@article {CharlesA113, author = {Autreaux Charles and Botte Marc and Verroul Sabine}, title = {247 Improving comprehensive care of patients with cardiovascular risk factors}, volume = {19}, number = {Suppl 1}, pages = {A113--A114}, year = {2010}, doi = {10.1136/qshc.2010.041624.66}, publisher = {BMJ Publishing Group Ltd}, abstract = {Objective (s), context Cardiovascular mortality is very high in the Nord-Pas-de-Calais region of France.In 2004, a study of risk levels carried out in the Berlaimont district reported (1) a high level of cardiovascular risk in the population, (2) and confirmed the need for specific training inciting to comprehensive care. This prompted the setting up of an experimental regional project evaluating the impact of a comprehensive care program for patients with high cardiovascular risk.Program The program included four phases: designing and dissemination of tools, training in the identification of risk levels and in the implementation of comprehensive care for high-risk patients, follow-up care in patients aged over 40, including an evaluation of their risk level 1 year later, and analysis of results.Method Over a 1-month period between November, 2005 and December, 2007, patients aged over 40 and presenting previous history of cardiovascular disease or diabetes, or a minimum of three risk factors (RF), or a SCORE>=5\% were recruited from four districts{\textemdash}Berlaimont, Cambrai, Montreuil and Maubeuge (max 100 patients/doctor). The tools developed for the intervention included a decision-making support kit, a questionnaire and eight follow-up indicators. Seven of these indicators were elaborated based on current recommendations validated by the AFSSAPS, ESC, ANAES and HAS. The steering group chose one impact indicator of comprehensive care based on an objective considered attainable within 1 year of appropriate follow-up care. The results are expressed as average mean differences for patients between baseline and year 1 (T1yr - T initial). The frequency of variables was compared using the one-sided χ2 test p=5\%.Results Thirty doctors attended four training courses (estimated satisfaction: 9.02/10), 14 went on to participate to the comprehensive management study, and eight reported 1-year follow-up in their patients. Eight hundred and forty-nine patients were initially recruited (65 patients/doctor), 44\% were lost to follow-up (256 with \>3 RF and 139 with \>5 RF) and 66\% were still being followed up at 1 year (559 patients, 70 patients/doctor, 83\% \> 3 RF, 28\% \> 5 RF).After 1 year: (1) Consumption of portions of fruits and vegetables per day increased by +46.2\%; (2) Blood sugar level \< 1.26 g/l: +42.9\%; (3) Decrease in BMI (-1 category): +35.6\%, (4) Physical activity (30 min 3 times/week): +17.4\%; 5) Consumption of fish (twice/week): +16.9\%; 6) Decreased smoking prevalence: +5.7\%; 7) Cholesterol control: +5\%; 8) Reduction of at least one risk factor in 1 year: 32.1\%. p\<0.05 for all the indicators.Development, perspectives, limitations After 1 year, the study shows significant improvement in comprehensive care (8/8 modifiable criteria were significantly improved). Study limitations relate to the number of follow-up criteria, absence of a principal outcome measure and of a control group, participation of voluntary doctors, and proportion of patients lost to follow-up. Nevertheless, further to these encouraging results, the decision-making support kit has since been used in the region for Continuing Professional Development training sessions, organised by the URMEL and cardiovascular disease networks, and for professional practice evaluation.Conclusion The study showed that tailored training using a specific educational tool and clinically relevant indicators helped support a regional comprehensive care program that significantly improved risk levels in high cardiovascular risk patients after 1 year of follow up.Objectif(s), contexte La mortalit{\'e} cardiovasculaire est tr{\`e}s {\'e}lev{\'e}e dans le Nord-Pas de Calais. Une {\'e}tude du niveau de risque r{\'e}alis{\'e}e dans le canton de Berlaimont a rapport{\'e} en 2004 (1) un niveau {\'e}lev{\'e} du risque cardiovasculaire de la population, (2) la n{\'e}cessit{\'e} d{\textquoteright}une formation sp{\'e}cifique {\`a} sa prise en charge. La dynamique r{\'e}gionale a alors mis en place un programme exp{\'e}rimental d{\textquoteright}am{\'e}lioration de la prise en charge globale des patients {\`a} risque cardiovasculaire.Programme Le programme comprend 4 phases: la conception et mise {\`a} disposition d{\textquoteright}outils, une formation {\`a} l{\textquoteright}identification du niveau de risque et {\`a} la prise en charge globale des patients {\`a} haut risque, l{\textquoteright}{\'e}valuation avec suivi {\`a} 1 an par les m{\'e}decins form{\'e}s des patients de plus de 40 ans {\`a} haut risque et l{\textquoteright}analyse des r{\'e}sultats.M{\'e}thode Ont {\'e}t{\'e} inclus sur une p{\'e}riode d{\textquoteright}un mois entre novembre 2005 - d{\'e}cembre 2007, {\`a} Berlaimont, Cambrai, Montreuil et Maubeuge (max 100 patients/m{\'e}decin), les patients de plus de 40 ans avec des ant{\'e}c{\'e}dents personnels vasculaires, ou un diab{\`e}te ou au moins 3 facteurs de risque (FR) ou un SCORE >= 5\%. Les outils con{\c c}us et utilis{\'e}s sont un classeur d{\textquoteright}aide {\`a} la d{\'e}cision, un questionnaire et 8 indicateurs de suivi (7 {\'e}labor{\'e}s {\`a} partir des recommandations 2004-2007 (AFSSAPS, ESC, ANAES, HAS) et 1 indicateur d{\textquoteright}impact de la prise en charge globale bas{\'e} sur un objectif estim{\'e} atteignable en 1 an de suivi appropri{\'e} (groupe de travail)). Les r{\'e}sultats sont exprim{\'e}s en moyenne des diff{\'e}rences par patients T1an - T initial. La fr{\'e}quence des variables a {\'e}t{\'e} compar{\'e}e avec le test du Khi 2. p unilat{\'e}ral = 5\%.R{\'e}sultats 30 m{\'e}decins ont particip{\'e} aux 4 sessions de formation (satisfaction {\'e}valu{\'e}e {\`a} 9,02/10). 14 se sont engag{\'e}s dans le programme de suivi dont 8 avec suivi compl{\'e}t{\'e} {\`a} 1 an.849 patients ont {\'e}t{\'e} inclus (65 patients/m{\'e}decin). 44\% patients ont {\'e}t{\'e} perdus de vue (256 avec \> 3 FR et 139 avec \> 5 FR) et 66\% ont {\'e}t{\'e} suivis {\`a} 1an (559 patients, 70 patients/m{\'e}decin, 83\% \> 3 FR, 28\% \> 5 FR).A 1 an: 1) Consommation de fruits et l{\'e}gumes (portions/j): +46,2\%; 2) Glyc{\'e}mie \<1,26g/l: +42,9\%; 3) IMC (-1 cat{\'e}gorie): +35,6\%, 4) Activit{\'e} physique (>=30 min, 3 fois/semaine): +17,4\%; 5) Consommation de poissons (>= 2 fois/semaine): +16,9\%; 6) Arr{\^e}t du tabac: +5,7\%; 7) Contr{\^o}le d{\textquoteright}une dyslipid{\'e}mie: +5\%; 8) Perte d{\textquoteright}au moins un facteur de risque en 1 an: 32,1\%. p \< 0.05 pour tous les indicateurs.D{\'e}veloppement, perspectives, limites L{\textquoteright}{\'e}tude rapporte une am{\'e}lioration significative de la prise en charge globale {\`a} 1 an de suivi (8/8 crit{\`e}res modifiables ont {\'e}t{\'e} significativement am{\'e}lior{\'e}s). L{\textquoteright}{\'e}tude pr{\'e}sente des limites li{\'e}es notamment au nombre de crit{\`e}res de suivi, absence de crit{\`e}re principal et de groupe t{\'e}moin (patient suivis par des m{\'e}decins non form{\'e}s), participation de m{\'e}decins volontaires, nombre de perdus de vue. N{\'e}anmoins, suite {\`a} ces r{\'e}sultats encourageants, le classeur d{\textquoteright}aide {\`a} la d{\'e}cision est depuis utilis{\'e} en r{\'e}gion dans le cadre de la Formation M{\'e}dicale Continue (URMEL, r{\'e}seaux cardiovasculaires) et de l{\textquoteright}Evaluation des Pratiques Professionnelles.Conclusion L{\textquoteright}{\'e}tude a montr{\'e} qu{\textquoteright}une formation avec un outil p{\'e}dagogique d{\'e}di{\'e} et des indicateurs cliniquement pertinents, permet de mettre en {\oe}uvre un programme r{\'e}gional faisable et efficace qui am{\'e}liore significativement le niveau de risque des patients {\`a} haut risque cardiovasculaire et la prise en charge globale {\`a} 1 an de suivi.}, issn = {1475-3898}, URL = {https://qualitysafety.bmj.com/content/19/Suppl_1/A113.2}, eprint = {https://qualitysafety.bmj.com/content/19/Suppl_1/A113.2.full.pdf}, journal = {BMJ Quality \& Safety} }