title: The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] A randomized controlled trial of an extensive lifestyle management intervention (ELMI) following cardiac rehabilitation: study design and baseline data Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial Selection bias in enrollment to a programme aimed at the secondary prevention of ischaemic heart disease in general practice: a cohort study. Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction [Smoking cessation among patients with acute heart disease. A randomised intervention project]. A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health [Postmyocardial infarction cardiac rehabilitation in low risk patients. Results with a coordinated program of cardiological and primary care]. Do patients with angina alone have a more benign prognosis than patients with a history of acute myocardial infarction, revascularisation or both? Findings from a community cohort study A minimal-contact intervention for cardiac inpatients: long-term effects on smoking cessation. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. Improving pharmacotherapy after myocardial infarction by group academic detailing using feedback data on a patient level. Clinical trial of an educational intervention to achieve recommended cholesterol levels in patients with coronary artery disease. A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: The Braveheart Project. An educational intervention to improve data recording in the management of ischaemic heart disease in primary care. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: randomised controlled study Changes in functional health status of older women with heart disease: evaluation of a program based on self-regulation. Randomised controlled trial of health promotion in general practice for patients at high cardiovascular risk A case-management program of medium intensity does not improve cardiovascular risk factor control in coronary artery disease patients: the Heartcare I trial. Randomized controlled trial of an informatics-based intervention to increase statin prescription for secondary prevention of coronary disease Clinical outcomes in managed-care patients with coronary heart disease treated aggressively in lipid-lowering disease management clinics: the alliance study. Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial [Intensified after-care--a method for improving occupational reintegration after myocardial infarct and/or bypass operation]. Influence of coronary nursing management follow up on lifestyle after acute myocardial infarction. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Cognitive-behavioural stress management does not improve biological cardiovascular risk indicators in women with ischaemic heart disease: a randomized-controlled trial. Effects of an enhanced secondary prevention program for patients with heart disease: a prospective randomized trial. A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. 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). A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care A Case-Management System for Coronary Risk Factor Modification after Acute Myocardial Infarction Efficacy of an intensive prevention program in coronary patients in primary care, a randomised clinical trial. Effects of preventive group education on the resistance of LDL against oxidation and risk factors for coronary heart disease in bypass surgery patients Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial. Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial Five year follow up of patients at high cardiovascular risk who took part in randomised controlled trial of health promotion Clinical trial of an Internet-based case management system for secondary prevention of heart disease. The Effects of a Collaborative Peer Advisor/Advanced Practice Nurse Intervention: Cardiac Rehabilitation Participation and Rehospitalization in Older Adults After a Cardiac Event Impact of opinion leader-endorsed evidence summaries on the quality of prescribing for patients with cardiovascular disease: a randomized controlled trial. Outcomes of cardiac rehabilitation with versus without a follow-up intervention rendered by telephone (Luebeck follow-up trial): overall and gender-specific effects The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial Effects of sustained audit/feedback on self-reported health status of primary care patients. A home-based maintenance exercise program after center-based cardiac rehabilitation: effects on blood lipids, body composition, and functional capacity. [Individual outcome-oriented cardiologic rehabilitation treatment]. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care Impact of self-management education on the functional health status of older adults with heart disease. Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease Surveillance and treatment of dyslipidemia in the post-infarct patient: can a nurse-led management approach make a difference?
abstract: Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components Background Cardiac rehabilitation programs ( CRP ) represent comprehensive interventions that are typically limited to four months . Following completion of CRP , it appears that risk factors and lifestyle behaviours may deteriorate . The Extensive Lifestyle Management Intervention ( ELMI ) Following Cardiac Rehabilitation trial will investigate the benefits of a r and omized intervention to prevent these adverse changes . Methods Patients with ischemic heart disease ( IHD ) were r and omized following a st and ard CRP to the ELMI or to usual care .  The ELMI program is a case-managed intervention aim ed at individualizing risk factor and lifestyle management based on current treatment guidelines . The program consists of cardiac rehabilitation sessions , telephone follow-up and risk factor and lifestyle counselling sessions . Health professionals work with participants using behavioural counselling and communications with participants ' family physicians . Usual care participants return to their family physicians ' care , and come to the study clinic only to undergo annual outcomes assessment . The primary outcome is change in IHD global risk after four years . Secondary outcomes include combined cardiovascular events , health care utilization , lifestyle adherence , quality of life and risk factors . Results Over 28 months , 302 men and women were r and omized . This represented 29 % of the total population screened . The average age of study participants is 64 years , 18 % are women , 53 % have had a previous myocardial infa rct ion , 73 % have undergone previous revascularization and 20 % have diabetes mellitus .  Ischemic heart disease risk factors for the entire cohort improved significantly after subjects had gone through previous CRPs . Baseline risk factors , lifestyle behaviours and medications were similar between the groups . Conclusions This study population is representative of patients completing a st and ard CRP  . Results of the ELMI trial will provide valuable information for the future design of CRPs Abstract Objective : To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care . Design : A before and after pragmatic cluster r and omised controlled trial utilising a two by two incomplete block design . Setting : 60 general practice s in north east Engl and . Participants : General practitioners and practice nurses in the study practice s and their patients aged 18 or over with angina or asthma . Main outcome measures : Adherence to the guidelines , based on review of case notes and patient reported generic and condition specific outcome measures . Results : The computerised decision support system had no significant effect on consultation rates , process of care measures ( including prescribing ) , or any patient reported outcomes for either condition . Levels of use of the software were low . Conclusions : No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care . This was probably due to low levels of use of the software , despite the system being optimised as far as was technically possible . Even if the technical problems of producing a system that fully supports the management of chronic disease were solved , there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex , multiple conditions OBJECTIVE To evaluate differences between adults who participated in a secondary prevention of ischaemic heart disease ( IHD ) programme and those who did not . DESIGN Population -based cohort study . SETTING A r and om selection of 12 Irish general practice s. PARTICIPANTS A total of 493 adults with IHD identified in 2000/2001 . INTERVENTION Medical records search and postal question naires in 2000/2001 and 2005/2006 . MAIN OUTCOME MEASURES Differences in demographic characteristics and indicators of process of care and risk factor management between participants and non- participants . RESULTS Multiple logistic regression confirmed that female gender was associated with a reduced likelihood of participation in the secondary prevention programme [ odds ratio ( OR ) 0.53 ( 95 % CI : 0.32 - 0.87 ) ] , while an adequately controlled total cholesterol level was associated with an increased likelihood of enrollment [ OR 1.82 ( 95 % CI : 1.18 - 