View Article PDF

Reducing the impact of cardiovascular disease (CVD) is one of the 6 health targets of the New Zealand (NZ) Ministry of Health (MOH).1 This encourages at-risk individuals to modify lifestyle through smoking cessation, improving nutrition, increasing exercise and weight loss and to consider pharmacological treatment for blood pressure, cholesterol and blood sugar levels.Patients experience healthcare through individual consultations and community activities. The complexity of CVD impact reduction is best understood through patients perspectives, which include individual and community approaches to non-pharmacological lifestyle modification and pharmacological treatment.Increasingly, database analysis for indicators of the provision of quality care is used in NZ and international primary care settings to evaluate practitioner or practice performance. The NZ CVD indicator defines the well population eligible for CVD risk assessment based on the NZ CVD guidelines2 and is evaluated by counting recorded CVD risk percentages.The specific MOH target is to 'increase the percent of eligible adults who have their CVD risk assessed' which assumes that such activity translates to risk modification in currently well individuals and then to improved health outcomes. Non-pharmacological lifestyle modification is difficult to evaluate in a randomised controlled trial (RCT) setting but observational data suggest significant benefits, including all-cause mortality reduction.3 Pharmacological approaches are amenable to randomised trials but the extent of long-term relevant benefits for primary prevention remains controversial.4-6Individual non-pharmacological lifestyle modification advice complements population-based healthy lifestyle activities. Patients are influenced both through daily contact with their community and intermittent contact with the medical profession but research is limited in addressing which method (individual vs population) is most effective for reducing the impact of CVD. Community-based research indicates multifaceted interventions are more effective7-9 such as using multimedia (e.g. Internet, videos) and local businesses (e.g. supermarkets) and providing group-based support (e.g. weekly meetings, food planning courses, etc).The cexchange concept, which means people receive valued benefits in return for their efforts and changed behavioursd11 may explain this success and is part of social marketing strategies such as NZs recently terminated 'Healthy Eating Healthy Action (HEHA): Oranga Kai - Oranga Pumau'.10 Understanding whether services and interventions are valued by a population is important.The study reviews individual and population approaches to reducing the burden of CVD that prevail in a geographically constrained rural community. The challenge is to gauge whether populations gain more through GP performance indicator programmes or by improved access to and use of activities likely to improve lifestyle.Methods This study aims to: Assess the practical implementation of PHO performance indicators in a rural practice, by evaluating the difference between risk assessment determined through direct record audit and the PHO performance indicator calculated rate for the practice. Explore consumer awareness of and barriers to use of existing community activities and services that promote healthy lifestyles. First aimThe PHO for this practice used the BestPractice CVD risk tool12 alone to assess performance indicators. An audit of the patient population in Akaroa enrolled with the sole local health centre was conducted to determine the eligible population for CVD risk assessment as defined by the NZ CVD Guidelines (including high risk groupsrefer Table 2).13 The national performance indicator group uses a modified set of criteria based only on gender, age and ethnicity to calculate the vast majority of the eligible population.2 Completed formal assessments of CVD risk recorded in the practice management software were counted. These included the BestPractice CVD risk calculation, men and women's Wellness Checks14 and the Annual Diabetes Review. Both the Wellness Checks and BestPractice CVD risk calculation were initiated in the last 2 years and the diabetes review is annual, so an audit was done of the last 2 years using the MedTech32 query builder in the practice software. MedTech32 is the main software provider for NZ general practices. Second aimAn exploratory survey was designed to assess awareness, barriers and facilitators of access to services in the same local community likely to promote improved lifestyle. Through discussion with community organisers (e.g. health centre, social service centre, pharmacy, school nutritionist, PHO community service coordinator and community education coordinator) a list of 17 local services potentially associated with CVD risk reduction was built (e.g. nutrition, physical activity and psychological well-being [stress]). A one-page survey was created with input from these community organisers that asked three questions: Which of the 17 services were respondents aware of? (yes/no), Whether respondents participated in the listed service? (yes/no), and Comments about services and barriers and facilitators to participation? (open-ended). Pre-coded categories were developed during analysis of the free text comments. The questionnaire also asked participants to record age, gender, whether a participant had children and whether they had a health concern. Ethnicity data was not collected because this study was not designed to assess cultural influences on CVD risk reduction. Source populationTwo anonymous surveys were delivered to all post boxes on Banks Peninsula. Sample populationCVD risk assessment is generally 10 years later for women but the Wellness Checks begin at age 45 years for both women and men. Analysis was limited to replies from the sample eligible for CVD risk assessment: those 45 years and older. Data entry and analysisData was entered into an Excel spreadsheet and frequencies and proportions and statistical tests were calculated using Excel and OpenEpi Version 2.3 software.15 Results PHO performance CVD risk assessment indicatorThe enrolled population of the Akaroa Health Centre is 1684 people. The PHO generated list16 given to the health centre based on the performance indicator criteria2 identified 694 people eligible for a CVD risk assessment and 88/694 (12.7%) had a BestPractice CVD risk percentage recorded. Table 1. Eligible Population for CVD Risk assessment from April 2007-April 2009 CVD risk assessments Number Percentage CVD risk calculated and entered (Best Practice)1 88 11.80% Wellness Checks2 50 6.70% Annual DM review completed3 25 3.40% No CVD risk calculated/WC/DM assessment completed - routine screening (eligible for Wellness Check) - high risk 579 544 (389) 35 78% Total as counted by query builds: 742 100.00% 1 may include those who have also had a Diabetes review or Wellness Check 2 may include those who have also had a Diabetes review 3 includes those with diabetes who have NOT had CVD risk calculated (i.e. not total population with diabetes). In contrast, this study found 742 individuals eligible for CVD risk assessment, with 722 over 45 years of age. Of all those eligible (n=742, Table 1), 88/742 (11.8%) had a BestPractice CVD risk percentage recorded. An additional 50/742 (6.7%) had a Wellness Check and 25/742 (3.4%) a Diabetic Review giving a combined total of 21.9% of eligible patients with a CVD risk assessment. The difference between these data from the direct audit (21.9%) and the PHO Performance estimate (12.7%) is significant (p<0.001). The remaining (579/742; 78%) eligible population have not had a CVD risk assessment. About two-thirds (389/579; 67.2%) of this group are of the age group eligible for a Wellness Check (age 45 - 65yrs). Obtaining the appropriate data was complex and time-consuming: Seven sub-groups were used to determine the eligible population based on the NZ Cardiovascular Guidelines Handbook 200913 using variables of gender, ethnicity, high risk factors and age (see Table 2). More than 15 separate MedTech32 Query builds were required to identify patients in these subgroups. The queries then had to be manually searched to remove duplicates of individuals and combine queries. Table 2 is included solely to illustrate the complexity of this process and contains no additional data. Community awareness of lifestyle resources1400 surveys were delivered to households and 385 participants replied who were over 45 years of age (65 replied under 45 years of age). There were 981 enrolled patients in the practice over the age of 45 years. Assuming all survey respondents are enrolled in the practice, this is a response rate of 39.2% (385/981). Of 17 well-being services offered in the community, respondents of the survey were aware of an average of 6.2 services (6.2/17; 36%). Six respondents recognised no services (6/385; 1.6%). Over half of respondents (219/385; 56.9%) report participating in at least one of these activities and this proportion is the same whether they had a health concern or not. The potential participation rate drops to 22% (219/981) if non-responders dont participate or increases the rate to 83% (815/981) if they do participate. The best-recognised services are sports groups, dance classes, TaiChi Classes and GP Wellness Checks (n/2369; 9 - 14.1%). Of PHO supported services, awareness was 4.1% (96/2369) for smoking cessation, 2.6% (62/2369) for Green Prescription, 2.5% (60/2369) for falls prevention exercise programme, 1.8% (42/2369) for the Appetite for Life nutrition service, 1.4% (32/2369) for dietician services and 1.3% (30/2369) for the Ageing/Changing fitness programme. Table 2. Complexity of identifying sub-groups without a BestPractice CVD calculation recorded (n = 742 - 88) BPac risk- Best Practice CVD risk calculation; DM review- Annual Diabetes Review M/WWC- Mens or Womens Wellness Check. ++High Risk sub-groups (1), (3) & (7): read codes- current smoker, diabetes, obesity, [add for (7)- IHD, renal disease]; prescriptions- anti-hypertensives, lipid lowering [not included- gestational diabetes, IGT, renal, family history premature CVD] Around one-third (142/385; 36.9%) of respondents did not attend any activities. Barriers reported were not enough time (28/142; 19.7%), no need (10/142; 7%) and living too far away (10/142; 7%). Just under half (65/142; 45.8%) gave no reason. Only 2 respondents (1.4%) stated cost as a reason for non-attendance. Other comments were suggestions for services (30/162; 18.5%), positive comments about existing services (30/162;18.5%) and comments about which activities people attended (29/162; 17.9%). Suggestions were mostly about swimming pool and gym services. Table 2 lists the results of the survey. Table 3: Survey results from respondents over 45 years of age Variables Number % Characteristics of all participants 385 n=385 Males 157 40.8% Age: 45-55 yrs 56-66 yrs 67+ yrs 133 133 150 34.5% 34.5% 39.0% Have children 238 61.8% Health concerns that would benefit from lifestyle modification. 112 29.1% Attendance at any of the activities If yes had health concern (n=112), and attended activities If had no health concern (n=227), and attended activities 219 64 130 56.9% 57.1% 57.3% Any comment made 162 42.1% All activities identified from a list of 17 options Average number of services identified per participant (n=385) Most common services recognised- Sports groups (e.g., bowls, croquet, golf, tennis, walking, golf, badminton, rugby) Dance classes TaiChi classes GP Wellness Checks Wellbeing services (e.g., Akaroa Body Care) Yoga classes Counselling services 2369 6.2 335 322 261 256 231 228 142 n=2369 14.1% 13.6% 11.0% 10.8% 9.8% 9.6% 9.0% Non-attendance Gave no reason No Time (including No time + live too far) No need Live too far away Only recently arrived Cost Other 142 65 28 10 10 5 2 22 n=142 45.8% 19.7% 7.0% 7.0% 3.5% 1.4% 15.5% Respondents who commented [Some respondents made multiple comments] Reasons for not attending Suggestions - about use of pool - access to a gym Positive comments on services Activities attended 162 77 30 7 5 30 29 n=162 47.7% 18.5% 18.5% 17.9% Note: Numbers do not all add up to the total due to non-responders. Discussion Government health targets to reduce the impact of CVD

