management of data on major cardiovascular risk factors in physicians using ES than in those ... electronic (ES) support on the clinical management appro-.
ORIGINAL RESEARCH ARTICLE
High Blood Press Cardiovasc Prev 2010; 17 (1): 37-47 1120-9879/10/0001-0037/$49.95/0
ª 2010 Adis Data Information BV. All rights reserved.
Use of Electronic Support for Implementing Global Cardiovascular Risk Management Analysis of the Results of the EFFECTUS (Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation) Educational Programme Giuliano Tocci,1 Andrea Ferrucci,1 Pietro Guida,2 Angelo Avogaro,3 Marco Comaschi,4 Alberto Corsini,5 Claudio Cortese,6 Carlo Bruno Giorda,7 Enzo Manzato,8 Gerardo Medea,9 Gian Francesco Mureddu,10 Gabriele Riccardi,11 Giulio Titta,12 Giuseppe Ventriglia,9 Giovanni Battista Zito13 and Massimo Volpe,1,14on behalf of the EFFECTUS Steering Committee 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Chair and Division of Cardiology, II Faculty of Medicine, University ‘‘La Sapienza’’, Sant’Andrea Hospital, Rome, Italy Cardiology Unit, Emergency and Organ Transplantation Department, University of Bari, Bari, Italy Department of Clinic and Experimental Medicine, Chair of Metabolic Diseases, University of Padua, Padua, Italy Department of Emergency Medicine, University of Genova, San Martino Hospital, Genova, Italy Department of Pharmacological Sciences, University of Milan, Milan, Italy Department of Internal Medicine, University of Rome ‘‘Tor Vergata’’, Rome, Italy Metabolism and Diabetes Unit, ASL Turin 5, Chiari, Turin, Italy Department of Medical and Surgical Sciences, University of Padua, Padua, Italy Italian College of General Practice (SIMG), Rome, Italy Department of Cardiovascular Disease, San Giovanni-Addolorata Hospital, Rome, Italy Division of Endocrinology and Metabolic Disease, University of Naples ‘‘Federico II’’, Naples, Italy Italian Federation of General Medicine, Turin, Italy Cardiology Unit, ASL Napoli 3 Sud, Pompei, Naples, Italy IRCCS Neuromed, Pozzilli, Isernia, Italy
Abstract
Introduction: The EFFECTUS (Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation) study is an educational programme, aimed at implementing global cardiovascular risk management in daily clinical practice in Italy. Objective: To evaluate global cardiovascular risk management among physicians stratified according to the use of conventional (CS) or electronic (ES) support for clinical data collection and registration. Methods: Involved physicians were asked to submit data into a study-designed, case-report form, covering the first ten adult outpatients consecutively seen in May 2006. A case-report form was made available on CS or ES, depending on physicians’ preferences and attitudes. All available data were centrally analysed for global cardiovascular risk assessment and cardiovascular risk profile characterization. Results: Overall, 1078 physicians (27% females, aged 50 – 7 years) collected data from 9904 outpatients (46.5% females, aged 67 – 9 years). 299 physicians used CS for 2672 (27.0%) patients, whereas the remaining 779 physicians used ES for 7232 patients (73.0%). A higher prevalence of obesity, diabetes mellitus, ischaemic heart disease (mostly previous myocardial infarction) and stroke, was recorded by physicians using CS compared with those using ES. Blood pressure and fasting glucose levels were significantly higher in the CS group than in the ES group, although a significantly higher number of antihypertensive, glucose and lipid-lowering prescriptions was reported in the former than in the latter group. Physicians using ES paid significantly more attention to collecting data concerning cardiovascular risk factors, which were also more up-to-date compared with those recorded by physicians using CS. Conclusions: This sub-analysis of the EFFECTUS study indicates a higher attention to the collection and management of data on major cardiovascular risk factors in physicians using ES than in those using CS. Our findings may suggest a potential way to improve global cardiovascular risk management in the clinical practices of Italy.
Tocci et al.
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Received for publication 8 February 2010; accepted for publication 14 March 2010. Keywords: global cardiovascular risk, cardiovascular risk management, electronic support, electronic case-report form, hypertension, hypercholesterolaemia, diabetes.
Introduction In the modern era of medicine, various tools are becoming available for improving physicians’ management of cardiovascular diseases. In particular, the large diffusion of electronic devices, technological supports and specifically designed hardware and software have substantially contributed to ameliorate the current standard of quality care, mostly in Western countries. Also, these devices have largely contributed to the improvement of physicians’ awareness of the importance of global cardiovascular risk stratification and to facilitate their attitude to cardiovascular disease prevention. This progressive shift from traditional supports toward modern and integrated clinical tools is basically aimed at reducing the global burden of cardiovascular diseases, which still represents the leading cause of morbidity and mortality, worldwide. The EFFECTUS (Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation) programme is an observational, multicentre study, designed to raise awareness of global cardiovascular risk management among physicians operating in daily clinical practice in Italy.[1] In this population, we recently demonstrated a very high prevalence of cardiovascular risk factors, irrespective of the clinical settings (patients followed by cardiologists rather than diabetologists and general practitioners),[1] as well as a significantly higher prevalence of major cardiovascular risk factors in southern areas than that recorded in northern and central areas (unpublished observations). In a further analysis, we were also able to demonstrate that a more intensive clinical data recording paralleled a better adherence to guidelines, suggesting that accuracy in recording translates into better management of patients at risk in daily clinical practice.[2] This large and representative population of physicians distributed throughout the whole Italian territory, provide information on patients at risk followed in different clinical settings and areas. In the present analysis we aimed to examine the potential influence of the use of either conventional (CS) or electronic (ES) support on the clinical management appropriateness of outpatients at cardiovascular risk. Therefore, the primary aim of this pre-specified analysis is to evaluate the potential differences and discrepancies in cardiovascular risk management among physicians involved in the EFFECTUS ª 2010 Adis Data Information BV. All rights reserved.
programme and stratified according to the use of CS or ES in their routine clinical practice.
