Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: A paired, cluster-randomised controlled trial

Department of Cardiovascular Medicine, National Heart and Lung Institute at Charing Cross Campus, Imperial College, London, UK.
The Lancet (Impact Factor: 45.22). 07/2008; 371(9629):1999-2012. DOI: 10.1016/S0140-6736(08)60868-5
Source: PubMed


Our aim was to investigate whether a nurse-coordinated multidisciplinary, family-based preventive cardiology programme could improve standards of preventive care in routine clinical practice.
In a matched, cluster-randomised, controlled trial in eight European countries, six pairs of hospitals and six pairs of general practices were assigned to an intervention programme (INT) or usual care (UC) for patients with coronary heart disease or those at high risk of developing cardiovascular disease. The primary endpoints-measured at 1 year-were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescription of cardioprotective drugs. Analysis was by intention to treat. The trial is registered as ISRCTN 71715857.
1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC, respectively. In patients with coronary heart disease who smoked in the month before the event, 136 (58%) in the INT and 154 (47%) in the UC groups did not smoke 1 year afterwards (difference in change 10.4%, 95% CI -0.3 to 21.2, p=0.06). Reduced consumption of saturated fat (196 [55%] vs 168 [40%]; 17.3%, 6.4 to 28.2, p=0.009), and increased consumption of fruit and vegetables (680 [72%] vs 349 [35%]; 37.3%, 18.1 to 56.5, p=0.004), and oily fish (156 [17%] vs 81 [8%]; 8.9%, 0.3 to 17.5, p=0.04) at 1 year were greatest in the INT group. High-risk individuals and partners showed changes only for fruit and vegetables (p=0.005). Blood-pressure target of less than 140/90 mm Hg was attained by both coronary (615 [65%] vs 547 [55%]; 10.4%, 0.6 to 20.2, p=0.04) and high-risk (586 [58%] vs 407 [41%]; 16.9%, 2.0 to 31.8, p=0.03) patients in the INT groups. Achievement of total cholesterol of less than 5 mmol/L did not differ between groups, but in high-risk patients the difference in change from baseline to 1 year was 12.7% (2.4 to 23.0, p=0.02) in favour of INT. In the hospital group, prescriptions for statins were higher in the INT group (810 [86%] vs 794 [80%]; 6.0%, -0.5 to 11.5, p=0.04). In general practices in the intervention groups, angiotensin-converting enzyme inhibitors (297 [29%] INT vs 196 [20%] UC; 8.5%, 1.8 to 15.2, p=0.02) and statins (381 [37%] INT vs 232 [22%] UC; 14.6%, 2.5 to 26.7, p=0.03) were more frequently prescribed.
To achieve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to individual countries, which are accessible by all hospitals and general practices caring for coronary and high-risk patients.

