title: A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway – a randomized controlled trial Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994-2005. Targeted versus standard feedback: results from a randomized quality improvement trial. A randomized trial to assess the impact of opinion leader endorsed evidence summaries on the use of secondary prevention strategies in patients with coronary artery disease: the ESP-CAD trial protocol [NCT00175240] Improving the management of non-ST elevation acute coronary syndromes: systematic evaluation of a quality improvement programme European QUality Improvement Programme for Acute Coronary Syndrome: The EQUIP-ACS project protocol and design Recruitment activities for a nationwide, population-based, group-randomized trial: the VA MI-Plus study A multifaceted intervention according to the Audit Project Odense method improved secondary prevention of ischemic heart disease: a randomised controlled trial. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial. A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care Using paper chart based clinical reminders to improve guideline adherence to lipid management. Collaborative care intervention for stable ischemic heart disease. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: the BRIDGE-ACS randomized trial. The Enhancing Secondary Prevention in Coronary Artery Disease trial The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance Secondary prevention in coronary artery disease. Achieved goals and possibilities for improvements. Cluster-randomized trial to evaluate the effects of a quality improvement program on management of non-ST-elevation acute coronary syndromes: The European Quality Improvement Programme for Acute Coronary Syndromes (EQUIP-ACS). A multifaceted intervention to narrow the evidence-based gap in the treatment of acute coronary syndromes: rationale and design of the Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes (BRIDGE-ACS) cluster-randomized trial.
abstract: Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended CONTEXT Coronary heart disease ( CHD ) mortality has declined substantially in Canada since 1994 . OBJECTIVE To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments . DESIGN , SETTING , AND PATIENTS Prospect i ve analytic study of the Ontario , Canada , population aged 25 to 84 years between 1994 and 2005 , using an up date d version of the vali date d IMPACT model , which integrates data on population size , CHD mortality , risk factors , and treatment uptake changes . Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and ( 1 ) evidence -based therapies in 8 distinct CHD sub population s ( acute myocardial infa rct ion [ AMI ] , acute coronary syndromes , secondary prevention post-AMI , chronic coronary artery disease , heart failure in the hospital vs in the community , and primary prevention for hyperlipidemia or hypertension ) and ( 2 ) population trends in 6 risk factors ( smoking , diabetes mellitus ,  systolic blood pressure ,  plasma cholesterol level , exercise , and obesity  ) . MAIN OUTCOME MEASURES The number of deaths prevented or delayed in 2005 ; secondary outcome measures were improvements in medical treatments and trends in risk factors . RESULTS Between 1994 and 2005 , the  age-adjusted CHD mortality rate  in Ontario decreased by 35 % from 191 to 125 deaths per 100,000 inhabitants , translating to an estimated 7585 fewer CHD deaths in 2005 . Improvements in medical and surgical treatments were associated with 43 % ( range , 11 % to 124 % ) of the total mortality decrease , most notably in AMI ( 8 % ; range , -5 % to 40 % ) , chronic stable coronary artery disease ( 17 % ; range , 7 % to 35 % ) , and heart failure occurring while in the community ( 10 % ; range , 6 % to 31 % ) . Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed ( 48 % of total ; range , 28 % to 64 % ) , specifically , reductions in total cholesterol ( 23 % ; range , 10 % to 33 % ) and systolic blood pressure ( 20 % ; range , 13 % to 26 % ) . Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6 % ( range , 4 % to 8 % ) and 2 % ( range , 1 % to 4 % ) , respectively . CONCLUSION Between 1994 and 2005 , there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments , each explaining about half of the decrease BACKGROUND Quality improvement is central to improving the care of patients with cardiovascular disease ; however , the optimum type of data feedback to support such efforts is unknown . METHODS Over 26 months , 149 eligible Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals were r and omized to receive either st and ard ( n = 76 control ) or targeted ( n = 73 intervention ) performance feedback reports for acute myocardial infa rct ion patient care . Each report summarized performance on identified metrics ( providing hospitals with detailed data on their 3 lowest-performing quality metrics , relative to their peers ) . Intervention sites received 5 targeted feedback reports .  