Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

A case-management system was effective in modifying coronary risk factors after a myocardial infarction

ACP J Club. 1994 Sept-Oct;121:44. doi:10.7326/ACPJC-1994-121-2-044


Source Citation

DeBusk RF, Miller NH, Superko R, et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994 May 1;120:721-9.


Abstract

Objective

To determine the effectiveness of a physician-directed, nurse-managed, home-based case-management system for modifying coronary risk factors in patients who have had a myocardial infarction (MI).

Design

1-year randomized controlled trial.

Setting

5 community hospitals.

Patients

585 patients (mean age 57 y) who were < 70 years of age and hospitalized for acute MI. Follow-up 1 year after MI was 85% in the intervention group and 88% in the usual care group.

Intervention

Patients were randomly assigned to receive usual care (n = 292) consisting of smoking cessation and diet counseling during hospitalization by a physician and nutritionist and lipid-lowering drug therapy after hospital discharge, or to receive special intervention (n = 293). In addition to usual care, patients in the special intervention group received instruction on monitoring the health habits they wanted to change and on setting attainable goals for smoking cessation, exercise training, and diet-drug treatment from specially trained nurses. After discharge they were contacted by telephone and mailed progress reports, and they visited the program nurse for treadmill exercise testing, drug therapy, and smoking cessation counseling.

Main outcome measures

Degree of smoking cessation was confirmed by plasma cotinine and expired carbon monoxide; diet practices were assessed by plasma low-density lipoprotein (LDL), high-density lipoprotein, and total cholesterol and triglyceride levels; and functional capacity was measured by treadmill testing.

Main results

Compared with patients receiving usual care, patients receiving the special intervention had higher smoking cessation rates (70% vs 53%, P = 0.03), greater decreases in plasma LDL and total cholesterol levels (P for both < 0.001), and higher functional capacity (9.3 METS vs 8.4 METS, P = 0.001).

Conclusion

A nurse-managed, case-management system was more effective than usual care in modifying smoking behavior, diet, and exercise capacity in patients followed for 1 year after an acute myocardial infarction.

Source of funding: National Institutes of Health.

For article reprint: Dr. R.F. DeBusk, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite 106, Palo Alto, CA 94304-1517, USA. FAX 415-723-6798.


Commentary

This excellent study by DeBusk and colleagues has considerable relevance to current clinical practice. Can "managed care" do as well as standard clinical practice for delivering health care? This randomized trial of academic expert-driven managed care dealing with a focused issue only, that of risk factor modification in patients who have had an MI, showed a positive effect on cardiac risk in the short term. This study also showed the benefit of having a specially trained nurse coordinate the delivery of this type of preventive health care.

I have 3 comments of interest rather than criticism. First, I would be interested in the follow-up of the 10% dropouts in each group, because deaths, complications, and other poor outcomes are likely to be concentrated among these patients. Second, I would prefer to see the exercise capacity outcome data presented as change from baseline as well as absolute score. Third, by way of explanation of the benefit, I would like to know the cardiac medication profile of the 2 groups. Were the nurses more successful than usual-care givers at keeping patients on β-blockers, for instance?

For this approach, which is demanding on the patient and health care team, to be generalizable beyond this well-organized health maintenance organization, more information on 3 key topics is needed: 1) effect of the risk factor modification on major end points (e.g., reinfarction and death); 2) feasibility; and 3) economic analysis, because this add-on intervention may cost more than usual care.

Victor F. Froelicher, MD
Stanford University School of MedicineStanford, California, USA