STRATEGIES for helping primary care physicians to assess the risk of cardiovascular disease (CVD) in their patients have shown promise, but research published today in the Medical Journal of Australia shows combining several tools in a complex intervention with several moving parts was not effective.
The research, led by The George Institute for Global Health, UNSW Sydney, and involving collaborators across Australia, set out to determine whether a multifaceted primary health care intervention helped control CVD risk factors in patients with high risk better than usual care.
The INTEGRATE intervention involved electronic point-of-care decision support for general practices (HealthTracker); combination cardiovascular medications (polypills); and a pharmacy-based medication adherence program. It was introduced in 71 Australian general practices between 5 December 2016 and 13 September 2019, accompanied by a level of training and ongoing support that might be considered feasible if this intervention was delivered at scale. They measured the proportion of patients with high CVD risk not on an optimal preventive medication regimen at baseline who achieved both blood pressure and low-density lipoprotein (LDL) cholesterol goals at study end.
“The proportion of patients who achieved both treatment targets was similar in the intervention (423 of 2156; 19.6%) and control groups (466 of 2321; 20.1%),” Webster and colleagues reported.
“Further, no statistically significant differences were found for a number of secondary outcomes, including risk factor screening, preventive medication prescribing, and risk factor levels.
“Use of intervention components was low; it was highest for HealthTracker, used at least once for 347 of 3236 undertreated patients with high CVD risk (10.7%). Polypills were prescribed for fewer than 2% of eligible patients, and the Pharmacy Adherence Support Service was used even less frequently.”
Webster and colleagues surmised that the complexity of the intervention was possibly one barrier to uptake.
“Difficulties in integrating the intervention into the usual clinical workflow, uncertainty about the future availability of polypills, and inadequate incentives for quality improvement in reimbursement models in general practice may have inhibited its uptake,” they wrote.
“The multifaceted INTEGRATE intervention was not broadly implemented and did not improve CVD risk management in participating Australian general practices.
“A detailed process evaluation will provide greater insight into this problem, as well as into the influence of broader contextual factors, such as the infrastructure, policy, and reimbursement environment in which any quality improvement initiative must operate,” they concluded.
- Cate Swannell