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DETERMINANTS OF SUCCESSFUL IMPLEMENTATION OF SELECTIVE PREVENTION OF CARDIO-METABOLIC DISEASES ACROSS EUROPE [SPIM EU] [663309] - Project
Project abstract

The SPIM EU project aims at contributing to the reduction of cardio-metabolic morbidity and mortality in EU Member States by establishing the feasibility of implementing innovative selective prevention actions in primary care. In addition, the SPIM EU project will provide a toolbox for tailoring selective prevention actions in all EU Member States. The evidence based guideline of the Dutch College of General Practitioners represents an innovative approach for efficiently implementing selective prevention by a stepwise identification process of persons at high risk in the general population. However, successful implementation of this approach in EU Member States with different health care systems calls for tailoring of this action.The SPIM EU project includes five Work Packages (WP4-WP8), in addition to three horizontal Work Packages. WP4 includes the mapping of existing selective prevention programs in all EU Member States, and their strengths and weaknesses. In WP5 a systematic literature review will be conducted to summarize the knowledge from the literature about facilitating and hampering factors in implementing selective prevention programs and to identify determinants of their uptake and compliance. WP6 includes a survey among primary health care professionals and a sample of the general population in five EU Member States [SWE, DNK, NLD, CZE, GRE] to gain more insight into the task perceptions and attitudes towards selective prevention actions. In WP7 the results of WP4-WP6 will be collated and synthesized into tailored designs for implementing selective prevention actions (inspired by the Dutch guideline) in the five fore-mentioned EU Member States with the aim to test their feasibility. The feasibility tests are the core element of WP8. This will result in a toolbox of measures to tailor the implementation of selective prevention actions in all EU Member States taking their respective social, cultural, political and health care system contexts into account

Summary of context, overal objectives, strategic, relevance and contribution of the action

The SPIMEU project aimed at contributing to the reduction of cardio-metabolic morbidity and mortality in EU Member States by establishing the feasibility of implementing innovative evidence based selective prevention actions in five EU Member States representing various health care systems. For this, the SPIMEU project provided a toolbox for tailoring selective prevention actions in all EU Member States. This toolbox provided elements and factors important for a successful implementation of selective prevention programs, including elements to identify persons with a high risk for cardio-metabolic diseases. The EU Member States can select and use the elements that fit into their own health care organization.

The SPIMEU project included five Work Packages (WP4-WP8, in addition to three horizontal Work Packages (WP1-WP3 for coordination, dissemination and evaluation)). The objectives of the study were:
• To identify models of implementation of selective prevention for cardio-metabolic diseases which are currently being practiced in all 28 EU Member States
• To systematically review the existing evidence on determinants of uptake and compliance with selective prevention actions
• To assess the attitude of both health care professionals and the general population in five EU Member States towards selective prevention actions
• To design a generic stepwise program for identifying people at high risk for cardio-metabolic diseases, that can be tailored to the country-specific context in five EU Member States
• To test the feasibility of the stepwise program in five EU Member States
• To create a toolbox to support tailoring of selective prevention programs to the national context in EU Member States

The SPIMEU project represented an action under thematic priority 1 of the Work Programme 2014 of the EC Public Health Programme: “Promoting health, preventing diseases and fostering supportive environments for healthy lifestyles taking into account the ‘health in all policies’ principle”. Theme 2.1.1.1. specifically addresses to make “use of the potential of innovation for the prevention and management of major chronic diseases (diabetes, cardiovascular diseases…)”.

According to the Work Programme 2014, the projects’ objectives “…should put more emphasis on new approaches to prevention of major chronic diseases, including linking prevention to healthcare interventions, with an emphasis on groups most at risk”. The objectives of the SPIMEU project were completely congruent with these priorities. The SPIMEU project will provide empirical evidence for successfully implementing selective prevention (focusing on the high risk population) in primary health care settings.

Methods and means

The SPIMEU project included various methods to reach its objectives. The following methods were used:
• Publication and communication technologies for disseminating the results (WP2)
• Analyse strength and weaknesses of existing selective prevention programmes (WP4)
• Systematic literature review (WP5)
• Survey methodology (WP6)
• Consensus meetings (WP2 and WP7)
• Feasibility study methodology including quantitative and qualitative analyses (WP8).

Work performed during the reporting period

The SPIMEU project started in May 2015 and ended in July 2018. During this period the following activities were carried out:

WP2 – dissemination of SPIMEU
• A project website (www.spimeu.org) was published online.
• Project leaflets were made in English, Dutch, Swedish, Greek, Czech and Danish, and distributed at (inter)national conferences.
• A project Twitter account was established (#SPIMEU).
• SPIMEU was represented at WONCA Conferences in 2015, 2016, 2017, 2018.
• Four newsletters were published on the website as well as the project Twitter account.
• Six scientific publications were submitted to, or published in international peer-reviewed journals. The summaries of these publications were published on the SPIMEU website
• A toolbox to support the implementation of selective preventive programs in EU Member States was composed. The toolbox was published on the SPIMEU website.

