Most ischaemic heart disease is managed in the community. This Cochrane review looked at whether primary care-based interventions affect adherence to secondary prevention guidelines
Christie J (2011) Ischaemic heart disease prevention. Nursing Times; 107: 30/31, early on-line publication
What is the effect of primary care service organisation on clinician and patient adherence to secondary prevention recommendations for ischaemic heart disease, regarding risk factor modification, health monitoring and prophylactic medication?
Approximately 50 million people worldwide have ischaemic heart disease. More people are now living with the condition because the population is aging and care has improved.
Most management of the condition occurs in primary care in multidisciplinary services in community settings that provide initial access to health services. Secondary prevention of the disease aims to reduce the risk of recurrent cardiac events and may include: promoting healthy lifestyles, such as smoking cessation; monitoring a patient’s health status; or prescription of prophylactic medication, such as statins or beta-blockers.
While these interventions are supported by evidence-based guidelines, organisational issues, such as a lack of time or costs, may limit patients’ or clinicians’ adherence to the guidelines. Therefore, a systematic review was required to evaluate whether primary care-based organisational interventions affected adherence to internationally recognised ischaemic heart disease secondary prevention guidelines.
This systematic review with meta-analysis included 11 randomised studies with a total of 12,074 participants with an average age of 62-69 years (Buckley et al, 2010).
The reviewers searched for studies that recruited patients who had ischaemic heart disease – a diagnosis of acute myocardial infarction, previous cardiac artery revascularisation or angina – from a primary care or community setting.
The intervention was any organisational systematic changes to community or primary care service provision that lasted for at least 12 months. The outcome measures were: improved prescribing of medication; improved risk factor monitoring; enhanced adherence to medication; and alteration of modifiable lifestyle risk factors.
Summary of key evidence
Three studies that investigated maintaining blood pressure within target levels were pooled and achieved borderline statistical significance at 12 months in favour of interventions. However, when this data was re-analysed and combined with another randomised study that collected outcome measures at 18 months, no statistical significance was found. Data was also pooled for mean (average) blood pressure at 18 months and at the end of the study. No significant effect was detected in either of these analyses.
Three studies investigated if blood cholesterol achieved recommended levels. Two collected data at 12 months and found an improvement in intervention groups compared with controls. When all three studies (including one with data collection at 18 months) were combined, no effect was found. Four studies reported mean total cholesterol levels, but there was no significant effect when results were pooled.
No significant effect was found for pooled data on: prescribing lipid-lowering drugs, beta-blockers, ACE inhibitors or anti-platelet drugs. Nor was any pooled effect found for any modifiable lifestyle risk factor, such as physical activity, smoking or obesity/body mass index.
The review authors also examined outcomes by intervention and reported it was difficult to determine which intervention had the most effect on outcomes. The three pooled randomised studies with borderline significance on blood pressure and the two pooled studies demonstrating a significant effect on cholesterol used the following interventions: “structured monitoring and assessment of risk factors”; “pre-planned appointments or patient recall”; and “patient education and awareness raising”. Two of the three studies that showing blood pressure and one of the two studies showing lowered cholesterol levels used interventions concerning “clinician education or awareness raising”.
“Improved secondary/primary care interface” interventions achieved improved blood pressure and cholesterol levels in one study. However, studies using IT-based support, pharmacist care management, and nurse care management found no evidence that any of these interventions were associated with better outcomes than other types of organisational interventions.
There is weak evidence that suggests organisational intervention – including systematic monitoring of risk factors, medication, patient education or awareness raising, and pre-planned appointments – can improve adherence to guidelines on cholesterol and blood pressure control for patients with ischaemic heart disease.
For details of the full review report, including references, click here
Author Janice Christie is teaching fellow/deputy director doctor of nursing practice, School of Nursing and Midwifery, Queen’s University Belfast and a member of the Cochrane Nursing Care Field
Buckley BS et al (2010) Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database of Systematic Reviews; Issue 3, Art No: CD006772. DOI: 10.1002/14651858.CD006772.pub2