Patients' experiences of health checks in general practice: a sample survey. Ebeltoft project: baseline data from a five-year randomized, controlled, prospective health promotion study in a Danish population. Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults General health screenings to improve cardiovascular risk profiles: a randomized controlled trial in general practice with 5-year follow-up. [Can systematic general health screening and patient-physician health discussions improve the cardiovascular profile of the population? A randomized controlled trial in general practice with a 5-year follow-up]. NHS health checks through general practice: randomised trial of population cardiovascular risk reduction [The health project Ebeltoft: health check ups and discussions in general practice. Basic data from a 5-year, prospective, randomized, controlled population study]. A randomized general population study of the effects of repeated health checks on incident diabetes A randomised controlled trial of the outcome of health assessment of people aged 75 years and over. The Effect of a Primary Care PracticeBased Depression Intervention on Mortality in Older Adults Improving population-based cervical cancer screening in general practice: effects of a national strategy. Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Clinical Implications of a Reduction in Psychological Distress on Cardiac Prognosis in Patients Participating in a Psychosocial Intervention Program Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial. Effect of a disease-specific planning intervention on surrogate understanding of patient goals for future medical treatment. The OXCHECK Study: a nursing perspective. Oxford and Collaborators Health Check.
The 1990 contract for general practitioners in the UK offered incentives for them to organize health promotion clinics and required them to perform ' lifestyle ' checkups of their patients every 3 years , despite uncertainty about the impact of such checks on patient health . To address this lack of appropriate evaluation , a follow-up study to assess benefits in terms of patient behaviour and health result ing from the introduction of lifestyle checkups in general practice in a sample of more than 7000 patients aged 30 - 70 from 18 practice s in three FHSA areas ( in south London , Surrey and Yorkshire ) has been performed . Eighteen per cent of the r and om sample of patients reported having a health check in the previous year . A full health check comprising measurement of blood pressure , height and weight , urinalysis and question ing about smoking habits , alcohol consumption , exercise , diet and family illnesses had been given to 29 % of respondents reporting a health check of any kind . Respondents in less privileged socioeconomic groups were more likely to have had a health check , but less likely to have had a ' full ' check . Reactions to the checks were mainly positive ; 81 % regarded the check as helpful , and only 6 % reported it to be worrying and 6 % a waste of time . The implication s for the new health promotion b and ing system in the UK are discussed BACKGROUND There is increasing political pressure on the medical profession to approach welfare diseases , such as coronary heart disease and diabetes , through prevention . General practitioners are required to offer regular health checks to healthy people  , in spite of the lack of scientific evidence for the universal need , usefulness and side effects of such an intervention . R and omized controlled trials are needed . AIM A study was carried out to investigate people 's interest in participating in health checks and in discussion s about health with their own general practitioner , participants ' health status , the proportion who received health advice following health checks , and the lifestyle goals they set following discussion with their general practitioner . This study reports the baseline data from a five-year r and omized , controlled , prospect i ve , population -based study in general practice s in Ebeltoft , Denmark . METHOD All general practitioners from the four practice s in Ebeltoft and a r and om sample of 2000 people aged between 30 and 50 years were invited to participate . Participants were r and omly divided into three groups -- one control group and two intervention groups . One intervention group were given a health check which included being screened for cardiovascular risk factors , lung and liver function , fitness , sight and hearing and an optional test for the human immunodeficiency virus ( HIV ) ; this group received written feedback from the general practitioner . The other intervention group were also given a health check and written feedback ; in addition , they were given the opportunity to attend their general practitioner to discuss preventive health . RESULTS A total of 1370 people participated in the study ( 69 % response rate ) . Health advice was given to 76 % of 905 participants following health checks . Almost all of the 456 participants ( 96 % ) who were offered the opportunity of discussing their health with their general practitioner took up the offer ; 64 % of the 456 participants reported that they had decided to undertake lifestyle changes . Eleven of those who discussed