Koelewijn-van Loon commented on our study, a pragmatic randomised
trial of the clinical effectiveness of nurses as substitutes for GPs in
cardiovascular risk management. In our study, we found a greater decrease
in the mean value of risk factors in the practice nurse group than in the
GP group, but after confounders and baseline risk factors were controlled
for, a statistically significant decrease was found only for tot...
Koelewijn-van Loon commented on our study, a pragmatic randomised
trial of the clinical effectiveness of nurses as substitutes for GPs in
cardiovascular risk management. In our study, we found a greater decrease
in the mean value of risk factors in the practice nurse group than in the
GP group, but after confounders and baseline risk factors were controlled
for, a statistically significant decrease was found only for total
cholesterol [1].
The majority of patients included concerned secondary prevention.
Indeed, "these patients were probably already aware of the need for a good
lifestyle". Still, we found that many patients did not meet the treatment
targets and were not adherent to a healthy lifestyle. Non-adherence to
treatment is a major factor in the lack of success of cardiovascular
prevention hence caregivers should communicate with patients about their
drug use and adherence to life style interventions. In this regard,
improvement of cardiovascular prevention is still needed. The outcomes
achieved by practice nurses were better than those of general
practitioners, still nurses only inquired about drug use in only 40% of
patients [2].
Koelewijn-van Loon did question if the effect is caused by nurses
acting as substitutes for GPs or by the fact that "nurses were
specifically trained", "nurses performed well because this new task
recognized their position" or/and "nurses were familiar with lifestyle
counselling in contrast to GPs". Indeed, these factors could give an
explanation for the results achieved by practice nurses, still
cardiovascular risk management was a new task for practice nurses in our
study. In addition, they were not specifically trained. Therefore, it is
expected that in the future practice nurses will achieve even better
health outcomes, as their education improves and more experience is
gained. The possibility must be taken into account that practice nurses in
our study were more successful compared to other practice nurses because
of the awareness that their performance was being assessed. However, this
also could be stated for participating general practitioners. Our
qualitative study among nurses also showed that nurses in our study were
uncertain about the content of lifestyle advice [3]. Still, we found that
practice nurses play an important role in the successive removal of
barriers to the implementation of cardiovascular prevention within the
health care centre and therefore will improve cardiovascular prevention in
primary care. It could be concluded that substitution of cardiovascular
risk management from GPs to practice nurses concerns more the performance
of complementary tasks instead of substitution of tasks.
Another comment concerned the study population being unbalanced. From
an univariate analysis of variance - with control for healthcare centre -
no baseline differences were found, except for body mass index
(SBP:1.9(-1.4-5.3)p=0.258, DBP:0.003(-1.70-0.17)p=0.997, TChol:-0.07(-0.03
-0.12)p=0.460, LDL:-0.03(-0.22-0.16)p=0.783, HDL:0.06(-.001-0.123)p=0.055,
BMI-1.05(-1.76--0.34)p=0.004).
Body mass index was underestimated in the general practitioner group
because of the lack of correction for self-reported body length.
Our conclusion that practice nurses achieve the same or even better
results in cardiovascular risk management compared with GPs is therefore
justified. However, more education for nurses is needed; this training
should include knowledge of cardiovascular diseases (symptoms) to allow
early recognition of recurrences or new expressions of cardiovascular
disease, cardiovascular pharmacology and content of lifestyle intervention
related to cardiovascular diseases. Moreover, it is important to enhance
practical skills in lifestyle interventions.
REFERENCES
1. Voogdt-Pruis HR, Beusmans GH, Gorgels AP, Kester AD, Van Ree JW.
Effectiveness of nurse-delivered cardiovascular risk management in primary
care: a randomised trial. Br J Gen Pract.2010 Jan;60(570):40-6.
2. Voogdt-Pruis HR, Van Ree JW, Gorgels AP, Beusmans GH. Adherence to
a guideline on cardiovascular prevention: A comparison between general
practitioners and practice nurses. Int J Nurs Stud. 2010 Dec 20.
doi:10.1016/j.ijnurstu.2010.11.008.
3.Voogdt-Pruis HR, Beusmans GHMI, Gorgels APM, Van Ree JW.
Experiences of doctors and nurses implementing nurse-delivered
cardiovascular prevention in primary care: a qualitative study. Journal
of Advanced Nursing. 2011; doi: 10.1111/j.1365-2648.2011.05627.
Koelewijn-van Loon commented on our study, a pragmatic randomised trial of the clinical effectiveness of nurses as substitutes for GPs in cardiovascular risk management. In our study, we found a greater decrease in the mean value of risk factors in the practice nurse group than in the GP group, but after confounders and baseline risk factors were controlled for, a statistically significant decrease was found only for tot...