Swedish Agency for Health Technology Assessment and Assessment of Social Services
Population screening of risk factors and brief lifestyle counselling as primary prevention of cardiovascular disease
Cardiovascular disease is the most common cause of death among both men and women in Sweden. There are several known risk factors for cardiovascular disease, including high blood pressure, obesity, diabetes, old age and smoking. Several regions in Sweden have introduced population-oriented prevention programs. The programs invite all individuals from a certain age group to a targeted health check or screening to assess the presence of cardiovascular risk factors as well as a subsequent “health talk” where participants receive information such as their individual risk factors as well as advice and counselling regarding their lifestyle.
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Question
What systematic reviews are there on population screening programs on cardiovascular risk factors in combination with brief lifestyle counselling?
Identified literature
| Included studies | Population/Intervention | Outcome |
| Patnode et al, 2017 [1] | ||
| 88 Articles (87 RCTs and 1 non-RCT) reported in 145 publications were included. Included studies had to be conducted in the primary care or was conducted from the primary care (e.g. telephone support). |
Adults above 18 years without CVD, hypertension, dyslipidaemia, diabetes, impaired fasting glucose or glucose tolerance. The interventions had to be focused on improving dietary habits, increasing physical activity and/or reducing sedentary time with primary aim of CVD primary prevention. Interventions targeting persons categorized as high risk where excluded. |
Health outcomes: Cardiovascular morbidity and Mortality, all-cause mortality, health-related quality of life. Risk factors: Blood pressure, lipid levels, glucose levels, adiposity, BMI, weight and waist circumference. Behaviour: Dietary intake, physical activity and sedentary behaviour. Adverse effect: Harms of intervention. |
| Authors' conclusion: “Diet and physical activity behavioural interventions for adults not at high risk for cardiovascular disease result in consistent modest benefits across a variety of important intermediate health outcomes across 6 to 12 months, including blood pressure, low-density lipoprotein and total cholesterol levels, and adiposity, with evidence of a dose-response effect, with higher-intensity interventions conferring greater improvements. There is very limited evidence on longer-term intermediate and health outcomes or harmful effects on these interventions.” |
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| Dyakova et al, 2016 [2] | ||
| Included only RCTs. Focus on primary prevention so RCT’s covering participants without known CVD were included. |
Healthy adults from the general population, including both low and high-risk individuals. Studies on individuals already diagnosed with CVD were excluded. The intervention was a systematic risk assessment for primary prevention of CVD involving people who are systematically invited to attend in a primary care setting |
Primary outcomes: All-cause mortality, cardiovascular mortality, Non-fatal cardiovascular endpoints. CVD major risk factors: Lipid levels, blood pressure, type 2 diabetes. Intermediate outcomes: Case-finding rates, attendance rates, acceptability, satisfaction, follow-up rates. Adverse effects Costs |
| Authors' conclusion: “The results of this systematic review do not provide enough evidence to inform changes in clinical practice, national/local policies or the introduction of mass population cardiovascular screening programmes. There is limited evidence for beneficial effects on CVD risk factors, but trials are heterogeneous and at some risk of bias and results are therefore uncertain.“ |
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| Álvarez-Bueno et al, 2014 [3] | ||
| Included 8 systematic reviews consisting of totally 219 studies. | Adults free of cardiovascular disease. Multifactorial interventions carried out in community settings as primary prevention strategy to reduce cardiovascular risk. |
Total mortality, CVD mortality and morbidity. Changes in four cardiovascular risk factors: DBP, SBP, total cholesterol, BMI and smoking. |
| Authors' conclusion: “Our study provides evidence supporting that multifactorial community interventions are useful to improve cardiovascular risk factors levels and have a small, but potentially important, effect on population mortality. Moreover, this systematic review highlights that multifactorial interventions seem to be more effective in the at-risk population and when they are carried out at a high level of intensity. |
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| Lee et al, 2017 [4] | ||
| Included 14 health economic evaluations. Five studies were based on RCT’s, seven on observational studies and two were based on hypothetical modelling. | The population of interest were the adult general population. The intervention had two components. Screening with a risk tool to assess a global risk score and referral to appropriate lifestyle and pharmacological interventions to modify relevant risk factors. Screening programs for specific diseases or risk factors were excluded. |
Risk factors, CVD outcomes, utility, life years, event-free time, disability adjusted life years, quality adjusted life years and net monetary impact. |
| Authors' conclusion: “Recommendations for population-wide risk assessment and management programmes lack a robust, real world, evidence basis. Given implementation is resource intensive there is need for robust economic evaluation, ideally conducted alongside trials, to assess cost effectiveness. Further the efficiency and equity impact of different delivery models should be investigated, and also the combination of targeted screening with whole population interventions recognising that there multiple approaches to prevention.” |
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| BMI = Body mass index; CVD = Cardiovascular disease; DBP = Diastolic blood pressure; RCT = Randomised control study; SBP = Systolic blood pressure | ||
References
- Patnode CD, Evans CV, Senger CA, Redmond N, Lin JS. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA: Journal of the American Medical Association 2017;318:175-193.