their health with the doctor were referred to a specialist ( 2 % ) . CONCLUSION There was considerable interest in participating in health promotion . Three out of four of those having a health check were given health advice . Two out of three of those offered a health talk with the general practitioner appeared willing to make relevant lifestyle changes . Long-term follow up is needed to determine effects and side effects of health checks and health talks Background Cardiovascular disease is the leading cause of death for adults in Australia . In recent years there has been a shift in health service delivery from institutional to community‐based care for chronic conditions , including cardiovascular disease . The general practice setting is seen to offer greater flexibility , higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector . It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management . To date , significant descriptive research has been conducted exploring the demographics , roles , educational needs and issues facing practice nurses . However , there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes , clinician satisfaction and cost‐effectiveness . Objectives This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults , as well as those with established cardiovascular disease or known cardiac risk factors . Search Strategy A systematic literature search was performed using Medline ( 1966 ‐ 2005 ) , CINAHL ( 1982 −2005 ) , Cochrane Controlled Trials Register ( Issue 4 , 2005 ) and the Joanna Briggs Institute Evidence Library . In addition , the reference lists of retrieved papers , conference proceedings and the Internet , were scrutinised for additional trials . Selection Criteria This review considered any English language r and omised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors . Interventions conducted by specialist cardiac nurses in general practice were excluded . Outcomes measured included blood pressure , smoking cessation , total cholesterol , exercise , body weight/body mass index and cost‐effectiveness . Results Eighteen trials , reported in 33 papers , were included in the review . Ten trials investigated multifaceted interventions , while the remaining eight trials reported targeted interventions . Of the trials that reported multifaceted interventions , three trials investigated risk reduction in those with established cardiovascular disease , four trials focused on those with known cardiovascular disease risk factors and three trials included the general community . The eight trials which examined the efficacy of targeted interventions focused upon dietary intake ( two trials ) , smoking cessation ( three trials ) , weight reduction ( one trial ) and physical activity ( two trials ) . The effect of both the multifaceted and targeted interventions on patient outcomes was variable . However , both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables . Improvements were demonstrated by most studies in blood pressure , cholesterol level , dietary intake and physical activity . The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions . Conclusions While interventions to reduce cardiovascular disease risk factors have produced variable results , they offer significant potential to assist patients in modifying their personal risk profile and should be developed . The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals . Further well‐ design ed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost‐effectiveness OBJECTIVES To investigate the impact of general health screenings and discussion s with general practitioners on the cardiovascular risk profile of a r and om population of patients . STUDY DESIGN A population -based , r and omized , controlled , 5-year follow-up trial conducted in a primary care setting . POPULATION The study group consisted of 2000 patients , r and omly selected middle-aged men and women aged 30 to 50 years from family practice s in the district of Ebeltoft , Denmark . Of these patients , 1507 ( 75.4 % ) agreed to participate . Patients were r and omized into ( 1 ) a control group who did not receive health screenings , ( 2 ) an intervention group that received 2 health screenings , ( 3 ) an intervention group that received both the 2 screenings and a 45-minute follow-up consultation annually with their general practitioner . OUTCOMES MEASURED Cardiovascular risk score ( CRS ) , body mass index ( BMI ) , blood pressure , serum cholesterol , carbon monoxide in expiratory air , and tobacco use . RESULTS After 5 years , the CRS , BMI , and serum cholesterol levels were lower in the intervention groups compared with the control group . The improved outcome was greater in the baseline risk groups . The number of patients with elevated CRS in the intervention groups was approximately half the number of patients with elevated CRS in the control group . The difference was not a result of medication use . There was no difference between the group that received consultations after the screenings and the group that had health screenings alone . CONCLUSIONS Health screenings reduced the CRS in the intervention groups . After 5 years of follow-up , the number of persons at elevated cardiovascular risk was about half that expected , based