Overall composite performance was compared between cohorts at end of study and as a change from baseline . RESULTS Intervention ( n = 60 ) and control ( n = 64 ) hospitals that completed the study had similar baseline performance ( median score 83.7 % vs 84.2 % ) . Over 26 months of follow-up , the change in overall composite score across hospitals was neutral ( median 0.1 % [ interquartile range { IQR } -2.4 % to 3.3 % ] ) . There was no difference in observed improvement in either the intervention ( median -0.2 % [ IQR-2.6 % to 3.3 % ] ) or control ( median 0.1 % [ IQR -2.2 % to 3.4 % ] ) hospitals . CONCLUSIONS We were unable to demonstrate that targeted performance feedback reports lead to more rapid care improvements than st and ard reports . Future directions should explore the relationship between hospital self- selection of targeted metrics and the identification and promulgation of less common metrics -- particularly those that reflect processes of care Background Although numerous therapies have been shown to be beneficial in the prevention of myocardial infa rct ion and /or death in patients with coronary disease , these therapies are under-used and this gap contributes to sub-optimal patient outcomes . To increase the uptake of proven efficacious therapies in patients with coronary disease , we design ed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care , with one-page treatment guidelines endorsed by local opinion leaders ( " Local Opinion Leader Statement " ) . This trial is design ed to evaluate the impact of these Local Opinion Leader Statements on the practice s of primary care physicians caring for patients with coronary disease . In order to isolate the effects of the messenger ( the local opinion leader ) from the message , we will also test an identical quality improvement intervention that is not signed by a local opinion leader ( " Unsigned Evidence Statement " ) in this trial . Methods R and omized trial testing three different interventions in patients with coronary disease : ( 1 ) usual care versus ( 2 ) Local Opinion Leader Statement versus ( 3 ) Unsigned Evidence Statement .  Patients diagnosed with coronary artery disease after cardiac catheterization ( but without acute coronary syndromes ) will be r and omly allocated to one of the three interventions by cluster r and omization ( at the level of their primary care physician ) , if they are not on optimal statin therapy at baseline . The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization . Secondary outcomes include examinations of the use of ACE inhibitors , anti-platelet agents , beta-blockers , non-statin lipid lowering drugs , and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms . Although r and omization will be clustered at the level of the primary care physician , the design effect is anticipated to be negligible and the unit of analysis will be the patient . Discussion If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease , they can be easily modified and applied in other communities and for other target conditions Background Acute coronary syndromes , including myocardial infa rct ion and unstable angina , are important causes of premature mortality , morbidity and hospital admissions . Acute coronary syndromes consume large amounts of health care re sources , and have a major negative economic and social impact through days lost at work , support for disability , and coping with the psychological consequences of illness . Several registries have shown that evidence based treatments are under-utilised in this patient population , particularly in high-risk patients . There is evidence that systematic educational programmes can lead to improvement in the management of these patients . Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes , we propose to test a quality improvement programme in a general group of hospitals in Europe . Methods / Design This will be a multi-centre cluster-r and omised study in 5 European countries : France , Spain , Pol and , Italy and the UK . Thirty eight hospitals will be r and omised to receive a quality improvement programme or no quality improvement programme . Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study data base and the sample size is estimated at 2,000 - 4,000 patients . The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population ( risk stratification , early coronary angiography , anticoagulation , beta-blockers , statins , ACE-inhibitors , clopidogrel as a loading dose and at discharge ) . After the quality improvement programme , each of the eight measures will be compared between the two groups , correcting for cluster effect . Discussion If we can demonstrate important improvements in the quality of patient care as a result of a quality improvement programme , this could lead to a greater acceptance that such programmes should be incorporated into routine health training for health professionals and hospital managers . Trial registration Clinical trials.gov Background The Veterans Health Administration ( VHA ) oversees the largest integrated healthcare system in the United States . The feasibility of a large-scale , nationwide , group-r and omized implementation trial of VHA outpatient practice s has not been reported . We describe the recruitment and enrollment of such a trial testing a clinician-directed , Internet-delivered intervention for improving the care of postmyocardial infa rct ion patients with multiple comorbidities . Methods With a recruitment goal of 200 eligible community-based outpatient clinics , parent VHA facilities ( medical centers ) were recruited because they oversee their affiliated clinics and the research conducted there . Eligible facilities had at least four VHA-owned and -operated primary care clinics , an affiliated Institutional Review Board ( IRB ) , and no ongoing , potentially overlapping , quality -improvement study . Between December 2003 and December 2005 , in two consecutive phases , we used initial and then intensified recruitment strategies . Results Overall , 48 of 66 ( 73 % ) eligible facilities were recruited . Of the 219 clinics and 957 clinicians associated with the 48 facilities , 168 ( 78 % ) clinics and 401 ( 42 % ) clinicians participated . The median time from initial facility contact to clinic enrollment was 222 days , which decreased by over one-third from the first to the