Dr Robert Sanson-Fisher
University of Newcastle
Cardiovascular Disease and Depression Strategic Research Program
Project completion year
Cardiovascular disease (CVD) is associated with physiological factors and lifestyle behaviours such as smoking, inappropriate alcohol consumption, unhealthy diet and physical inactivity. Recently, links have also been found with CVD and psychosocial factors such as depression, social isolation and lack of quality social support, with a possible dose-response relationship between depression and CVD.
Depression has also been associated with physical inactivity and smoking in people at risk of CVD, indicating that primary prevention efforts need to modify both lifestyle factors and depression. In women with CVD, depression and social isolation together have been found to accelerate disease progression. Further, the presence of five or more CVD risk factors results in a three-fold increased risk for heart attack or stroke and a six-fold increased risk for angina, compared to those with no risk factors5. Recent initiatives of the Council of Australian Governments have strongly supported the primary and secondary prevention of lifestyle-related illnesses through the systematic identification of multiple risk factors, and use of effective strategies for lifestyle change in the primary care setting. The Commonwealth Government has developed and disseminated printed risk assessment materials and referral resources for Smoking, Nutrition, Alcohol, Physical Activity and Obesity for the Primary Care Setting as part of Lifescripts initiative.
While there are higher rates of utilisation by women and older people,6 general practitioners (GPs) in Australia are accessed by a large and relatively representative sample of the population. Further, prevention, detection and intervention for CVD and psychological disorders are perceived by patients as an important part of a GP’s role. GPs also accept their central role in health prevention. Each patient visit in primary care represents an opportunity for interventions and screenings for health risks. The effectiveness of brief interventions by GPs has been shown in reducing alcohol consumption, increasing physical activity levels, and smoking cessation. Anxiety and depression are among the most common reasons for primary care consultations.
Aims of the study
1. To determine the effectiveness of a systems-based approach involving waiting room electronic assessment of CVD risk and feedback of best practice recommendations supported by CME, web-based access to specialist advice and performance feedback in rural general practices for:
- decreasing the prevalence of depression among patients at intervention practices at 12 month follow up compared to control practices. Patients who score 10 or higher on the Patient Health Questionnaire will be classified as depressed.
- decreasing from baseline to 12 months the proportion of patients in intervention group practices with lifestyle factors which increase CVD risk compared to control group practices. The lifestyle practices to be examined are smoking, harmful alcohol consumption, being overweight and inadequate physical activity.
2. To assess the acceptability of the electronic assessment and feedback system for GPs and patients.
3. To examine the patient and practice factors (including a previous CVD-related event) which are related to decreased prevalence of depression and risk-inducing lifestyles during the study.
4. To assess the health economic costs associated with the intervention in terms of health service utilisation, absence from work and associated changes in quality of life.
The research involved a trial using rural general practices. Cross-sectional data collected at pre-intervention (months one to two) and post-intervention (months 13 to 14) for each surgery will be used for outcome assessment. All practices will be involved contemporaneously in the pre-test and all data collection must be conducted during warmer months to minimise the effects of seasonal variation on outcomes. The design allowed a systems-based intervention approach to be undertaken. Consenting general practices were randomly allocated to one of two experimental conditions: usual care or intervention. The intervention condition utilised a within-practice electronic assessment and feedback system supported by CME, web-based access to specialist advice and feedback. Pre-and post-intervention outcomes were collected from randomly selected patients in each group at each of the two month periods pre- and post intervention.
Results and findings
- 1,925 patients were recruited into the study from eight general practices. Findings indicate that 89.9 per cent of presenting patients were eligible to participate and 88.2 per cent agreed to complete the touch screen computer survey.
- 18.6 per cent of participants required additional assistance in using the touch screen computer. Preliminary results are as follows:
o Depression: 22.2 per cent of general practice patients scored 10 and above on the Patient Health Questionnaire, indicating possible depression
o CVD lifestyle risk factors: 57 per cent of participants were classed as overweight or obese; 11 per cent were current smokers and 45 per cent reported insufficient physical activity. The proportion of patients not screened in line with the preventive guidelines for high blood pressure is 4.0 per cent, high cholesterol is 17.3 per cent and diabetes is 12.7 per cent.
- 96 per cent of participants indicated that the system was easy to use, the survey easy to understand and the touch screen provided enough privacy. 78 per cent were happy for GPs to have their survey responses.
Implications for policy and practice
- 18.6 per cent of patients reported clinically significant depressive symptoms.
- 89 per cent reported one or more CVD lifestyle risk factor (smoking, risky alcohol intake, physical inactivity or overweight/obesity).
- 17.5 per cent reported being under-screened for one or more CVD risk factors (high blood pressure, high cholesterol or blood glucose tests).
- Electronic health risk assessments are feasible and acceptable in the general practice setting. Most patients consented to complete the assessment (82 per cent), and were happy for the results of their assessment to be given to their doctor (78 per cent).
1 Rosengren A, Wilhelmsen L, Orth-Gomer K. Coronary disease in relation to social support and social class in Swedish men: a 15 year follow-up in the study of men born in 1933. European Heart Journal 2004;25:56-63.
2 Bunker SJ, Colquhoun DM, Esler MD, Hickie IB, Hunt D, Jelinek VM, et al. "Stress" and coronary heart disease: psychosocial risk factors: National Heart Foundation of Australia position statement update. Medical Journal of Australia 2003;178:272-276.
3 Lett HS, Blumenthal JA, Babyak MA, Strauman TJ, Robins C, Sherwood a. Social support and coronary heart disease: epidemiologic evidence and implications for treatment. Psychosomatic Medicine 2005;67:869-878.
4 Wang H-X, Mittleman MA, Leineweber C, Orth-Gomer K. Depressive symptoms, social isolation, and progression of coronary artery atherosclerosis: the Stockholm Female Coronary Angiography Study. Psychotherapy and Psychosomatics 2006;75(2):96-102.
5 Australian Institue of Health and Welfare. Living dangerously, Australians with multiple risk factors for cardiovascular disease, 2005.
6 Britt H, Miller GC, Knox S, Charles J, Bayram C, Pan Y, et al. General Practice Activity in Australia 2006-07. Canberra: Australian Institute of Health and Welfare, 2008.
7 Sanson-Fisher RW, Webb GR, Reid ALA, editors. Appendix 2 of Chapter 11: The role of the medical practitioner as an agent for disease prevention. Canberra: Australian Government Publishing Service, 1986.
8 Brotons C, Bjorkelund C, Bulc M, Ciurna R, Godycki-Cwirko M, Jurgova E, et al. Prevention and health prevention in clinical practice: the views of general practitioners in Europe. Preventive Medicine 2005;40(5):595-601.
9 Bertholet N, Daeppen J-B, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and analysis. Archives of Internal Medicine 2005;165:986-995.
10 Elley CR, Kerse N, Arroll B, Robinson E. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. British Medical Journal 2003;326:793-798.
11 Hilberink SR, Jacobs JE, Bottema BJAM, de Vries H, Grol RPTM. Smoking cessation in patients with COPD in daily general practice (SMOCC): six months' results. Preventive Medicine 2005;41(5- 6):822-827.
12 Knox SA, Britt H. The contribution of demographic and morbidity factors to self-reported visit frequency of patients: a cross-sectional study of general practice patients in Australia. BMC Family Practice 2004;5:17-23.