Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care

Campbell, Neil; Ritchie, Lewis D; Thain, J; Deans, Heather; Rawles, John; Squair, J

doi:10.1136/hrt.80.5.447

Cited by 221 publications

(184 citation statements)

References 12 publications

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“…19 Specially trained nurses instructed to follow detailed protocols and algorithms under the supervision of a specialist has been shown to improve diabetes outcomes, 20 as have nurse-led clinics. 21 A Canadian outreach program was effective in lowering blood pressure among people with diabetes living in a rural setting. 22 New strategies and partnerships that include family physicians, nurses and specialists are required if cardiovascular risk factors such as hypertension are to be controlled.…”

Section: Discussionmentioning

confidence: 99%

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

Tobe

Pylypchuk²,

Wentworth³

et al. 2006

Canadian Medical Association Journal

115

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Section: Discussionmentioning

confidence: 99%

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

Tobe

Pylypchuk²,

Wentworth³

et al. 2006

Canadian Medical Association Journal

115

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“…Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the majority of cases (13). These observations imply that alternatives to conventional care for patients with hypertension and diabetes are required.Nurse-led clinics (NLCs) can improve care outcomes in some chronic circulatory diseases (14,15). It is unknown whether the intensification of BP management by this approach is more effective than conventional care.…”

mentioning

confidence: 99%

Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes

et al. 2003

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OBJECTIVE -To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) Ն140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA 1c , UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores.RESULTS -The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9 -19.3) (P ϭ 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP Ͻ140 mmHg compared with conventional care (P ϭ 0.003). A significant fall in 10-year CHD (P ϭ 0.004) and stroke risk (P ϭ 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months.CONCLUSIONS -Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP Ͻ140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores. Diabetes Care 26:2256 -2260, 2003H ypertension is a major and modifiable risk factor for cardiovascular disease that frequently coexists with diabetes (1). A progressive rise in blood pressure (BP) is also a promoter of renal dysfunction and the development of end-stage renal failure (2). The presence of proteinuria and hypertension also increases the risk of premature death from cardiovascular disease eightfold compared with unaffected patients (3,4). A large evidence base of randomized controlled trials have demonstrated that treating hypertension reduces morbidity and mortality from hypertension-related diseases (5,6). More recently, the use of antihypertensive agents that interrupt the renin-angiotensin system has been shown to be an effective strategy to retard the progression of nephropathy and reduce cardiovascular events in people with diabetes (7-9). Throughout the western world, expert committees on hypertension recommend that treatment to lower BP is warranted in patients with diabetes who have a systolic BP Ն140 mmHg (10,11). Currently, hypertension is poorly managed. The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the maj...

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“…Nurse-led psychosocial interventions have been shown to be effective, including in heart disease. 72,73 However, many nurses complained of a lack of time. A previous study 41 has shown that it is possible to have a flexible attitude to time management in primary care in order to manage depression effectively.…”

Section: Timing Of the Interventionmentioning

confidence: 99%

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Tylee

Barley

Walters

et al. 2016

Programme Grants Appl Res

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BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

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Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care

Cited by 221 publications

References 12 publications

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

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