Heart Disease In General Practice Research Articles

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice

ObjectiveTo determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.DesignA 6-year follow-up of a cluster randomised controlled trial,...

Evaluation of Strategies of Care in the Secondary Prevention of Heart Disease: Critical Appraisal of a Cluster Randomized Trial

Evaluation of: Murphy AW, Cupples ME, Smith SM, Byrne M, Myrne MC, Newell J; for the SPHERE study team: Effect of tailored practice and patients care plans on secondary prevention of heart disease in general practice: cluster randomized controlled trial. BMJ 339, B4220 (2009). Coronary heart disease is the main cause of morbidity/mortality in developed countries and the costs of this epidemic are a major concern and a focus of public health policies. The cornerstone in controlling the incidence of coronary heart disease is the management of risk factors and an evaluation of the best strategy is of the greatest importance. Murphy et al. conducted a cluster randomized trial to evaluate the strategies of tailored practice and patient care plans on secondary prevention of heart disease in general practice. The study found that at 18 months of follow-up, there were no significant differences between intervention and control groups in the proportion of patients above the recommended limits of systolic blood pressure, diastolic blood pressure and total cholesterol concentrations. The number of patients admitted to hospital significantly decreased in the intervention group. Although secondary prevention programs have positive impacts on the process of care, the benefit was clear after a longer period of follow-up in many studies. The practice of preventive cardiology in patients with coronary heart disease is difficult to achieve, particularly when the population already had a lower prevalence of uncontrolled risk factors, as Murphy et al. found in their study. It is possible that the patients included in this and other studies were at a sufficiently low risk that the likelihood of detecting a beneficial effect in a short period of time was small. There is good evidence that healthcare professionals can help patients; nonetheless, they also need guidance and programs to help them. Some questions regarding these multidisciplinary programs also remain to be answered, and their cost-effectiveness remains unclear. The incremental benefit of secondary prevention programs may be very small in the settings in which those trials were performed, but they certainly will be beneficial in settings where usual care is less optimal; these scenarios are often found around the world.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. The intervention strategy resulted in mean cost savings per patient of euro512.77 (95 percent confidence interval [CI], -1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, -0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay euro45,000 per additional QALY. Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

Objective To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease.Design Cluster randomised controlled multicentre trial.Setting General practices...

Prevention of Coronary Heart Disease in General Practice

Coronary heart disease in the UK is a very common problem. Coronary heart disease (CHD) causes over 117,000 deaths a year in the UK: approximately 1 in five deaths in men and one in six deaths in women. Although death rates from CHD have been falling rapidly in the UK since the late 1970s, they are still among the highest in Western Europe. There is considerable variation in death rates from CHD in the UK: death rates are higher in Scotland than in the south of England, as shown in Figure 1 , and this is typical of all age groups and both sexes. Also death rates are higher in manual workers than non-manual workers and are particularly high among Indian and Pakistani men.

Monitoring treatment fidelity in a randomized controlled trial of a complex intervention

This paper is a report of a study to describe how treatment fidelity is being enhanced and monitored, using a model from the National Institutes of Health Behavior Change Consortium. The objective of treatment fidelity is to minimize errors in interpreting research trial outcomes, and to ascribe those outcomes directly to the intervention at hand. Treatment fidelity procedures are included in trials of complex interventions to account for inferences made from study outcomes. Monitoring treatment fidelity can help improve study design, maximize reliability of results, increase statistical power, determine whether theory-based interventions are responsible for observed changes, and inform the research dissemination process. Treatment fidelity recommendations from the Behavior Change Consortium were applied to the SPHERE study (Secondary Prevention of Heart DiseasE in GeneRal PracticE), a randomized controlled trial of a complex intervention. Procedures to enhance and monitor intervention implementation included standardizing training sessions, observing intervention consultations, structuring patient recall systems, and using written practice and patient care plans. The research nurse plays an important role in monitoring intervention implementation. Several methods of applying treatment fidelity procedures to monitoring interventions are possible. The procedure used may be determined by availability of appropriate personnel, fiscal constraints, or time limits. Complex interventions are not straightforward and necessitate a monitoring process at trial stage. The Behavior Change Consortium's model of treatment fidelity is useful for structuring a system to monitor the implementation of a complex intervention, and helps to increase the reliability and validity of evaluation findings.

