Feasibility of a Preventive Program Against Lifestyle Related Diseases
Condition: Type-2 Diabetes; Cardiovascular Diseases; Chronic Obstructive Pulmonary Disease (COPD)
MeSH terms: Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Cardiovascular Diseases
Study type: Interventional

Summary: 
      The continuously increasing prevalence of cardiovascular diseases, type-2 diabetes, and COPD
      is a major health problem in developed countries and is mainly caused by an unhealthy
      lifestyle. Most important lifestyle related causes of morbidity and mortality are smoking,
      obesity and physical inactivity, and increasing rates of obesity and physical inactivity in
      combination with smoking will lead to an increase in the number of patients with lifestyle
      related diseases in the coming decades. There is, therefore, an urgent need to identify and
      establish strategies and to implement interventions, allowing for the identification and
      management of citizens at increased risk of disease.

      Two recent systematic reviews of general practice based health checks suggest that people at
      increased risk of a chronic disease may benefit from a targeted approach to health checks.
      Targeted or selective preventive actions are a generally accepted and well integrated part of
      the health care system (e.g. treatment of hypertension and hyperlipidemia). However,
      selective prevention is challenged in terms of how to identify citizens at increased risk of
      disease in the general population in order to start the indicated preventive actions.

      The aim of the present pilot study is to test the acceptability, feasibility and short-term
      effect of a selective preventive program that systematically helps citizens evaluate
      individual risk of lifestyle related disease and offers targeted and coordinated preventive
      services in the primary health care sector.

      The intervention comprises four elements: 1) Systematic collection of information on
      lifestyle risk factors using questionnaire 2) Risk estimation and stratification into risk
      groups based on questionnaire data and information from the electronic patient record (EPR)
      using validated risk estimation models, 3) An individual electronic health profile with
      personalized advise on lifestyle change and 4) targeted preventive services at the general
      practitioner (GP) or the municipality for citizens at risk of lifestyle disease and citizens
      with risk behavior, respectively.

      The intervention is supported by a patient-centered health information system that
      facilitates informed patient action and integrates general practice and municipality health
      care providers.
    

Detailed description: 
      Recruitment strategy:

      The study is carried out in two municipalities in the Region of Southern Denmark (Haderslev
      and Varde municipality. Total number of inhabitants: 98.925). All general practitioners in
      the two municipalities (n=68) have been invited, and a total of 47 have agreed to participate
      in the study. A total of 200 citizens born 1957-1986 are selected from the patient list of
      each participating GP. Before selection, the citizens are stratified into households, and
      subsequently households are randomly selected until the total number of citizens per enrolled
      GP reaches 200. In selection of households the proportion of citizens living alone and the
      proportion of citizens living with one or more potential participants is taken into account.
      No disease-related criteria for excluding a citizen are defined prior to the study. The
      selected citizens are invited to participate and asked to sign a declaration of consent.

      Risk stratification and preventive services offered:

      Enrolled participants receive a 15-item questionnaire on lifestyle, familiar disposition of
      lifestyle disease and selected symptoms. From the individual electronic patient records (EPR)
      at the GP information on diagnoses and treatment of COPD, type-2 diabetes, hyperlipidemia,
      hypertension and ischemic heart disease are drawn. Based on questionnaire and EPR data the
      participants are stratified into four groups: 1) Citizens with an already diagnosed lifestyle
      related disease, 2) Citizens with an increased risk of lifestyle related disease, 3) Citizens
      with risk behavior and 4) Citizens with a healthy lifestyle.

      Citizens in group 1 are already being treated and/or receive behavioral interventions and are
      therefore not the primary target of this study. Citizens in group 2 has a calculated
      increased risk of lifestyle related disease(s) based on validated predictive models for risk
      of COPD, type-2 diabetes and cardiovascular disease. The risk of COPD is calculated using the
      COPD-PS screener algorithm taking into account information on age, total cigarette
      consumption and respiratory symptoms. The risk of type-2 diabetes is calculated based on the
      algorithm used in the Addition study including information on age, gender, BMI, history of
      hypertension, physical activity and family history of diabetes. The cut-off value for being
      at risk of type-2 diabetes, and COPD follows the recommendations of the two models. The risk
      of cardiovascular disease is calculated using the Heart Score BMI score based on information
      about age, gender, smoking status and BMI. An increased risk of cardiovascular disease is
      defined in citizens with a ≥5% risk of dying of cardiovascular disease within the next 10
      years. Citizens in group 2 are offered a preventive program at the GP including an initial
      health examination and subsequent behavior counselling. Citizens in group 3 are defined by
      having a BMI>35, being daily smoker, having a high risk alcohol consumption, having unhealthy
      eating habits and/or low physical activity. Evaluation of eating habits is based on the
      recommendations in the Swedish National Guidelines on Disease Prevention, and evaluation of
      alcohol consumption and physical activity is based on recommendations from the Danish Health
      Authority. Citizens in group 3 are offered behavior counselling in the municipality and
      community health services, if necessary. Citizens in group 4 are not offered any further
      services.

      Electronic health information system:

      The intervention is supported by a patient-centered health information system that
      facilitates informed patient action based on the predictive model for identification and
      stratification of citizens to the appropriate care providers and that supports the initiation
      and follow up of preventive care through the provision of health information resources,
      decision aids, risk calculators, personalized motivational messages and integrates primary
      care and municipality health care providers.

      Common training course:

      Before the study commences enrolled GPs, practice staff and health professionals from the
      municipalities are offered a common training course. The aim of the course is to train the
      specific intervention elements and to improve the inter-sectoral knowledge and collaboration
      on prevention of lifestyle diseases.

      Evaluation:

      Evaluation of the study will be carried out using quantitative as well as qualitative
      research methods. Details on evaluation methods are included in section 9.

      Results of the present pilot study will be used for the adjustment of the intervention prior
      to a large scale study comprising 10 municipalities, up to 360 GPs and 200.000 citizens.
    

Intervention name(s): Lifestyle intervention
Intervention type(s): Behavioral
Intervention description(s): 1) Systematic collection of information on lifestyle risk factors using questionnaire 2) Risk estimation and stratification into risk groups based on questionnaire data and information from the electronic patient record (EPR) using validated risk estimation models, 3) An individual electronic health profile with personalized advise on lifestyle change and 4) targeted preventive services incl. lifestyle counseling at the GP or the municipality for citizens at increased risk of lifestyle disease and citizens with risk behavior, respectively.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Tailored lifestyle intervention; Selective prevention; Primary care; Web based health risk assessment; Patient-centered health information system; Lifestyle intervention; preventive treatment