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    • "Nurse-coordinated prevention programmes (NCPPs) have been shown to be more effective than usual care in reducing cardiovascular risk (Allen & Dennison, 2010; Jørstad et al., 2013; Murchie, Campbell, Ritchie, Simpson, & Thain, 2003; Wood et al., 2008). Therefore, the European Society of Cardiology (ESC) 2012 European Guidelines on cardiovascular disease prevention in clinical practice recommend NCPPs be integrated into healthcare systems. "
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    ABSTRACT: Background: Secondary prevention of coronary artery disease (CAD) is increasingly provided by nurses in nurse-coordinated prevention programs (NCPP). However, little is known about nurses' perspectives on these programs. Aim: This survey aimed to investigate nurses' perspectives and experiences in NCPPs in acute coronary syndrome (ACS) patients (consisting of 4 visits in the 6 first months post-ACS) as part of the RESPONSE (Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists) trial. Methods: Thirteen nurses with a minimum of a bachelors degree in nursing participating in NCPPs in 11 medical centers in the RESPONSE trial completed an online survey containing 45 items evaluating 3 outcome categories, completed an online survey containing 45 items evaluating 3 outcome categories; 1) conducting NCPP visits; 2) effects of NCPP interventions on risk profiles; 3) the process of care. Results: Nurses felt confident in counselling/ motivating patients to reduce CAD risk. Interventions targeting LDL, systolic blood pressure and medication adherence were reported as successful, corresponding with significant improvements of these risk factors. Improving weight, smoking and physical activity was reported as less effective. Components perceived as effective included education/awareness, psychological components and monitoring/feedback. Screening for anxiety/ depression was suggested as an improvement. Collaboration with treating physicians was satisfactory, but amenable to improvement. Conclusions: Nurses participating in an NCPP acknowledge the importance and effectiveness of such programs, and they correctly identify which components of the program are the most succesfull. Nurses' perspectives described in this study provide a basis for implementation and for quality improvement of NCCPs. Trial registration: Identifier TC1290.
    Full-text · Article · Nov 2015 · Contemporary nurse: a journal for the Australian nursing profession
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    • "“If I had not joined this program, I would have been all on my own” (Claire) [4] "
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    ABSTRACT: Coronary heart disease (CHD) is one of the leading causes of death worldwide. Scientific literature shows that prevention of CHD is inadequate. The clinical pharmacist's role in patient-centred care has been shown favourable in a large amount of studies, also in relation to reduction of risk factors related to CHD. We developed and piloted a pharmacist-led follow-up program for patients with established CHD after hospital discharge from a hospital in North Norway. The aim of the present study was to explore how participants in the follow-up program experienced the program with regard to four main topics; medication knowledge, feeling of safety and comfort with medications, the functionality of the program and the clinical pharmacist's role in the interdisciplinary team. We performed semi-structured thematic interviews with four patients included in the program. After verbatim transcribing, we analysed the interviews using "qualitative content analyses" by Graneheim and Lundman. Trial registration NCT01131715. All participants appreciated the follow-up program because their medication knowledge had increased, participation had made them feel safe, they were reassured about the appropriateness of their medications, and they had become more involved in their own medication. The participants reported that the program was well structured and the clinical pharmacist was said to be an important caretaker in the health-care system. The importance of collaboration between pharmacists and physicians, both in hospital and primary care, was emphasized. Our results indicate that the follow-up program was highly appreciated among the four participants included in this study. The results must be interpreted in the context of the health care system in Norway today. Here, few pharmacists are working in hospitals or in close relation to the general practitioners. In addition, physicians are short of time in order to supply appropriate medication information, both in hospital and primary care. Involving pharmacists in follow-up of patients with CHD seems to be highly appreciated among patients and may be a step towards improving patient care. The study is limited by the low number of participants.
    Full-text · Article · Mar 2014 · BMC Research Notes
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    • "The MyAction model of care evolved from the EuroAction study [38], which demonstrated that a nurse-managed, multidisciplinary, and family-based programme could achieve healthier lifestyle changes and better risk factor control than usual care at one year. Subsequently, Croí MyAction was established as a partnership between Croí (an Irish heart and stroke charity) and Imperial College London, the co-ordinating centre for the EuroAction study [39]. The Croí MyAction programme has demonstrated striking results so far in terms of improving adherence to a healthy diet, reducing both obesity and central obesity and also significantly improving physical activity levels [40] – all interventions which have been shown to reduce risk of progression to type 2 diabetes. "
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    ABSTRACT: Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Lifestyle intervention can prevent progression to type 2 diabetes in high risk populations. We designed a randomised controlled trial (RCT) to evaluate the effectiveness of an established lifestyle intervention compared to standard care for delaying diabetes onset in European women with recent GDM. Recruitment into the RCT was more challenging than anticipated with only 89 of 410 (22%) women agreeing to participate. This paper identifies factors that could enhance participation of the target population in future interventions. We hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined, and secondly that it would be possible to predict participation on the bases of those risk factors. To test our hypothesis, we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3-5 years following GDM, reducing the sample to 43 participants and 73 decliners. We considered established diabetes risk factors: smoking, daily fruit and vegetable intake, participation in exercise, family history of diabetes, glucose values and BMI scores on post-partum re-screens, use of insulin during pregnancy, and age at delivery. We also analysed narrative data from 156 decliners to further understand barriers to and facilitators of participation. Two factors differentiated participants and decliners: age at delivery (with women older than 34 years being more likely to participate) and insulin use during pregnancy (with women requiring the use of insulin in pregnancy less likely to participate). Binary logistic regression confirmed that insulin use negatively affected the odds of participation. The most significant barriers to participation included the accessibility, affordability and practicality of the intervention. Women with recent GDM face multiple barriers to lifestyle change. Intervention designers should consider: (i) the practicalities of participation for this population, (ii) research designs that capitalise on motivational differences between participants, (iii) alleviating concerns about long-term diabetes management. We hope this work will support future researchers in developing interventions that are more relevant, effective and successful in recruiting the desired population.Trial registration: Current Controlled Trials ISRCTN41202110.
    Full-text · Article · Jan 2014 · BMC Medical Research Methodology
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