2.80 ) ] . CONCLUSIONS There is limited evidence that biases , which have been shown to affect participation in research , also affect participation in care programmes in everyday practice . A gender bias appears to have affected the enrollment of participants for the secondary preventive programme considered by this study , with enrollment favouring men with well-managed cholesterol . Reimbursement dependent upon patient adherence may incentivise the enrollment of adherent patients , although the influence of patient choice is unclear : the need to maintain records relating to patients who opt out of such interventions is thus highlighted BACKGROUND Increases in life stress have been linked to poor prognosis , after myocardial infa rct ion ( MI ) . Previous research suggested that a programme of monthly screening for psychological distress , combined with supportive and educational home nursing interventions for distressed patients , may improve post-MI survival among men . Our study assessed this approach for both men and women . We aim ed to find out whether the programme would reduce 1-year cardiac mortality for women and men . METHODS We carried out a r and omised , controlled trial of 1376 post-MI patients ( 903 men , 473 women ) assigned to the intervention programme ( n = 692 ) or usual care ( n = 684 ) for 1 year . All patients completed a baseline interview that included assessment of depression and anxiety . Survivors were also interviewed at 1 year . FINDINGS The programme had no overall survival impact . Preplanned analyses showed higher cardiac ( 9.4 vs 5.0 % , p = 0.064 ) and all-cause mortality ( 10.3 vs 5.4 % , p = 0.051 ) among women in the intervention group . There was no evidence of either benefit or harm among men ( cardiac mortality 2.4 vs 2.5 % , p = 0.94 ; all-cause mortality 3.1 vs 3.1 % , p = 0.93 ) . The programme 's impact on depression and anxiety among survivors was small . INTERPRETATION Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI . The poorer overall outcome for women , and the possible harmful impact of the intervention on women , underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials INTRODUCTION Our goal was to investigate whether ambulatory smoking cessation among patients in a cardiologic department would ( 1 ) reduce the number of smokers by at least 25 % after 12 months compared to a control group and ( 2 ) influence whether the individual patient was readmitted to hospital . We used a r and omised , controlled , prospect i ve intervention project design . MATERIAL S AND METHODS Everyone hospitalised during the project period was screened . Those who fulfilled the criteria for inclusion were r and omised for inclusion in either the intervention group or the  control group . Both groups were given the department 's smoking cessation information . In addition , the intervention group attended five ambulatory smoking cessation intervention sessions . Each patient 's smoking status was registered after 12 months . chi2-test and logistic regression analysis were used to test differences , associations and control of confounders . RESULTS In all , 3,982 patients were screened , 29.5 % of whom were smokers . The study included 105 patients : 54 in the intervention group and 51 in the control group . After 12 months , 52 % of those in the intervention group compared to 39 % in the control group had become non-smokers , which was non-significant ( p = 0,14 ) . Ischemic heart disease ( IHS ) was significantly associated with smoking cessation . After adjustment for this confounder , the result was enhanced ( p = 0,06 ) . Readmission to hospital was not affected by smoking cessation ( p = 0,73 ) . DISCUSSION Ambulatory smoking cessation intervention had no significant effect on smoking cessation on an unselected group of patients in a cardiologic hospital department . The project does indicate that ambulatory smoking cessation interventions could have an effect on patients with IHS BACKGROUND Joint consultation sessions of a small group of general practitioners ( GPs ) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients . Cardiac complaints comprise an important category of health problems with high referral rates . AIMS To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints . DESIGN OF STUDY R and omised controlled trial . SETTING Forty-nine GPs participated in 16 consultation groups , each with one of 13 cardiologists , in monthly joint consultations  over a period of about 18 months . METHOD The GPs selected patients about whom they were uncertain , and those needing urgent referral were excluded . Patients were r and omly assigned to joint consultation or to usual care . After a follow-up period all patients had a joint consultation for outcome assessment . Referral data were provided by two regional health insurance companies and question naires were given to the patients , GPs , and cardiologists to gauge their opinion of the trial . RESULTS One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol . The quality of care was similar in both groups . In the intervention group , 34 % of the patients were referred , compared with 55 % in the control group ( P = 0.001 ) , and fewer patients underwent further diagnostic procedures ( 7 % compared with 16 % , P = 0.013 ) . Referrals to cardiology as a proportion of all referrals decreased in the practice s of the participating GPs , compared with their reference districts ( P = 0.024 ) . CONCLUSION Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care Abstract Objective : To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease . Design : R and omised controlled trial of clinics over one year with assessment by self completed postal question naires and audit of medical records at the start and end of the trial . Setting : R and om sample of 19 general practice s in northeast Scotl and . Subjects : 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound . Intervention : Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures : Health status measured by the SF-36 question naire , chest pain by the angina type specification , and anxiety and depression by the hospital anxiety and depression scale . Use of health services before and during the study . Results : There were significant improvements in six of eight health status domains ( all functioning scales , pain , and general health ) among patients attending the clinic . Role limitations attributed to physical problems improved most ( adjusted difference 8.52 , 95 % confidence interval 4.16 to 12.9 ) . Fewer patients reported worsening chest pain ( odds ratio 0.59 , 95 % confidence interval 0.37 to 0.94 ) . There were no significant effects on anxiety or depression . Fewer intervention group patients required hospital admissions ( 0.64 , 0.48 to 0.86 ) , but general practitioner consultation rates did not alter . Conclusions : Within their first year secondary prevention clinics improved patients ' health and reduced hospital admissions . Key messages Nurse led clinics in general practice were used to promote secondary prevention to patients with coronary heart disease Within the first year the health of patients invited to the clinics improved Most benefit was in functional status , but chest pain improved too There was no effects on anxiety or depression There were significant reductions in hospital admissions in the first INTRODUCTION AND OBJECTIVES To assess the efficacy of cardiac rehabilitation with a mixed primary and cardiological care program in patients with low-risk myocardial infa rct ion . PATIENTS AND METHOD The participants in this 12-month prospect i ve study were 153 consecutive patients with low-risk myocardial infa rct ion ( MI ) referred to their primary care center for follow-up care . Of these patients , 113 were referred to a mixed primary and specialized care program that included physical exercise , cardiovascular risk control , an antismoking program , health education talks and psychological evaluation . The other 40 patients served as controls . We analyzed the results after 3 months and 1 year of follow-up . RESULTS There were no differences between the two groups at baseline . After 1 year , improvements were seen in smoking habit ( 4.6 % vs 15.6 % ; P<.05 ) and body mass index ( 26 [ 2 ] vs 29 [ 2 ] ; P<.05 ) . Dyslipidemia , glucose and blood pressure were similar in both groups after follow-up . Greater improvements in the group of patients who participated in the program were seen after 1 year in quality of life ( 78 [ 2 ] vs 91 [ 2 ] ; P<.05 ) , exercise capacity ( 10.3 [ 2 ] vs 8.4 [ 3 ] ; P<<.01 ) and return to active employment ( 84.6 % vs 53.3 % ; P<.05 ) . CONCLUSIONS After 1 year of follow-up , the cardiac rehabilitation program coordinated by cardiological and primary care services for low-risk post-MI patients improved quality of life , and increased exercise tolerance , active employment , and the number of participants who quit smoking . The mixed program also reduced body mass index . These results suggest the need for similar programs Aim : To compare prognosis for patients with a diagnosis of angina alone to patients postacute myocardial infa rct ion ( AMI ) and /or revascularisation and /or angina . Design : Community-based retrospective cohort study . Setting : A r and om selection of 37 Irish general practice s. Participants : 1,609 adults with ischaemic heart disease ( IHD ) identified in 2000/1 . Intervention : Medical records search es and postal question naires in 2000/1 and 2005/6 . Outcome measures : Primary : all-cause and IHD-related mortality . Secondary :  acute myocardial infa rct ion ( AMI ) , cardiac artery bypass grafting ( CABG ) and percutaneous transluminal coronary angioplasty ( PTCA ) ; physical and mental health status as measured by SF36 and SF12 ; process of care measurements and behavioural risk factor outcomes . Results : Compared with patients with previous AMI and /or revascularisation , patients with angina alone had slightly lower risks of all-cause and IHD-related death : however , although hazard ratios of 0.73 ( 95 % CI 0.55 to 0.98 ) and 0.65 ( 95 % CI 0.44 to 0.98 ) , respectively , were significant at the p<0.05 level , they were not significant at the p<0.01 level currently suggested as appropriate in observational research . Proportional hazards models identified no statistically significant differences in adjusted risks of subsequent AMI , CABG or PTCA between patients with angina-alone and those with other IHD . Over the 4.5-year follow-up , physical functioning was consistently lower among those with angina alone , and the extent to which physical functioning was increasingly impaired was slightly greater . Conclusions : Prognosis to death or cardiac outcomes for patients with angina alone was similar to those with previous AMI and /or revascularisation , while health status was poorer . The clinical importance of angina should not be underestimated in primary care . Further descriptive research is needed among representative community cohorts of people with angina BACKGROUND This study examined the 1-year effects of a minimal-contact smoking cessation intervention for cardiac in patients . METHODS The multicenter study included cardiac in patients who had smoked prior to hospitalization . A pretest-posttest quasi-experimental design was used . Patients ' experimental condition depended on the hospital they were assigned to . The design was partially r and omized : 4 of the 11 hospitals selected the experimental condition themselves ( 2 experimental , 2 control ) , while the remaining 7 hospitals were r and omly assigned . The experimental group consisted of patients of 5 hospitals ( N = 388 ) . Patients of 6 other hospitals served as the control group ( N = 401 ) . The intervention included stop-smoking advice by the cardiologist , brief counseling by the nurse , the provision of self-help material s , and aftercare by the cardiologist . RESULTS Logistic regression analyses controlling for baseline differences and covariates did not show significant intervention effects on point prevalence and continuous abstinence . The study also showed that the outcomes were not significantly related to the way hospitals were assigned to the experimental condition . CONCLUSIONS While short-term effects were found , the minimal-contact intervention did not result in significant effects after 12 months , at least if patients lost to follow-up were treated as posttest smokers . Efforts should be made to improve the intervention , especially the aftercare Objective To evaluate whether  nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease . Design R and omised controlled trial . Setting A r and om sample of 19 general practice s in northeast Scotl and . Patients 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease , but without terminal illness or dementia and not housebound .  Intervention Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures Components of secondary prevention assessed at baseline and one year were : aspirin use ; blood pressure management ; lipid management ; physical activity ; dietary fat ; and smoking status . A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient . Results There were significant improvements in aspirin management ( odds ratio 3.22 , 95 % confidence interval 2.15 to 4.80 ) , blood pressure management ( 5.32 , 3.01 to 9.41 ) , lipid management ( 3.19 , 2.39 to 4.26 ) , physical activity ( 1.67 , 1.23 to 2.26 ) and diet ( 1.47 , 1.10 to 1.96 ) . There was no effect on smoking cessation ( 0.78 , 0.47 to 1.28 ) . Of six possible components of secondary prevention , the baseline mean was 3.27 . The adjusted mean improvement attributable to intervention was 0.55 of a component ( 0.44 to 0.67 ) . Improvement was found regardless of practice baseline performance . Conclusions  Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease . Most patients gained at least one effective component of secondary prevention and , for them , future cardiovascular events and mortality could be reduced by up to a third BACKGROUND Disease management programs ( DMPs ) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status . Evaluations of cardiac DMPs delivered by home health nurses are required . METHODS Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes . Patients who agreed were r and omly assigned to participate in a DMP or to receive usual care .  The DMP included 6 home visits by a cardiac-trained nurse , a st and ardized nurses ' checklist , referral criteria for specialty care , communication with the family physician and patient education . We measured readmission days per 1000 follow-up days for angina , congestive heart failure ( CHF ) and chronic obstructive pulmonary disease ( COPD ) ; all-cause readmission days ; and provincial cl aims for emergency department visits , physician visits , diagnostic or therapeutic services and laboratory services . RESULTS We screened 715 consecutive patients admitted with elevated cardiac markers between August 1999 and August 2000 . Of those screened 71 DMP and 75 usual care patients met the diagnostic criteria for myocardial infa rct ion , were eligible for visits from a home health nurse and consented to participate in the study . Readmission days for angina , CHF and COPD per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( incidence density ratio [ IDR ] = 1.59 , 95 % confidence interval [ CI ] 1.27 - 2.00 , p < 0.001 ) . All-cause readmission days per 1000 follow-up days were significantly higher for usual care patients than for DMP patients ( IDR = 1.53 , 95 % CI 1.37 - 1.71 , p < 0.001 ) . The difference in emergency department encounters per 1000 follow-up days was significant ( IDR = 2.08 , 95 % CI 1.56 - 2.77 , p < 0.001 ) . During the first 25 days after discharge , there were significantly fewer provincial cl aims su bmi tted for DMP patients than for usual care patients for emergency department visits ( p = 0.007 ) , diagnostic or therapeutic services ( p = 0.012 ) and laboratory services ( p = 0.007 ) . INTERPRETATION The results provide evidence that an appropriately developed and implemented community-based inner-city DMP delivered by home health nurses has a positive impact on patient outcomes STUDY OBJECTIVE To develop and evaluate a peer review group ( PRG ) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infa rct ion . DESIGN Prospect i ve follow-up study . DATA SOURCE General practitioners ' computerized patients records ( intervention patients ) and the PHARMO record linkage system  ( controls ) . PATIENTS Forty patients in the intervention group and 1030 control patients ; both groups had documented myocardial infa rct ion . INTERVENTION The intervention , which was based on the principles of group academic detailing , consisted of scoring current cardiovascular treatment on separate forms for each patient , presenting an overview of , and discussing , evidence -based treatment after myocardial infa rct ion , defining the target population , formulating a binding consensus , and identifying patients who were eligible for improvement of pharmacotherapy . MEASUREMENTS AND MAIN RESULTS Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention . Of the patients who received the intervention and were not treated according to the PRG consensus at baseline , 40 % received treatment according to the consensus 12 months after the PRG meeting . In the control group , the  proportion of patients was 9.5 % ( prevalence ratio 4.2 , 95 % confidence interval 1.8 - 9.7 ) . CONCLUSION Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infa rct ion BACKGROUND Despite national efforts to improve cholesterol management for patients with coronary artery disease , many patients are not reaching recommended cholesterol target levels . We sought to determine whether a nurse-based educational intervention , design ed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein ( LDL ) cholesterol target levels and encourage partnership with physicians , could increase adherence with National Cholesterol Education Program target levels ( LDL cholesterol level < or = 100 mg/dL ) . METHODS Patients hospitalized with confirmed coronary artery disease were r and omized to undergo a  nurse-based educational intervention ( 375 patients ) or usual care ( 381 patients ) for a 12-month period after hospitalization . The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization . The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels . RESULTS The groups were similar at baseline in demographic and