second recruitment phase ( medians : 323 and 195 days , respectively ; p < .001 ) , when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff . Conclusions Large group-r and omized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment . A large-scale , nationally representative , group-r and omized trial of community-based clinics is feasible within the VHA or a similar national healthcare system BACKGROUND No single quality improvement instrument has proved consistently effective , but multifaceted interventions are believed to have the greatest impact . However , only little is known regarding what combinations are likely to be successful . OBJECTIVE To evaluate the impact of a multifaceted intervention strategy combining GP registration s , outreach visits and feedback , targeting secondary prevention of ischemic heart disease in general practice . METHODS A r and omised controlled trial including 28 GPs in Ringkjøbing County , Denmark . Half of the GPs received outreach visits and feedback on their prescribing of heart disease drugs . Evaluation was based on registration of consultations with patients suffering from ischemic heart disease . RESULTS The intervention had a statistically significant impact on prescribing of lipid lowering drugs [ odds ratio 1.59 ; 95 % confidence interval ( CI ) 1.00 to 2.53 ] and acetylsalicylic acid ( odds ratio 2.54 ; 95 % CI 1.21 to 5.31 ) . CONCLUSION An intervention strategy combining outreach visits , feedback and GP registration s is a promising way of improving the quality of preventive treatment in general practice Abstract Objective : To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care . Design : Pragmatic , unblinded , cluster r and omised controlled trial . Setting : Warwickshire . Subjects : 21 general practice s received intervention ; outcome measured in 1906 patients aged 55 - 75 years with established coronary heart disease . Interventions : Audit of notes with summary feedback to primary health care team ( audit group ) ; assistance with setting up a disease register and systematic recall of patients to general practitioner ( GP recall group ) ; assistance with setting up a disease register and systematic recall of patients to a nurse led clinic ( nurse recall group ) . Main outcome measures : At 18 months ' follow up : adequate assessment ( defined ) of 3 risk factors ( blood pressure , cholesterol , and smoking status ) ; prescribing of hypotensive agents , lipid lowering drugs , and antiplatelet drugs ; blood pressure , serum cholesterol level , and plasma cotinine levels . Results : Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups ( 85 % , 76 % ) than the audit group ( 52 % ) . The advantage in the nurse recall compared with the audit group was 33 % ( 95 % confidence interval 19 % to 46 % ) ; in the GP recall group compared with the audit group 23 % ( 10 % to 36 % ) , and in the nurse recall group compared with the GP recall group 9 % ( −3 % to 22 % ) . However , these differences in assessment were not reflected in clinical outcomes . Mean blood pressure ( 148/80 , 147/81 , 148/81 mm Hg ) , total cholesterol ( 5.4 , 5.5 , 5.5 mmol/l ) , and cotinine levels ( % probable smokers 17 % , 16 % , 19 % ) varied little between the nurse recall , GP recall , and audit groups respectively , as did prescribing of hypotensive and lipid lowering agents . Prescribing of antiplatelet drugs was higher in the nurse recall group ( 85 % ) than the GP recall or audit groups ( 80 % , 74 % ) . After adjustment for baseline levels , the advantage in the nurse recall group compared with the audit group was 10 % ( 3 % to 17 % ) , in the nurse recall group compared with the GP recall group 8 % ( 1 % to 15 % ) and in the GP recall group compared with the audit group 2 % ( −6 % to 10 % ) . Conclusions : Setting up a register and recall system improved patient assessment at 18 months ' follow up but was not consistently better than audit alone in improving treatment or risk factor levels . Underst and ing the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease . What is already known on this topic Effective preventive care of patients with any chronic disease requires planned and quality assured follow up on the basis of an up to date register Strategies for changing clinical practice in primary care have been of limited effectiveness What this study adds Setting up a coronary heart disease register for a practice substantially increases follow up and adequate assessment of patients at risk Improved assessment and follow up does not necessarily improve clinical outcome Follow up by nurses is as effective as , and may be more effective than , follow up by doctors Patients are being followed up and adequately assessed without the recommended preventive drugs being PURPOSE To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating out patients with acute myocardial infa rct ion or heart failure . METHODS The study comprised 509 patients with myocardial infa rct ion and 323 patients with heart failure who were discharged from hospital . The primary care physicians caring for these patients were assigned r and omly to either the intervention or control group ; the intervention group was mailed practice guidelines immediately after patient discharge , and patients were cited by name . During a 6-month assessment period , the records of primary care physicians ( and cardiologists , if any ) were review ed to assess mean conformance with the guidelines , using seven measures of care for myocardial infa rct ion and eight measures of care for heart failure . RESULTS After adjusting for demographic and clinical characteristics of patients , and the number of eligible measures