WP4 – Overview of current selection prevention program activities in the EU
• A questionnaire was sent to experts in all EU Member States in order to establish an inventory with characteristics of selective prevention programs in EU Member States
• A list of 19 selective prevention programs in all EU Member States available has been produced.
• The results were summarized in a publication submitted to a peer-reviewed journal.

WP5 – Systematic review
• A protocol was written for a systematic literature review about the existing evidence on determinants of uptake and compliance with selective prevention actions
• The final search revealed 28 articles regarding attitudes of professionals and 39 articles regarding the attitudes of the population.
• The results were summarized in two publications in peer-reviewed journals;

WP6 – attitude of professionals and the population
• A questionnaire to determine the attitude of professionals regarding selective prevention programs has been sent to GPs in the five EU Member States of the partners of SPIMEU
• A questionnaire to determine the attitude of the population regarding selective prevention programs has been send out to the population in the five participating countries.
• Results of these surveys were published / submitted to peer-reviewed scientific journals.

WP7 - To design a generic stepwise program for identifying people at high risk for cardio-metabolic diseases, that can be tailored to the country-specific context
• In total, 32 statements covering different aspects of selective cardio-metabolic prevention programs, based on a synthesis of evidence from a systematic literature review and surveys conducted within SPIMEU project supplied with relevant literature, were identified. The Rand/UCLA Appropriateness method (RAM) was used to find consensus on these statements among a panel of international experts in CMD prevention.
• The results of WP7 are presented in a manuscript that has been submitted to a peer-reviewed scientific journal.

WP8 – To determine the feasibility of a patient identification and recruitment method based on the results from the different WPs of the SPIMEU project.
• A total of 1,000 patients, 200 in each partner country, were invited to complete a risk score test, and if needed, and appointment with their GP.
• This feasibility study demonstrated that implementation for selective prevention of SMD in daily GP practice is achievable.
• The results of WP8 were presented in a final report.

WP2 – SPIMEU Toolbox
• The results from all WPs was summarized in a Toolbox containing a set of evidence-based practical recommendations for health care professionals and policy makers interested in applying effective selective prevention programs in primary care.
• In the Toolbox each recommendation is supplemented with specific and concrete evidence-based suggestions as how to exactly one might implement these recommendations across different cultural, political, and systemic settings in the ‘real world’.

The main output achieved so far and their potential impact and use by target group (including benefits)

Work package 4 – Characteristics of current European selective prevention programmes
Among the 19 identified programmes, several common denominators stood out. The majority of programmes focused on people between the age of 40 and 55 and included a combination of questionnaires, laboratory tests, physical examinations, treatment, and follow-up. The programmes were often implemented in countries with strong primary care sectors, and most were designed and implemented by two or three key stakeholders, typically including primary health care providers, public health organizations, and/or policy makers.

Work package 5 – Patient and GP uptake of selective prevention programmes
We conducted two systematic literature reviews into the barriers and facilitators as they related to GPs and patients. We structured the results of our review as they relate to GPs into five categories; Structural; Organizational; Professional; Social; GP attitude.
In the review of barriers and facilitators as they relate to patients, we organized the evidence into three distinct categories: Characteristics; Attitude; Practical reasons.

Work package 6 – Patient and GP attitudes towards selective prevention programmes
We conducted two surveys. In the first, we surveyed 575 GPs, recruited evenly in the five SPIMEU countries. The central aim was to provide an up-to-date overview of the current practice of, and GP attitudes towards selective prevention of CMD in primary care. Most GPs perceived selective prevention as a useful tool to combat the spread of CMD. However, less than half of participating GPs actually employed selective prevention measures regularly, and less than a quarter had implemented a protocol to this end. In other words, there was a clear discrepancy between GPs’ attitudes to selective prevention of CMD and their actions.
In the second survey, we aimed to determine the willingness of patients to participate in preventive CMD-health check. We found a broad patient support for preventive care in general practice and willingness to participate in health checks of this nature. Nonetheless, certain subgroups of the participant population were less likely to attend a health check, and several of these groups represented people who most certainly would benefit from a health check (e.g. smokers, overweight people).

Work package 7 – The development of a generic selective prevention programme for European primary care: Consensus meeting
On the basis of the results from WP4, WP5 and WP6 and the literature, WP7 focused on the more concrete development of a generic selective CMD-prevention program for European primary care. We employed the Rand/UCLA Appropriateness Method (RAM) . At its core, this method represents an efficient way to reach formal agreement on how the best available evidence from a given scientific field should be interpreted and applied with maximum efficacy and value in the ‘real world’.
In total, 14 experts in the field systematically discussed a set of 32 statements on what should be considered when designing and implementing CMD selective prevention programmes. The proposed recommendations had been developed by the SPIMEU team. After two days of constructive discussion and two rounds of voting, the expert panel returned a list of 31 statements of which they had achieved consensus on 28. In sum, the experts agreed on most issues relating to programme scope and development, organization and funding, target population identification methods, and the notion of embedding programs in primary care. Fundamentally, the panel conceded that there is a need for selective CMD-prevention programs in Europe, and that such programs should be developed by experts in the field, tailored to and piloted in local settings, and mandated and financed by governments. These findings directly informed the final WP of the SPIMEU project, which centered on the development and feasibility of a generic CMD-prevention program.