on the prevalence/proportion in a population not receiving the health checks ( the control group ) . The impact of intervention was higher among at-risk individuals . Consultations about health did not appear to improve the cardiovascular profile of the study population INTRODUCTION We investigated the impact of general health screenings and discussion s with general practitioners on the  cardiovascular risk profile of the population . MATERIAL AND METHODS A population -based , r and omised , controlled , 5-year follow-up trial conducted in a primary care setting . In total 2000 r and omly selected men and women , aged 30 - 50 years , from family practice s in the district of Ebeltoft , Denmark . Of these persons , 1507 ( 75.4 % ) agreed to participate , and were r and omised into : ( 1 ) a control group who did not receive health screenings ; ( 2 ) an intervention group that received two health screenings ; or ( 3 ) an intervention group that received both the two screenings and a 45-minute follow-up consultation annually with their general practitioner . All were followed up after 5 years by question naires and health screenings . The outcome measures were : cardiovascular risk score ( CRS ) , body mass index ( BMI ) , blood pressure , serum cholesterol , carbon monoxide in expiratory air , and use of tobacco . RESULTS After 5 years , the CRS , BMI , and serum cholesterol levels were lower in the intervention groups , as compared with the control group . The improved outcome was greater in the baseline risk groups . The number of persons with elevated CRS in the intervention groups was about half the number of persons with elevated CRS in the control group . The difference was not a result of medication use . There was no difference between the group that received consultations after the screenings and the group that had health screenings alone . DISCUSSION Systematic health screenings reduce the cardiovascular risk score in a middle-aged population . After 5 years of follow-up , the number of persons at elevated cardiovascular risk was about half the expected . The impact of intervention is higher in at-risk individuals . Planned consultations about health did not appear to improve the cardiovascular profile of the study population Background The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century . The Department of Health in Engl and has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk . The aims of this study were to monitor population changes in cardiovascular disease ( CVD ) risk factors over the first year of the new service and to assess the value of tailored lifestyle support , including motivational interview with ongoing support and referral to other services . Methods R and omised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent , Engl and . Thirty eight general practice s and 601 ( 365 usual care , 236 additional lifestyle support ) patients were recruited and r and omised independently between September 2009 and February 2010 . Changes in population CVD risk between baseline and one year follow-up were compared , using intention-to-treat analysis . The primary outcome was the Framingham 10 year CVD risk score . Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories . Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for : weight management , physical activity , cook and eat and positive thinking . Results Average population CVD risk decreased from 32.9 % to 29.4 % ( p < 0.001 ) in the NHS Health Check only group and from 31.9 % to 29.2 % ( p < 0.001 ) in the NHS Health Check plus additional lifestyle support group . There was no significant difference between the two groups at either measurement point . Prevalence of high blood pressure , high cholesterol and smoking were reduced significantly ( p < 0.01 ) in both groups . Prevalence of central obesity was reduced significantly ( p < 0.01 ) in the group receiving additional lifestyle support but not in the NHS Health Check only group . Conclusions The NHS Health Check service in Stoke on Trent result ed in significant reduction in estimated population CVD risk . There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction A study was carried out to investigate people 's interest in participating in health check-up and in discussion s about health with their own general practitioner , participants ' health status , the proportion who received health advice following health check-up , and the lifestyle goals they set following discussion with their general practitioner . This study reports the baseline data from a five-year r and omized , controlled , prospect i ve , population -based study in general practice s in Ebeltoft , Denmark . All general practitioners from the four practice s in Ebeltoft and a r and om sample of 2,000 people aged between 30 and 50 years were invited to participate . Participants were r and omly divided into three groups-one control group and two intervention groups . One intervention group was given a health check-up which included a range og tests ( Table 2 and 3 ) ; this group received written feedback from the general practitioner . The other intervention group was also given a health check-up and written feedback , in addition , they were given the opportunity to attend their general practitioner to discuss health-promoting measures .  