Summary

Abstract

Aim

This study explores how the New Zealand (NZ) population experiences approaches to cardiovascular disease (CVD) risk management: (1) the Primary Health Organisation (PHO) CVD risk performance indicator programme in Akaroa, Canterbury NZ and (2) consumer use of community services that promote healthier lifestyles.

Method

An audit identified patients enrolled at the Akaroa Health Centre eligible for CVD risk assessments and the portion with completed formal assessments. This was compared with the standard PHO performance tool for assessing CVD. An exploratory survey identified awareness of and barriers to use of local lifestyle resources that may directly or indirectly reduce CVD risk, in respondents over the age of 45 years.

Results

Distinguishing the eligible population who had not already had their CVD risk calculated required complex database analysis. As of April 2009 11.8% of the eligible population had a CVD risk calculated using the PHO performance tool. However, another 10.1% had had these risks assessed through other tools. The combined total of 21.9% meets the minimum target of 21.7% for the year ending June 30th 2009. The community survey found around a third (36%) of lifestyle promoting resources available were recognised with about half (56.9%) of respondents participating in the activities. Barriers to use included lack of time and perceived need of the service.

Conclusion

The current performance indicator approach is not practical, subject to error and may have significant opportunity costs. Furthermore, barriers exist in engaging the population identified as at risk in health-promoting activities.

