Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: A cluster randomised controlled trial

Department of Cardiovascular Sciences, University of Leicester, Leiscester, England, United Kingdom
Heart (British Cardiac Society) (Impact Factor: 5.6). 11/2007; 93(11):1398-405. DOI: 10.1136/hrt.2006.106955
Source: PubMed

ABSTRACT To evaluate the effect of a disease management programme for patients with coronary heart disease (CHD) and chronic heart failure (CHF) in primary care.
A cluster randomised controlled trial of 1316 patients with CHD and CHF from 20 primary care practices in the UK was carried out. Care in the intervention practices was delivered by specialist nurses trained in the management of patients with CHD and CHF. Usual care was delivered by the primary healthcare team in the control practices.
At follow up, significantly more patients with a history of myocardial infarction in the intervention group were prescribed a beta-blocker compared to the control group (adjusted OR 1.43, 95% CI 1.19 to 1.99). Significantly more patients with CHD in the intervention group had adequate management of their blood pressure (<140/85 mm Hg) (OR 1.61, 95% CI 1.22 to 2.13) and their cholesterol (<5 mmol/l) (OR 1.58, 95% CI 1.05 to 2.37) compared to those in the control group. Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed (OR 4.69, 95% CI 1.88 to 11.66) or excluded (OR 3.80, 95% CI 1.50 to 9.64) in the intervention group compared to the control group. There were significant improvements in some quality-of-life measures in patients with CHD in the intervention group.
Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care.

