Nurse led disease management clinics may improve long-term coronary heart disease outcomes in primary care

Robson, John MD FRCGP

General Practitioner and Senior Lecturer; Department of General Practice; Queen Mary University of London; United Kingdom

Abstracted from:Murchie P, Campbell NC, Ritchie LD et al. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. BMJ 2003; 326: 84-90 .

Sources of funding: Chief Scientist Office at the Scottish Executive.

Correspondence to: P Murchie, Department of General Practice and Primary Care, University of Aberdeen, Scotland. Email: [email protected]

Abstract provided by Bazian Ltd, London

Evidence-based Healthcare 7(2):p 55-56, June 2003.

BACKGROUND

Secondary prevention may reduce the risk of coronary events and death among people with coronary heart disease. Effective secondary prevention is multifactorial, including lifestyle, behavioural and pharmaceutical interventions. Most secondary prevention takes place in primary care settings. The authors found that nurse led clinics in primary care improved components of secondary prevention after one year. It remains uncertain whether programmes that improve lifestyle and medical factors translate into reduced coronary event and death rates.

OBJECTIVE

To assess the long-term impacts of nurse led primary care clinics for secondary prevention in coronary heart disease.

SETTING

Nineteen general practices in north east Scotland; timeframe not specified.

METHOD

Randomised trial.

PARTICIPANTS

1343 people aged under 80 years (mean 68 years) participated in the original trial. All were diagnosed with coronary heart disease, but were not terminally ill or housebound. Forty-two percent were women. Long-term follow-up data were available for 91% (961).

INTERVENTION

Nurse led secondary prevention clinics or usual primary care. The nurse led clinics offered regular follow-up and promoted medical and lifestyle changes for secondary prevention of cardiovascular disease.

OUTCOMES

Secondary prevention outcomes (use of aspirin, blood pressure management, lipid management, healthy diet, exercise, non-smoking); total mortality; coronary events (non-fatal myocardial infarctions and coronary deaths). Mean follow-up was 4.7 years

MAIN RESULTS

During the 1-one year intervention period, most components of secondary prevention were improved in those attending nurse led clinics compared with usual care. At long-term follow-up, there were no significant differences between groups. This may be because many participants in the control group attended nurse led clinics after the intervention period. At 4.7 years, cumulative death rates were 14.5% for the nurse led clinic group and 18.9% for usual care (adjusted hazard ratio 0.75, 95% CI 0.58 to 0.98). Cumulative coronary event rates were 14.2% and 18.2%, respectively (adjusted hazard ratio 0.76, 95% CI 0.58 to 1.0).

AUTHORS' CONCLUSIONS

Nurse led primary care clinics improved clinical and lifestyle components of secondary prevention in cardiovascular disease.

NOTE

Long-term outcomes may be confounded by considerable cross over (usual care group using intervention clinics).