A primary healthcare information intervention for communicating cardiovascular risk to patients with poorly controlled hypertension: The Education and Coronary Risk Evaluation (Educore) study—A pragmatic, cluster-randomized trial

Autoři: Esperanza Escortell-Mayor aff001;  Isabel del Cura-González aff001;  Elena Ojeda-Ruiz aff004;  Teresa Sanz-Cuesta aff001;  Isidro Rodríguez-Salceda aff005;  Jesús García-Soltero aff006;  María-José Rojas-Giraldo aff007;  Pedro Herrera-Municio aff006;  Alicia Jorge-Formariz aff005;  Ángela Lorenzo-Lobato aff008;  Luisa Cabello-Ballesteros aff009;  Rosario Riesgo-Fuertes aff002;  Sofía Garrido-Elustondo aff002;  Mariel Morey-Montalvo aff001;  Milagros Rico-Blázquez aff001;  Ricardo Rodríguez-Barrientos aff001;  María-Dolores Fuente-Arriaran aff013;  Gloria Sierra-Ocaña aff014;  Encarnación Serrano-Serrano aff015;  Carmelina Sanz-Velasco aff013;  Roberto Carrascoso-Calvo aff005;  Juan Carlos Recio-Velasco aff016;  Marta Sanz-Sanz aff017;  Mercedes Rumayor-Zarzuelo aff018;  Olga-Inés Bermejo-Mayoral aff005;  Josefina Galán-Esteban aff006;  Antonio Sarría-Santamera aff002
Působiště autorů: Unidad de Apoyo a la Investigación, Gerencia Asistencial de Atención Primaria, Madrid, Spain aff001;  Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain aff002;  Área Medicina Preventiva y Salud Pública, Departamento Especialidades Médicas y Salud Pública, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain aff003;  Centro Nacional de Epidemiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain aff004;  Centro de Salud La Veredilla, Torrejón de Ardoz, Madrid, Spain aff005;  Centro de Salud Santa Isabel, Madrid, Spain aff006;  Centro de Salud Parque Loranca, Fuenlabrada, Madrid, Spain aff007;  Centro de Salud Alcalá de Guadaira, Madrid, Spain aff008;  Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Noroeste, Madrid, Spain aff009;  Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Sur. Getafe, Madrid, Spain aff010;  Unidad Docente Multiprofesional de Atención Familiar y Comunitaria Sureste, Madrid, Spain aff011;  Servicio de Prevención de la Enfermedad, Subdirección General de Promoción, Prevención y Educación para la Salud, Dirección General de Salud Pública, Madrid, Spain aff012;  Centro de Salud Sector 3, Getafe, Madrid, Spain aff013;  Centro de Salud Manuel Merino, Alcalá de Henares, Madrid, Spain aff014;  Centro de Salud Los Fresnos, Torrejón de Ardoz, Madrid, Spain aff015;  Centro de Salud Andrés Mellado, Madrid, Spain aff016;  Centro de Salud Las Águilas, Madrid, Spain aff017;  Área Única de Salud Pública-2, Dirección General de Salud Pública, Madrid, Spain aff018;  Departamento de Gestión de Servicios Sanitarios, Escuela Nacional de Sanidad, Instituto de Salud Carlos III (ISCIII), Madrid, Spain aff019;  Facultad de Medicina y Farmacia, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain aff020
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0226398



Uncertainty exists regarding the best way to communicate cardiovascular risk (CVR) to patients, and it is unclear whether the comprehension and perception of CVR varies according to the format used. The aim of the present work was to determine whether a strategy designed for communicating CVR information to patients with poorly controlled high blood pressure (HBP), but with no background of cardiovascular disease, was more effective than usual care in the control of blood pressure (BP) over the course of a year.


A pragmatic, two-arm, cluster-randomized controlled trial was performed. Consecutive patients aged 40–65 years, all diagnosed with HBP in the last 12 months, and all of whom showed poor control of their condition (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg), were recruited at 22 primary healthcare centres. Eleven centres were randomly assigned to the usual care arm, and 11 to the informative intervention arm (Educore arm). At the start of the study, the Educore arm subjects were shown the "low risk SCORE table", along with impacting images and information pamphlets encouraging the maintenance of good cardiovascular health. The main outcome variable measured was the control of HBP; the secondary outcome variables were SCORE table score, total plasma cholesterol concentration, use of tobacco, adherence to prescribed treatment, and quality of life.


