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Although the authors assert that their study is the largest RCT of its kind, the COMPETE III investigators might suggest otherwise. Our trial randomized 1102 patients with vascular risk factors with a secondary prevention subset approximately the same size as the Verneeij study. The CIII study included an Internet vascular risk tracker for patients and a clinical care coordinator. In addition, the patient's primary care physician also had a version of the tracker linked to their electronic medical record.
Although we were able to show a significant improvement in the processes of monitoring vascular risk factors, we found no overall improvement in vascular risk, as measured by a composite score. Both studies tested complex interventions aimed at improving multiple behaviours. Although Internet-based interventions may be useful for a segment of the computer-literate population, we have not found them popular with older patients. The best combination of computer-based personalized risk factor monitoring and decision support; supportive coaching by care coordinators, family or peer volunteers; and physician management to optimize behaviour change in vascular disease, remains to be seen.
References
1. Holbrook A, Pullenayegum E, Thabane L, Troyan S, Foster G, Keshavjee K, Chan D, Dolovich L, Gerstein H, Demers C, Curnew G. Shared Electronic Vascular Risk Decision Support in Primary Care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) Randomized Trial. Arch Intern Med 2011;171(19):1736-1744.
Competing interests: None declared
McMaster University, c/o Centre for Evaluation of Medicines, 105 Main St E, Hamilton, ON
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+Dear Editor,
I read with great interest the recent publication by Vernooij et al titled, “Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial” (1). I believe there are issues with this study which must be addressed.
The design of this study excluded those without access to the internet at home thereby likely hindering participation from the lower socioeconomic classes the most. The authors mention that the measurements of vascular risk were items such as drug use, exercise, smoking, blood pressure, weight, lipids and glucose – all of which are consistently found to be higher in the lower socioeconomic classes (2). Furthermore regarding vascular disease itself, the lower socioeconomic classes have repeatedly been shown in numerous studies to comprise a significantly higher proportion of total cases relative to higher socioeconomic classes (3, 4). These factors not only illustrate substantial bias to the results of this study as the patient selection would have been non-representative, but they also make the application of such internet services widen the socioeconomic gap of inequality as only those who can afford computers and internet access can truly benefit from such a service.
I believe this study perpetuates age-old issues which are now at the front-line of reform: socioeconomic healthcare inequalities and the “inverse care law” – a theory postulating that those who least need healthcare utilise it more frequently and effectively while the opposite is true for those who need healthcare the most (i.e. the lower socioeconomic classes). Though an internet-based vascular risk management tool may be useful I believe that these patients who are unable to get internet accessed should be addressed and accommodated to ensure they can benefit from such a tool.
Other than what is formerly mentioned I believe that Vernooij et al should be commended for their contribution to the British Medical Journal and I look forward to their future publications.
1. Vernooij JWP, Kaasjager HAH, van der Graaf Y, et al. Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial. BMJ 2012;344:e3750.
2. Marmot M, et al (2010). The Marmot Review: Fair Society, Healthy Lives. Strategic review of health inequalities in England post-2010. The Marmot Review, London.
3. Clark AM, DesMeules M, Luo W, et al. Socioeconomic status and cardiovascular disease: risks and implications for care. Nat Rev Cario 2009;6:712-22.
4. Addo J, Ayerbe L, Mohan KM, et al. Socioeconomic status and stroke: an updated review. Stroke 2012;43:1186-91.
Competing interests: None declared
Brighton and Sussex Medical School, 126B Edward Street, Brighton, BN2 0JL
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