Selection bias in enrolment to a programme aimed at the secondary prevention of ischaemic heart disease in general practice: a cohort study

To evaluate differences between adults who participated in a secondary prevention of ischaemic heart disease (IHD) programme and those who did not. Population-based cohort study. A random selection of 12 Irish general practices. A total of 493 adults with IHD identified in 2000/2001. Medical records search and postal questionnaires in 2000/2001 and 2005/2006. Differences in demographic characteristics and indicators of process of care and risk factor management between participants and non-participants. Multiple logistic regression confirmed that female gender was associated with a reduced likelihood of participation in the secondary prevention programme [odds ratio (OR) 0.53 (95% CI: 0.32-0.87)], while an adequately controlled total cholesterol level was associated with an increased likelihood of enrollment [OR 1.82 (95% CI: 1.18-2.80)]. There is limited evidence that biases, which have been shown to affect participation in research, also affect participation in care programmes in everyday practice. A gender bias appears to have affected the enrollment of participants for the secondary preventive programme considered by this study, with enrollment favouring men with well-managed cholesterol. Reimbursement dependent upon patient adherence may incentivise the enrollment of adherent patients, although the influence of patient choice is unclear: the need to maintain records relating to patients who opt out of such interventions is thus highlighted.

The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411

BackgroundThe aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.MethodsSPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions.The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires.The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Exercise treadmill test may predict clinical outcome among working-aged patients suspected of coronary heart disease in general practice

ObjectiveTo specify the diagnostic value of treadmill tests conducted in primary health care by trained GPs for working-aged patients. DesignA two-year follow-up study. SettingKangasala Health Centre, Finland. SubjectsAll patients under the age of 60 (n=348) examined by exercise treadmill test carried out by trained GPs during a period of three years. Main outcome measuresThe number of patients having a diagnosis of coronary heart disease at the end of two years’ follow-up. Predictive values of the exercise test. ResultsDuring the two years’ follow-up period CHD was diagnosed in six of the patients who did not yield a positive finding in the test. A negative finding in the test was very reliable; coronary heart disease manifested in only 2% of these cases. Almost half of the patients yielding a positive finding ended up having coronary angiography and 1 in 10 underwent coronary bypass surgery. ConclusionAmong working-aged patients suspected of coronary heart disease an exercise treadmill test may predict clinical outcome in general practice.

Primary prevention of coronary heart disease in general practice: a cross sectional population study.

The aim of this study was to assess the interventions by general practitioners on cardiovascular risk factors among persons without a history of cardiovascular disease attending for a cardiovascular check-up. All inhabitants of three Belgian towns aged between 45 and 64 years were invited for a cardiovascular check-up and blood test. Of all the attending persons without a history of cardiovascular disease (n = 898), 51% received at least one prescription, diet or health advice: 28% for hyperlipidaemia, 23% for physical activity, 22% for caloric intake, 9% for blood sugar, 5% for blood pressure and 4% for smoking. Interventions on lipoproteins, blood sugar and smoking habits were significantly more often proposed to persons with a medium or high cardiovascular risk compared to those at low cardiovascular risk. For persons at low cardiovascular risk, therapeutic lifestyle changes are often not advised, and isolated risk factors often remain untreated.

Application of Framingham risk estimates to ethnic minorities in United Kingdom and implications for primary prevention of heart disease in general practice: cross sectional population based study

Objective: To compare the 10 year risk of coronary heart disease (CHD), stroke, and combined cardiovascular disease (CVD) estimated from the Framingham equations.Design:Population based cross sectional survey.Setting: Nine general practices...

