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PRIMARY CARE: Michael Moher, Patricia Yudkin, Lucy Wright, Rebecca Turner, Alice Fuller, Theo Schofield, and David Mant Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care BMJ 2001; 322: 1338 [Abstract] [Full text]

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Improved secondary prevention following introduction of a care pathway

Paul Kalra   (24 June 2001)

Improved secondary prevention following introduction of a care pathway 24 June 2001
Paul Kalra, Clinical research fellow National Heart and Lung Institute, London Send response to journal: Re: Improved secondary prevention following introduction of a care pathway	Editor - Despite excellent data supporting the benefits of secondary prevention in patients with ischaemic heart disease (IHD), in clinical practice it remains far from optimal. In an attempt to improve this within primary care, Moher et al. evaluated the effects of setting up a practice register of eligible patients and arranging systematic recall to see either the general practitioner or practice nurse . Whilst they confirmed an increase in follow-up and assessment this unfortunately did not translate into optimal patient care. This deficit in secondary prevention is not restricted to primary care. In 1995 the ASPIRE study revealed that both risk factor recording and subsequent control were inadequate in IHD patients in district hospitals within the United Kingdom . A recent European study has confirmed that this shortfall remains . Therefore significant potential still exists to reduce mortality and morbidity in this large group of patients. Emphasis on evidence-based medicine and clinical governance has led to the development of Clinical Care Pathways, where guidelines encourage appropriate documentation and suggest treatment regimes. We have recently shown that the introduction of a Myocardial Infarction Care Pathway can contribute to improved clinical care . We assessed 50 consecutive patients with acute myocardial infarction, 25 constituted the pre-Care Pathway group and 25 the Care Pathway group. Risk factor documentation was similar between groups, varying between 66% for hypercholesterolaemia and 94% for a family history of IHD (combined data). At presentation in the pre-Care Pathway group 88% of the subjects had blood cholesterol measured and 76% blood glucose. Although these figures increased to 100% and 92% respectively, within the Care-Pathway group, the difference was not significant. The use of intravenous insulin in patients presenting with blood glucose >11mmol/L was increased within the Care-Pathway group (p=0.048). Furthermore, introduction of the Care Pathway led to enhanced use of angiotensin-converting-enzyme inhibitors (18/25 vs 7/25, p=0.004). Of additional importance the majority of patients in both groups were still receiving their discharge medication at 6-month follow-up (aspirin 98%, angiotensin-converting-enzyme inhibitors 91%, beta-blockers 87%). Whilst an improvement was seen in this study shortcomings still exist and further ways of implementing secondary prevention need to be sought. However, our study exemplifies the need to initiate secondary prevention at the time of presentation, since once implemented it appears to be continued. Whether similar pathways can improve the management of all patients with IHD remains to be seen. PR Kalra(1), A Jones(2), MD Thomas(1), RS More(3), J Watkins(3) 1 National Heart and Lung Institute, Imperial College School of Medicine, Dovehouse Street, London. SW3 6LY 2 Centre For Cardiovascular Genetics, The Rayne Institute, London 3 Department of Cardiology, Portsmouth NHS Trust, St. Mary’s Hospital, Milton Road, Portsmouth. PO3 6AD Correspondence to: Dr Paul Kalra Cardiology Research Fellow National Heart and Lung Institute Dovehouse Street London SW3 6LY Tel: 0207 351 8513 Fax: 0207 351 8733 Email: p.kalra@ic.ac.uk Competing interests: None 1. Moher M, Yudkin P, Wright L, Turner R, Fuller A, Schofield T, et al. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. BMJ 2001;322:1338-1342 2. ASPIRE Steering Group. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996;75:334-342 3. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 counties. Principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001;22:554-572 4. Kalra P, Jones A, Thomas MD, More RS, Watkins J. Improved secondary prevention following the introduction of a myocardial infarction care pathway. Clin Sci 2000;99 (suppl 43):14p