Evaluation of intervention programmes for hypercholesterolaemia, excessive drinking and physicians' prescribing in primary care

Abstract

Interventions against riskful lifestyles and information to promote rational use of drugs are important in health care. The aim of this thesis is to assess the effectiveness of such interventions, looking at both costs and effects.

In the catchment area of Vårby Health Centre, all subjects, aged 25-54 years, were offered a health check and 2 338 subjects participated. In this population, 40% were immigrants, mainly from Finland and the Mediterranean area. Smoking habits, length, weight, blood pressure, blood glucose, serum-cholesterol (S-Chol) and serum gamma-glutamyl transferase (GGT) were checked. Those with S-Chol in the range 6.5-7.0 mMol/l were randomised into a medium-intensity and a low intensity non-pharmacological treatment, comparing the values, costs and effects of the intervention. 222 individuals had GGT above 0.89 ukat/l, 100 were randomised to a nurse-conducted intervention group and 122 to a control group. The brief intervention aimed at reducing alcohol consumption in excessive drinkers.

The investigation of the population of Vårby showed important ethnic differences in risk factor patterns. The Finns had the highest mean S-Chol levels and blood pressures. The Mediterranean group, in spite of a significantly higher body mass index, had blood pressures that were significantly lower compared with the Swedes and the Finns. Smoking rates among the Mediterranean men were high (58%) compared with the national smoking rate (27%). The non-pharmacological intervention against hypercholesterolaemia resulted in a decrease in total S-Chol of 3.5% in both groups. The intervention cost per subject in the low-intensity group was SEK 753 and in the medium-intensity group SEK 3 614. Therefore the brief intervention in the low-intensity group is to be preferred from the cost-effectiveness point of view. The brief intervention among the excessive drinkers resulted in significant reductions of both GGT and mean weekly alcohol consumption.

General practitioners (GPs) at all the 27 health centres in an area of Stockholm County were given feed-back on their own prescriptions. From prescription data collected at the local pharmacies, the number of drugs used, defined daily doses per drug group, and drug costs were measured. A second controlled study focused on the pharmacological treatment of asthma bronchiale, assessing the GPs' knowledge of the diagnosis, and treatment, their prescribing and the asthmatic patients' knowledge of their disease before and after intervention.

The base-line prescription survey revealed major differences between health centres. This incited the GPs to arrange workshops on drug use in primary care. The GPs developed a drug list of 167 recommended drugs. At the follow-up, there was a clear trend towards smaller volumes and cost per prescription item for the health centres in the study area. Compared with the national prescribing pattern, prescribing in the study area represented a 20% lower drug cost.

The asthma-treatment intervention showed significant differences between the intervention and the control area as regarding the knowledge of the GPs after the intervention. There was a significant change in prescribing in the intervention area; the change was in line with the intervention message. It is concluded that interventions aiming to affect lifestyle have to involve the recipient actively in order to obtain a change. Because health-care resources are scarce, there is a need to compare different strategies for treatment, looking at both the medical and the financial consequences.