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


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
    Full-text · Article · Jul 2011 · Journal of Advanced Nursing
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    • "Improvement of adherence to guidelines on cardiovascular prevention by caregivers and patient compliance to lifestyle advice and prescribed treatment is therefore still necessary (EUROASPIRE 2001, Penning-van Beest et al. 2007). Studies have shown that nurses can contribute to improvement of cardiovascular prevention (Khunti et al. 2007, Clark et al. 2010). Nurses tend to be more compliant to guidelines than doctors (Hulscher et al. 1997). "
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    ABSTRACT: Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver. To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners. Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses). 701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire. Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found. Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.
    Full-text · Article · Dec 2010 · International journal of nursing studies
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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.
    Full-text · Article · May 2010 · Trials
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