- Dyakova M, Shantikumar S, Colquitt JL, Drew CM, Sime M, Maciver J, et al. Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2016;2016.
- Alvarez-Bueno C, Cavero-Redondo I, Martínez-Andrés M, Arias-Palencia N, Ramos-Blanes R, Salcedo-Aguilar F, et al. Effectiveness of multifactorial interventions in primary health care settings for primary prevention of cardiovascular disease: A systematic review of systematic reviews. Preventive Medicine 2015;76:S68-75.
- Lee JT, Lawson KD, Wan Y, Majeed A, Morris S, Soljak M, et al. Are cardiovascular disease risk assessment and management programmes cost effective? A systematic review of the evidence. Preventive Medicine 2017;99:49-57.
Literature search
| The search result, usually found at the end of the documentation, forms the list of abstracts.; [MeSH] = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; [MeSH:NoExp] = Does not include terms found below this term in the MeSH hierarchy; [MAJR] = MeSH Major Topic; [TIAB] = Title or abstract; [TI] = Title; [AU] = Author; [TW] = Text Word; Systematic[SB] = Filter for retrieving systematic reviews; * = Truncation | ||
| Search terms | Items found | |
| Population: | ||
| 1. | exp Primary Health Care/ | 151,697 |
| 2. | ((Primary ADJ2 care) OR (health centre$ or health center$ OR community intervention OR patient behavioral change OR primary prevention OR cardiovascular screening)).ti,ab,kw. | 171,405 |
| 3. | (community care OR community health centre$ OR family practi* or general practi*).ti,ab. | 91,841 |
| 4. | 1 OR 2 OR 3 | 339,226 |
| Intervention: | ||
| 5. | (Multiple adj2 risk adj3 (intervention* or prevention)).ti,ab. | 575 |
| 6. | (multifactor* adj2 (intervention or prevention)).ti,ab. | 689 |
| 7. | (behavio?r* adj3 risk adj2 factor* adj3 (reduc* or manag* or intervention* or modification)).ti,ab. | 191 |
| 8. | ((coronary or heart or cardiovascular) adj3 risk? adj2 information).ti,ab. | 269 |
| 9. | ((Lifestyle or Life-style or "Life style") adj3 (Recomendat* or advice or Dialogue or counsel* or consult* or modification or intervention?)).ti,ab. | 14,004 |
| 10. | (Health? adj3 (advice or dialogue or counsel* or consult* or recomendat*)).ti,ab. | 10,008 |
| 11. | "behavioral counseling".ti,ab. | 695 |
| 12. | ((behavio?r* or lifestyle or "life-style" or "life style") adj3 (chang* or modification or alter*) adj3 (intervention? or program* or prevent*)).ti,ab. | 6,675 |
| 13. | (care check* or "checkup?" or "check‐up?" or "health check?").ti,ab. | 8,882 |
| 14. | screen*.af. | 789,289 |
| 15. | ((cardi* or primary prevention) adj3 risk assessment).ti,ab. | 1,891 |
| 16. | 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 | 825,790 |
| Outcome: | ||
| 17. | exp Cardiovascular Diseases/ | 2,316,277 |
| 18. | exp Hypertension/ | 248,859 |
| 19. | exp Heart Diseases/ | 1,095,175 |
| 20. | exp Cholesterol/ | 157,330 |
| 21. | exp Blood Pressure/ | 285,231 |
| 22. | (cardi* or coronary* or heart* or hypertensi* or blood pressure or cholesterol*).af. | 3,208,497 |
| 23. | ((Cardiovascular or coronary) adj1 "risk factor?").af. | 36,652 |
| 24. | ((Coronary or Cardiovascular) adj2 disease?).ti,ab. | 285,770 |
| 25. | 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 | 4,003,417 |
| Limits: | ||
| 26. | (diabete? not (diabete? and (cardi* or heart? or hyper* or chol*))).ti. | 196,415 |
| Study types: | ||
| 27. | exp "Systematic Review"/ OR exp Meta-Analysis/ | 259,316 |