clinical characteristics , percent at LDL cholesterol target level ( 43.9 % and 41.1 % , respectively ) , and percent with knowledge of LDL cholesterol target levels ( both 5 % ) . The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention ( 70.2 % ) and usual care group ( 67.4 % , P = .46 ) . At the conclusion of the trial , patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group ( 19.6 % and 6.7 % , respectively , P = .001 ) , but this was not associated with improved cholesterol management . CONCLUSIONS Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization . Although the intervention improved patient knowledge of LDL cholesterol target levels , overall rates of LDL cholesterol knowledge remained low , and it was not associated with improved cholesterol management OBJECTIVE to examine the effects and feasibility of educating and empowering older people with ischaemic heart disease using trained senior lay health mentors . DESIGN r and omised controlled trial with blinded evaluation . SETTING Falkirk and District Royal Infirmary . PARTICIPANTS in patients and out patients aged 60 or over attending secondary care with a diagnosis of angina or acute myocardial infa rct ion . Three-hundred and nineteen entered and 289 completed exit assessment s. The intervention group took part in mentoring groups for 1 year , meeting monthly for 2 hours , each led by two trained lay health mentors in addition to st and ard care . MAIN OUTCOME MEASURES primary outcome measures were changes in coronary risk factors , medication usage and actual use of secondary care health services . Secondary outcomes were total and cardiovascular events ; changes in medication compliance , non-medical support requirement , health status and psychological functioning , and social inclusion . RESULTS there were significant improvements in a reported current exercise score ( mean + 0.33 , + 0.02 to + 0.52 ) , in the average time spent walking per week by 72 minutes ( + 1 to + 137 minutes ) , and in the SF36 Physical Functioning Score ( + 6.1 , + 2.4 to + 9.5 ) . There was a 1.0 % reduction in total fat ( 95 % CI -3.0 % to -0.6 % ) and a 0.6 % reduction in saturated fat ( 95 % CI -1.5 % to -0.03 % ) . The intervention group showed reduced outpatient attendance for coronary heart disease ( -0.25 appointments , -0.61 to -0.08 ) . Attendance rates were high . Socio-economic grouping did not affect participation . CONCLUSIONS Lay Health Mentoring is feasible , practical and inclusive , positively influencing diet , physical activity , and health re source utilisation in older subjects with ischaemic heart disease without causing harm BACKGROUND Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality st and ards in primary care difficult to demonstrate . The aim of this study was to examine the effect of an educational intervention on data quality in primary care . METHODS A before- and -after study of key data quality measures was carried out in 87 general practice s in eight primary care organizations in Engl and in phase 1 and 84 general practice s in phase 2 . The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2 . The main outcome measures were improvement in the completeness and quality of the computerized medical record . Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice . Data quality workshops were arranged , in which reflection can take place , backed up by summary statistics . Practice visits provided training and personalized feedback of patients needing intervention . RESULTS In the patients with heart disease , nearly 16,000 new clinical entries were made in the key improvement areas . The percentage of patients advised to quit smoking increased by 49.3 per cent , from 23.6 per cent to 61.9 per cent . There were also significant improvements in many other aspects of management . CONCLUSION Focused interventions that provide targeted and relevant clinical information can be implemented in primary care . Such interventions can lead to a rise in data quality in primary care , but their effectiveness needs to be further tested in more rigorous research setting s such as r and omized controlled trials 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 Abstract Objective : To study the efficacy of case method learning , for general practitioners , on patients ' lipid concentrations in the secondary prevention of coronary artery disease . Design : Prospect i ve controlled trial . Setting : Södertälje , Stockholm County , Sweden . Participants : 255 consecutive patients with coronary artery disease . Intervention : Guidelines were mailed to all general practitioners ( n=54 ) and presented at a common lecture . General practitioners who were r and omised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period . A locally well known cardiologist served as a facilitator . Main outcome measure : Concentration of low density lipoprotein cholesterol at baseline and after two years . Analysis according to intention to treat ( intervention and control groups ( n=88 ) ) was based on group affiliation at baseline . Results : Low density lipoprotein cholesterol was reduced by 0.5 mmol/l ( 95 % confidence interval 0.2 to 0.8 mmol/l ) ( 9.3 % ( 2.9 % to 15.8 % ) ) from baseline in patients in the intervention group and by 0.5 ( 0.1 to 0.9 ) mmol/l compared with controls ( P<0.05 ) . No change occurred in the control group ( 0.0 ( −0.2 to 0.2 ) mmol/l ) . Low density lipoprotein cholesterol decreased by 0.6 ( 0.4 to 0.8 ) mmol/l in a group of patients who received specialist care . Conclusion : Case method learning result ed in a lowering of low density lipoprotein cholesterol in the primary care patients with coronary artery disease comparable to that achieved at a specialist clinic . Conventional presentation of practice guidelines had no effect OBJECTIVES This study involving 570 women aged 60 years or older with heart disease , assessed the effects of a disease management program on physical functioning , symptom experience , and psychosocial status . METHODS Women were r and omly assigned to control or program groups . Six to eight women met weekly with a health educator and peer leader over 4 weeks to learn self-regulation skills with physical activity as the focus . Evaluative data were collected through telephone interviews , physical assessment s , and medical records at baseline and 4 and 12 months post baseline . RESULTS At 12 months , compared with controls , program women were less symptomatic ( p < .01 ) , scored better on the physical dimension of the Sickness Impact Profile ( SIP ; p < 0.05 ) , had improved ambulation as measured by the 6-minute walk ( p < 0.01 ) , and lost more body weight ( p < .001 ) . No differences related to psychosocial factors as measured by the SIP were noted . CONCLUSION A self-regulation-based program that was provided to older women with heart disease and that focused on physical activity and disease management problems salient to them , improved their physical functioning and symptom experience . Psychosocial benefit was not evident and may be a result of measurement error or due to insufficient program time spent on psychosocial aspects of functioning Abstract Objective : To assess the value of health education for patients with angina in reducing risk factors for cardiovascular disease and lessening the effect of angina on everyday activities . Design : R and omised controlled trial of personal health education given every four months . Setting : 18 general practice s in the greater Belfast area . Subjects : 688 patients aged less than 75 years and known to have had angina for at least six months ; 342 r and omised to receive education and 346 to no education .  Main outcome measures : Restriction of everyday activities , dietary habit , smoking habit , frequency of physical exercise ; blood pressure , body mass index , and serum total cholesterol concentration at entry to trial and after two years . Results : 317 in the intervention group and 300 in the control group completed the trial . At the two year review more of the intervention group ( 140 , 44 % ) reported taking daily physical exercise than the control group ( 70 , 24 % ) . The intervention group also reported eating a healthier diet than the control group and less restriction by angina in any everyday activity . No significant differences were found between the groups in smoking habit , systolic or diastolic blood pressure , cholesterol concentration , or body mass index . Conclusion : Despite having no significant effect on objective cardiovascular risk factors , personal health education of patients with angina seems to increase exercise and improve dietary habits and is effective in lessening the restriction of everyday activities BACKGROUND Case-management programs for secondary prevention of coronary artery disease that utilize extensive re sources can reduce cardiovascular risk factors , but less intensive approaches have failed to show benefits . This r and omized trial evaluated whether a medium intensity case-management program improves risk factor control in patients with coronary artery disease . METHODS We assigned 201 consecutive patients hospitalized for acute coronary events in the intensive care unit of University Hospital , Basel , Switzerl and , to either a