Author Information

Emily Gill, GP Registrar, Akaroa Medical Centre, Akaroa, Canterbury; Dee Mangin, Associate Professor, Department of GP, Christchurch Medical School, University of Otago, Christchurch

Acknowledgements

Ethics approval was given for this audit and survey by the Upper South A Regional Ethics Committee (Ref- URA/09/10/EXP). Funding was provided by the Rural Canterbury PHO and the lead author. We also thank the many people who donated their time and services to this project including the Akaroa Medical Centre team, the Rural Canterbury PHO, Alison Wilkie, the Heartlands team, Mary the Akaroa postie, and Jesse Galloway who did the data-entry.

Correspondence

Emily Gill, 1829/24B Moorfield Rd, Johnsonville, Wellington, New Zealand.

Correspondence Email

emily.gill@actrix.co.nz

Competing Interests

None.

Website: Ministry of Health; Health Targets: Better diabetes and cardiovascular services, 2009.http://www.moh.govt.nz/moh.nsf/indexmh/healthtargets-targets-diabetesPHO Performance Programme, (DHBNZ); Indicator Definitions: 1 July 2008 Performance Indicator Set. 2008.Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343(1):16-22. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10882764Rangno R, McCormack J, Virani A, et al. Therapeutics Education Collaboration: Episodes 1 - 12: Discussions about Cardiovascular Disease; [PodCast]. Canada.. http://therapeuticseducation.org/Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373(9678):1849-60.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19482214Abramson J, Wright JM. Are lipid-lowering guidelines evidence-based? The Lancet 2007;369(9557):168.Barton RL, Whitehead K. A review of community based healthy eating interventions. J Hum Nutr Diet 2008;21(4):378-79.Heshka S., Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289(14):1792-8. http://jama.ama-assn.org/cgi/content/full/289/14/1792Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of community-based physical activity interventions. Am J Prev Med 2008;35(6):578-88. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19000846Website: Ministry of Health; Welcome to HEHA- Healthy Eating - Healthy Action: Oranga Kai - Oranga Pumau. 2009:http://www.heha.org.nz/Quiglet and Watts Ltd, (Health Sponsorship Council); Healthy Eating: Rapid Evidence Review of Nutrition Social Marketing Interventions to Prevent Obesity. 2007.Bestpractice- Decision Support for Health Professionals [program]. Dunedin: Best Practice Advocacy Centre Inc (BPAC Inc), 2008.NZ Guidelines Group, NZ Cardiovascular Guidelines Handbook: A summary resource for Primary Care Practitioners. 2009.Rural Canterbury PHO. Men's and Women's Wellness Checks, 2009. http://www.rcpho.org.nz/services/pho-programmes/women-s-wellness-checks/Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, 2009.http://www.OpenEpi.comWilkie Alison (Performance Programme Coordinator, Rural Canterbury DHB). New Performance Indicators- PPP 1July 2008 - 30 June 2009; [Letter and emails]. 2009.Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 1995;310(6987):1099-104.http://www.bmj.com/cgi/content/abstract/310/6987/1099Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician 2008;54(12):1706-13.Wood DA, Kinmonth AL, Davies GA, et al. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. BMJ 1994;308(6924):313-20.http://www.bmj.com/cgi/content/abstract/308/6924/313Website: National Health Committee; Screening to Improve Health in New Zealand: Summary. 2003:http://www.nhc.health.govt.nz/moh.nsf/0/EFC453A05BDDF425CC2572AA0010F4FELangham S, Thorogood M, Normand C, et al. Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study. BMJ 1996;312(7041):1265-68. http://www.bmj.com/cgi/content/abstract/312/7041/1265Richardson CR, Newton TL, Abraham JJ, et al. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med 2008;6(1):69-77. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18154676Dalziel K, Segal L, Elley CR. Cost utility analysis of physical activity counselling in general practice. Aust N Z J Public Health 2006;30(1):57-63.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Reducing the impact of cardiovascular disease (CVD) is one of the 6 health targets of the New Zealand (NZ) Ministry of Health (MOH).1 This encourages at-risk individuals to modify lifestyle through smoking cessation, improving nutrition, increasing exercise and weight loss and to consider pharmacological treatment for blood pressure, cholesterol and blood sugar levels.Patients experience healthcare through individual consultations and community activities. The complexity of CVD impact reduction is best understood through patients perspectives, which include individual and community approaches to non-pharmacological lifestyle modification and pharmacological treatment.Increasingly, database analysis for indicators of the provision of quality care is used in NZ and international primary care settings to evaluate practitioner or practice performance. The NZ CVD indicator defines the well population eligible for CVD risk assessment based on the NZ CVD guidelines2 and is evaluated by counting recorded CVD risk percentages.The specific MOH target is to 'increase the percent of eligible adults who have their CVD risk assessed' which assumes that such activity translates to risk modification in currently well individuals and then to improved health outcomes. Non-pharmacological lifestyle modification is difficult to evaluate in a randomised controlled trial (RCT) setting but observational data suggest significant benefits, including all-cause mortality reduction.3 Pharmacological approaches are amenable to randomised trials but the extent of long-term relevant benefits for primary prevention remains controversial.4-6Individual non-pharmacological lifestyle modification advice complements population-based healthy lifestyle activities. Patients are influenced both through daily contact with their community and intermittent contact with the medical profession but research is limited in addressing which method (individual vs population) is most effective for reducing the impact of CVD. Community-based research indicates multifaceted interventions are more effective7-9 such as using multimedia (e.g. Internet, videos) and local businesses (e.g. supermarkets) and providing group-based support (e.g. weekly meetings, food planning courses, etc).The cexchange concept, which means people receive valued benefits in return for their efforts and changed behavioursd11 may explain this success and is part of social marketing strategies such as NZs recently terminated 'Healthy Eating Healthy Action (HEHA): Oranga Kai - Oranga Pumau'.10 Understanding whether services and interventions are valued by a population is important.The study reviews individual and population approaches to reducing the burden of CVD that prevail in a geographically constrained rural community. The challenge is to gauge whether populations gain more through GP performance indicator programmes or by improved access to and use of activities likely to improve lifestyle.Methods This study aims to: Assess the practical implementation of PHO performance indicators in a rural practice, by evaluating the difference between risk assessment determined through direct record audit and the PHO performance indicator calculated rate for the practice. Explore consumer awareness of and barriers to use of existing community activities and services that promote healthy lifestyles. First aimThe PHO for this practice used the BestPractice CVD risk tool12 alone to assess performance indicators. An audit of the patient population in Akaroa enrolled with the sole local health centre was conducted to determine the eligible population for CVD risk assessment as defined by the NZ CVD Guidelines (including high risk groupsrefer Table 2).13 The national performance indicator group uses a modified set of criteria based only on gender, age and ethnicity to calculate the vast majority of the eligible population.2 Completed formal assessments of CVD risk recorded in the practice management software were counted. These included the BestPractice CVD risk calculation, men and women's Wellness Checks14 and the Annual Diabetes Review. Both the