Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

BMJ 1999;318:1522-1526 ( 5 June )

General Practice

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

Editorial by Bradley and Cupples

Gene Feder, senior lecturer, ^a Chris Griffiths, senior lecturer, ^a Sandra Eldridge, lecturer, ^b Matthew Spence, research associate. ^a

^a Department of General Practice and Primary Care, St Bartholomew's and the Royal London Hospital Medical School, Queen Mary and Westfield College, London E1 4NS, ^b Department of Medical Statistics, Wolfson Institute, St Bartholomew's and the Royal London Hospital Medical School, London EC1M 6BQ

Correspondence to: G Feder g.s.feder{at}mds.qmw.ac.uk

Objectives: To determine whether postal prompts to patientswho have survived an acute coronary event and to their generalpractitioners improve secondary prevention of coronary heartdisease.
Design: Randomised controlledtrial.
Setting: 52 general practices in east London, 44 ofwhich had received facilitation of local guidelines for coronaryheartdisease.
Participants: 328 patients admitted to hospital for myocardialinfarction or unstableangina.
Interventions: Postal prompts sent 2 weeks and 3 months afterdischarge from hospital. The prompts contained recommendationsfor lowering the risk of another coronary event, including changesto lifestyle, drug treatment, and making an appointment to discussthese issues with the general practitioner or practicenurse.
Main outcome measures: Proportion of patients in whom serum cholesterolconcentrations were measured; proportion of patients prescribed $beta$ blockers (6 months after discharge); and proportion of patientsprescribed cholesterol lowering drugs (1 year afterdischarge).
Results: Prescribing of $beta$ bockers (odds ratio 1.7,95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol loweringdrugs (1.7, 0.8 to 3.4, P>0.05) did not differ between interventionand control groups. A higher proportion of patients in the interventiongroup (64%) than in the control group (38%) had their serum cholesterolconcentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondaryoutcomes were significantly improved for consultations for coronaryheart disease, the recording of risk factors, and advice given.There were no significant differences in patients' self reportedchanges to lifestyle or to the belief that it is possible to modifythe risk of another coronaryevent.
Conclusions: Postal prompts to patients who had had acutecoronary events and to their general practitioners in a localitywhere guidelines for coronary heart disease had been disseminateddid not improve prescribing of effective drugs for secondary preventionor self reported changes to lifestyle. The prompts did increaseconsultation rates related to coronary heart disease and the recordingof risk factors in the practices. Effective secondary preventionof coronary heart disease requires more than postal prompts andthe dissemination ofguidelines.

Key messages

Postal prompts to patients and their general practitioners about effective secondary prevention after a myocardial infarction did not improve the prescribing of cholesterol lowering drugs and $beta$ blockers
The prompts did improve general practice recording of cardiovascular risk factors and lifestyle advice given to patients, but they made no difference to patients' reports of changes to lifestyle
Other methods are needed to improve the quality of secondary prevention of coronary heart disease in general practice

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