The study participants were 411 patients (185 in the Educore arm and 226 in the usual care arm). Multilevel logistic regression showed that, at 12 months, the Educore intervention achieved better control of HBP (OR = 1.57; 1.02 to 2.41). No statistically significant differences were seen between the two arms at 12 months with respect to the secondary outcomes.


Compared to usual care, the Educore intervention was associated with better control of HBP after adjusting for age, baseline SBP and plasma cholesterol, at 12 months.

Klíčová slova:

Antihypertensives – Blood pressure – Cardiovascular diseases – Communications – Hypertension – Cholesterol – Patients – Quality of life


1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83: 457–502. doi: 10.1111/j.1468-0009.2005.00409.x 16202000

2. Green L, Fryer G, Yawn B, Lanier D, Dovey S. The ecology of medical care revisited. The New England journal of medicine. 2001. pp. 2021–2025. doi: 10.1056/NEJM200106283442611 11430334

3. Zabaleta-del-Olmo E, Bolibar B, García-Ortíz L, García-Campayo J, Llobera J, Bellón JÁ, et al. Building interventions in primary health care for long-term effectiveness in health promotion and disease prevention. A focus on complex and multi-risk interventions. Prev Med (Baltim). 2015;76: S1–S4. doi: 10.1016/j.ypmed.2015.03.011 25778858

4. Whelton PK, Carey RM, Aronow WS, Ovbiagele B, Casey DE, Smith SC, et al. 2017 ACC / AHA / AAPA / ABC / ACPM / AGS / APhA / ASH / ASPC / NMA / PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults A Report of the American College of Cardiology / American Heart Association T [Internet]. Journal of American College of Cardiology. 2017. doi: 10.1161/HYP.0000000000000065/-/DC1.The

5. NICE. Hypertension in adults: diagnosis and management. Guidel—Summ Clin Guidel Prim care. 2017; 59–65.

6. Hackam DG, Quinn RR, Ravani P, Rabi DM, Dasgupta K, Daskalopoulou SS, et al. The 2013 Canadian hypertension education program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2013;29: 528–542. doi: 10.1016/j.cjca.2013.01.005 23541660

7. He J, Irazola V, Mills KT, Poggio R, Beratarrechea A, Dolan J, et al. Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318: 1016–1025. doi: 10.1001/jama.2017.11358 28975305

8. Goodyear-Smith F, Arroll B, Chan L, Jackson R, Wells S, Kenealy T. Patients prefer pictures to numbers to express cardiovascular benefit from treatment. Ann Fam Med. 2008;6: 213–217. doi: 10.1370/afm.795 18474883

9. Powers BJ, Danus S, Grubber JM, Olsen MK, Oddone EZ, Bosworth HB. The effectiveness of personalized coronary heart disease and stroke risk communication. Am Heart J. Elsevier B.V.; 2011;161: 673–680. doi: 10.1016/j.ahj.2010.12.021 21473965

10. Neuner-Jehle S, Senn O, Wegwarth O, Rosemann T, Steurer J. How do family physicians communicate about cardiovascular risk? Frequencies and determinants of different communication formats. BMC Fam Pract. BioMed Central Ltd; 2011;12: 15. doi: 10.1186/1471-2296-12-15 21466686

11. Waldron C-A, van der Weijden T, Ludt S, Gallacher J, Elwyn G. What are effective strategies to communicate cardiovascular risk information to patients? A systematic review. Patient Educ Couns. Elsevier Ireland Ltd; 2011;82: 169–181. doi: 10.1016/j.pec.2010.04.014 20471766

12. Hawley ST, Zikmund-Fisher B, Ubel P, Jancovic A, Lucas T, Fagerlin A. The impact of the format of graphical presentation on health-related knowledge and treatment choices. Patient Educ Couns. 2008;73: 448–455. doi: 10.1016/j.pec.2008.07.023 18755566

13. Rodríguez-Salceda I, Escortell-Mayor E, Rico-Blázquez M, Riesgo-Fuertes R, Asúnsolo-del Barco A, Valdivia-Pérez A, et al. EDUCORE project: a clinical trial, randomised by clusters, to assess the effect of a visual learning method on blood pressure control in the primary healthcare setting. BMC Public Health. 2010;10: 449. doi: 10.1186/1471-2458-10-449 20673325

14. Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ. Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol. 2004;57: 785–794. doi: 10.1016/j.jclinepi.2003.12.013 15485730

15. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ Br Med J. 2007;334: 455–459. doi: 10.1136/bmj.39108.379965.BE 17332585

16. Graham B. Clinical practice guidelines: what are they and how should they be disseminated? Hand Clin. Elsevier Inc; 2014;30: 361–5, vii. doi: 10.1016/j.hcl.2014.04.007 25066855

17. Perera R, Heneghan C, Yudkin P. Graphical method for depicting randomised trials of complex interventions. BMJ Br Med J. 2007;334: 127–129. doi: 10.1136/bmj.39045.396817.68 17235093

18. Nogués Solán X, Sorli Redó ML, Villar García J. Tools to measure treatment adherence. An Med Interna. 2007;24: 138–141. doi: 10.4321/s0212-71992007000300009 17590137

19. Roca-Cusachs À, Badia X, Dalfó A, Gascón G, Abellán J, Lahoz R, et al. Relación entre variables clínicas y terapéuticas y calidad de vida relacionada con la salud en pacientes con hipertensión arterial. Estudio MINICHAL. Med Clin (Barc). 2003;121: 12–17. doi: 10.1157/13048476

20. Carvalho M a Silva IB, Ramos SB Coelho LF, Goncalves ID, Figueiredo Neto J a, et al. Quality of Life of Hypertensive Patients and Comparison of two Instruments of HRQOL Measure. Arq Bras Cardiol. 2012;98: 442–450. doi: 10.1590/s0066-782x2012005000032 22481643

21. Salim A, Mackinnon A, Christensen H, Griffiths K. Comparison of data analysis strategies for intent-to-treat analysis in pre-test-post-test designs with substantial dropout rates. Psychiatry Res. 2008;160: 335–345. doi: 10.1016/j.psychres.2007.08.005 18718673

22. Rabe-Hesketh S, Skrondal A. Multilevel and Longitudinal Modeling Using Stata. Stata Pres. Texas; 2008.

23. Campbell MK, Piaggio G, Elbourne DR, Altman DG. Consort 2010 statement: extension to cluster randomised trials. BMJ. 2012;345: e5661. doi: 10.1136/bmj.e5661 22951546

24. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. BMJ. 2015;350: h2147. doi: 10.1136/bmj.h2147 25956159

25. Ma J, Akhtar-Danesh N, Dolovich L, Thabane L. Imputation strategies for missing binary outcomes in cluster randomized trials. BMC Med Res Methodol. 2011;11: 18. doi: 10.1186/1471-2288-11-18 21324148

26. O’Connor PJ, Magid DJ, Sperl-Hillen JM, Price DW, Asche SE, Rush W a., et al. Personalised physician learning intervention to improve hypertension and lipid control: randomised trial comparing two methods of physician profiling. BMJ Qual Saf. 2014;23: 1014–1022. doi: 10.1136/bmjqs-2014-002807 25228778

27. Edelman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AS, Datta S, et al. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Ann Intern Med. United States; 2010;152: 689–696. doi: 10.7326/0003-4819-152-11-201006010-00001 20513826

28. Naik G, Ahmed H, Edwards AG. Communicating risk to patients and the public. Br J Gen Pract. 2012;62: 213. doi: 10.3399/bjgp12X636236 22520906

29. Manganello J a., Clayman ML. The Association of Understanding of Medical Statistics with Health Information Seeking and Health Provider Interaction in a National Sample of Young Adults. J Health Commun. 2011;16: 163–176. doi: 10.1080/10810730.2011.604704 21951250

30. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ. 2002;324: 827–830. doi: 10.1136/bmj.324.7341.827 11934777

31. Trevena LJ, Davey HM, Barratt A, Butow P, Caldwell P. A systematic review on communicating with patients about evidence. J Eval Clin Pract. 2006;12: 13–23. doi: 10.1111/j.1365-2753.2005.00596.x 16422776

32. Persell SD, Eder M, Friesema E, Connor C, Rademaker A, French DD, et al. EHR-based medication support and nurse-led medication therapy management: rationale and design for a three-arm clinic randomized trial. J Am Heart Assoc. 2013;2: e000311. doi: 10.1161/JAHA.113.000311 24157649

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