Wellness Checks and BestPractice CVD risk calculation were initiated in the last 2 years and the diabetes review is annual, so an audit was done of the last 2 years using the MedTech32 query builder in the practice software. MedTech32 is the main software provider for NZ general practices. Second aimAn exploratory survey was designed to assess awareness, barriers and facilitators of access to services in the same local community likely to promote improved lifestyle. Through discussion with community organisers (e.g. health centre, social service centre, pharmacy, school nutritionist, PHO community service coordinator and community education coordinator) a list of 17 local services potentially associated with CVD risk reduction was built (e.g. nutrition, physical activity and psychological well-being [stress]). A one-page survey was created with input from these community organisers that asked three questions: Which of the 17 services were respondents aware of? (yes/no), Whether respondents participated in the listed service? (yes/no), and Comments about services and barriers and facilitators to participation? (open-ended). Pre-coded categories were developed during analysis of the free text comments. The questionnaire also asked participants to record age, gender, whether a participant had children and whether they had a health concern. Ethnicity data was not collected because this study was not designed to assess cultural influences on CVD risk reduction. Source populationTwo anonymous surveys were delivered to all post boxes on Banks Peninsula. Sample populationCVD risk assessment is generally 10 years later for women but the Wellness Checks begin at age 45 years for both women and men. Analysis was limited to replies from the sample eligible for CVD risk assessment: those 45 years and older. Data entry and analysisData was entered into an Excel spreadsheet and frequencies and proportions and statistical tests were calculated using Excel and OpenEpi Version 2.3 software.15 Results PHO performance CVD risk assessment indicatorThe enrolled population of the Akaroa Health Centre is 1684 people. The PHO generated list16 given to the health centre based on the performance indicator criteria2 identified 694 people eligible for a CVD risk assessment and 88/694 (12.7%) had a BestPractice CVD risk percentage recorded. Table 1. Eligible Population for CVD Risk assessment from April 2007-April 2009 CVD risk assessments Number Percentage CVD risk calculated and entered (Best Practice)1 88 11.80% Wellness Checks2 50 6.70% Annual DM review completed3 25 3.40% No CVD risk calculated/WC/DM assessment completed - routine screening (eligible for Wellness Check) - high risk 579 544 (389) 35 78% Total as counted by query builds: 742 100.00% 1 may include those who have also had a Diabetes review or Wellness Check 2 may include those who have also had a Diabetes review 3 includes those with diabetes who have NOT had CVD risk calculated (i.e. not total population with diabetes). In contrast, this study found 742 individuals eligible for CVD risk assessment, with 722 over 45 years of age. Of all those eligible (n=742, Table 1), 88/742 (11.8%) had a BestPractice CVD risk percentage recorded. An additional 50/742 (6.7%) had a Wellness Check and 25/742 (3.4%) a Diabetic Review giving a combined total of 21.9% of eligible patients with a CVD risk assessment. The difference between these data from the direct audit (21.9%) and the PHO Performance estimate (12.7%) is significant (p<0.001). The remaining (579/742; 78%) eligible population have not had a CVD risk assessment. About two-thirds (389/579; 67.2%) of this group are of the age group eligible for a Wellness Check (age 45 - 65yrs). Obtaining the appropriate data was complex and time-consuming: Seven sub-groups were used to determine the eligible population based on the NZ Cardiovascular Guidelines Handbook 200913 using variables of gender, ethnicity, high risk factors and age (see Table 2). More than 15 separate MedTech32 Query builds were required to identify patients in these subgroups. The queries then had to be manually searched to remove duplicates of individuals and combine queries. Table 2 is included solely to illustrate the complexity of this process and contains no additional data. Community awareness of lifestyle resources1400 surveys were delivered to households and 385 participants replied who were over 45 years of age (65 replied under 45 years of age). There were 981 enrolled patients in the practice over the age of 45 years. Assuming all survey respondents are enrolled in the practice, this is a response rate of 39.2% (385/981). Of 17 well-being services offered in the community, respondents of the survey were aware of an average of 6.2 services (6.2/17; 36%). Six respondents recognised no services (6/385; 1.6%). Over half of respondents (219/385; 56.9%) report participating in at least one of these activities and this proportion is the same whether they had a health concern or not. The potential participation rate drops to 22% (219/981) if non-responders dont participate or increases the rate to 83% (815/981) if they do participate. The best-recognised services are sports groups, dance classes, TaiChi Classes and GP Wellness Checks (n/2369; 9 - 14.1%). Of PHO supported services, awareness was 4.1% (96/2369) for smoking cessation, 2.6% (62/2369) for Green Prescription, 2.5% (60/2369) for falls prevention exercise programme, 1.8% (42/2369) for the Appetite for Life nutrition service, 1.4% (32/2369) for dietician services and 1.3% (30/2369) for the Ageing/Changing fitness programme. Table 2. Complexity of identifying sub-groups without a BestPractice CVD calculation recorded (n = 742 - 88) BPac risk- Best Practice CVD risk calculation; DM review- Annual Diabetes Review M/WWC- Mens or Womens Wellness Check. ++High Risk sub-groups (1), (3) & (7): read codes- current smoker, diabetes, obesity, [add for (7)- IHD, renal disease]; prescriptions- anti-hypertensives, lipid lowering [not included- gestational diabetes, IGT, renal, family history premature CVD] Around one-third (142/385; 36.9%) of respondents did not attend any activities. Barriers reported were not enough time (28/142; 19.7%), no need (10/142; 7%) and living too far away (10/142; 7%). Just under half (65/142; 45.8%) gave no reason. Only 2 respondents (1.4%) stated cost as a reason for non-attendance. Other comments were suggestions for services (30/162; 18.5%), positive comments about existing services (30/162;18.5%) and comments about which activities people attended (29/162; 17.9%). Suggestions were mostly about swimming pool and gym services. Table 2 lists the results of the survey. Table 3: Survey results from respondents over 45 years of age Variables Number % Characteristics of all participants 385 n=385 Males 157 40.8% Age: 45-55 yrs 56-66 yrs 67+ yrs 133 133 150 34.5% 34.5% 39.0% Have children 238 61.8% Health concerns that would benefit from lifestyle modification. 112 29.1% Attendance at any of the activities If yes had health concern (n=112), and attended activities If had no health concern (n=227), and attended activities 219 64 130 56.9% 57.1% 57.3% Any comment made 162 42.1% All activities identified from a list of 17 options Average number of services identified per participant (n=385) Most common services recognised- Sports groups (e.g., bowls, croquet, golf, tennis, walking, golf, badminton, rugby) Dance classes TaiChi classes GP Wellness Checks Wellbeing services (e.g., Akaroa Body Care) Yoga classes Counselling services 2369 6.2 335 322 261 256 231 228 142 n=2369 14.1% 13.6% 11.0% 10.8% 9.8% 9.6% 9.0% Non-attendance Gave no reason No Time (including No time + live too far) No need Live too far away Only recently arrived Cost Other 142 65 28 10 10 5 2 22 n=142 45.8% 19.7% 7.0% 7.0% 3.5% 1.4% 15.5% Respondents who commented [Some respondents made multiple comments] Reasons for not attending Suggestions - about use of pool - access to a gym Positive comments on services Activities attended 162 77 30 7 5 30 29 n=162 47.7% 18.5% 18.5% 17.9% Note: Numbers do not all add up to the total due to non-responders. Discussion Government health targets to reduce the impact of CVD