Medical treatment and secondary prevention of coronary heart disease in general practice in Iceland

Objective - To evaluate the implementation of secondary prevention and treatment of coronary heart disease (CHD) in general practice in Iceland. Settings - Two health care centers adjacent to Reykjavik with a total of 25766 inhabitants. Patients - All patients (533) with CHD living in the study area were sent an invitation letter and a request for informed consent. Those who chose to participate answered a questionnaire about CHD risk factors and their current treatment, and their medical records were reviewed. The patients were divided into four groups on the basis of their history: I. Coronary artery bypass surgery (CABG), II. Percutaneous transluminal coronary angioplasty (PTCA), III. Myocardial infarction (MI), IV. Angina pectoris (AP). If a patient fulfilled the criteria for more than one diagnostic group the CABG group had the highest priority followed by PTCA, MI and finally AP. Main outcome measures - Blood pressure, smoking habits, BMI, exercise profile, cholesterol levels and drug therapy. Results - Of 533 patients with CHD, 402 (75%) participated in the study, 15% were managed exclusively by their family physician and 23% by both cardiologists and family physicians. Obesity was relatively common, with nearly 60% being overweight (BMI > 25). Average cholesterol in the total group was 6.2 mmol/L (95% CI 6.07 to 6.34). Blood pressure had been recorded in 92% of the patients, and mean systolic and diastolic blood pressures were 143 and 82 mmHg, respectively. While 15% were current smokers, 56% were ex-smokers. A total of 113 patients (28%) were being treated with cholesterol-lowering drug therapy at the time of the study. Respective treatment ratios in the four subgroups were 47% in group I, 42% in II, 25% in III and 13% in group IV. Aspirin was taken by 284 patients (71%), beta blockers by 52% and calcium channel blockers by 36%. More than twice as many women than men were treated with nitrates, 57% versus 27%. Conclusions - The results indicate that there are numerous possibilities for improvements in secondary prevention and medical management of coronary heart disease in Iceland. Particular emphasis should be placed on smoking cessation, life-style modification with exercise and diet recommendations to lower BMI and lipid-lowering therapy.

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey

Objective: To study differences in treatment for men and women with ischaemic heart disease by using standards defined in England's national service framework for coronary artery disease.Design: Cross sectional survey...

Time changes in new cases of ischaemic heart disease in general practice.

There are no recent studies of the presentation of ischaemic heart disease (IHD) in general practice. What information exists is derived from the secondary care setting, where seasonal and daily variation has been reported in admissions for IHD. There are epidemiological studies that show a falling incidence and mortality for IHD. It is not clear, however, if this is also the case in clinical general practice. The aims of the present study were to (i) estimate the number of cases of IHD in general practice populations; (ii) determine the recorded diagnosis and time of first presentation of IHD during a 5 year period; and (iii) perform time series analysis on the above data. The design of the study was a retrospective survey, using MIQUEST software, of computer databases in five general practices with a combined population of nearly 40,000 patients. The five practices were selected randomly from volunteering practices in the Trent Focus Collaborative Research Network. All patients with a new diagnosis of IHD recorded between January 1993 and December 1997 inclusive were included in the study. The number of new cases of IHD, the recorded diagnosis and time of first presentation of IHD were the main outcome measures. A total of 644 new cases of IHD were identified during the study period: 54.0% 'angina pectoris', 26. 9% 'acute myocardial infarction', 18.8% 'ischaemic heart disease', 0. 3% 'coronary atherosclerosis'. Time series analysis reveals a seasonal and weekly pattern to new cases of IHD, with peak cases occurring in January and on Mondays/Fridays. A downward trend was detected for new cases of IHD (all diagnoses) over the 5 year period, and for new cases of IHD (excluding acute myocardial infarction). An upward trend was observed for new cases of acute myocardial infarction. Presentation of IHD in general practice varies according to season and day of the week. The proportion of new cases recorded as 'angina pectoris' or 'ischaemic heart disease' is falling, and this decline masks a rise in the incidence recordings of 'acute myocardial infarction'.

Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records

Objectives: To identify patients with ischaemic heart disease by using a practice computer and to estimate the work required to do so.Design: Cross sectional study. Data from the notes and...

Presentation, management and course of angina and suspected angina in primary care