| 28. | ((systematic* adj3 review*) or meta analy* or metaanaly*).ti,ab. | 175,779 |
| 29. | 27 OR 28 | 280,985 |
| Combined sets: | ||
| 30. | 4 AND 16 AND 25 | 7,969 |
| 31. | 30 NOT 26 | 7,376 |
| Final | 31 AND 29 | 359 |
| /de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase | ||
| Search terms | Items found | |
| Population: | ||
| 1. | 'primary health care'/exp OR 'primary medical care'/exp | 161,725 |
| 2. | ((primary NEXT/2 care):ti,ab,kw) OR ’health centre$’:ti,ab,kw OR ’health center$’:ti,ab,kw OR 'community intervention':ti,ab,kw OR ’patient behavioral change$’:ti,ab,kw OR 'primary prevention' OR 'cardiovascular screening' | 258,207 |
| 3. | 'community care':ti,ab OR ’community health centre$’:ti,ab OR 'family practi*':ti,ab OR 'general practi*':ti,ab | 119,257 |
| 4. | 1 OR 2 OR 3 | 399,140 |
| Intervention: | ||
| 5. | (Multiple NEXT/2 risk NEAR/3 (intervention* OR prevention)):ti,ab | 668 |
| 6. | ((multifactor* NEXT/2 (intervention OR prevention)):ti,ab) | 814 |
| 7. | (behavio?r* NEAR/3 risk NEXT/2 factor* NEAR/3 (reduc* OR manag* OR intervention* OR modification)):ti,ab | 92 |
| 8. | ((coronary OR heart OR cardiovascular) NEAR/3 risk$ NEXT/2 information):ti,ab | 95 |
| 9. | ((Lifestyle OR Life-style OR ’Life style’) NEAR/3 (Recomendat* OR advice or Dialogue OR counsel* OR consult* OR modification OR intervention$)):ti,ab | 21,401 |
| 10. | (Health$ NEAR/3 (advice OR dialogue OR counsel* OR consult* OR recomendat*)):ti,ab | 13,026 |
| 11. | 'behavioral counseling':ti,ab | 855 |
| 12. | ((behavio?r* OR lifestyle OR 'life-style' OR 'life style') NEAR/3 (chang* OR modification OR alter*) NEAR/3 (intervention$ OR program* OR prevent*)):ti,ab | 5,142 |
| 13. | ('care check*' OR checkup$ OR check‐up$ OR ’health check$’):ti,ab | 23,986 |
| 14. | ’screen*' | 1,287,399 |
| 15. | ((cardi$* OR 'primary prevention') NEAR/3 'risk assessment'):ti,ab | 3,092 |
| 16. | 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 | 1,344,022 |
| Outcome: | ||
| 17. | 'cardiovascular disease'/exp | 4,265,432 |
| 18. | ’hypertension’/exp | 726,457 |
| 19. | 'heart disease'/exp | 1,914,720 |
| 20. | ’Cholesterol’/exp | 313,027 |
| 21. | ’Blood pressure’/Exp | 570,450 |
| 22. | (cardi$* OR coronary* OR heart* or hypertensi* OR ’blood pressure’ OR cholesterol*) | 4,817,516 |
| 23. | (Cardiovascular OR coronary) NEXT/1 risk factor$ | 136,982 |
| 24. | ((Coronary OR Cardiovascular) NEXT/2 disease$):ti,ab | 415,971 |
| 25. | 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 | 6,105,389 |
| Limits: | ||
| 26. | (diabete$:ti NOT (diabete$:ti AND (cardi*:ti OR heart$:ti OR hyper*:ti OR chol*:ti))) | 274,417 |
| Study types: | ||
| 27. | ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim) | 322,382 |
| 28. | (systematic* NEXT/3 review*):ab,ti OR ‘meta analy*’:ab,ti OR metaanaly*:ab,ti | 329,736 |
| 29. | 27 OR 28 | 418,127 |
| Combined sets: | ||
| 30. | 4 AND 16 AND 25 | 14,238 |
| 31. | 30 NOT 26 | 13,158 |
| Final | 31 AND 29 | 633 |
| The search result, usually found at the end of the documentation, forms the list of abstracts.; AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase | ||
| Search terms | Items found | |
| Population: | ||
| 1. | (MH "Primary Health Care") | 56,519 |