Summary

Abstract

Aim

This study explores how the New Zealand (NZ) population experiences approaches to cardiovascular disease (CVD) risk management: (1) the Primary Health Organisation (PHO) CVD risk performance indicator programme in Akaroa, Canterbury NZ and (2) consumer use of community services that promote healthier lifestyles.

Method

An audit identified patients enrolled at the Akaroa Health Centre eligible for CVD risk assessments and the portion with completed formal assessments. This was compared with the standard PHO performance tool for assessing CVD. An exploratory survey identified awareness of and barriers to use of local lifestyle resources that may directly or indirectly reduce CVD risk, in respondents over the age of 45 years.

Results

Distinguishing the eligible population who had not already had their CVD risk calculated required complex database analysis. As of April 2009 11.8% of the eligible population had a CVD risk calculated using the PHO performance tool. However, another 10.1% had had these risks assessed through other tools. The combined total of 21.9% meets the minimum target of 21.7% for the year ending June 30th 2009. The community survey found around a third (36%) of lifestyle promoting resources available were recognised with about half (56.9%) of respondents participating in the activities. Barriers to use included lack of time and perceived need of the service.

Conclusion

The current performance indicator approach is not practical, subject to error and may have significant opportunity costs. Furthermore, barriers exist in engaging the population identified as at risk in health-promoting activities.

Author Information

Emily Gill, GP Registrar, Akaroa Medical Centre, Akaroa, Canterbury; Dee Mangin, Associate Professor, Department of GP, Christchurch Medical School, University of Otago, Christchurch

Acknowledgements

Ethics approval was given for this audit and survey by the Upper South A Regional Ethics Committee (Ref- URA/09/10/EXP). Funding was provided by the Rural Canterbury PHO and the lead author. We also thank the many people who donated their time and services to this project including the Akaroa Medical Centre team, the Rural Canterbury PHO, Alison Wilkie, the Heartlands team, Mary the Akaroa postie, and Jesse Galloway who did the data-entry.

Correspondence

Emily Gill, 1829/24B Moorfield Rd, Johnsonville, Wellington, New Zealand.

Correspondence Email

emily.gill@actrix.co.nz

Competing Interests

None.

