Organising preventive care in community settings for people with heart disease

Ischaemic heart disease is the term used for conditions caused by a narrowing of the arteries that supply blood to the heart muscle. Patients may have angina, or may have had a previous myocardial infarction (heart attack) or surgery to widen or bypass the affected arteries. "Secondary prevention" is the term used to describe health care that aims to prevent further events or the worsening of such conditions in these patients.

Research has been done to try to find the best way to organise health care so that people with heart disease benefit most from lifestyle changes and medications that are known to help to reduce the risk of heart disease getting worse.

This research suggests that careful changes in the way health care and advice are provided may increase the proportion of patients whose total cholesterol levels and blood pressure are within target levels, but the evidence is weak. No evidence was found that suggested similar changes can help to reduce other risk factors or improve the prescribing of medicines that can prevent further disease. The changes that appear to be more effective include regular planned appointments with a clinician, careful monitoring of medications and risk factors (such as blood pressure, cholesterol and lifestyle), and education for patients to raise awareness of the importance of secondary prevention.

Authors' conclusions: 

There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured.

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Background: 

Ischaemic heart disease (IHD) is a major cause of mortality and morbidity and its prevalence is set to increase. Secondary prevention aims to prevent subsequent acute events in people with established IHD. While the benefits of individual medical and lifestyle interventions is established, the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community settings is less so.

Objectives: 

To assess the effectiveness of service organisation interventions, identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity) and appropriate prophylactic medication.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 4), MEDLINE (1966 to Feb 2008), EMBASE (1980 to Feb 2008), and CINAHL (1981 to Feb 2008). Bibliographies were checked. No language restrictions were applied.

Selection criteria: 

Randomised or quasi-randomised controlled trials of service organisation interventions in primary care or community settings in populations with established IHD.

Data collection and analysis: 

Analyses were conducted according to Cochrane recommendations and Odds Ratios (with 95% confidence intervals) reported for dichotomous outcomes, mean differences (with 95% CIs) for continuous outcomes.

Main results: 

Eleven studies involving 12,074 people with IHD were included. Increased proportions of patients with total cholesterol levels within recommended levels at 12 months, OR 1.90 (1.04 to 3.48), were associated with interventions that included regular planned appointments, patient education and structured monitoring of medication and risk factors, but significant heterogeneity was apparent. Results relating to blood pressure within target levels bordered on statistical significance. There were no significant effects of interventions on mean blood pressure or cholesterol levels, prescribing, smoking status or body mass index. Few data were available on the effect on diet. There was some suggestion of a "ceiling effect" whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached.

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