risk factor case-management program ( n = 99 ) or care as usual ( n = 102 ) using the patients ' primary care physicians as the unit of r and omization ( cluster r and omization ) . The case-management program consisted of an hour of counseling by a clinician during hospitalization and two short reminders by phone and mail 3 and 6 months later . Treatment decisions were left to patients and their primary care physicians . RESULTS After 9 and 18 months of follow-up , there were no significant differences in lipid values , blood pressure control , fasting blood glucose , body-mass index , or number of smokers between the two groups . However , significantly more patients in the intervention group than in the care as usual group achieved target cholesterol values after 18 months ( 48 % versus 27 % , P = 0.002 and remained significant after Bonferroni-Holms correction ) but not after 9 months of follow-up ( 31 % versus 27 % , P > 0.2 ) . CONCLUSION This hospital-based case-management and outreach program , limited to counseling by a clinician , did not substantially improve cardiovascular risk factor control among patients hospitalized for coronary events OBJECTIVE : Suboptimal treatment of hyperlipidemia in patients with coronary artery disease ( CAD ) is well documented . We report the impact of a computer-assisted physician-directed intervention to improve secondary prevention of hyperlipidemia . DESIGN AND SETTING : Two hundred thirty-five patients under the care of 14 primary care physicians in an academically affiliated practice with an electronic health record were enrolled in this proof-of-concept physician-blinded r and omized , controlled trial . Each patient with CAD or risk equivalent above National Cholesterol Education Program-recommended low-density lipoprotein ( LDL ) treatment goal for greater than 6 months was r and omized , stratified by physician and baseline LDL . Physicians received a single e-mail per intervention patient . E-mails were visit independent , provided decision support , and facilitated “ one-click ” order writing . MEASUREMENTS : The primary outcomes were changes in hyperlipidemia prescriptions , time to prescription change , and changes in LDL levels . The time spent using the system was assessed among intervention patients . RESULTS : A greater proportion of intervention patients had prescription changes at 1 month ( 15.3 % vs 2 % , P=.001 ) and 1 year ( 24.6 % vs 17.1 % , P=.14 ) . The median interval to first medication adjustment occurred earlier among intervention patients ( 0 vs 7.1 months , P=.005 ) . Among patients with baseline LDLs > 130 mg/dL , the first postintervention LDLs were substantially lower in the intervention group ( 119.0 vs 138.0 mg/dL , P=.04 ) . Physician processing time was under 60 seconds per e-mail . CONCLUSION : A visit-independent disease management tool result ed in significant improvement in secondary prevention of hyperlipidemia at 1-month postintervention and showed a trend toward improvement at 1 year OBJECTIVES This study sought to determine if an aggressive , focused low-density lipoprotein cholesterol (LDL-C)-lowering strategy was superior to usual care for coronary heart disease ( CHD ) patients enrolled in health maintenance organization or Veterans Administration setting s. BACKGROUND Statin therapy benefits are well established . No prospect i ve , r and omized studies have tested strategies to optimize these benefits in a " real-world " setting . METHODS A total of 2,442 CHD patients with hyperlipidemia were r and omized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average . Atorvastatin-group patients were titrated to LDL-C goals of < 80 mg/dl ( 2.1 mmol/l ) or a maximum atorvastatin dose of 80 mg/day . Usual-care patients received any treatment deemed appropriate by their regular physicians . End point assessment s were complete in 958 atorvastatin-group and 941 usual-care patients . Partial assessment s occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events , withdrawn consent , or follow-up loss . The primary efficacy parameter was time to first cardiovascular event . RESULTS A total of 289 ( 23.7 % ) patients in the atorvastatin group compared with 333 ( 27.7 % ) patients in the usual care group experienced a primary outcome ( hazard ratio , 0.83 ; 95 % confidence interval 0.71 to 0.97 , p = 0.02 ) . This reduction in morbidity was largely due to fewer non-fatal myocardial infa rct ions ( 4.3 % vs. 7.7 % , p = 0.0002 ) . Levels of LDL-C were reduced more ( 34.3 % vs. 23.3 % , p < 0.0001 ) and National Cholesterol Education Program goals ( LDL-C < 100 mg/dl ) more likely met at end-of- study visits ( 72.4 % vs. 40.0 % ) in patients receiving atorvastatin compared with those receiving usual care . CONCLUSIONS An aggressive , focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD Objective To test the effectiveness of a complex intervention design ed , within a theoretical framework , to improve outcomes for patients with coronary heart disease . Design Cluster r and omised controlled multicentre trial . Setting General practice s in Northern Irel and and the Republic of Irel and , regions with different healthcare systems . Participants 903 patients with established coronary heart disease registered with one of 48 practice s. Intervention Tailored care plans for practice s ( 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 review s every four months at the practice s. Control practice s 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 IS RCT N24081411 Objective To evaluate the effectiveness of a structured group education programme on biomedical , psychosocial , and lifestyle measures in people with newly diagnosed type 2 diabetes . Design Multicentre cluster r and omised controlled trial in primary care with r and omisation at practice level . Setting 207 general practice s in 13 primary care sites in the United Kingdom . Participants 824 adults ( 55 % men , mean age 59.5 years ) . Intervention A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care . Main outcome measures Haemoglobin A1c levels , blood pressure , weight , blood lipid levels , smoking status , physical activity , quality of life , beliefs about illness , depression , and emotional impact of diabetes at baseline and up to 12 months . Main results Haemoglobin A1c levels at 12 months had decreased by 1.49 % in the intervention group compared with 1.21 % in the control group . After adjusting for baseline and cluster , the difference was not significant : 0.05 % ( 95 % confidence interval −0.10 % to 0.20 % ) . The intervention group showed a greater weight loss : −2.98 kg ( 95 % confidence interval −3.54 to −2.41 ) compared with 1.86 kg ( −2.44 to −1.28 ) , P=0.027 at 12 months . The odds of not smoking were 3.56 ( 95 % confidence interval 1.11 to 11.45 ) , P=0.033 higher in the intervention group at 12 months . The intervention group showed significantly greater changes in illness belief scores ( P=0.001 ) ; directions of change were positive indicating greater underst and ing of diabetes . The intervention group had a lower depression score at 12 months : mean difference was −0.50 ( 95 % confidence interval −0.96 to −0.04 ) ; P=0.032 . A positive association was found between change in perceived personal responsibility and weight loss at 12 months ( β=0.12 ; P=0.008 ) . Conclusion A structured group education programme for patients with newly diagnosed type 2 diabetes result ed in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A1c levels up to 12 months after diagnosis . Trial registration Current Controlled Trials IS RCT N17844016 Occupational reintegration after coronary heart disease of patients who are insured by the German workers pension ( Arbeiterrentenversicherung ) succeeds in 40 - 60 % of the recorded cases . Patients who were not able to return to work after finishing their regular cardiac rehabilitation took part in a program called " Intensivierte Nachsorge ( INA ) " . INA is an interdisciplinary support program , taking place twice a week for a whole day over a period of six weeks . On the remaining three days patients were either progressively reintegrated into their working place or stayed at home . The results of the INA group were compared to those of a control group . Two years after patients had terminated the cardiac rehabilitation , statistically significant effects could still be found : 70.2 % of the INA group had returned to work compared to 52.6 % of the control group . This is a difference of 17.6 % . After the results had been corrected by considering age differences between the two groups , the control group had a recalculated return to work rate of 57.4 % . A significant difference of 12.8 % could still be identified with respect to the INA group . Support programs which follow regular cardiac rehabilitation seem to be specially suitable for older patients with highly perceived job strain , because our results showed that these patients had lower return to work rates . 