A total of 1370 people participated in the study ( 69 % response rate ) . Health advice was given to 76 % of 905 participants following health check-up . Almost all of the 456 participants ( 96 % ) who were offered the opportunity of discussing their health with their general practitioner took up the offer : 64 % of the 456 participants reported that they had decided to undertake lifestyle changes . Eleven of those who discussed their health with the doctor were referred to a specialist ( 2 % ) . There was considerable interest in participating in health promotion . Three out of four of those who had a health check-up were given health advice . Two out of three of those who were offered a health talk with the general practitioner appeared willing to make relevant lifestyle changes . Longterm follow up is needed to determine effects and side effects of health check-up and health talks Background It is not clear whether offering health checks to the general population can be used to prevent diabetes . Few r and omized studies have had a long-term follow-up . We used a r and omly selected population cohort as a r and omized trial to examine the effect of repeated health checks on the 30-year incidence of diabetes . Methods The study included all persons from 11 municipalities in Copenhagen aged 30 , 40 , 50 , and 60 years ( n = 17845 ) . An age-stratified and gender-stratified r and om sample ( N = 4789 ) was invited to participate in a maximum of three health checks between 1982 and 1994 ( ‘ intervention group ’ ) . The remaining 12994 persons were defined as the ‘  control group ’ . The health checks included a question naire , a physical examination including assessment of overweight and blood pressure , and blood sampling with determination of serum lipid levels .  Based on the person ’s answers and test results , the participants were given individual information about the results , disease risk and lifestyle . Their general practitioner , too , was provided with written information on the test results . Both groups were followed in the Danish Civil Registration System , the Danish National Diabetes Register , the Cause of Death Registry , and the National Patient Registry until 31 December 2012 . Findings There were 2636 incident cases of diabetes and a mean follow-up time of 24.1 years . The age-adjusted and gender-adjusted hazard ratio ( HR ) ( 95 % confidence interval , CI ) for the intervention group versus the control group was HR = 1.07 ( 95 % CI : 0.98 , 1.16 , p = 0.153).InterpretationOffering repeated general health checks to the general population had no preventive effect on the development of diabetes during 30 years of follow-up OBJECTIVES To measure the outcomes of a health assessment , conducted by a nurse , of people aged 75 years and older ( 75+HA ) living independently in their own homes . DESIGN R and omised controlled trial ( RCT ) . SETTING A convenience sample of six general practice s within the Adelaide Western Division of General Practice ( AWDGP ) . A r and om sample of 100 participants was drawn from practice age-sex registers . Data were collected in initial visits between 1 August 1998 and February 1999 , then in follow-up visits one year later . PARTICIPANTS Participants were aged 75 years and over on 1 August 1998 and living independently in the community . 145 eligible patients were invited to join the study , and 100 of these consented to enrol ( 69 % ) . INTERVENTION A 75+HA conducted in the participant 's home by a nurse and reported to their usual general practitioner . MAIN OUTCOME MEASURES Primary : number of problems in each group ; number of participants with problems ; and mortality . Secondary : physical function ; psychological ( including cognitive ) function ; falls ; and admission to institution . RESULTS There were no significant differences between the control and intervention groups at follow-up in the number of problems , the number of participants with problems , or mortality . In the intervention group , there was significant improvement in self-rated health , geriatric depression score ( GDS 15 ) , and number of falls . CONCLUSIONS This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care Context Persons with depression are more likely to die , but studies have not shown that treatment of depression reduces mortality . Contribution Investigators observed a 45 % reduction in the hazard of death among patients with major depression cared for in primary care practice s that were r and omly assigned to a depression care management program . Caution s The reduction in deaths occurred almost exclusively among patients who died of cancer . The mechanism for the effect is unclear and might be due to misclassification of cause of death or vital status . Implication A practice -level depression care management program seemed to reduce deaths due to cancer in older patients with major depression . The Editors Prospect i ve , observational studies from many setting s have shown that depression is independently associated with an increased risk for death ( 15 ) . However , few studies have evaluated whether an intervention focused on depression can modify this risk . Intervention studies that have reported on death in