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    • "Studies have shown that nurses can contribute to improvement of cardiovascular prevention ( Clark et al . 2010 , Khunti et al . 2007 ) . Nurses tend to be more compliant to guidelines than doctors ( Hulscher et al . 1997 ) . The authors conducted a randomised trial on the clinical effectiveness of nurse - delivered cardiovascular prevention to high - risk patients in primary care ( Voogdt - Pruis HR et al . 2010 ) . Six primary health care centres in the Netherlands "
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    ABSTRACT: Aim. This paper reports on a study of the experiences of general practitioners and practice nurses implementing nurse-delivered cardiovascular prevention to high risk patients in primary care. Background. Difficulties may arise when innovations are introduced into routine daily practice. Whether or not implementation is successful is determined by different factors related to caregivers, patients, type of innovation and context. Methods. A qualitative study nested in a randomized trial (2006-2008) to evaluate the effectiveness of nurse-delivered cardiovascular prevention. Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses) participated in the trial. Interviews were held on two occasions: at 3 and at 18months after commencement of consultation. The first occasion was a group interview with six practice nurses. The second consisted of semi-structured interviews with one general practitioner and one practice nurse from each centre. Findings. Main barriers to the implementation included: lack of knowledge about the guideline, attitudes towards treatment targets, lack of communication, insufficient coaching by doctors, content of life style advice. At the start of the consultation project, practice nurses expressed concern of losing nursing tasks. Other barriers were related to patients (lack of motivation), the guideline (target population) and organizational issues (insufficient patient recording and computer systems). Conclusions. Both general practitioners and practice nurses were positive about nurse-delivered cardiovascular prevention in primary care. Nurses could play an important role in successive removal of barriers to implementation of cardiovascular prevention. Mutual confidence between care providers in the healthcare team is necessary. © 2011 The Authors. Journal of Advanced Nursing
    Journal of Advanced Nursing 07/2011; 67(8):1758 - 1766. DOI:10.1111/j.1365-2648.2011.05627.x · 1.74 Impact Factor
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    • "Previous studies have shown variability in the complexity of case management (elements of the intervention, integration of care sectors, education and training of case managers, and patient empowerment): While overall positive effects on predominantly disease-specific QoL were found in the short term (3 to 6 months) follow-up [45-48], the results for longer follow-ups (9 months to 1 year) were predominantly neutral [5,12,49-52]: Typically, short-term positive effects on quality of life were observed in hospitalised and acutely ill patients, who started with low scores at baseline enabling the short-term effects in comparison to control [46-48]. However, our patient sample included stable chronic systolic heart failure and, in relation to their age and disease, relatively high quality of life scores at baseline [28,52]. Regarding generic QoL, our results suggest that an effect size of 5 points would not be reached irrespective of the power of the sample size. "
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    ABSTRACT: Chronic (systolic) heart failure (CHF) represents a clinical syndrome with high individual and societal burden of disease. Multifaceted interventions like case management are seen as promising ways of improving patient outcomes, but lack a robust evidence base, especially for primary care. The aim of the study was to explore the effectiveness of a new model of CHF case management conducted by doctors' assistants (DAs, equivalent to a nursing role) and supported by general practitioners (GPs). This patient-randomised controlled trial (phase II) included 31 DAs and employing GPs from 29 small office-based practices in Germany. Patients with CHF received either case management (n = 99) consisting of telephone monitoring and home visits or usual care (n = 100) for 12 months. We obtained clinical data, health care utilisation data, and patient-reported data on generic and disease-specific quality of life (QoL, SF-36 and KCCQ), CHF self-care (EHFScBS) and on quality of care (PACIC-5A). To compare between groups at follow-up, we performed analyses of covariance and logistic regression models. Baseline measurement showed high guideline adherence to evidence-based pharmacotherapy and good patient self-care: Patients received angiotensin converting enzyme inhibitors (or angiotensin-2 receptor antagonists) in 93.8% and 95%, and betablockers in 72.2% and 84%, and received both in combination in 68% and 80% of cases respectively. EHFScBS scores (SD) were 25.4 (8.4) and 25.0 (7.1). KCCQ overall summary scores (SD) were 65.4 (22.6) and 64.7 (22.7). We found low hospital admission and mortality rates. EHFScBS scores (-3.6 [-5.7;-1.6]) and PACIC and 5A scores (both 0.5, [0.3;0.7/0.8]) improved in favour of CM but QoL scores showed no significant group differences (Physical/Mental SF-36 summary scores/KCCQ-os [95%CI]: -0.3 [-3.0;2.5]/-0.1 [-3.4;3.1]/1.7 [-3.0;6.4]). In this sample, with little room for improvement regarding evidence-based pharmacotherapy and CHF self-care, case management showed no improved health outcomes or health care utilisation. However, case management significantly improved performance and key intermediate outcomes. Our study provides evidence for the feasibility of the case management model. ISRCTN30822978.
    Trials 05/2010; 11(1):56. DOI:10.1186/1745-6215-11-56 · 1.73 Impact Factor
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    • "A limited number of randomised controlled trials evaluated improvement programmes for the treatment of heart failure in primary care [20-24]. Interventions consisted of nurse-led contacts, computer based treatment suggestions, practice guideline recommendations and disease management programmes, for instance. "
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    ABSTRACT: Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF. An observational study was performed in 19 general practices in the south-eastern part of the Netherlands, evaluation involving 15 general practitioners and 77 CHF patients. The programme for improvement comprised educational and organizational components and was delivered by a trained practice visitor to the practices. The evaluation was based on case registration forms completed by health professionals and telephone interviews. Management relating to diet and physical exercise seemed to have improved as eight patients were referred to dieticians and five to physiotherapists. The seasonal influenza vaccination rate increased from 94% to 97% (75/77). No impact on smoking was observed. Pharmaceutical treatment was adjusted according to guideline recommendations in 12% of the patients (9/77); 7 patients started recommended medication and 2 patients received dosage adjustments. General practitioners perceived the programme to be feasible. Clinical task delegation to nurses and assistants increased in some practices, but collaboration with other healthcare providers remained limited. The improvement programme proved to have moderate impact on patient care. Its effectiveness should be tested in a larger rigorous evaluation study using modifications based on the pilot experiences.
    BMC Health Services Research 01/2010; 10(1):8. DOI:10.1186/1472-6963-10-8 · 1.71 Impact Factor
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