Implementing and Testing a Cardiovascular Assessment Screening Program (CASP)
Implementing and Testing a Cardiovascular Assessment Screening Program (CASP)
This study is a randomized controlled trial (RCT) and there will be two groups: an
 intervention group and a control group. Nurse practitioners (NPs) across Newfoundland and
 Labrador (NL) who agree to participate will be randomly assigned to one of the two groups.
 The NPs in the intervention group will be asked to screen about 30 individuals aged 40-74
 years without established cardiovascular disease (CVD) that currently come to their clinics.
 The NPs will be asked to screen these patients for CVD using a set of specific data
 collection tools that will be in electronic format. The control group will carry on with
 usual practice. Their charts will be reviewed by the researchers at a later date. At the end
 of the study, the screening program, with tools and strategies for CVD screening, will be
 given to NPs in the control group.
The RCT will be conducted to test the screening intervention, the Cardiovascular Assessment
 Screening Program, with nurse practitioners across NL.

 Research Questions

 1. What is the effect of implementing the Cardiovascular Assessment Screening Program on
 comprehensiveness of screening by nurse practitioners in NL?

 2. What is the effect of implementation of the Cardiovascular Assessment Screening Program
 on the identification of individuals at high risk of CVD within the nurse practitioner
 practice?

 3. What is the effect of implementation of the Cardiovascular Assessment Screening Program
 on recommendations that are made by nurse practitioners in NL?

 4. What components of the Cardiovascular Assessment Screening Program are effective in
 promoting CVD screening and appropriate follow-up by nurse practitioners in NL?

 5. What are the patients' and nurse practitioners' factors that influence participation in
 the Cardiovascular Assessment Screening Program in NL? The main outcome is the
 comprehensiveness of CVD screening. The null hypothesis for the RCT is stated as
 follows: There will be no difference in comprehensiveness of screening between the
 intervention group and the control group.

 Methodology The RCT study will involve implementation and evaluation of the Cardiovascular
 Assessment Screening Program across the province of NL. The RCT will use block randomization
 following NP recruitment to allocate participating NP practices to either the intervention
 group or the control group. The NPs in the intervention group will participate in scheduled
 face-to-face educational sessions as well as webinars from their workplaces to receive
 support on using specific tools to identify, screen, and follow-up with patients. The NPs
 will also receive instructions on data collection methods using the study's Access Database
 developed by Newfoundland and Labrador Centre for Health Information (NLCHI).

 The NPs in the control group will participate in a webinar education session and will be
 instructed to follow usual practice to screen patients for CVD. The NPs in the control group
 will receive instructions on keeping a record of patients who were seen in their clinics and
 whether or not the patients will be eligible to participate in the study based on age and
 history. This information will be used by researchers to conduct a retrospective chart review
 on a specified date during the data collection period. The specific CVD screening tools
 provided to the NPs in the intervention group will be made available to NPs in the control
 group following conclusion of this study.

 Setting & Sample The RCT will take place in community-based clinics with NP practices from
 both rural and urban areas in the various regional health authorities across NL. NPs may be
 working in solo practice or working with several other NPs in a group practice. There will be
 four types of NP practices: 1) rural solo, 2) rural group, 3) urban solo and, 4) urban group.
 NPs working in the same group practice will need to be allocated to the same group, so block
 randomization will be used once all of the NP practices have been recruited. Using a random
 number generator, NP practices will be allocated to either the intervention group or the
 control group within each block (type) of practice.

 The sample size estimation for this study was determined using the proportion of eligible
 patients who were comprehensively screened as the outcome measure of interest. A study that
 considered the effectiveness of a national risk assessment program for patients aged 40-74
 years found that approximately 40% had complete Health Checks and 60% had partial Health
 Checks among high risk patients in the United Kingdom (UK) National Health Service Health
 Check Program (Artec et al., 2013). The sample size for this proposed study was calculated
 based on the assumption that 40% of the screening will be comprehensive in the control group
 practices. The research team decided that comprehensive screening of 70% of patients seen by
 the NPs in the intervention group during this study would indicate an effective intervention.
 Using a two-sided alpha of 0.05 and 90% power, the sample size was calculated to be 250
 patients (125 patients per group). Considering that patients would need to provide consent to
 participate in this study the research team assumed that 20% of those approached would
 refuse. This means that 300 patients with 150 patients per group would be required. To be
 realistic about workload, each NP would need to include 25-30 patients. A minimum of 10 NPs
 therefore needs to be recruited. The duration of the data collection period will vary by NP
 according to the number of eligible patients seen. For example, if an NP sees one eligible
 patient per day for five days a week, then the data collection period would be six weeks for
 a total of 30 patients. If an NP sees two eligible patients per day, then the data collection
 period would be three weeks.
Inclusion Criteria for NPs:

 -  Employment as a full-time NP in community-based settings

 -  Access to healthy, asymptomatic patients between the ages of 40-74 years of age

 -  Ability of the practice to collect data.

 Inclusion Criteria for the Patients:

 -  Eligible based on age,

 -  No established CVD (such as coronary heart disease (CHD) or ischemic heart disease
 (IHD), myocardial infarctions (MIs), congestive heart failure (CHF), transient
 ischemic attacks (TIAs), cerebrovascular accidents (CVAs), peripheral vascular disease
 (PVD), and pulmonary emboli (PE).

 -  Willingness to participate in the study.

 Exclusion Criteria

 -  Age less than 20 or over 75 years

 -  Established Cardiovascular Disease (such as coronary heart disease (CHD) or ischemic
 heart disease (IHD), myocardial infarctions (MIs), congestive heart failure (CHF),
 transient ischemic attacks (TIAs), cerebrovascular accidents (CVAs), peripheral
 vascular disease (PVD), and pulmonary emboli (PE)).

 -  Inability to attend NP clinic visit