patients with depression have serious limitations : They lacked r and omization to the intervention condition ( 68 ) , focused only on patients after cardiovascular events ( 912 ) , or adjusted for treatment in examining the association of depression with death rather than study ing the effect of treatment ( 6 , 13 ) . In our study , we analyzed the relationship between a depression care management intervention and the risk for death among older primary care patients during a 5-year interval . We used data from the Prevention of Suicide in Primary Care Elderly : Collaborative Trial ( PROSPECT ) , which we supplemented with data from the National Death Index ( NDI ) . The PROSPECT was an effectiveness study design ed to assess the effect of care management on reducing risk factors for late-life suicide ( 14 ) . It integrated a r and omized trial with a population -based , public health model . The study intervention was implemented at the practice level and involved a depression care manager working with physicians to provide algorithm-based care ( 14 ) . The primary care practice was the unit of r and omization , and practice s that were not r and omly assigned to the intervention were expected to provide usual care . Patients were not assigned to receive specific treatments , so patients and their physicians in the intervention and usual care practice s decided whether patients would receive depression treatment . Our research question focused on whether this practice -level intervention influenced a patient-level outcome , namely survival . We hypothesized that older adults with depression in practice s r and omly assigned to a depression management intervention would experience an attenuated risk for death compared with those patients in usual care practice s. Guided by published criteria for performing and reporting subgroup analyses ( 15 , 16 ) , we were particularly interested in whether the effects of care management were specific to patients meeting st and ard criteria for major depression ( Diagnostic and Statistical Manual for Mental Disorders , fourth edition [ DSM-IV ] [ 17 ] ) . Methods Study Sample The PROSPECT was conducted in 20 primary care practice s located in greater New York , New York , and Philadelphia and Pittsburgh , Pennsylvania , from May 1999 to August 2001 , with individual patients followed for 2 years . After being paired by urban location , academic affiliation , size , and population type , practice s were r and omly assigned to the intervention or to usual care by coin flip ( cluster r and omization by practice ) . Patients were recruited from an age-stratified ( 60 to 74 years and 75 years ) , r and om sample of patients with upcoming appointments . Research associates confirmed study eligibility ( age 60 years , Mini-Mental State Examination score 18 [ 18 ] , and English-speaking ) of consenting patients and screened patients for depression by using the Centers for Epidemiologic Studies Depression scale ( 19 ) . Eligibility Criteria All patients scoring greater than 20 on the Centers for Epidemiologic Studies Depression scale  were invited to enroll . Patients from a 5 % sample with lower scores were also invited for assessment of false-negative results on screening . To increase the sensitivity of screening , the PROSPECT investigators also recruited patients with scores less than 20 and positive responses to questions about previous depression episodes or treatment . Research associates met patients at the practice , obtained written consent , and administered a baseline interview ( 20 ) . The sampling strategy yielded a cohort that approximated a representative sample of attendees of the PROSPECT practice s , with oversampling of patients with depression symptoms . Depression Assessment We conducted a Structured Clinical Interview for DSM-IV Disorders Axis I ( SCID-I ) and allowed for the full range of DSM-IV diagnoses for depression disorders ( 17 , 21 ) . Our investigation focused on patients targeted by the intervention  , that is , patients who met DSM-IV criteria for major depression ( 17 ) or who had clinical ly significant minor depression , defined by DSM-IV criteria for minor depression that we modified by requiring 4 depression symptoms , Hamilton Depression Rating Scale ( HDRS ) score of 10 or more , and duration of 4 weeks or more ( 22 ) . To minimize variation in applying criteria for depression , the Cornell Advanced Center for Intervention and Services Research , White Plains , New York , conducted regular teleconferences with research associates to review diagnostic practice s and conduct reliability assessment s. Ongoing monitoring indicated excellent reliability within and across sites for SCID-I assessment s ( intraclass correlation , 0.78 to 1.00 ) . Assessment of Patient Characteristics We obtained baseline information on age , sex , marital status , self-reported ethnicity , educational attainment , and smoking status ( according to tobacco use within the past 6 months ) . We included ethnicity in describing our sample because it has been associated with patterns of mental health service use ( 23 , 24 ) . Patients self-reported having a medical comorbid condition according to the Charlson Comorbidity Index ( 25 ) . The 24-item HDRS measured depression