoring method?	#82 new zealand table$
#12 chd risk scor$	#48 scoring scheme?	#83 ncep guideline?
#13 cardiovascular risk scor$	#49 risk scoring system?	#84 smac guideline?
#14 cardiovascular disease$ risk scor$	#50 risk prediction?	#85 copenhagen risk?
#15 cvd risk scor$	#51 predictive instrument?	#86 or/57–85
#16 cv risk scor$	#52 project$ risk?	#87 56 or 86
#17 or/1–16	#53 cdss	#88 exp decision support techniques/
#18 cardiovascular diseases/	#54 or/28–53	#89 Diagnosis, Computer-Assisted/
#19 coronary disease/	#55 27 and 54	#90 Decision Support Systems, Clinical/
#20 cardiovascular disease$	#56 17 or 55	#91 algorithms/
#21 heart disease$	#57 new zealand chart$	#92 algorithm?
#22 coronary disease$	#58 sheffield table$	#93 algorythm?
#23 cardiovascular risk?	#59 procam	#94 decision support?
#24 coronary risk?	#60 General Rule to Enable Atheroma Treatment	#95 predictive model?
#25 exp hypertension/	#61 dundee guideline$	#96 treatment decision?
#26 exp hyperlipidemia/	#62 shaper scor$	#97 scoring method$
#27 or/18–26	#63 (brhs adj3 score$)	#98 (prediction$ adj3 method$)
#28 risk function	#64 (brhs adj3 risk$)	#99 or/88–98
#29 Risk Assessment/mt (Methods)	#65 copenhagen risk	#100 Risk Factors/
#30 risk functions	#66 precard	#101 exp Risk Assessment/
#31 risk equation$	#67 (framingham adj1 (function or functions))	#102 (risk? adj1 assess$)
#32 risk chart?	#68 (framingham adj2 risk)	#103 risk factor?
#33 (risk adj3 tool$)	#69 framingham equation	#104 or/100–103
#34 risk assessment function?	#70 framingham model$	#105 27 and 99 and 104
#35 risk assessor	#71 (busselton adj2 risk$)	#106 87 or 105 (448.950)
#36 risk appraisal$
Adjustments for the current review
#107 106 and quality* health care	#116 115 and clin* trial	#129 128 and cardio* risk*
#108 106 and practice pattern* health care	#117 115 and rand* trial	#130 128 and risk tables
#109 106 and implement* strateg*	#118 115 and randomised trial	#131 128 and cardio* risk?
#110 106 and implement*	#119 115 and randomized trial	#132 128 and risk manag*
#111 106 and dissemination	#120 115 and clinical trial
#112 106 and diffus*	#121 115 and cohort	#133 115 and process assessment
#113 106 and guideline*	#121 115 and control* trial	#134 115 and process evaluation
#114 106 and implementation?	#122 115 and comparat* study	#135 115 and #17
#115 107–114 (18607)	#123 115 and random* control* trial
	#124 115 and observat* study
	#125 115 and rand* clin* trial
	#126 115 and control* study
	#127 115 and rand* study
	#128 116–127

Table 3A Empirical studies on stimulation of actual and appropriate use of cardiovascular risk tables in normal practice, characteristics, and effects. Studies using one (or more) professional strategies without patient involvement

Author:, year: Setting: location of care, country Participants: profession Patients (N) Study design:	Methods: a Quality criteria for RCTs: Study period	Type of intervention: Professional Financial Organizational Regulatory		Main outcome(s): a) health professional outcome(s) b) patient outcome(s)	Results:
		Intervention group	Controls
Hetlevik, 1999 General Practice, Norway General practitioners, assistants Patients, N = 2239 RCT	UA: general practice US: patient level Quality criteria: 1 ? 2 no 18 months	Professional: - distrib.educat. materials -educat. telephone calls -educat. meeting (90 min.) -stand-alone CDSS including risk score	usual care	a) recording CV risk factors b) blood pressure, cardiovascular risk score, serum cholesterol, and weight (or BMI)	a) no differences between the groups b) I: sign. mean reduction in diastolic blood pressure (1mm Hg.) compared to C (p = 0.05), no differences between the groups in choles-terol, BMI, or CV risk *CDSS was applied for 104 patients (12%) only
Peters, 1999, Montgomery, 2000 General practice, UK General practitioners (n = 74), practice nurses (n = 11) Patients, N = 614 RCT (3-arms)	UA: general practice US: professionals, patients Quality criteria: 1 yes 2 ? 12 months *multi-level analysis	Professional: -stand-alone CDSS including training plus paper version of the risk chart or: -paper version of the risk chart only	usual care	a) ability to identify patients at high risk (5-year cardiovascular risk ≥ 10%) compared to gold standard a) prescribing of cardiovascular drugs b) cardiovascular risk reduction	a) no differences in terms of patients identified as being at high risk a) moderate agreement between professionals’ risk assessment and ‘gold standard‘ (κ = 0.49 at baseline and 0.56 at 12 mths.) a) increased prescribing of CV drugs in the chart-only grp. compared to usual care and CDSS group (p = 0.007) b) no differences between I and C
de Muylder, 2004 General practice, Belgium CME-groups of GPs GPs, N = 343 Randomized trial	UA: CME-group US: GPs Quality criteria: 1 no 2 ? 16 months	Professional: - educat. meeting	-	a) actual use of the risk assessment tool	a) I: use of risk assessment tool I: 76% compared to C: 52% (p = 0.003)

a Notes: Methods: UA = unit of allocation, US = unit of analysis, Quality criteria for RCTs: 1 concealed allocation, 2 blinded assessment of primary outcome(s).

Table 3C Empirical studies on stimulation of actual and appropriate use of cardiovascular risk tables in normal practice, characteristics, and effects. Studies using/combining professionaland organization strategies

Author:, year: Setting: location of care, country Participants: profession Patients (N) Study design:	Methods: a Quality criteria for RCTs: Study period	Type of intervention: Professional Financial Organizational Regulatory		Main outcome(s): a) health professional outcome(s) b) patient outcome(s)	Results:
		Intervention group	Controls
Ford, 2001 General Practice, UK General Practitioners Patients, N – 999 Non-controlled study	UA: GP US: patients Quality criteria: n/a 1 - 2 -12 months	Org., structural: -risk calculation facility embedded in lipid test ordering procedure	n/a	a) start of lipid-lowering drugs	a) improved statin prescription after CHD risk assessment *a minority of general practices (N = 14) used the service; requested CHD risk assessment
Hall, 2003 Hospital outpatient clinic, UK Medical doctors Patients, N = 323 RCT	UA: patients US: patients Quality criteria: 1 yes 2 ? Duration ?	Org., structural: -calculated CVD risk indicated on patients’ file	usual care	a) diabetes treatment, prescribing antihypertensive and lipid-lowering drugs, and referral to dietician	a) all patients -no changes in prescribing, referral, or number of interventions a) high-risk group (> 20% five year risk) -I: increased prescribing of anti-hypertensive and lipid-lowering drugs compared to C (p = 0.01).
Jacobson, 2006 Hospital outpatient clinics, USA Physicians N=164 Patients, N= 368 RCT	UA: patients US: patients Quality criteria: 1 yes 2 ? 5 months	Professional: - educat. meeting Org., structural: -calculated CVD risk indicated on patient file (external reviewers)	detailed educational form without CVD-risk	a) statin prescriptions for high-risk patients	a) no differences in statin prescribing in high-risk group, I: 40%, C: 38%
Sinclair G, 2006 Primary Care, New Zealand Primary Practice Team, GPs and nurses Patients, N = 6570 Noncontr. before and after design	UA: patients US: patients Quality criteria: n/a 1 – 2 – 12 months	Professional: -electronic or paper-based risk calculator -(computerized) reminders for screening -CDSS for management Org., structural: -letter to patient with invitation for risk assessment by nurse	n/a	a) 5-year CV-risk assessment recorded	a) CV risk assessment increased from 4.7% up to 53.5% one year after implementation of the system change *screening rates were higher in practices where nurses led the screening

a Notes: Methods: UA = unit of allocation, US = unit of analysis, Quality criteria for RCTs: 1 concealed allocation, 2 blinded assessment of primary outcome(s).

Table 3B Empirical studies on stimulation of actual and appropriate use of cardiovascular risk tables in normal practice, characteristics, and effects. Studies combining professional- and patient-mediated strategies

Author:, year: Setting: location of care, country Participants: profession Patients (N) Study design:	Methods: a Quality criteria for RCTs: Study period	Type of intervention: Professional Financial Organizational Regulatory		Main outcome(s): a) health professional outcome(s) b) patient outcome(s)	Results:
		Intervention group	Controls
Fretheim, 2006 General practice, Norway General practitioners GPs, N =501 Cluster randomized controlled Trial	UA: general practice US: patients Quality criteria: 1 yes 2 yes 12 months *multi-level analysis	Professional: -elec. risk calculator - stand-alone CDSS - (computerized) reminders -educat. outreach visits by pharmacist -audit and feedback Patient: -printed educat. materials	-short telephone interview	a) CV risk assessed before prescribing anti-hypertensive or lipid-lowering drugs	a) no changes in CV risk assessment
van Steenkiste, 2007 General practice, The Netherlands General practitioners (N = 34) Patients, N = 623 Cluster randomized trial	UA: GPs US: patients Quality criteria: 1 yes 2 no 6 months *multi-level analysis	Professional: -distrib. of educat. materials -educat. meeting (4 hrs.) Patient: -decision aid including the risk chart	-distrib. educat. materials -educat. meeting	a) appropriate risk classification, risk assessment, and risk management	a) no signifi cant differences in GPs’performance regarding risk classifi cation, assessment, and management

a Notes: Methods: UA = unit of allocation, US = unit of analysis, Quality criteria for RCTs: 1 concealed allocation, 2 blinded assessment of primary outcome(s).

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