Nurse-run clinics in primary care increased secondary prevention in coronary artery disease
ACP J Club. 1999 May-June;130:80. doi:10.7326/ACPJC-1999-130-3-080
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Campbell NC, Ritchie LD, Thain J, et al. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart. 1998 Nov;80:447-52.
Can clinics run by nurses in primary care improve secondary prevention in patients with coronary artery disease (CAD)?
Randomized, unblinded, controlled trial with 1-year follow-up.
19 general practices in northeastern Scotland.
1343 patients < 80 years of age (about 58% men) with CAD. Patients who had terminal illness or dementia or who were housebound were excluded. Follow-up was 87%.
673 patients were allocated to attend nurse-run clinics in general practice that included regular follow-up visits (usually every 2 to 6 mo) for 1 year (intervention group). Nurses reviewed patient symptoms, drug treatment, blood pressure and lipid management, physical activity, dietary fat intake, and smoking; promoted aspirin use; made general practitioner referrals; and suggested behavioral changes if appropriate. 670 patients were allocated to standard care (control group).
Main outcome measures
Aspirin use, blood pressure and lipid management, physical activity, dietary fat intake, smoking status, and overall secondary prevention (based on a cumulative score of 6 secondary prevention components, generated by counting the number of appropriate treatments and behaviors per patient) at baseline and at 1 year.
82% of patients in the intervention group attended at least 1 nurse-run clinic. Analysis was by intention to treat. Nurse-run clinics increased aspirin use (odds ratio [OR] 3.22, 95% CI 2.15 to 4.80) and moderate physical activity (OR 1.67, CI 1.23 to 2.26), improved blood pressure management (OR 5.32, CI 3.01 to 9.41) and lipid management (OR 3.19, CI 2.39 to 4.26), and decreased dietary fat intake (OR 1.47, CI 1.10 to 1.96) but had no effect on smoking cessation (OR 0.78, CI 0.47 to 1.28). The mean change in the cumulative score of 6 secondary prevention components between baseline and 1 year was greater for the intervention group than for the control group (0.59 vs 0.06, P < 0.001), which showed an overall improvement by secondary prevention.
In patients with coronary artery disease, nurse-run clinics in primary care that offered medical and lifestyle counseling were effective in secondary prevention.
Sources of funding: Chief Scientist Office at the Scottish Office and Grampian Healthcare Trust.
For correspondence: Dr. N.C. Campbell, Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, Scotland, UK. FAX 44-1224-840791.
The studies by Campbell and Cline and their colleagues build on growing evidence that secondary prevention of chronic disease can be enhanced by nursing support to educate patients and help them to follow recommnded treatments.
Campbell and colleagues showeed that patient counseling (mean 82 min/patient-y) in nurse-run clinics improved adherence to recommended practices for patients with established CAD, especially for such outcomes as aspirin use, hypertension, and lipid management. Intervention had the greatest benefit for behavior related to lipid management. The finding of suboptimal adherence to cholesterol guidelines is consistent with various other studies that included both generalist and specialist physicians (1). Since 1994, there has been increasing evidence supporting aggressive control of dyslipidemia in patients with existing CAD, with benefits usually apparent after 1 year (2).
Lifestyle variables, in particular tobacco use, were less likely to be influenced by nurse-mediated follow-up. The persistence of smoking in 17% of patients is consistent with findings of resistance to change in other studies (3). As small-scale educational interventions are unlikely to permanently effect change in this group of persons who persistently smoked, more intensive and costly strategies (both behavioral modification and pharmaceutical) need to be considered.
Campbell and colleagues concluded that nurse-run clinics reduced the risk for recurrent CAD. They did not measure cardiovascular events or mortality but suggested that these outcomes could be reduced by up to 1 third. Because of the high risk for patients with established CAD, the benefit of such improvement in multiple risk factors, even of smaller magnitude, is likely to result in clinically important decreases in subsequent CAD events. The presence of multiple risk factors, especially in patients with existing disease, demands a more aggressive treatment approach by all providers.
Cline and colleagues followed an elderly group of patients with CHF, initially identified during hospital admission. Nurse-run education sessions provided > 120 minutes per patient and telephone access. The intervention group showed an increased time to first readmission and trends of reduced mean number of readmissions and days in the hospital. Survival benefits were only apparent early in this 1-year trial. Benefits of such a short-term intervention may lessen over time, given the natural progression of CHF and the nature of patient compliance; thus, additional 'booster' interventions may be useful in future evaluations.
Because of the lower number of hospitalizations in the intervention group, economic evaluation showed a trend toward a mean annual reduction of overall costs of U.S. $1300 per patient. However, because the mean cost for Swedish hospitalization was U.S. $381/day, the study likely underestimated the cost benefits in such venues as the United States.
This program may have achieved these benefits by delaying the progression of CHF. When compared with the year preceding the intervention, the number of hospital days in the study group remained stable, whereas that in the control group increased. Although greater use of angiotensin-converting enzyme (ACE) inhibitors in the intervention group than in the control group may have contributed to this effect (4), it is unlikely because treatment was started at various times during the follow-up year and treatment differences were small.
Despite the value of improved drug treatments, such as ACE inhibitors and statins, clinical practice must include much more than prescribing drugs. Providers must do more to increase patient knowledge and understanding to improve outcomes in these chronic cardiac conditions (5). Close and continuing follow-up is needed, and this is perhaps best done by skilled nursing staff, as in these studies.
Jeffrey K. Mills, MD, MSc
University of TorontoToronto, Ontario, Canada
2. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344: 1383-9.
4. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995;273: 1450-6.