Work package 8

Achieved outcomes compared to the expected outcomes

The outcomes were as planned.

List of all publications in international peer reviewed journals
• Hollander M, de Waard AM, Korevaar JC, Carlsson AC, Lionis C, Seifert B, Kral N, Agapi A, Søndergaard J, Sønderlund AL, de Wit NJ, Schellevis FG; SPIMEU Project Group.No “one size fits all” or “sine qua non” for selective cardiometabolic prevention programmes in Europe. Submitted
• Wändell PE, de Waard AM, Holzmann MJ, Gornitzki C, Lionis C, de Wit N, Søndergaard J, Sønderlund AL, Kral N, Seifert B, Korevaar JC, Schellevis FG, Carlsson AC. Barriers and facilitators among health professionals in primary care to prevention of cardiometabolic diseases: A systematic review. Fam Pract. 2018 Jan 29. doi: 10.1093/fampra/cmx137.
• de Waard AM, Wändell PE, Holzmann MJ, Korevaar JC, Hollander M, Gornitzki C, de Wit NJ, Schellevis FG, Lionis C, Søndergaard J, Seifert B, Carlsson AC; SPIMEU Research Group. Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: A systematic review. Eur J Prev Cardiol. 2018 Aug;25(12):1326-1340.
• de Waard AM, Hollander M, Korevaar JC, Nielen MMJ, Carlsson AC, Lionis C, Seifert B, Thilsing T, de Wit NJ, Schellevis FG; SPIMEU Project Group. Selective prevention of cardiometabolic diseases: activities and attitudes of general practitioners across Europe. Eur J Public Health. 2018 Jul 16. doi: 10.1093/eurpub/cky112.
• de Waard AM, Korevaar JC, Hollander M, Nielen MMJ, Seifert B, Carlsson AC, Lionis AC, Soendergaard J, Schellevis FG, de Wit NJ. Willingness to participate in health checks for cardiometabolic diseases: a survey among primary health care patients in five European countries. Submitted
• Kral N, de Waard AM, Schellevis FG, Korevaar JC, Lionis C, Carlsson AC Sønderlund AL, Søndergaard J, Larsen LB, Hollander M, Thilsing T, Angelaki A, de Wit NJ, Seifert B. Design of generic selective cardio-metabolic prevention programs in primary care: consensus development using the RAND/UCLA appropriateness method. Submitted.

Toolbox - published on the SPIMEU website (www.SPIMEU.org)
Laymens summary - published on the SPIMEU website (www.SPIMEU.org)
Report of the feasibility studies- published on the SPIMEU website (www.SPIMEU.org)

Dissemination and evaluation activities carried out so far and their major results

A website, Twitter-account, project leaflet and newsletters have been created. The website is updated on a regular basis. Presentations were given at (inter)national conferences, and the toolbox was developed and published. Results have been discussed during an invitational conference with the target group as mentioned in the proposal; policy makers, professionals and researchers. The toolbox will be brought under attention via (inter)national publication, the website, and tweets. Moreover, all partners will be ambassadors for the toolbox and bring it under attention among stakeholders in their own country and if feasible in other countries. The results were and will be actively distributed among various international stakeholders and stakeholder organizations, like EUROPREV network, EFPC (European Forum for Primary Care), WHO European Observatory for Health Systems and Policies, EGPRN (European General Practice Research Network), EUPHA (European Public Health Association), EPHA (European Public Health Alliance). Importantly, results will be made publicly available via the toolbox and website.

Moreover, the SPIMEU group has created a proposal to carry on with the results of the current SPIMEU proposal via a COST Action study (PRimary care: DEfining its role in CArdiovascular Disease risk management, PReDECADe Proposal Reference OC-2018-1-22852). If the proposal is rewarded, this is a good opportunity for further dissemination of the current results.

In addition, all results and articles, including a PhD thesis, will be actively distributed among the experts of WP7.

Evaluation:
At regular interval progress reports were completed by each partner revealing the current-state-of the art, all partners completed all progress report as requested.
At the last partner meeting, 19 June 2018 in Utrecht, we reflected on the entire SPIM process.
During the reflection session the following points were mentioned as process points that went very well in this SPIMEU project:
• WP 1 was well coordinated and in charge
• Chairman gave the opportunity to everyone to give his/her opinion
• Proud of the collaboration between all partners
• Quick responses via e-mail, on manuscripts with supportive and positive feedback
• the good atmosphere during partner meetings
The improvement points that emerged from the reflection session where:
• Start with an overview of current activities in each country.
• Less strict time schedule/ less tight time planning
• Involve experts more frequently between WPs meetings
• More emphasis on dissemination from te beginning
• Better general communication, for example more frequent skype meetings
• It was not always clear, for everyone, who was in charge of a specific task
• More discussion on harmonisation of data collection was needed
In general everyone was very satisfied with the process and proud of the amount of work that was achieved in 3 years!