44.2 % of the INA group and 21.9 % of the control group were progressively reintegrated into their work place . Two years after their regular rehabilitation 36.3 % of the INA group patients took part in ambulatory heart groups compared with 10.4 % of the control group . It was also found that patients of the INA group showed improvements in activities of daily life . The INA program however does not seem to have an influence on behavioral components such as eating habits , relaxation , and smoking as well as on the psychological status . The physical fitness measured in watt x min at the beginning of the INA program ( T1 ) was 589.46 + /- 255.03 in the control group . This number increased to 598.32 + /- 276.01 six months after regular rehabilitation ( T3 ) and continued to rise to 661.15 + /- 362.01 after two years ( T4 ) . In the INA group the numbers were as follows : 658.13 + /- 263.63 at T1 , 751.83 + /- 318.15 at T3 , and 717.93 + /- 336.76 at T4 . The differences between the groups are significant at T1 and T3 , whereas at T4 there is no significant difference . It should also be stated that the lipid parameters indicated no differences between the groups except for the triglyceride values which were significantly lower statistically in the INA group than in the control group OBJECTIVE : To examine the ability of a secondary prevention programme to improve the lifestyle in myocardial infa rct ion patients aged 50 - 70 years . DESIGN : Habitual physical activity , food habits , and smoking habits were assessed from question naires at admission to hospital and at the one year follow up . Initially , all patients were invited to join an exercise programme and were informed about cardiovascular risk factors . Four weeks after discharge from the hospital , 87 patients were r and omised to follow up at the coronary prevention unit by a special trained nurse ( the intervention group )  , and 81 to follow up by their general practitioners (  the  usual care group ) . After r and omisation , the intervention group was educated about the effects of smoking cessation , dietary management , and regular physical activity . The intervention group also participated in a physical training programme two to three times weekly for 10 - 12 weeks . MAIN RESULTS : 89 % of the patients referred to the intervention group improved their food habits compared with 62 % of the patients referred to the usual care group ( P = 0.008 ) . Furthermore , 50 % of the smokers referred to the intervention group stopped smoking compared to 29 % in the usual care group ( P = 0.09 ) . Changes in physical activity did not differ between the groups . CONCLUSIONS : This secondary prevention programme based on a nurse rehabilitator was successful in improving food habits in patients with acute myocardial infa rct ion . Initiating the smoking cessation programme during the hospital stay followed by repeated counselling during follow up might have improved the results . The exercise programme had no advantage in supporting physical activity compared to usual care BACKGROUND Although primary care is the major target of coronary heart disease ( CHD ) clinical recommendations , little is known of how community physicians view guidelines and their implementation . The REACT survey was design ed to assess the views , and perceived implementation , of CHD and lipid treatment guidelines among primary care physicians . METHODS Semi-structured vali date d telephone interviews were conducted , in the relevant native tongue , with 754 r and omly selected primary care physicians ( GPs and family doctors ) in five European countries ( France , Germany , Italy , Sweden and the UK ) . RESULTS Most physicians ( 89 % ) agreed with the content of current guidelines and reported use of them ( 81 % ) . However , only 18 % of physicians believed that guidelines were being implemented to a major extent . Key barriers to greater implementation of guidelines were seen as lack of time ( 38 % of all physicians ) , prescription costs ( 30 % ) , and patient compliance ( 17 % ) . Suggestions for ways to improve implementation centred on more education , both for physicians themselves ( 29 % ) and patients ( 25 % ) ; promoting , publicizing or increasing guideline availability ( 23 % ) ; simplifying the guidelines ( 17 % ) ; and making them clearer ( 12 % ) . Physicians perceived diabetes to be the most important risk factor for CHD , followed by hypertension and raised LDL-C. Most physicians ( 92 % ) believe their patients do associate high cholesterol levels with CHD . After establishing that a patient is ' at risk ' of CHD , physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required . Factors preventing this included insufficient time ( 42 % ) , having too many other patients to see ( 27 % ) and feeling that patients did not listen or underst and anyway ( 21 % ) . CONCLUSIONS Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations . This need is recognized by clinicians OBJECTIVES Psychosocial factors , such as stress and vital exhaustion , are associated with an increased risk of cardiovascular events , and women report more psychosocial ill-being after an acute myocardial infa rct ion than men . We have earlier shown that a cognitive-behavioural intervention in women with ischaemic heart disease ( IHD ) improved psychosocial well-being . In the present study , we tested the hypothesis that the improvement in psychosocial well-being is associated with an improvement in biochemical indicators of cardiovascular risk . DESIGN R and omized-controlled trial in northern Sweden . SETTING Outpatient care . SUBJECTS Women with IHD were r and omized to either a 1-year cognitive-behavioural stress management programme or usual care . Of the 159 women who completed the study , 77 were in the intervention group , and 82 in the control group . INTERVENTIONS A 1-year cognitive-behavioural stress management programme versus conventional care . RESULTS Group assignment was not found to be a determinant of waist circumference , high sensitive C-reactive protein ( hs-CRP ) , fibrinogen , von Willebr and factor ( vWF ) , plasminogen activator inhibitor type 1 ( PAI-1 ) activity , tissue plasminogen activator ( tPA ) activity , tPA antigen , tPA-PAI-1 complex , leptin , or HOMA2 insulin resistance index ( HOMA2-IR ) at follow up . Changes in psychosocial variables were not associated with changes in any of the biological risk indicators . CONCLUSIONS Even if our cognitive-behavioural stress management programme had effects on proximal targets , such as stress behaviour and vital exhaustion , we found no improvement in intermediate biochemical targets related to the metabolic syndrome and IHD . Our results challenge the proposition that the relationship between psychological well-being and biological cardiovascular risk indicators is a direct cause-effect phenomenon BACKGROUND Secondary prevention medications in cardiac patients improve outcomes . However , prescription rates for these drugs and long-term adherence are suboptimal . OBJECTIVE To determine whether an enhanced secondary prevention program improves outcomes . METHODS Hospitalized patients with indications for secondary prevention medications were r and omly assigned to either usual care or an intervention arm , in which an intensive program was used to optimize prescription rates and long-term adherence . Follow-up was 19 months . RESULTS A total of 2643 patients were r and omly assigned in the study ; 1342 patients were assigned to usual care and 1301 patients were assigned to the intervention arm .  Prescription rates were near optimal except for lipid-lowering medications . Rehospitalization rates per 100 patients were 136.2 and 132.6 over 19 months in the usual care and intervention groups , respectively ( P=0.59 ) . Total days in hospital per patient were similar ( 10.9 days in the usual care group versus 10.2 days in the intervention group ; P not significant ) . Crude mortality was 6.2 % and 5.5 % in the usual care and intervention groups , respectively , with no significant difference ( P=0.15 ) in overall survival . Post hoc analysis suggested that after the study team became experienced , days in hospital per patient were reduced by the program ( 11.1+/-0.91 and 8.9+/-0.61 in the usual care and intervention groups , respectively ; P<0.05 ) . CONCLUSIONS The intervention program failed to improve outcomes in the present study . One explanation for these results is the near optimal physician compliance with guidelines in both groups . It is also possible that a substantial learning curve for the staff was involved , as suggested by the reduction in total days in hospital in the intervention patients during the second part of the study AIM The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu , China . BACKGROUND Epidemiological studies indicate a dose- , level- and duration -dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality . Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes . DESIGN METHODS A r and omized controlled trial was conducted . Coronary heart disease patients ( n = 167 ) who met the sampling criteria in two tertiary medical centres in Chengdu , south-west China , were r and omly assigned to either an intervention group ( the cardiac rehabilitation programme ) or control group ( the routine care ) . The change of health behaviours ( walking performance , step II diet adherence , medication adherence , smoking cessation ) and physiological risk parameters ( serum lipids , blood pressure , body weight ) were assessed to evaluate the programme effect . RESULTS Patients in the intervention group demonstrated a significantly better performance in walking , step II diet adherence , medication adherence ; a significantly greater reduction in serum lipids including triglyceride , total cholesterol , low-density lipoprotein ; and significantly better control of systolic and diastolic blood pressure at three months . The majority of these positive impacts were maintained at six months . The effect of the programme on smoking cessation , body weight , serum high-density lipoprotein , was not confirmed . CONCLUSIONS A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients . Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease . RELEVANCE TO CLINICAL PRACTICE This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients . Furthermore , the hospital-home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care OBJECTIVE : To measure the potential for secondary prevention of coronary disease in the United Kingdom . DESIGN : Cross sectional survey of a representative sample of coronary patients from a retrospective review of hospital medical records and patient interview and examination . SETTING : Stratified r and om sample of 12 specialist cardiac centres and 12 district general hospitals drawn from 34 specialist cardiac centres and 261 district general hospitals in 12 geographic areas in the United Kingdom . SUBJECTS : 2583 patients < or = 70 yr ; 25 consecutive males and 25 consecutive females identified retrospectively in each of four diagnostic categories : coronary artery bypass grafting , percutaneous transluminal coronary angioplasty , acute myocardial infa rct ion , and acute myocardial ischaemia without evidence of infa rct ion . MAIN OUTCOME MEASURES : Risk factor recording and management in medical records ; the prevalence and control of risk factors at interview six months after the procedure or event . RESULTS : Recording of coronary risk factors in patient 's records was incomplete and this varied by risk factor . Smoking habit and blood pressure were most completely recorded , whereas a history of hyperlipidaemia and blood cholesterol concentrations were least complete . Risk factor records were more likely to be complete in cardiac centres than in district hospitals . At interview 10 % to 27 % of patients were still smoking cigarettes and 75 % remained overweight , females more severely so . Up to a quarter of patients remained hypertensive , males more severely so than females . Over three quarters had a total cholesterol > 5.2 mmol/l . In patients on medication for blood pressure , cholesterol or glucose , risk factor profiles were little better than in those who were not . Only about one patient in three was taking a beta blocker after infa rct ion . Up to a fifth of patients who had had acute myocardial ischaemia were not taking aspirin at follow up . CONCLUSIONS : There is considerable potential to reduce the risk of a further major ischaemic event in patients with established coronary disease . This can be achieved by effective lifestyle intervention , the rigorous management of blood pressure and cholesterol , and the appropriate use of prophylactic drugs 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 Table . SI Units Systematic modification of coronary risk factors is not integrated into the medical care provided to most of the more than 1 million patients treated annually in the United States for acute myocardial infa rct ion by percutaneous transluminal coronary angioplasty or coronary artery surgery .  Most of such patients have lipoprotein abnormalities [ 1 ] , and nearly one half smoke [ 2 ] . These risk factors , which contribute to subsequent morbidity and mortality , remain highly prevalent after acute cardiac events . Failure to integrate comprehensive risk factor modification into the st and ard medical care provided to patients after acute cardiac events primarily reflects the lack of an organizational framework or system . This deficiency in re source allocation for preventive and rehabilitative aspects of care in turn reflects the predominant orientation of the U.S. health care system to the management of acute illness [ 3 ] . Several clinical research studies have shown the effectiveness of risk factor modification , especially treatment of lipoprotein abnormalities [ 4 - 7 ] , in achieving regression of coronary artery lesions and reducing the clinical consequences of coronary artery disease [ 6 , 7 ] . However , risk factor interventions shown to be effective in clinical trials may not prove equally effective in clinical practice because of a paucity of re sources , especially nonphysician personnel . The lack of effective management systems limits the expected reduction in morbidity and mortality and the corresponding reduction in medical care costs that motivates current efforts to orient the priorities of the American health care system toward preventive and rehabilitative care . This r and omized , controlled trial compared the effectiveness of a physician-directed , nurse-managed , home-based case-management system for coronary risk factor modification with that of usual medical care . Outcomes were measured in both groups immediately after the end of the first year after acute myocardial infa rct ion . The term case-management system has been used in various context s. As used here , it refers to a system in which a nurse case-manager , working with different health care specialists ( a psychiatrist , a cardiologist , a lipid specialist , a nutritionist , and a nurse coordinator ) , managed coronary risk factors . Methods Enrollment and Orientation Program nurses enlisted patients on hospital day 3 or as soon as their medical condition stabilized . Study participants gave written informed consent to be r and omly assigned to a treatment group . Immediately after r and omization , program nurses introduced patients to the special intervention with the aid of a videotape . Usual Care The 585 patients in our study were cared for by 215 internists and 34 cardiologists in the five participating medical centers who were organized into practice groups of 5 to 10 physicians each . Cardiology consultation was often provided during hospitalization , but primary responsibility for follow-up care was generally assumed by internists . The usual care offered by the Kaiser Permanente Medical Care Program included physician counseling on smoking cessation and nutritionist counseling on dietary change during hospitalization and physician-managed , lipid-lowering drug therapy after hospital discharge . Group outpatient smoking cessation programs were available for a $ 50 fee . Group exercise rehabilitation , not generally provided by the Kaiser Permanente Medical Care Program during this study , was available to patients at various community facilities at an average cost of $ 1800 to $ 2700 for 3 months ' participation . Special Intervention The behavioral interventions in our case-management system , which were offered to the 293 patients in the intervention group in addition to usual care , were derived from social learning theory [ 8 , 9 ] and modified for medical problems [ 10 ] . In this model , persons must learn how to monitor the health habits they seek to change , set attainable sub goals to motivate and direct their efforts , use feedback of progress in ways that promote health , and enlist incentives and social support to sustain the effort needed to succeed [ 8 , 9 ] . In the hospital , patients were instructed on how to complete  self-reports [ status reports ] of smoking , dietary intake , and exercise .  Scheduled interactions between case managers and patients after discharge took three forms : 1 ) nurse-initiated telephone contacts ; 2 ) computer-generated progress reports mailed to patients based on question naires completed by patients and mailed to the nurses ; and 3 ) visits to the program nurse for treadmill exercise testing , initiation of lipid-lowering drug therapy , if indicated , and a single counseling session after a smoking relapse . The maximum number of treatment contacts during the year , including outcome measurement at 6 and 12 months , was as follows : 14 nurse-initiated telephone contacts , 8 patient visits to the blood chemistry laboratory , and 4 patient visits to the nurse case manager . Smoking Intervention Smoking was defined as the use of cigarettes , cigars , cigarillos , pipe tobacco , or any other form of tobacco in the 6 months before admission . Forty-three percent of patients were smokers . Patients who had smoked during the 6 months before hospitalization received the same intensive smoking cessation intervention during hospitalization ; this intervention has been described previously [ 11 ] . Physicians used a written script that enabled them to provide st and ardized counseling in less than 2 minutes . The hospital-based smoking cessation counseling focused on relapse prevention . Nurses conducted a st and ardized smoking history to evaluate patients ' addiction to smoking . Patients ' reported self-efficacy or confidence to resist smoking in each of 28 potentially high-risk situations was measured ; patients were then counseled on how to manage the situations in which they reported less than 70 % confidence . Patients also received a relapse prevention manual and a relaxation audiotape . They were advised that the nurse would telephone them 48 hours and 1 week after hospital discharge and at monthly intervals for as long as 6 months . Patients who relapsed were offered one additional visit with the nurse for further counseling . Nicotine polacrilex or transdermal nicotine patches were reserved for highly addicted patients who relapsed after hospital discharge . Nutritional Counseling A computer-based expert system developed by the investigators was used to provide nutritional counseling on a National Cholesterol Education Program [ 12 ] Step 2 diet that was low in cholesterol and saturated fat . A food frequency question naire design ed by the investigators was scored using the Cholesterol and Saturated Fat Index developed by Connor and colleagues [ 13 ] . Calculations of cholesterol and saturated fat totals were based on weekly rather than daily average food intakes . Data from the food frequency question naires , mailed by patients to the Stanford coordinating center and entered into a microcomputer , were used to generate progress reports that characterized patients ' dietary patterns , prioritized dietary change goals , and provided guides for managing difficult situations by directing patients to relevant sections of a nutrition workbook entitled Good Eating for Good Health developed by the program nutritionist . Patients in the intervention group completed a food frequency question naire during hospitalization that described their eating habits in the previous month . Patients also completed food frequency question naires 6 , 11 , and 26 weeks after admission . Progress reports were mailed to patients within 48 to 72 hours after the food frequency question naires were received . Detailed strategies for maintenance of dietary change were incorporated into the 26-week progress report . Question naires to evaluate outcomes were also completed at 36 and 52 weeks . Lipid-Lowering Drug Therapy The therapeutic goal of a plasma low-density lipoprotein (LDL)-cholesterol value of 2.46 mmol/L ( 95 mg/dL ) adopted for this trial was based on the mean post-treatment level of LDL cholesterol found in patients in the study by Blankenhorn and colleagues [ 4 ] . Patients with mean plasma LDL cholesterol values ( based on measurements in two separate blood sample s drawn 75 and 90 days after infa rct ion ) that exceeded this value were given initial drug therapy according to the four algorithms shown in Table 1 . Patients unable to tolerate bile acid-binding resin or nicotinic acid because of comorbid conditions or potentially adverse interactions with these agents received lovastatin or gemfibrozil . During a visit 90 days after discharge , the nurses did a brief physical examination and obtained a history relevant to hyperlipidemia . They provided detailed counseling to patients regarding the rationale for lipid-lowering drug therapy and ways to maximize drug efficacy and minimize drug side effects , and they advised patients on the schedule of laboratory visits and nurse-initiated follow-up telephone contacts . Table 1 . Initial Drug Therapy * Changes in drug therapy at 120 , 150 , and 180 days , which were coordinated by nurse-initiated telephone contacts , were based on three types of responses to initial therapy : 1 ) if lipoprotein levels returned to normal , the effective drug therapy was continued ; 2 ) if the response was incomplete , the dose of the effective medication was increased or another drug was added , or both ; and 3 ) if comorbid conditions worsened or blood chemistry abnormalities or intolerable side effects occurred , drug dosage was reduced or the patient was switched to another agent or both . A physician lipid specialist and a Stanford-based senior nurse-coordinator provided telephone consultation to the case managers . Before initiating lipid-lowering drug therapy at 90 days and at each subsequent step , nurses review ed the patients ' blood chemistry and lipoprotein values and elicited any symptoms requiring a change in therapy . The BACKGROUND Most studies that have analysed the effect of secondary prevention of coronary heart disease come from hospitals . Those that are community-based have been conducted mainly by nurses and follow-up was generally too short to show impact on cardiovascular events . METHODS This is a multi-centre r and omised controlled clinical trial in which patients in the intervention group received periodic postal reminders to see their general practitioner every three months during a 3-year follow-up . General practitioners reinforced healthy lifestyle recommendations to patients and review ed drug therapies at these quarterly intervals . Patients in the control group  received usual care . RESULTS A total of 983 patients aged 30 - 79 were included . During the 3-year follow-up , 67 patients died and 156 experienced a non-fatal cardiovascular event . The event rates and all-cause mortality were similar in the intervention and control groups ( 24.0 % and 23.5 % , and 8.1 % and 9.9 % , respectively ) . Improvement in quality of life was similar in both groups . Blood pressure and high-density lipoprotein cholesterol were more frequently within recommended levels in the intervention group than in controls : odds ratio 1.63 , 95 % confidence interval 1.05 - 2.51 , and odds ratio 2.61 , 95 % confidence interval 1.32 - 5.18 , respectively . CONCLUSIONS Intensive secondary prevention conducted by general practitioners may improve long-term blood pressure control and increase high-density lipoprotein cholesterol in patients with stable coronary disease BACKGROUND . Comprehensive preventive education for heart patients is effective in reducing cardiac events . However , very dem and ing counselling protocol s can not easily be implemented as an integral part of clinical practice in hospitals . AIM . To evaluate whether recurrent preventive group education for coronary artery bypass grafting patients affects the resistance of LDL against oxidation and the classical risk factors for coronary heart disease . METHODS . A prospect i ve , controlled study with one-year follow-up was carried out in Southern Finl and . Coronary artery bypass patients were allocated late ( S 18 months ) after the operation in the intervention and control groups . RESULTS . Seventy two patients ( 65 men and 7 women ) completed the study . Twelve-hour group education on healthy life-style had a significant ( 25 % , P = 0.01 ) but transient positive effect on the resistance of LDL against oxidation . There was a trend towards increased physical activity in the intervention group . The impact of education on patients ' weight was also more consistent ( 1.2 kg at 12 months , P < 0.05 ) , whereas long-term effects on fibrinogen and serum lipids were small . CONCLUSIONS . Repeated group education applied as an economically feasible part of specialist care had only small positive effects on patients ' risk factors . There was a significant , but transient , increase in the resistance of LDL against oxidation . However , effective lipid lowering drug treatment is indicated for most coronary artery bypass patients rather than repeated health education alone BACKGROUND Despite increasing evidence that treating dyslipidemia reduces cardiovascular events , many patients do not achieve recommended lipid targets . METHODS To determine whether showing physicians and patients the patient 's calculated coronary risk can improve the effectiveness of treating dyslipidemia in a primary care setting , patients were  r and omized  to receive usual care or ongoing feedback regarding their calculated coronary risk and the change in this risk after lifestyle changes , pharmacotherapy , or both to treat dyslipidemia . Outcomes , based on intention-to-treat analysis , included changes in blood lipid levels , coronary risk , and the frequency of reaching lipid targets . RESULTS Two hundred thirty primary care physicians enrolled 3,053 patients . After 12 months of follow-up , 2,687 patients ( 88.0 % ) remained in the study . After adjustment for baseline lipid values , significantly greater mean reductions in low-density lipoprotein cholesterol levels and the total cholesterol to high-density lipoprotein cholesterol ratio were observed in patients receiving risk profiles ( 51.2 mg/dL [ to convert to millimoles per liter , multiply by 0.0259 ] and 1.5 , respectively ) vs usual care ( 48.0 mg/dL and 1.3 , respectively ) , but the differences were small ( -3.3 mg/dL ; 95 % confidence interval [ CI ] , -5.4 to -1.1 mg/dL ; and -0.1 ; 95 % CI , -0.2 to -0.1 , respectively ) . Patients in the risk profile group were also more likely to reach lipid targets ( odds ratio , 1.26 ; 95 % CI , 1.07 to 1.48 ) . A significant dose-response effect was also noted when the impact of the risk profile was stronger in those with worse profiles . CONCLUSIONS Discussing coronary risk with the patient is associated with a small but measurable improvement in the efficacy of lipid therapy . The value of incorporating risk assessment in preventive care should be further evaluated Abstract Objectives : To determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease . Design : R and omised controlled trial . