Current Challenges in Developing an Evidence-Based Protocol of Preventive E-Counselling for Cardiovascular Disease
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Abstract
Background: A major challenge in preventive e-counseling for cardiovascular disease (CVD) is to establish a core, standardized and evidence-based protocol to evoke therapeutic change in modifiable risk factors.
Objective: This presentation will review findings from a meta-analysis that assessed the efficacy of internet-based interventions to improve blood pressure control among subjects with blood pressure in the range of prehypertension (systolic blood pressure, SBP, 120-139 mmHg; diastolic blood pressure, DBP 80-89 mmHg) or hypertension (SBP/DBP ≥ 140/90 mmHg). In addition, a current randomized controlled trial conducted by our team will be presented: Reducing Risk with e-Based Support for Adherence to Lifestyle Change in Hypertension (REACH). Discussion of the research design and methodology of REACH will highlight key challenges in applying an evidence-based guideline (based on motivational interviewing and cognitive-behavioral therapy) to a preventive e-counseling program.
Methods: For the meta-analysis, the literature search was conducted using MEDLINE, Pubmed, Embased and Cochrane Library, from January 2000 to June 2012, with the following key words: web-based, internet, blood pressure and hypertension. Inclusion criteria required that: i) the intervention was conducted via a website or e-mail, ii) outcome measures included blood pressure, iii) baseline SBP/DBP was within the pre-hypertensive range or higher, iv) the research design utilized a randomized controlled trial, and v) publication was in an English language journal. The effect size for the magnitude of BP change following baseline assessment was calculated using Cohen’s formula. In addition, key features of the clinical method and content of our current REACH trial are presented.
Results: BP was significantly reduced relative to Control among 16 clinical trials that met inclusion criteria for the meta-analysis: mean SBP decrease = -3.78 mmHg; 95% Confidence Interval, -5.6 to -1.9 mmHg; p < 0.01; mean DBP decrease = -1.33 mmHg; 95% CI, -2.6 to -0.02 mmHg; p < 0.05. There was significant heterogeneity for trial outcomes. Duration of the e-based intervention in these trials ranged from 8 weeks to 12 months. Critical features that were associated with greater blood pressure reduction will be discussed with regard to (i) duration of the e-based intervention, (ii) number of behaviour change techniques utilized, and (iii) proactive vs. reactive strategy to deliver the e-based intervention. Accordingly, design features for the clinical method and content of the e-based intervention in REACH will be discussed with regard to the above-noted findings. Design features of REACH that highlight key components from established models of behavioural counselling (e.g. motivational interviewing and cognitive-behavioral therapy) will also be reviewed.
Conclusion: Meta-analytic findings support the efficacy of utilizing e-based interventions to reduce blood pressure among subjects at elevated CVD risk. However, heterogeneity of outcomes is a major concern. Efforts to replicate and further develop a standardized and evidence-based protocol of preventive e-counseling may be enhanced by specifying how key components of e-based interventions are organized within established models of preventive behavioral counseling.
Objective: This presentation will review findings from a meta-analysis that assessed the efficacy of internet-based interventions to improve blood pressure control among subjects with blood pressure in the range of prehypertension (systolic blood pressure, SBP, 120-139 mmHg; diastolic blood pressure, DBP 80-89 mmHg) or hypertension (SBP/DBP ≥ 140/90 mmHg). In addition, a current randomized controlled trial conducted by our team will be presented: Reducing Risk with e-Based Support for Adherence to Lifestyle Change in Hypertension (REACH). Discussion of the research design and methodology of REACH will highlight key challenges in applying an evidence-based guideline (based on motivational interviewing and cognitive-behavioral therapy) to a preventive e-counseling program.
Methods: For the meta-analysis, the literature search was conducted using MEDLINE, Pubmed, Embased and Cochrane Library, from January 2000 to June 2012, with the following key words: web-based, internet, blood pressure and hypertension. Inclusion criteria required that: i) the intervention was conducted via a website or e-mail, ii) outcome measures included blood pressure, iii) baseline SBP/DBP was within the pre-hypertensive range or higher, iv) the research design utilized a randomized controlled trial, and v) publication was in an English language journal. The effect size for the magnitude of BP change following baseline assessment was calculated using Cohen’s formula. In addition, key features of the clinical method and content of our current REACH trial are presented.
Results: BP was significantly reduced relative to Control among 16 clinical trials that met inclusion criteria for the meta-analysis: mean SBP decrease = -3.78 mmHg; 95% Confidence Interval, -5.6 to -1.9 mmHg; p < 0.01; mean DBP decrease = -1.33 mmHg; 95% CI, -2.6 to -0.02 mmHg; p < 0.05. There was significant heterogeneity for trial outcomes. Duration of the e-based intervention in these trials ranged from 8 weeks to 12 months. Critical features that were associated with greater blood pressure reduction will be discussed with regard to (i) duration of the e-based intervention, (ii) number of behaviour change techniques utilized, and (iii) proactive vs. reactive strategy to deliver the e-based intervention. Accordingly, design features for the clinical method and content of the e-based intervention in REACH will be discussed with regard to the above-noted findings. Design features of REACH that highlight key components from established models of behavioural counselling (e.g. motivational interviewing and cognitive-behavioral therapy) will also be reviewed.
Conclusion: Meta-analytic findings support the efficacy of utilizing e-based interventions to reduce blood pressure among subjects at elevated CVD risk. However, heterogeneity of outcomes is a major concern. Efforts to replicate and further develop a standardized and evidence-based protocol of preventive e-counseling may be enhanced by specifying how key components of e-based interventions are organized within established models of preventive behavioral counseling.
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