severity ( 26 ) , and the Scale for Suicidal Ideation indicated the presence of suicidal ideation ( 27 ) . Description of Usual Care and Intervention Groups Practice s r and omly assigned to usual care received educational sessions for primary care physicians and notification of the depression status of their patients . No specific recommendations were given to physicians about individual patients , except for psychiatric emergencies . The following were made available to practice s r and omly assigned to the intervention : educational sessions for primary care physicians , education for patients ' families , and a depression care manager who worked within the practice . The care manager implemented the intervention by review ing patients ' depression status , medical history , and medication use and subsequently worked with the primary care physician to recommend treatment according to st and ard guidelines . Care managers had psychiatric backup , including on-dem and consultation , weekly supervision by psychiatrist- investigators , and monthly interpersonal therapy cross-site supervision . They were introduced to patients by research associates immediately after the baseline interview . The 15 care managers included social workers , nurses , and psychologists who interacted with patients in person or by telephone at scheduled intervals and as necessary . Care managers focused efforts on depression treatment ( not on care for medical conditions or preventive services ) by monitoring symptoms , adverse effects of medications , and treatment adherence . All patients with depression received citalopram for first-line treatment . Citalopram therapy was initiated at 10 mg before bedtime on the first day , 20 mg/d for the next 6 days , and 30 mg/d subsequently . After 6 weeks , the target dosage was maintained if the patient exhibited a substantial improvement ( 50 % reduction in the HDRS score ) ( 26 ) and was increased if the patient exhibited a partial improvement ( 30 % to 50 % reduction in the HDRS score ) . Nonresponders , for whom guidelines called for switching to another antidepressant , were defined as patients who did not demonstrate either minimal improvement after 6 weeks of treatment at the target dosage or substantial improvement after the dose was increased to the maximum recommended dose after 12 weeks of treatment ( 28 ) . For patients who had not responded at 12 weeks , the health specialist followed guidelines for switching antidepressants ( 28 ) . Health specialists informed patients and their family members about the possible occurrence of specific side effects and to contact them if side effects occurred . When side effects occurred , health specialists provided support and , if warranted , asked primary care physicians to adjust doses or time of administration or to institute symptomatic treatment ( 28 ) . The PROSPECT treatment algorithm also took account whether patients were already being treated for depression . For example , for patients already receiving pharmacotherapy who remained symptomatic , the care manager optimized the current antidepressant before switching patients to another antidepressant ( 28 ) . Interpersonal therapy could be used alone or as an augmentation strategy , depending on whether the patient tolerated the antidepressant therapy and on the presence or absence of a partial response . Care managers from each site , all of whom had some experience in psychotherapy for depression , participated in interpersonal therapy training at the University of Pittsburgh Medical Center , Pittsburgh . In both study groups , physicians were informed by letter if patients reported any suicidal ideation and immediately when patients were identified as being at high risk for suicide according to prespecified guidelines . Other sources detail the PROSPECT treatment algorithm and implementation , including the role of OBJECTIVE To assess the effects of a Dutch national prevention programme , aim ed at general practitioners ( GPs ) , on the adherence to organizational guidelines for effective cervical cancer screening  in general practice . To identify the characteristics of general practice s determining success . DESIGN A prospect i ve question naire study with pre- and post-measurement ( before and 15 months after the introduction of the national programme ) . SETTING AND STUDY PARTICIPANTS A r and om sample of one-third of all 4758 Dutch general practice s. One GP was asked to participate per practice . INTERVENTION A national GP prevention programme to improve population -based prevention of cervical cancer combining various methods for quality improvement in general practice , performed on a national , district and practice level . Outreach visitors were a key strategy in bringing about behavioural changes . MAIN OUTCOME MEASURES The proportion of practice s adhering to 10 recommendations ( in four guidelines ) to organize effective cervical cancer screening .  RESULTS After 15 months , all Dutch practice s showed significant improvement in adherence to nine out of 10 recommendations . Two recommendations , in particular ' identifying women who should be medically excluded from screening ' and ' sending a reminder to non-compliers ' showed the largest absolute increases of 26 % and 33 % , respectively . Besides more intensive support of outreach visitors , practice characteristics such as ' computerization ' and ' delegation of many clinical tasks to the practice assistant ' were important in improving the adherence to guidelines . CONCLUSION The national programme , with a combination of various methods for quality improvement , appeared to be effective in improving the organization of cervical screening in general practice . Computerization and , to a lesser extent , delegation of many clinical tasks to the practice assistant and more intensive support to practice s , positively influenced the effectiveness of the national programme BACKGROUND Past research has documented that primary care physicians and family members are often inaccurate when making substituted judgments for patients without advance directives ( ADs ) . This study compared the accuracy of substituted judgments made by primary care physicians , hospital-based physicians , and family surrogates on behalf of elderly out patients and examined the effectiveness of ADs in improving the accuracy of these judgments . PARTICIPANTS AND METHODS Participants were 24 primary care physicians of 82 elderly out patients , 17 emergency and critical care physicians who had no prior experience with the patients , and a baseline comparison group of family surrogates .  The primary outcome was accuracy of physicians ' predictions of patients ' preferences for 4 life-sustaining treatments in 9 hypothetical illness scenarios . Physicians made substituted judgments after being provided with no patient AD , patient 's value-based AD , or patient 's scenario-based AD . RESULTS Family surrogates ' judgments were more accurate than physicians ' . Hospital-based physicians making predictions without ADs had the lowest accuracy . Primary care physicians ' accuracy was not improved by either AD . Accuracy and confidence in predictions of hospital-based physicians was significantly improved for some scenarios using a scenario-based AD . CONCLUSIONS Although ADs do not improve the accuracy of substituted judgments for primary care physicians or family surrogates , they increase the accuracy of hospital-based physicians . Primary care physicians are withdrawing from hospital-based care in growing numbers , and emergency medicine and critical care specialists most often are involved in decisions about whether to begin life-sustaining treatments . If ADs can help these physicians better underst and patients ' preferences , patient autonomy more likely will be preserved when patients become incapacitated Objective The objective of this secondary analysis was to examine the relationships between a reduction in psychological distress and long-term cardiac and psychological outcomes in post – myocardial infa rct ion patients who participated in a r and omized trial of home-based psychosocial nursing interventions ( the Montreal Heart Attack Readjustment Trial [ M-HART ] ) . Gender differences were considered . Methods We studied  433 patients ( 36.0 % women ) from the M-HART treatment group who received two home visits after achieving a high psychological distress score ( ie , ≥5 ) on the General Health Question naire ( GHQ ) .  Short-term GHQ success was determined by a return to a normal GHQ score ( < 5 ) or a reduction of ≥50 % after the two visits . Patients with short-term successful and unsuccessful GHQ outcomes were compared for mid-term maintenance of success , 1-year death and readmission rates , and 1-year depression and anxiety symptoms . Results Patients with short-term GHQ success were more likely to show mid-term GHQ success ( p < .001 ) , marginally less likely to die of any causes ( p = .087 ) , less likely to die of cardiac causes ( p = .043 ) , less likely to be readmitted for any reason ( p < .001 ) and for cardiac reasons ( p < .001 ) , and less likely to have high depression ( p < .001 ) and anxiety ( p < .001 ) at 1-year than patients with short-term unsuccessful GHQ outcomes . Results held for men and women and were not altered by controlling for potential confounders . However , the number of deaths prevented analysis with statistical controls . Conclusions Post – myocardial infa rct ion interventions that reduce psychological distress have the potential to improve long-term prognosis and psychological status for both men and women Objective The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital . Design A pragmatic ward-r and omised trial design was used , with intervention introduced to all wards in sequence . No blinding was possible . Setting Sixteen adult wards in an 800-bed general hospital in the north of Engl and . Patients and participants All admissions to the 16 surgical , medical and elderly care wards during 32-week study period were included ( 7450 patients in total , of whom 2903 were eligible for the primary comparison ) . Interventions Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care , a 24-h service , emphasis on education , support and practical help for ward staff . Measurements and results The main outcome measures were in-hospital mortality and length of stay .  Outreach intervention  reduced in-hospital mortality compared with control ( two-level odds ratio : 0.52 ( 95 % CI 0.32–0.85 ) . A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses . Conclusions The study suggests outreach reduces mortality in general hospital wards . It may also increase length of stay , but our findings on this are equivocal BACKGROUND Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults . We evaluated the impact of the Geriatric Care Model ( GCM ) on the quality of life of community-dwelling frail older adults . METHODS A 24-month stepped wedge cluster r and omized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practice s in the Netherl and s , and included 1147 frail older adults . The intervention consisted of a geriatric in-home assessment by a practice nurse , followed by a tailored care plan . Re assessment occurred every six months . Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams . Complex patients were review ed in multidisciplinary consultations . The primary outcome was quality of life ( SF-12 ) . Secondary outcomes were health-related quality of life , functional limitations , self-rated health , psychological wellbeing , social functioning and hospitalizations . RESULTS Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes . Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months ( B=-0.25 , 95%CI=-0.43 to -0.06 , p=0.007 ) , but this effect was not statistically significant after correction for multiple comparisons . CONCLUSION The GCM did not show beneficial effects on quality of life in frail older adults in primary care , compared to usual care . This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population . TRIAL REGISTRATION The Netherl and s National Trial Register NTR2160 OBJECTIVES To determine whether a disease-specific planning process can improve surrogate underst and ing of goals of patients with life-limiting illnesses for future medical treatments . DESIGN A multisite r and omized controlled trial conducted between January 1 , 2004 and July 31 , 2007 . SETTING Six outpatient clinics of large community or university health systems in three Wisconsin cities . PARTICIPANTS Competent , English-speaking adults aged 18 and older with chronic congestive heart failure or chronic renal disease and their surrogate decision-makers . INTERVENTION Trained health professionals conducted a structured , patient-centered interview intended to promote informed decision-making and to result in the completion of a document clarifying the goals of the patient with regard to four disease-specific health outcome situations and the degree of decision-making latitude granted to the surrogate . MEASUREMENTS Surrogate underst and ing of patient goals for care with regard to four expected , disease-specific outcomes situations and of the degree of surrogate latitude in decision-making . RESULTS Three hundred thirteen patient-surrogate pairs completed the study . As measured according to kappa scores and in all four situations and in the degree of latitude , intervention group surrogates demonstrated a significantly higher degree of underst and ing of patient goals than control group surrogates . Intervention group kappa scores ranged from 0.61 to 0.78 , whereas control group kappa scores ranged from 0.07 to 0.28 . CONCLUSION Surrogates in the intervention group had a significantly better underst and ing of patient goals and preferences than surrogates in the control group . This finding is the first step toward ensuring that patient goals for care are known and honored The Oxford and Collaborators Health CHECK Trial ( OXCHECK ) was a r and omized controlled trial of the effectiveness of  nurse-administered health checks in the general practice setting . It was design ed primarily to influence risk factors for cardiovascular disease and cancer . The fourth and final year has now been completed , and the data analysis on over 8,100 health checks is under way . The findings from Year I have not been very encouraging in terms of lifestyle changes in moderate risk groups . This article briefly describes the design and methodology of the project , but mainly focuses on the practical issues involved in performing the health checks and on how the nurses and patients have felt about participating in the project . Much has happened to general practice , health promotion and the economy since the inception of OXCHECK in 1988 . The OXCHECK nurses have experienced a variety of responses and attitudes from patients . These are significant insomuch as they may provide a rationale for design ing alternative methods of assessing lifestyle change and individuals ' perception of risk . The importance of providing a strong link between the academic department involved in the project and the local clinical practice s will be discussed in the context of other key facilitating roles . However , the appropriateness of promoting certain preventive measures in the general practice setting can also be question ed
General practice -based health checks are associated with statistically significant , albeit clinical ly small , improvements in surrogate outcome control , especially among high-risk patients .
BACKGROUND A recent review concluded that general health checks fail to reduce mortality in adults .
AIM This review focuses on general practice -based health checks and their effects on both surrogate and final outcomes .