per patient , we observed no effect of the intervention on care of patients with myocardial infa rct ion ( odds ratio [ OR ] = 0.98 ; 95 % confidence interval [ CI ] : 0.81 to 1.17 ) or heart failure ( OR = 1.25 ; 95 % CI : 0.96 to 1.59 ) . However , there was a higher likelihood of conformance with measures for patients with infa rct ion ( OR = 1.56 ; 95 % CI : 1.29 to 1.87 ) or heart failure ( OR = 1.71 ; 95 % CI : 1.29 to 2.23 ) who had also been seen by a cardiologist during the 6-month assessment period . CONCLUSION Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infa rct ion or heart failure . However , efforts to include cardiologists in the care of these patients might be worthwhile BACKGROUND Cardiovascular risk reduction in ambulatory patients who survive myocardial infa rct ion ( MI ) is effective but underused . We sought to evaluate a provider-directed , Internet-delivered intervention to improve cardiovascular management for post-MI out patients . METHODS The Department of Veterans Affairs ( VA ) MI-Plus study was a cluster-r and omized trial involving 168 community-based primary care clinics and 847 providers in 26 states , the Virgin Isl and s , and Puerto Rico , from January 1 , 2002 , through December 31 , 2008 , with the clinic as the r and omization unit . We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these . A multicomponent , Internet-delivered intervention included quarterly educational modules , practice guidelines , monthly literature summaries , and automated e-mail reminders delivered to providers for 27 months . Main outcome measures included percentage of patients who achieved each of 7 clinical indicators , a composite score of the 7 clinical indicators , and mean low-density lipoprotein cholesterol and hemoglobin A(1c ) levels . RESULTS Clinics had a median of 3 providers ( interquartile range , 2 - 6 ) , with a median of 50.0 % of providers ( 33.3%-66.7 % ) participating in the study . Patients in intervention clinics had greater improvements ( from 70.0 % to 85.5 % ) in the percentages prescribed β-blockers than patients in control clinics ( 71.9 % to 84.0 % ; adjusted improvement gain for intervention vs control , 2.6 % ; 95 % CI , 0.1%-4.1 % ) . We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c ) . CONCLUSION A longitudinal , Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients Context Interventions to promote guideline -recommended care have met with limited success . Quality improvement experts believe that multicomponent interventions are more effective than simpler strategies , but this belief rests on limited evidence . Contribution In this r and omized trial of 20 primary care practice s , intervention practice s received quarterly site visits and 2 network meetings about quality improvement in addition to copies of practice guidelines and quarterly performance reports . Intervention practice s had greater improvement in providing guideline -recommended care for cardiovascular disease prevention and treatment than practice s that received only the guidelines and performance reports . Caution s The study involved a small number of practice s. The Editors Widespread evidence reveals inadequate implementation of evidence -based clinical practice guidelines for prevention and management of cardiovascular disease and stroke in primary care setting s ( 1 - 3 ) . Primary prevention deficiencies exist in the screening and management of dyslipidemia ( 4 ) and hypertension ( 5 ) . Secondary prevention deficiencies include inadequate treatment of dyslipidemia in patients with coronary heart disease ( CHD ) ( 6 ) and inadequate use of antiplatelet therapy in patients with CHD or cerebrovascular disease ( 7 ) , inadequate use of -blockers after myocardial infa rct ion ( 8) , inadequate use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers in patients with heart failure ( 9 ) , and inadequate use of oral anticoagulant therapy in patients with atrial fibrillation ( 10 ) . Finally , patients with diabetes mellitus who are at high risk for cardiovascular disease as well as microvascular disease infrequently receive recommended screening and adequate treatment for elevated glycosylated hemoglobin levels , hypertension , and dyslipidemia ( 11 ) . Published systematic review s point to the importance of multifaceted interventions in increasing adherence to practice guidelines and improving disease control ( 12 , 13 ) . Little is known , however , about the relative effectiveness of different implementation strategies . More research is needed to develop and vali date effective , theoretically sound , and practical strategies for improving the provision of evidence -based medicine in primary care . Particularly important are studies that address multiple common , chronic conditions , which together reflect a large proportion of the work of primary care providers ( 14 ) . This study was design ed as a pragmatic clinical trial ( 15 ) , intended to assess whether a  multi method quality improvement intervention  was more effective than a less intensive intervention  for improving adherence to 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke . The multi method quality improvement intervention added practice site visits ( for academic detailing and quality improvement facilitation ) and network meetings ( for sharing best practice s ) to the approach of guideline dissemination and audit and feedback used in the less intensive intervention . The study was conducted in a practice -based research network ( PPRNet ) among users of a common electronic medical record ( Practice Partner Patient Records , Seattle , Washington ) , which historically provided audit and feedback to its practice members . Audit and feedback have already been shown to improve the practice of health care professionals , particularly in prescribing and test ordering ( 16 ) . Additional research is needed to assess the effect of audit and feedback in combination with other interventions . Methods Design The design was a cluster r and omized , controlled clinical trial , with the practice as the unit of r and omization . Twenty-three office-based primary care practice s in 15 states agreed to participate . The institutional review board at the Medical University of South Carolina approved the study . Study Indicators We derived the study indicators ( Table 1 ) from published sources ( 17 - 22 ) . Fourteen were process measures , which reflected whether recommended tests were done , appropriate diagnoses made , or appropriate medication prescribed . Seven were outcome measures , which reflected whether patients achieved recommended treatment goals . Some of the measures represented primary prevention , for example , screening for hypertension or dyslipidemia . Others represented secondary prevention , for example , reaching treatment goals for glycosylated hemoglobin levels , low-density lipoprotein ( LDL ) cholesterol levels , and blood pressure in patients with diabetes . An additional indicator , hormone replacement therapy for postmenopausal women , was included at the beginning of the study but was withdrawn in July 2002 when the results from the Women 's Health Initiative trial were published ( 23 ) . Table 1 . Study Indicators We determined practice performance for each study indicator at baseline and quarterly throughout the study . To determine performance , participating practice s ran a computer program to extract patient activity during the previous quarter from their electronic medical record . To protect patient confidentiality , the extract program assigned a unique , anonymous numerical identifier to each patient . The extract program obtained demographic information , such as age , race , and sex ; diagnoses ; medications ; laboratory data ; and vital signs . Text of progress notes , consultation reports , and discharge summaries were not extracted . The data were copied to a diskette and mailed to PPRNet or sent electronically via a secure server . In the PPRNet offices , the data were bridged to st and ard data dictionaries and converted to SAS data sets ( SAS Institute , Inc. , Cary , North Carolina ) on st and ard microcomputers for analyses . Interventions The intervention began on 1 January 2001 and was completed on 1 January 2003 . During the first quarter of 2001 , the medical director of each practice was sent printed copies of each practice guideline referenced in the study . Beginning in the first quarter of 2001 , the medical director was sent quarterly performance reports documenting the practice 's adherence to each of the 21 study indicators . Each report contained the practice 's current performance , calculated as the percentage of eligible patients who had received the recommended service , the number of patients who were receiving the recommended medication , or the number of patients who had achieved the treatment goal . The report also presented data on the practice s ' previous performance since the beginning of the study and the performance target , calculated as the 90th percentile at baseline among all practice s. In practice s with more than 1 clinician , individual provider data were not given because the study emphasized improvement at the practice level . The medical director was encouraged to share the reports with others in the practice in order to stimulate motivation for improvement . The 90th percentile was selected as the performance target because it reflected a bold but achievable goal ( at least 2 practice s were at this level of performance at baseline ) . Practice s in the control group received no other interventions during the study . An example of 1 page of a practice report is available in the Appendix Figure . Appendix Figure . Sample practice report for blood pressure in coronary heart disease .  Practice s in the intervention group also participated in practice site visits and network meetings . Six or seven 1- or 2-day site visits were held at each practice approximately every 3 months during 2001 and 2002 . The practice site visit was led by 1 of the physician co authors , assisted during the first few visits in 2001 by a clinical pharmacist with expertise in academic detailing ( 24 ) , and at later visits by other co authors with expertise in quality improvement . Initial site visits focused on engaging clinicians and staff members in the project , through a formal presentation by the site visitors and group discussion with all members of the practice team , including providers , nurses , medical assistants , and reception and administrative personnel . Because of vacation or hospital coverage responsibilities , 1 or 2 providers were occasionally absent in the multiprovider practice s , and 1 practice involved only a few members of their staff . We placed detailed attention on the scientific justification for the chosen study indicators and on published frameworks for clinician behavior change ( 25 , 26 ) . Baseline practice performance on each study indicator was discussed , and previous evidence of the ability of PPRNet practice s to improve care was presented ( 27 ) . Practice s were encouraged to increase the use of quality improvement tools available in the electronic medical record , such as note templates with embedded practice guidelines , query functions , prompts , reminders , and messaging . At each visit , a participatory planning session was held in which practice members identified specific clinical indicators they wished to work on and improvement activities to conduct before the next site visit . Lessons from complexity theory were used in this exercisethe influence of each practice member on the system , the importance of replicating successful approaches and focusing on motivators for patients and staff , and the notion that simple changes are easiest to adopt and can have profound effects . In subsequent site visits , we focused on discussing the practice 's success in adopting its planned improvement activities , presenting up date d performance data , and planning additional practice -level interventions . The site visitors presented results from recently published studies relevant to the study indicators . Successful and unsuccessful approaches to improvement by other intervention sites were also presented . Two-day network meetings were held in Charleston , South Carolina , in May 2001 and May 2002 . The lead clinician from each intervention practice and the research team attended the first meeting . At this RATIONALE , AIMS AND OBJECTIVES The objective of this study was to apply a paper-based clinical reminder to improve the adherence to lipid guidelines . METHODS Patients with coronary heart disease ( CHD ) without lipid-lowering therapy ( LLT ) were recruited , and medical records were review ed . Eligible subjects were r and omized ; a clinical reminder stating current st and ards and local insurance policy was stamped on the paper chart in the study group but not in the control . The primary outcome was new LLT subscription in the 6-month follow-up period , and the secondary end point was the composite result of LLT or lipid profile check-up . RESULTS Ninety-two patients were assigned to the study group and 102 to the control group . The primary outcome showed no difference at the end of 6 months ( OR : 1.70 , P = 0.248 , 95 % CI : 0.69 - 4.19 ) . The secondary end point was significantly higher in the reminder group ( OR : 2.81 , P = 0.001 , 95 % CI : 1.57 - 5.04 ) . CONCLUSION A paper chart based clinical reminder providing up date clinical recommendations could modify the doctor 's behaviour and improve the attention to lipid levels . However , its effect can not be transformed into an increase in LLT or a decrease in low-density lipoprotein level owing to local policy constraint BACKGROUND Accumulating evidence suggests that collaborative models of care enhance communication among primary care providers , improving quality of care and outcomes for patients with chronic conditions . We sought to determine whether a multifaceted intervention that used a collaborative care model and was directed through primary care providers would improve symptoms of angina , self-perceived health , and concordance with practice guidelines for managing chronic stable angina . METHODS We conducted a prospect i ve trial , cluster r and omized by provider , involving patients with symptomatic ischemic heart disease recruited from primary care clinics at 4 academically affiliated Department of Veterans Affairs health care systems . Primary end points were changes over 12 months in symptoms on the Seattle Angina Question naire , self-perceived health , and concordance with practice guidelines . RESULTS In total , 183 primary care providers and 703 patients participated in the study . Providers accepted and implemented 91.6 % of 701 recommendations made by collaborative care teams . Almost half were related to medications , including adjustments to β-blockers , long-acting nitrates , and statins . The intervention did not significantly improve symptoms of angina or self-perceived health , although end points favored collaborative care for 10 of 13 prespecified measures . While concordance with practice guidelines improved 4.5 % more among patients receiving collaborative care than among those receiving usual care ( P < .01 ) , this was mainly because of increased use of diagnostic testing rather than increased use of recommended medications . CONCLUSION A collaborative care intervention was well accepted by primary care providers and modestly improved receipt of guideline -concordant care but not symptoms or self-perceived health in patients with stable angina Aims : To evaluate the effect of a disease management programme for patients with coronary heart disease ( CHD ) and chronic heart failure ( CHF ) in primary care . Methods : A cluster r and omised controlled trial of 1316 patients with CHD and CHF from 20 primary care practice s in the UK was carried out . Care in the intervention practice s was delivered by specialist nurses trained in the management of patients with CHD and CHF . Usual care was delivered by the primary healthcare team in the control practice s. Results : At follow up , significantly more patients with a history of myocardial infa rct ion in the intervention group were prescribed a beta-blocker compared to the control group ( adjusted OR 1.43 , 95 % CI 1.19 to 1.99 ) . Significantly more patients with CHD in the intervention group had adequate management of their blood pressure ( < 140/85 mm Hg ) ( OR 1.61 , 95 % CI 1.22 to 2.13 ) and their cholesterol ( < 5 mmol/l ) ( OR 1.58 , 95 % CI 1.05 to 2.37 ) compared to those in the control group . Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed ( OR 4.69 , 95 % CI 1.88 to 11.66 ) or excluded ( OR 3.80 , 95 % CI 1.50 to 9.64 ) in the intervention group compared to the control group . There were significant improvements in some quality -of-life measures in patients with CHD in the intervention group . Conclusions : Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care CONTEXT Studies have found that patients with acute coronary syndromes ( ACS ) often do not receive evidence -based therapies in community practice . This is particularly true in low- and middle-income countries . OBJECTIVE To evaluate whether a multifaceted quality improvement ( QI ) intervention can improve the use of evidence -based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country . DESIGN , SETTING , AND PARTICIPANTS The BRIDGE-ACS ( Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes ) trial , a cluster-r and omized ( concealed allocation ) trial conducted among 34 clusters ( public hospitals ) in Brazil and enrolling a total of 1150 patients with ACS from March 15 , 2011 , through November 2 , 2011 , with follow-up through January 27 , 2012 .  INTERVENTION Multifaceted QI intervention including educational material s for clinicians , reminders , algorithms , and case manager training , vs routine practice ( control ) . MAIN OUTCOME MEASURES Primary end point was the percentage of eligible patients who received all evidence -based therapies ( aspirin , clopidogrel , anticoagulants , and statins )  during the first 24 hours in patients without contraindications . RESULTS Mean age of the patients enrolled was 62 ( SD , 13 ) years ; 68.6 % were men , and 40 % presented with ST-segment elevation myocardial infa rct ion , 35.6 % with non-ST-segment elevation myocardial infa rct ion , and 23.6 % with unstable angina . The r and omized clusters included 79.5 % teaching hospitals , all from major urban areas and 41.2 % with 24-hour percutaneous coronary intervention capabilities . Among eligible patients ( 923/1150 [ 80.3 % ] ) , 67.9 % in the intervention vs 49.5 % in the control group received all eligible acute therapies ( population average odds ratio [ OR(PA ) ] , 2.64 [ 95 % CI , 1.28 - 5.45 ] ) . Similarly , among eligible patients ( 801/1150 [ 69.7 % ] ) , those in the intervention group were more likely to receive all eligible acute and discharge medications ( 50.9 % vs 31.9 % ; OR(PA ) , , 2.49 [ 95 % CI , 1.08 - 5.74 ] ) . Overall composite adherence scores were higher in the intervention clusters ( 89 % vs 81.4 % ; mean difference , 8.6 % [ 95 % CI , 2.2%-15.0 % ] ) . In-hospital cardiovascular event rates were 5.5 % in the intervention group vs 7.0 % in the control group ( OR(PA ) , 0.72 [ 95 % CI , 0.36 - 1.43 ] ) ; 30-day all-cause mortality was 7.0 % vs 8.4 % ( ORPA , 0.79 [ 95 % CI , 0.46 - 1.34 ] ) . CONCLUSION Among patients with ACS treated in Brazil , a multifaceted educational intervention result ed in significant improvement in the use of evidence -based therapies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00958958 Background : Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions , result ing in suboptimal outcomes . We evaluated whether evidence summaries , which were either unsigned or signed by local opinion leaders , improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease . Methods : We performed a r and omized trial , clustered at the level of the primary care physician , with 3 study arms : control , unsigned statements or opinion leader statements . The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization . The primary outcome was improvement in  statin management ( initiation or dose increase ) 6 months after catheterization . Results : We enrolled 480 adults from 252 practice s. Although statin use was high at baseline ( n = 316 [ 66 % ] ) , most patients were taking a low dose ( mean 32 % of the guideline -recommended dose ) , and their low-density lipoprotein ( LDL ) cholesterol levels were elevated ( mean 3.09 mmol/L ) . Six months after catheterization , statin management had improved in 79 of 157 patients ( 50 % ) in the control arm , 85 of 158 ( 54 % ) patients in the unsigned statement group ( adjusted odds ratio [ OR ] 1.18 , 95 % CI 0.71–1.94 , p = 0.52 ) and 99 of 165 ( 60 % ) patients in the opinion leader statement group ( adjusted OR 1.51 , 95 % CI 0.94–2.42 , p = 0.09 ) . The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms : 2.35 ( st and ard deviation [ SD ] 0.86 ) mmol/L in the control arm compared with 2.24 ( SD 0.73 ) among those in the opinion leader group ( p = 0.48 ) and 2.19 ( SD 0.68 ) in the unsigned statement group ( p = 0.32 ) . Interpretation : Faxed evidence reminders for primary care physicians , even when endorsed by local opinion leaders , were insufficient to optimize the quality of care for adults with coronary artery disease . Clinical Trials.gov trial register no. NCT00175240 Background The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected population s. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes ( ACSs ) in a largely indigent county hospital setting . Methods Patients admitted for ACS were r and omized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit . Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines . Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence -based practice goals . Results One hundred forty consecutive patients were r and omized . A similar proportion of patients returned for study follow-up in both groups at 3 months ( 54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group ; P = 0.97 ) . Among those completing the 3-month visit , a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 ( 69 % ) of the usual care patients compared with 35 ( 57 % ) of those in the intervention group ( P = 0.43 ) . There was no statistical difference in implementation of therapeutic lifestyle changes ( smoking cessation , cardiac rehabilitation , or exercise ) between groups . Prescription rates of evidence -based therapeutics at 3 months were similar in both groups . Conclusion The implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence -based secondary prevention treatment goals . Despite initially high rates of evidence -based treatment at discharge , adherence with follow-up appointments and sustained implementation of evidence -based therapies remains a significant challenge in this high-risk cohort AIM To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronary artery disease at a university clinic . METHODS The presence of risk indicators , including tobacco use , lipid levels , blood pressure and glucometabolic status , including 24-hour blood pressure monitoring and an oral glucose-tolerance test , was analysed . RESULTS Of 1465 patients who were screened , 402 took part in the survey ( 50 % previous myocardial infa rct ion and 50 % angina pectoris ) . Mean age was 64 years ( range 40 - 85 years ) and 23 % were women . Present medications were : lipid lowering drugs ( statins ; 94 % ) , beta-blockers ( 85 % ) , aspirin or warfarin ( 100 % ) and ACE-inhibitors or angiotensin II blockers ( 66 % ) . Values above target levels recommended in guidelines were : a ) low density lipoprotein ( LDL ) in 40 % ; b ) mean blood pressure ( day or night ) in 38 % and c ) smoking in 13 % . Of all patients , 66 % had at least one risk factor ( LDL or blood pressure above target levels or current smoking ) . An abnormal glucose-tolerance test was found in 59 % of patients without known diabetes . If no history of diabetes , 85 % had either LDL or blood pressure above target levels , current smoking or an abnormal glucose-tolerance test . However , with treatment intensification to patients with elevated risk factors 56 % reached target levels for blood pressure and 79 % reached target levels for LDL . CONCLUSION Six months after hospitalisation due to coronary artery disease , despite the high use of medication aim ed at prophylaxis against recurrence , the majority were either above target levels for LDL or blood pressure or continued to smoke BACKGROUND Registries have shown that quality of care for acute coronary syndromes ( ACS ) often falls below the st and ards recommended in professional guidelines . Quality improvement ( QI ) is a strategy to improve st and ards of clinical care for patients , but the efficacy of QI for ACS has not been tested in r and omized trials . METHODS We undertook a prospect i ve , cluster-r and omized , multicenter , multinational study to evaluate the efficacy of a QI program for ACS . Participating centers collected data on consecutive admissions for non-ST-elevation ACS for 4 months before the QI intervention and 3 months after . Thirty-eight hospitals in France , Italy , Pol and , Spain , and the United Kingdom were r and omized to receive the QI program or not , 19 in each group . We measured 8 in-hospital quality indicators ( risk stratification , coronary angiography , anticoagulation , β-blockers , statins , angiotensin-converting enzyme inhibitors , and clopidogrel loading and maintenance ) before and after the intervention and compared composite changes between the QI and non-QI groups . RESULTS A total of 2604 patients were enrolled . The absolute overall change in use of quality indicators in the QI group was 8.5 % compared with 0.8 % in the non-QI group ( odds ratio for achieving a quality indicator in QI versus non-QI 1.66 , 95 % CI 1.43 - 1.94 ; P < .001 ) . The main changes were observed in the use of risk stratification and clopidogrel loading dose . CONCLUSIONS The QI strategy result ed in a significant improvement in the quality indicators measured . This type of QI intervention can lead to useful changes in health care practice for ACS in a wide range of setting Translating evidence into clinical practice in the management of acute coronary syndromes ( ACS ) is challenging . Few ACS quality improvement interventions have been rigorously evaluated to determine their impact on patient care and clinical outcomes . We design ed a pragmatic , 2-arm , cluster-r and omized trial involving 34 clusters ( Brazilian public hospitals ) . Clusters were r and omized to receive a multifaceted quality improvement intervention ( experimental group ) or routine practice ( control group ) . The 6-month educational intervention included reminders , care algorithms , a case manager , and distribution of educational material s to health care providers . The primary end point was a composite of evidence -based post-ACS therapies within 24 hours of admission , with the secondary measure of major cardiovascular clinical events ( death , nonfatal myocardial infa rct ion , nonfatal cardiac arrest , and nonfatal stroke ) . Prescription of evidence -based therapies at hospital discharge were also evaluated as part of the secondary outcomes . All analyses were performed by the intention-to-treat principle and took the cluster design into account using individual-level regression modeling ( generalized estimating equations ) . If proven effective , this multifaceted intervention would have wide use as a means of promoting optimal use of evidence -based interventions for the management of ACS
target: Conclusions Organisational and professional interventions improved prescribing of statins/lipid-lowering agents and target blood pressure in patients with IHDs but there was little evidence of change in other outcomes .
background: Objectives Ischaemic heart diseases ( IHDs ) are a leading cause of death worldwide .
  Although prescribing according to guidelines improves health outcomes , it remains suboptimal .
  We determined whether interventions targeted at healthcare professionals are effective to enhance prescribing and health outcomes in patients with IHDs .