Discussion
This study is the first to present 5-year follow-up results from a randomized controlled trial showing the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of a general population. The intervention had a modest impact on mean CRS in the general population, and a marked impact on the prevalence of those who were at cardiovascular risk. The impact was significantly greater for groups at cardiovascular risk; the relative risk reduction was approximately the same in those at risk as those not at risk, but with larger absolute risk reductions. The study does not indicate whether the reduction in CRS factors will result in reduced morbidity or mortality.
At the 5-year follow-up there was no difference between the CRS in the health screening plus discussion group and the screening only group. The discussion alone had no discernible impact. Several factors, however, may obscure the role of the discussions with general practitioners in this study. For ethical reasons, all persons advised of an elevated cardiovascular risk were offered a consultation with their general practitioner, regardless of their intervention group. Although consultations in such cases were probably not as extensive and detailed as those offered as part of the study, they may confound the difference in the degree of intervention between the 2 groups. The Danish Health System ensures that all participants can see their own general practitioner at no cost whenever they wish. Participants who were not offered a health discussion as part of the study may nevertheless have taken advantage of this free system to consult their general practitioner, especially if they were advised to do so. Moreover, the low rate of participation after the primary health discussion weakens the strength of the intervention in the health screening plus discussion group. Although the study thus does not provide evidence that such discussions played an essential role in the intervention, health screenings alone may not achieve the same impact. The psychological impact of the intervention may also be different for those who had personal consultations with their general practitioner after the health screening. The BMI values included a few individuals with unhealthily low BMI (<19). The distribution was not significantly different between the groups, although a tendency for an unhealthily low BMI of a slightly greater number of patients was seen in the intervention groups, highlighting the fact that weight loss is not always a relevant factor. Focusing on lifestyle changes might trigger some individuals to indulge in anorexic attitudes and behavior.
The results indicate that health screenings should be both population-based and individually oriented, and that general practitioners should be involved. The population screening is necessary to identify those at risk, since almost none of those with elevated cardiovascular risk were aware of their condition prior to screening. The fact that the general practitioner personally contacted the participants may have increased the participation rate, which is high in this study. In the written feedback after the screenings, general practitioners adjusted their advice to individual participants according to test results, and where appropriate advised them to come in for a personal consultation.
For several reasons, the impact of the intervention—both health screenings and discussions—may be greater than our findings suggest. We cannot measure the impact of the questionnaires on the control group—a methodological problem which also affected the OXCHECK study.7,8 In the British Family Heart Study,9,10 the control group was apparently unaffected, but the design of that study makes it impossible to assess the impact of subsequent intervention on baseline risk groups. Moreover, the fact that all the participants in the present study live in a small community may reduce the differences in degrees of intervention among the groups, although this is partially addressed by placing cohabiting couples in the same intervention group. Contact among patients within the various clinics involved may also have blurred the differences between the intervention groups.
In the present study, the general practitioners were not trained in any specific psychotherapeutic method for conducting the health discussions. The low rate of participation in follow-up consultations suggests a need to find better methods of motivating participants. Training general practitioners to use motivational discussions to inspire behavioral change, for example, might increase the impact of the intervention.3,4 Counseling to trigger changes in attitude and behavior, particularly when modified to the individual’s readiness to change, might be more effective than a traditional health discussion focusing mainly on various risk factors.
Important findings from this study are that a major part of the population is interested in having health screenings and discussions with their general practitioner, although interest declines rapidly; that individuals with elevated risk of coronary heart disease set relevant goals for themselves for lifestyle changes; and that cardiovascular risk after 5 years of follow-up is reduced. Planned health discussions about the health screening results do not seem to reduce cardiovascular risk.