Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trialBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4220 (Published 29 October 2009) Cite this as: BMJ 2009;339:b4220
- A W Murphy, professor of general practice1,
- M E Cupples, reader in general practice2,
- S M Smith, senior lecturer in primary care3,
- M Byrne, lecturer in primary care4,
- M C Byrne, lecturer in psychology1,
- J Newell, senior lecturer in biostatistics5,
- for the SPHERE study team
- 1Department of General Practice, National University of Ireland Galway, Ireland
- 2UKCRC Centre of Excellence for Public Health (Northern Ireland), Queen’s University Belfast, Northern Ireland
- 3Department of Public Health and Primary Care, Trinity College Dublin, Ireland
- 4School of Psychology, National University of Ireland Galway, Ireland
- 5Health Research Board Clinical Research Facility, National University of Ireland Galway, Ireland
- Correspondence to: A W Murphy
- Accepted 30 June 2009
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 in Northern Ireland and the Republic of Ireland, regions with different healthcare systems.
Participants 903 patients with established coronary heart disease registered with one of 48 practices.
Intervention Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care.
Main outcome measures The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12).
Results At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03).
Conclusions Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease.
Trial registration Current Controlled Trials ISRCTN24081411.
The SPHERE study team also includes C Leathem, A Houlihan, M O’Malley, V Spillane, H Grealish, and P Ryan (research nurses); M Corrigan, M D’Eath, and J Wilson (qualitative researchers); and A Kelly, E O’Shea, P Gillespie, M Donnelly, J Hinde, A Alvarez, and A Simpkin (statistical, economic, and policy advisers). We thank the patients and practitioners in each of the participating practices: Medical Centre, Old Bawn Road, Tallaght; Medical Centre, Main Street, Kilcullen; Guinness Medical Centre, Dublin 8; Beechlawn Medical Centre, Monkstown; Medical Centre, Carrig, Kill, Co Kildare; Unit 3 Neilstown Shopping Centre, Clondalkin; Derrinturn Health Centre, Carbury, Co Kildare; Medical Centre, Main Street, Blessington, Co Wicklow; 276 River Forest, Leixlip; Ballymun Family Practice, Ballymun Health Centre, Dublin 11; Medical Centre, Main Street, Celbridge, Co Kildare; Kildare Medical Centre, Bride Street, Kildare, Co Kildare; Bray Family Practice, Meath Road, Bray, Co Wicklow; 2a Brookdale Walk, Swords, Co Dublin; 138 Collins Avenue, Whitehall, Dublin 9; 31 Hazelwood Court, Artane, Dublin 5; Springfield Medical Centre, Alderwood Avenue, Tallaght; Primary Care Centre, Mohill, Co Leitrim; Medical Centre, Carrigart, Co Donegal; Millbrae Surgery, Carndonagh, Co Donegal; Claddagh Medical Centre, The Crescent, Galway; Medical Centre, Westport Road, Clifden, Co Galway; 4 Howley Terrace, Ballina, Co Mayo; Grove Medical Centre, Westport, Co Mayo; Eastland House, Dublin Road, Tuam, Co Galway; Health Centre, Athenry, Co Galway; Medical Centre, Carrowmore, Knock, Co Mayo; Health Centre, Moville, Co Donegal; Caheroyn Crescent, Athenry, Co Galway; Medical Centre, Dublin Road, Tuam, Co Galway; 216 Upper Salthill, Galway, Co Galway; Medical Centre, Kevin Barry Street, Ballina, Co Mayo; Medical Centre, Bangor Erris, Co Mayo; Health Centre, Turloughmore, Co Galway; Bangor Health Centre, Newtownards Road, Bangor; Ballywalter Health Centre, Fowler Way, Ballywalter; Old Mill Surgery, Church Street, Newtownards; Duncairn Surgery, Duncairn Gardens, Belfast; Kerrsland Surgery,Upper Newtownards Road, Belfast; Glenavy Family Practice, Main Street, Glenavy, Crumlin; Skegoneill Health Centre, Skegoneill Avenue, Belfast; Level 2, Lisburn Health Centre; Comber Health Centre, Newtownards Road, Comber; 181 Falls Road, Belfast; The Health Centre, High Street, Portaferry; Shankill Health Centres (1 and 2), Shankill Parade, Belfast; Loughview Medical Centre, Main Street, Kircubbin; Level 3, Lisburn Health Centre, Lisburn; Falls Road Medical Centre, Belfast; Stream Street Surgery, Downpatrick, Co Down; Woodbrook Medical Centre, Stewartstown Road, Dunmurry, Belfast.
Contributors: AWM, MEC, and SMS conceived the study and together with MB and MCB participated in the design of the trial and intervention. All authors, together with JN, participated in the acquisition and analysis of data and in critical revision of the manuscript, and have seen and approved the final version. AWM is the guarantor.
Funding: This study was funded by the Health Research Board and Irish Heart Foundation. The funders had no part in the design of the study; the collection, analysis, and interpretation of the data; the writing of the report; and the decision to submit the article for publication.
Competing interests: None declared.
Ethical approval: This study was approved by the Irish College of General Practitioners and the Queen’s University research ethics committee.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.