Website: Ministry of Health; Health Targets: Better diabetes and cardiovascular services, 2009.http://www.moh.govt.nz/moh.nsf/indexmh/healthtargets-targets-diabetesPHO Performance Programme, (DHBNZ); Indicator Definitions: 1 July 2008 Performance Indicator Set. 2008.Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343(1):16-22. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10882764Rangno R, McCormack J, Virani A, et al. Therapeutics Education Collaboration: Episodes 1 - 12: Discussions about Cardiovascular Disease; [PodCast]. Canada.. http://therapeuticseducation.org/Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373(9678):1849-60.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19482214Abramson J, Wright JM. Are lipid-lowering guidelines evidence-based? The Lancet 2007;369(9557):168.Barton RL, Whitehead K. A review of community based healthy eating interventions. J Hum Nutr Diet 2008;21(4):378-79.Heshka S., Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289(14):1792-8. http://jama.ama-assn.org/cgi/content/full/289/14/1792Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of community-based physical activity interventions. Am J Prev Med 2008;35(6):578-88. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19000846Website: Ministry of Health; Welcome to HEHA- Healthy Eating - Healthy Action: Oranga Kai - Oranga Pumau. 2009:http://www.heha.org.nz/Quiglet and Watts Ltd, (Health Sponsorship Council); Healthy Eating: Rapid Evidence Review of Nutrition Social Marketing Interventions to Prevent Obesity. 2007.Bestpractice- Decision Support for Health Professionals [program]. Dunedin: Best Practice Advocacy Centre Inc (BPAC Inc), 2008.NZ Guidelines Group, NZ Cardiovascular Guidelines Handbook: A summary resource for Primary Care Practitioners. 2009.Rural Canterbury PHO. Men's and Women's Wellness Checks, 2009. http://www.rcpho.org.nz/services/pho-programmes/women-s-wellness-checks/Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, 2009.http://www.OpenEpi.comWilkie Alison (Performance Programme Coordinator, Rural Canterbury DHB). New Performance Indicators- PPP 1July 2008 - 30 June 2009; [Letter and emails]. 2009.Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 1995;310(6987):1099-104.http://www.bmj.com/cgi/content/abstract/310/6987/1099Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician 2008;54(12):1706-13.Wood DA, Kinmonth AL, Davies GA, et al. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. BMJ 1994;308(6924):313-20.http://www.bmj.com/cgi/content/abstract/308/6924/313Website: National Health Committee; Screening to Improve Health in New Zealand: Summary. 2003:http://www.nhc.health.govt.nz/moh.nsf/0/EFC453A05BDDF425CC2572AA0010F4FELangham S, Thorogood M, Normand C, et al. Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study. BMJ 1996;312(7041):1265-68. http://www.bmj.com/cgi/content/abstract/312/7041/1265Richardson CR, Newton TL, Abraham JJ, et al. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med 2008;6(1):69-77. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18154676Dalziel K, Segal L, Elley CR. Cost utility analysis of physical activity counselling in general practice. Aust N Z J Public Health 2006;30(1):57-63.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Reducing the impact of cardiovascular disease (CVD) is one of the 6 health targets of the New Zealand (NZ) Ministry of Health (MOH).1 This encourages at-risk individuals to modify lifestyle through smoking cessation, improving nutrition, increasing exercise and weight loss and to consider pharmacological treatment for blood pressure, cholesterol and blood sugar levels.Patients experience healthcare through individual consultations and community activities. The complexity of CVD impact reduction is best understood through patients perspectives, which include individual and community approaches to non-pharmacological lifestyle modification and pharmacological treatment.Increasingly, database analysis for indicators of the provision of quality care is used in NZ and international primary care settings to evaluate practitioner or practice performance. The NZ CVD indicator defines the well population eligible for CVD risk assessment based on the NZ CVD guidelines2 and is evaluated by counting recorded CVD risk percentages.The specific MOH target is to 'increase the percent of eligible adults who have their CVD risk assessed' which assumes that such activity translates to risk modification in currently well individuals and then to improved health outcomes. Non-pharmacological lifestyle modification is difficult to evaluate in a randomised controlled trial (RCT) setting but observational data suggest significant benefits, including all-cause mortality reduction.3 Pharmacological approaches are amenable to randomised trials but the extent of long-term relevant benefits for primary prevention remains controversial.4-6Individual non-pharmacological lifestyle modification advice complements population-based healthy lifestyle activities. Patients are influenced both through daily contact with their community and intermittent contact with the medical profession but research is limited in addressing which method (individual vs population) is most effective for reducing the impact of CVD. Community-based research indicates multifaceted interventions are more effective7-9 such as using multimedia (e.g. Internet, videos) and local businesses (e.g. supermarkets) and providing group-based support (e.g. weekly meetings, food planning courses, etc).The cexchange concept, which means people receive valued benefits in return for their efforts and changed behavioursd11 may explain this success and is part of social marketing strategies such as NZs recently terminated 'Healthy Eating Healthy Action (HEHA): Oranga Kai - Oranga Pumau'.10 Understanding whether services and interventions are valued by a population is important.The study reviews individual and population approaches to reducing the burden of CVD that prevail in a geographically constrained rural community. The challenge is to gauge whether populations gain more through GP performance indicator programmes or by improved access to and use of activities likely to improve lifestyle.Methods This study aims to: Assess the practical implementation of PHO performance indicators in a rural practice, by evaluating the difference between risk assessment determined through direct record audit and the PHO performance indicator calculated rate for the practice. Explore consumer awareness of and barriers to use of existing community activities and services that promote healthy lifestyles. First aimThe PHO for this practice used the BestPractice CVD risk tool12 alone to assess performance indicators. An audit of the patient population in Akaroa enrolled with the sole local health centre was conducted to determine the eligible population for CVD risk assessment as defined by the NZ CVD Guidelines (including high risk groupsrefer Table 2).13 The national performance indicator group uses a modified set of criteria based only on gender, age and ethnicity to calculate the vast majority of the eligible population.2 Completed formal assessments of CVD risk recorded in the practice management software were counted. These included the BestPractice CVD risk calculation, men and women's Wellness Checks14 and the Annual Diabetes Review. Both the Wellness Checks and BestPractice CVD risk calculation were initiated in the last 2 years and the diabetes review is annual, so an audit was done of the last 2 years using the MedTech32 query builder in the practice software. MedTech32 is the main software provider for NZ general practices. Second aimAn exploratory survey was designed to assess awareness, barriers and facilitators of access to services in the same