Previous surveys may have underestimated both prevalence and incidence of ischemic heart disease in general practice. Case identification is difficult, as many patients presenting with chest pain turn out not to have ischemic heart disease, although their outcome is unclear otherwise. In this work we aimed to: (1) estimate prevalence and incidence of angina in one Oxford general practice; (2) describe the processes of assessment, investigation, and management of suspected angina; and (3) describe the 2-year symptomatic and functional outcome of angina patients, compared with patients whose provisional diagnosis of suspected ischemic heart disease (IHD) was not subsequently sustained (NCCP). A retrospective survey of patients was undertaken (aged 45–74 years) by hand searching paper and electronic medical records to find, as of 1 January 1992, all patients in the practice with continuing treatment of angina diagnosed before 1989, or those having a new diagnosis of angina being assessed (suspected angina) in the 3 years 1989–1991. Two years later, a postal questionnaire survey compared the symptomatic and functional outcome of confirmed IHD and NCCP. On 1 January 1992, the diagnosis of angina was recorded in the notes of 11.1% of patients aged 45–74 years, and the diagnosis was considered correct in 7.4%. Over a 3-year period, 129 people were suspected of suffering from angina, but in 71 (55%) the diagnosis was not confirmed; 76 (59%) were either referred to a specialist out-patient clinic or had an emergency admission. A 2-year follow-up found that similar proportions of patients with angina and noncardiac chest pain had a poor outcome in terms of symptoms, mental state, quality of everyday life, and continuing consultation. The clinical burden of ischemic heart disease in general practice has been underestimated by earlier methodological approaches using less complete ascertainment strategies. The adequacy of current diagnostic and management arrangements for patients with suspected angina merits review, at both the primary and secondary care levels.

Promotion of healthy behaviour among adults at increased risk of coronary heart disease in general practice: methodology and baseline data from the Change of Heart study

Previous attempts to influence individuals' behaviour in order to lessen cardiovas cular risk have met with limited success. We report on the way in which the Stages of Change model was used by trained practice nurses in a randomised controlled trial. Patients with one or more modifiable risk factors (regular smoking, high choles terol, or the combination of high body mass index and low physical activity) were recruited during routine care at 20 group general practices in inner city to rural areas over 18 months. Baseline measurements on 883 people show that the control and intervention groups were reasonably matched, with one, two and three risk factors found among approximately 43, 48 and 9 per cent, respectively. Some differences between groups in readiness to modify behaviour as assessed by stage of change were observed. This trial will evaluate systematically the impact of brief behav ioural counselling in general practice.

Secondary prevention in coronary heart disease: baseline survey of provision in general practice

Objective: To determine secondary preventive treatment and habits among patients with coronary heart disease in general practice.Design: Process of care data on a random sample of patients were collected from...

Guidelines for coronary heart disease in general practice. Practice‐based audit: results from a dissemination and implementation programme

The East London Clinical Guidelines Project aims to improve clinical effectiveness by disseminating locally developed guidelines linked to research evidence to inner city primary health care teams. Practice‐based educational sessions combined with audit are offered to help practices implement the guidelines. This paper reports on the baseline and one‐year audit results following facilitation and implementation of coronary heart disease guidelines.

Preventive care for patients following myocardial infarction. The Wessex Research Network (WReN).

We aimed to assess general practice care for patients following a myocardial infarction (MI). A structured review was carried out of general practice records of patients identified from hospital administration data. A total of 266 survivors following MI were identified from the discharge data of 13 hospitals in Southern England and registered with 71 GPs belonging to the Wessex Research Network. Median time since hospital discharge was 2.1 years. The main outcome measures were the provision of appropriate preventive care, including cardiac rehabilitation, drug therapy, and lifestyle advice for modifiable risk factors. Basic care was provided to nearly all patients; 253 (95.1%, 95% Cl 91.8-97.4) had blood pressure documented after their MI, 216 of 234 patients eligible for aspirin (92.3%; 88.1-95.4) had been recommended treatment, and the provision of advice on smoking cessation was documented for 27 of 33 continuing smokers (81.8%; 64.5-93.0). However, only 73 of 236 patients eligible to attend a structured rehabilitation programme (30.9%; 25.0-36.8) were documented as having received rehabilitation. Of 89 patients with heart failure following MI, 33 (37.1%; 27.1-48.0) had no record of having been offered treatment with an ACE inhibitor. Total cholesterol measurement was documented for only 144 patients (54.1%; 48.1-60.1). We estimate that there is still the potential to prevent between 4 and 9 deaths in this group of 266 surviving patients in the next 2 years by further improving the quality of follow-up care. Preventive care in patients with proven ischaemic heart disease in general practice remains haphazard, even among doctors enthusiastic to participate in research and to audit their quality of care. As general practitioners we should ensure that we are providing high quality preventive care to patients with clinical disease before we focus on the even more demanding task of primary prevention.