Methods Methodology of the Study
The methodology of the study has been previously described.[1] Briefly, EFFECTUS is an educational project, structured in two distinct phases, the first stage being designed to evaluate prevalence of major cardiovascular risk factors and the second stage to establish the potential influence of an educational intervention on global cardiovascular risk management among physicians operating in clinical practice in Italy. The study conformed to the Declaration of Helsinki and its subsequent modifications, and was authorized by the reference Ethical Committee. The confidentiality of the data was carefully and strictly protected. Written consent to participate in the educational programme was obtained by all involved physicians and confidentiality on demographic and clinical data of all patients was carefully preserved. Physicians’ Recruitment
Physicians’ recruitment was accomplished in May 2006. Participants involved in the programme were randomly selected (in order to have a representative sample of the physicians in Italy) from a community of medical doctors, who shared some specific features: (i) experience in data collection and clinical case report compilation; (ii) a routine practice of at least 60 patients per week, on average; and (iii) free online access to a remote central database. Physicians were invited to participate in an educational training programme, aimed at evaluating the efficacy of a clinical problem-oriented learning approach for improving individual global cardiovascular risk management in their routine clinical practice. Thus, involved physicians were blind to the final purposes of the survey. Acceptance of this initial invitation placed physicians under no obligation, and physicians were entitled to withdraw from the survey at any stage. High Blood Press Cardiovasc Prev 2010; 17 (1)
Cardiovascular Disease Management in Italy by Use of Electronic Support
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Written invitations were forwarded in a sizable number to ensure the study population sample was a sufficient representation and to achieve this target within a period of approximately 3–4 weeks. For this purpose, each of the 20–24 regional referral centres invited 60 physicians per region (35 general practitioners, 10 diabetologists and 15 cardiologists) to participate in this survey, for a total of 1400 individual physicians, selected on the basis of the above-mentioned clinical features and personal characteristics. Then, approximately 1250 invitations were issued and physicians were asked to complete questionnaires featuring their characteristics and practice (age, gender, geographic location, professional expertise or speciality, use of electronic or conventional database) and to reply anonymously to the administrative site of their regional referral centres. Following their acceptance, involved physicians were asked to report specific, relevant, clinical data extracted from their clinical records from the first ten consecutive adult Caucasian outpatients aged more than 50 years, whatever the reason they referred to their own attending physicians. The entire data collection was completed by participants on-site and then delivered to the data collection centre by online access to a remote database. At each study site, collection of data was conducted during one week in May 2006. Physicians who completed the programme did not receive any compensation for their participation. The planned sample size of the survey participants included about 1200 physicians, in order to achieve an adequate representation of all Italian regions, as well as to limit excessive heterogeneity in age, gender, geographic location, professional expertise and practice size. The predefined minimum percentage of responses to achieve in order to declare the representative sample size was arbitrarily fixed to 80% of the total sample. Overall, the survey generated a population sample of 1078 physicians (89.8% of the planned sample size) and reflected approximately an outpatient practice of about 11 000 patients per week. Physicians involved in this programme were stratified into two groups, according to the purpose of the present analysis, including physicians using ES or CS.
pressure levels, serum lipids, blood glucose and glycated haemoglobin (HbA1c) levels were extracted from available clinical records and generally did not exceed 12 months. Body mass index (BMI) was calculated on the basis of the anthropometric data, and expressed as bodyweight in kilograms divided by body surface area in square metres. Information on blood pressure, ECG, echocardiogram, carotid or peripheral vascular ultrasonography, fundus oculi examination and exercise stress test were also recorded by physicians, when available.
Data Collection
Data collection included full medical history and physical examination. Information was obtained on current therapy for hypertension, lipid and glucose disorders, diabetes mellitus and other cardiovascular diseases including coronary artery disease, arrhythmias and heart or renal failure, as well as any concomitant medication. Clinic systolic and diastolic blood ª 2010 Adis Data Information BV. All rights reserved.
Data Analysis
Available data were centrally analysed for global cardiovascular risk evaluation and cardiovascular risk profile characterization. Normal values of clinic and metabolic parameters were carefully assessed. The diagnosis of arterial hypertension was based on the presence of blood pressure levels >140/90 mmHg (or 130/80 mmHg in diabetic patients) and/or stable antihypertensive treatment by at least 4 weeks.[3] Hypercholesterolaemia or hypertriglyceridaemia were defined on the basis of serum lowdensity lipoprotein cholesterol (LDL-C) or triglyceride levels >150 mg/dL and/or the presence of lipid-lowering treatment. The diagnosis of diabetes was established in the presence of fasting glucose levels >126 mg/dL and/or antidiabetic treatment.[4] Overweight was defined as a BMI of 25–29, while obesity was defined as a BMI of >30. At the same time, in those patients under pharmacological treatment, systolic and diastolic blood pressure control was defined by blood pressure values of