| 2. | (AB (Primary W2 care) OR (health centre# or health center# OR “community intervention” OR “patient behavioral change” OR “primary prevention” OR “cardiovascular screening”)) OR (TI (Primary W2 care) OR (health centre# or health center# OR “community intervention” OR “patient behavioral change” OR “primary prevention” OR “cardiovascular screening”)) | 100,963 |
| 3. | (AB (“community care” OR “community health centre#” OR “family practi*” or “general practi*”) OR (TI (“community care” OR “community health centre#” OR “family practi*” or “general practi*”) | 32,291 |
| 4. | 1 OR 2 OR 3 | 145,872 |
| Intervention: | ||
| 5. | (AB (Multiple W2 risk N3 (intervention* or prevention))) OR (TI (Multiple W2 risk N3 (intervention* or prevention))) | 197 |
| 6. | (AB (multifactor* W2 (intervention or prevention))) OR (TI (multifactor* W2 (intervention or prevention))) | 451 |
| 7. | (AB (behavio#r* N3 risk W2 factor* N3 (reduc* or manag* or intervention* or modification))) OR (TI (behavio#r* N3 risk W2 factor* N3 (reduc* or manag* or intervention* or modification))) | 125 |
| 8. | (AB (coronary or heart or cardiovascular) N3 risk# W2 information) OR (TI (coronary or heart or cardiovascular) N3 risk# W2 information) | 71 |
| 9. | (AB (Lifestyle or “Life-style” or "Life style") N3 (Recomendat* or advice or Dialogue or counsel* or consult* or modification or intervention#)) OR (TI (Lifestyle or “Life-style” or "Life style") N3 (Recommendat* or advice or Dialogue or counsel* or consult* or modification or intervention#)) | 7,681 |
| 10. | (AB (Health# N# (advice or dialogue or counsel* or consult* or recomendat*))) OR (TI (Health# N# (advice or dialogue or counsel* or consult* or recomendat*))) | 154 |
| 11. | AB "behavioral counseling" OR TI "behavioral counseling" | 415 |
| 12. | (AB (behavio#r* or lifestyle or "life-style" or "life style") N3 (chang* or modification or alter*) N3 (intervention# or program* or prevent*)) OR (TI (behavio#r* or lifestyle or "life-style" or "life style") N3 (chang* or modification or alter*) N3 (intervention# or program* or prevent*)) | 4,272 |
| 13. | (AB (care check* or "checkup#" or "check‐up#" or "health check#")) OR (TI (care check* or "checkup#" or "check‐up#" or "health check#")) | 5,193 |
| 14. | screen* | 179,647 |
| 14. | (AB (cardi* or primary prevention) N3 risk assessment) OR (TI (cardi* or primary prevention) N3 risk assessment) | 1,268 |
| 15. | 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 | 195,777 |
| Outcome: | ||
| 16. | (MH "Cardiovascular Diseases+") | 513,232 |
| 17. | (MH "Hypertension+") | 68,715 |
| 18. | (MH "Heart Diseases+") | 241,516 |
| 19. | (MH "Cholesterol+") | 24,215 |
| 20. | (MH "Blood Pressure+") | 43,405 |
| 21. | (cardi* or coronary* or heart* or hypertensi* or blood pressure or cholesterol*) | 589,576 |
| 22. | ((Cardiovascular or coronary) W1 "risk factor?") | 1,453 |
| 23. | (AB (Coronary or Cardiovascular) W2 disease?) OR (TI (Coronary or Cardiovascular) W2 disease?) | 70,598 |
| 24. | 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 | 777,443 |
| Limits: | ||
| 25. | (TI (diabete? not (diabete# and (cardi* or heart# or hyper* or chol*)))) | 80,776 |
| Study types: | ||
| 26. | (MH "Systematic Review") OR (MH "Meta Analysis") | 95,064 |
| 27. | (AB (systematic* N3 review*) or meta analy* or metaanaly*) OR (TI (systematic* N3 review*) or meta analy* or metaanaly*) | 125,245 |
| 28. | 27 OR 28 | 149,919 |
| Combined sets: | ||
| 29. | 4 AND 16 AND 25 | 3,257 |
| 30. | 30 NOT 26 | 2,996 |
| Final | 31 AND 29 | 171 |
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