Delivery Of Secondary Prevention Research Articles

Cardiac rehabilitation – moving forward with new models of care

Background: Early prevention programmes, termed cardiac rehabilitation (CR), have been the traditional model for delivery of secondary prevention for patients with coronary heart disease (CHD). They consistently reduce mortality, coronary disease risk and improve quality of life. These programmes have involved attendance at rehabilitation facilities, mostly in hospitals, to participate in 6–8 week programmes of group-based health education, supervised exercise and psychosocial support. Strikingly, these programmes are poorly (10–30% of those eligible) attended, variously resourced and largely rejected by those in greatest need. With advancements in knowledge, medical technology and pharmacotherapy the number of people surviving acute coronary events is increasing, as is the frequency of repeat events, and as a matter of social justice the demand for effective secondary prevention is intensifying. Therefore, improving access and equity to an effective secondary prevention programme for patients with established disease is a pressing and urgent priority.Objective:The aim of this review is to summarize information currently available surrounding models of delivery of secondary prevention for people with CHD.Conclusions:Recent evidence suggests that more contemporary models of secondary prevention are safe and appear to benefit patients of all ages. These programmes complement traditional CR and provide more flexible and individualized interventions that frequently include ongoing support over the telephone, the internet (in limited cases) and the provision of taped or written supplementary materials. Provision of flexible models for delivery of secondary prevention in addition to standard medical care is likely to help close the well-documented evidence-practice gap by improving equity and access to services.

Using “get with the guidelines” to prevent recurrent cardiovascular disease

Clinical trials and guidelines provide strategies to reduce the rate of recurrent events in patients with cardiovascular disease. Despite multiple therapeutic options to enhance secondary prevention, many patients leave the hospital without these basic interventions. Delivery of secondary prevention is critically dependent on systems to ensure reliable delivery. The implementation of successful systems requires physician leadership, compatibility with hospital strategic priorities, multidisciplinary teams, use of tools such as preprinted orders and discharge protocols, and concurrent data collection and feedback. The process of testing and implementing effective systems is best done in a collaborative where teams from multiple hospitals share successes and lessons that were learned. Community level collaboratives also create momentum to gain support at the hospital level. The combination of collaborative learning with technology for data collection, feedback, and decision making is useful to move multiple hospitals to higher levels of performance in critical measures of secondary prevention.

Secondary prevention for stroke in the United Kingdom: results from the National Sentinel Audit of Stroke.

To measure the quality of secondary prevention of stroke provided to patients in England, Wales and Northern Ireland. Retrospective case note analysis. 235 hospitals (95% of all such hospitals), providing care for acute stroke patients in England, Wales and Northern Ireland and primary health care for follow-up data. 8,200 patients admitted with stroke between 1(st) April and 30(th) June 2001. Data on up to 40 consecutive cases submitted by each hospital. AUDIT TOOL: Royal College of Physicians Intercollegiate Stroke Working Party Stroke Audit. 24% of patients with previous cerebrovascular disease were not on anti-thrombotic medication at the time of admission. Nine percent of appropriate patients were not taking anti-thrombotic medication at discharge. Patients left with moderate to very severe disability (Barthel scores 14 or less) compared with those independent with mild disability (Barthel score 15-20) were more likely not to have anti-thrombotic treatment (18% versus 8%). Fifty-four percent of patients with known hyperlipidaemia and 21% of those with previous ischaemic heart disease were on lipid lowering therapy on admission. Sixty-four percent of patients had lipids measured during their hospital stay and of those with high total cholesterol or LDL the rate of non-treatment was 36%. Older patients (75+ years) were less likely to be treated (54%) than those <65 years (71%). Seventy-nine percent of known patients with hypertension were on treatment at admission, with 78% being treated by discharge from hospital. At 6 months after stroke a systolic blood pressure of 140 mmHg or less, and a diastolic of 85 mmHg or less, was achieved in 41% of known pre-stroke hypertensives on treatment, 31% of previously untreated hyper-tensives but on treatment at follow-up and 40% of patients not previously labelled as hypertensive. Major deficiencies in delivery of secondary prevention after stroke have been demonstrated. Services need reorganisation to prevent unnecessary mortality and morbidity in this group of patients.