local community likely to promote improved lifestyle. Through discussion with community organisers (e.g. health centre, social service centre, pharmacy, school nutritionist, PHO community service coordinator and community education coordinator) a list of 17 local services potentially associated with CVD risk reduction was built (e.g. nutrition, physical activity and psychological well-being [stress]). A one-page survey was created with input from these community organisers that asked three questions: Which of the 17 services were respondents aware of? (yes/no), Whether respondents participated in the listed service? (yes/no), and Comments about services and barriers and facilitators to participation? (open-ended). Pre-coded categories were developed during analysis of the free text comments. The questionnaire also asked participants to record age, gender, whether a participant had children and whether they had a health concern. Ethnicity data was not collected because this study was not designed to assess cultural influences on CVD risk reduction. Source populationTwo anonymous surveys were delivered to all post boxes on Banks Peninsula. Sample populationCVD risk assessment is generally 10 years later for women but the Wellness Checks begin at age 45 years for both women and men. Analysis was limited to replies from the sample eligible for CVD risk assessment: those 45 years and older. Data entry and analysisData was entered into an Excel spreadsheet and frequencies and proportions and statistical tests were calculated using Excel and OpenEpi Version 2.3 software.15 Results PHO performance CVD risk assessment indicatorThe enrolled population of the Akaroa Health Centre is 1684 people. The PHO generated list16 given to the health centre based on the performance indicator criteria2 identified 694 people eligible for a CVD risk assessment and 88/694 (12.7%) had a BestPractice CVD risk percentage recorded. Table 1. Eligible Population for CVD Risk assessment from April 2007-April 2009 CVD risk assessments Number Percentage CVD risk calculated and entered (Best Practice)1 88 11.80% Wellness Checks2 50 6.70% Annual DM review completed3 25 3.40% No CVD risk calculated/WC/DM assessment completed - routine screening (eligible for Wellness Check) - high risk 579 544 (389) 35 78% Total as counted by query builds: 742 100.00% 1 may include those who have also had a Diabetes review or Wellness Check 2 may include those who have also had a Diabetes review 3 includes those with diabetes who have NOT had CVD risk calculated (i.e. not total population with diabetes). In contrast, this study found 742 individuals eligible for CVD risk assessment, with 722 over 45 years of age. Of all those eligible (n=742, Table 1), 88/742 (11.8%) had a BestPractice CVD risk percentage recorded. An additional 50/742 (6.7%) had a Wellness Check and 25/742 (3.4%) a Diabetic Review giving a combined total of 21.9% of eligible patients with a CVD risk assessment. The difference between these data from the direct audit (21.9%) and the PHO Performance estimate (12.7%) is significant (p<0.001). The remaining (579/742; 78%) eligible population have not had a CVD risk assessment. About two-thirds (389/579; 67.2%) of this group are of the age group eligible for a Wellness Check (age 45 - 65yrs). Obtaining the appropriate data was complex and time-consuming: Seven sub-groups were used to determine the eligible population based on the NZ Cardiovascular Guidelines Handbook 200913 using variables of gender, ethnicity, high risk factors and age (see Table 2). More than 15 separate MedTech32 Query builds were required to identify patients in these subgroups. The queries then had to be manually searched to remove duplicates of individuals and combine queries. Table 2 is included solely to illustrate the complexity of this process and contains no additional data. Community awareness of lifestyle resources1400 surveys were delivered to households and 385 participants replied who were over 45 years of age (65 replied under 45 years of age). There were 981 enrolled patients in the practice over the age of 45 years. Assuming all survey respondents are enrolled in the practice, this is a response rate of 39.2% (385/981). Of 17 well-being services offered in the community, respondents of the survey were aware of an average of 6.2 services (6.2/17; 36%). Six respondents recognised no services (6/385; 1.6%). Over half of respondents (219/385; 56.9%) report participating in at least one of these activities and this proportion is the same whether they had a health concern or not. The potential participation rate drops to 22% (219/981) if non-responders dont participate or increases the rate to 83% (815/981) if they do participate. The best-recognised services are sports groups, dance classes, TaiChi Classes and GP Wellness Checks (n/2369; 9 - 14.1%). Of PHO supported services, awareness was 4.1% (96/2369) for smoking cessation, 2.6% (62/2369) for Green Prescription, 2.5% (60/2369) for falls prevention exercise programme, 1.8% (42/2369) for the Appetite for Life nutrition service, 1.4% (32/2369) for dietician services and 1.3% (30/2369) for the Ageing/Changing fitness programme. Table 2. Complexity of identifying sub-groups without a BestPractice CVD calculation recorded (n = 742 - 88) BPac risk- Best Practice CVD risk calculation; DM review- Annual Diabetes Review M/WWC- Mens or Womens Wellness Check. ++High Risk sub-groups (1), (3) & (7): read codes- current smoker, diabetes, obesity, [add for (7)- IHD, renal disease]; prescriptions- anti-hypertensives, lipid lowering [not included- gestational diabetes, IGT, renal, family history premature CVD] Around one-third (142/385; 36.9%) of respondents did not attend any activities. Barriers reported were not enough time (28/142; 19.7%), no need (10/142; 7%) and living too far away (10/142; 7%). Just under half (65/142; 45.8%) gave no reason. Only 2 respondents (1.4%) stated cost as a reason for non-attendance. Other comments were suggestions for services (30/162; 18.5%), positive comments about existing services (30/162;18.5%) and comments about which activities people attended (29/162; 17.9%). Suggestions were mostly about swimming pool and gym services. Table 2 lists the results of the survey. Table 3: Survey results from respondents over 45 years of age Variables Number % Characteristics of all participants 385 n=385 Males 157 40.8% Age: 45-55 yrs 56-66 yrs 67+ yrs 133 133 150 34.5% 34.5% 39.0% Have children 238 61.8% Health concerns that would benefit from lifestyle modification. 112 29.1% Attendance at any of the activities If yes had health concern (n=112), and attended activities If had no health concern (n=227), and attended activities 219 64 130 56.9% 57.1% 57.3% Any comment made 162 42.1% All activities identified from a list of 17 options Average number of services identified per participant (n=385) Most common services recognised- Sports groups (e.g., bowls, croquet, golf, tennis, walking, golf, badminton, rugby) Dance classes TaiChi classes GP Wellness Checks Wellbeing services (e.g., Akaroa Body Care) Yoga classes Counselling services 2369 6.2 335 322 261 256 231 228 142 n=2369 14.1% 13.6% 11.0% 10.8% 9.8% 9.6% 9.0% Non-attendance Gave no reason No Time (including No time + live too far) No need Live too far away Only recently arrived Cost Other 142 65 28 10 10 5 2 22 n=142 45.8% 19.7% 7.0% 7.0% 3.5% 1.4% 15.5% Respondents who commented [Some respondents made multiple comments] Reasons for not attending Suggestions - about use of pool - access to a gym Positive comments on services Activities attended 162 77 30 7 5 30 29 n=162 47.7% 18.5% 18.5% 17.9% Note: Numbers do not all add up to the total due to non-responders. Discussion Government health targets to reduce the impact of CVD

Summary

Abstract

Aim

This study explores how the New Zealand (NZ) population experiences approaches to cardiovascular disease (CVD) risk management: (1) the Primary Health Organisation (PHO) CVD risk performance indicator programme in Akaroa, Canterbury NZ and (2) consumer use of community services that promote healthier lifestyles.

Method

An audit identified patients enrolled at the Akaroa Health Centre eligible for CVD risk assessments and the portion with completed formal assessments. This was compared with the standard PHO performance tool for assessing CVD. An exploratory survey identified awareness of and barriers to use of local lifestyle resources that may directly or indirectly reduce CVD risk, in respondents over the age of 45 years.

Results

Distinguishing the eligible population who had not already had their CVD risk calculated required complex database analysis. As of April 2009 11.8% of the eligible population had a CVD risk calculated using the PHO performance tool. However, another 10.1% had had these risks assessed through other tools. The combined total of 21.9% meets the minimum target of 21.7% for the year ending June 30th 2009. The community survey found around a third (36%) of lifestyle promoting resources available were recognised with about half (56.9%) of respondents participating in the activities. Barriers to use included lack of time and perceived need of the service.

Conclusion

The current performance indicator approach is not practical, subject to error and may have significant opportunity costs. Furthermore, barriers exist in engaging the population identified as at risk in health-promoting activities.

Author Information

Emily Gill, GP Registrar, Akaroa Medical Centre, Akaroa, Canterbury; Dee Mangin, Associate Professor, Department of GP, Christchurch Medical School, University of Otago, Christchurch

Acknowledgements

Ethics approval was given for this audit and survey by the Upper South A Regional Ethics Committee (Ref- URA/09/10/EXP). Funding was provided by the Rural Canterbury PHO and the lead author. We also thank the many people who donated their time and services to this project including the Akaroa Medical Centre team, the Rural Canterbury PHO, Alison Wilkie, the Heartlands team, Mary the Akaroa postie, and Jesse Galloway who did the data-entry.

Correspondence

Emily Gill, 1829/24B Moorfield Rd, Johnsonville, Wellington, New Zealand.

Correspondence Email

emily.gill@actrix.co.nz

Competing Interests

None.

Website: Ministry of Health; Health Targets: Better diabetes and cardiovascular services, 2009.http://www.moh.govt.nz/moh.nsf/indexmh/healthtargets-targets-diabetesPHO Performance Programme, (DHBNZ); Indicator Definitions: 1 July 2008 Performance Indicator Set. 2008.Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343(1):16-22. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10882764Rangno R, McCormack J, Virani A, et al. Therapeutics Education Collaboration: Episodes 1 - 12: Discussions about Cardiovascular Disease; [PodCast]. Canada.. http://therapeuticseducation.org/Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373(9678):1849-60.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19482214Abramson J, Wright JM. Are lipid-lowering guidelines evidence-based? The Lancet 2007;369(9557):168.Barton RL, Whitehead K. A review of community based healthy eating interventions. J Hum Nutr Diet 2008;21(4):378-79.Heshka S., Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 2003;289(14):1792-8. http://jama.ama-assn.org/cgi/content/full/289/14/1792Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of community-based physical activity interventions. Am J Prev Med 2008;35(6):578-88. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19000846Website: Ministry of Health; Welcome to HEHA- Healthy Eating - Healthy Action: Oranga Kai - Oranga Pumau. 2009:http://www.heha.org.nz/Quiglet and Watts Ltd, (Health Sponsorship Council); Healthy Eating: Rapid Evidence Review of Nutrition Social Marketing Interventions to Prevent Obesity. 2007.Bestpractice- Decision Support for Health Professionals [program]. Dunedin: Best Practice Advocacy Centre Inc (BPAC Inc), 2008.NZ Guidelines Group, NZ Cardiovascular Guidelines Handbook: A summary resource for Primary Care Practitioners. 2009.Rural Canterbury PHO. Men's and Women's Wellness Checks, 2009. http://www.rcpho.org.nz/services/pho-programmes/women-s-wellness-checks/Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, 2009.http://www.OpenEpi.comWilkie Alison (Performance Programme Coordinator, Rural Canterbury DHB). New Performance Indicators- PPP 1July 2008 - 30 June 2009; [Letter and emails]. 2009.Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 1995;310(6987):1099-104.http://www.bmj.com/cgi/content/abstract/310/6987/1099Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician 2008;54(12):1706-13.Wood DA, Kinmonth AL, Davies GA, et al. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study. BMJ 1994;308(6924):313-20.http://www.bmj.com/cgi/content/abstract/308/6924/313Website: National Health Committee; Screening to Improve Health in New Zealand: Summary. 2003:http://www.nhc.health.govt.nz/moh.nsf/0/EFC453A05BDDF425CC2572AA0010F4FELangham S, Thorogood M, Normand C, et al. Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study. BMJ 1996;312(7041):1265-68. http://www.bmj.com/cgi/content/abstract/312/7041/1265Richardson CR, Newton TL, Abraham JJ, et al. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med 2008;6(1):69-77. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18154676Dalziel K, Segal L, Elley CR. Cost utility analysis of physical activity counselling in general practice. Aust N Z J Public Health 2006;30(1):57-63.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.

LOGINSUBSCRIBE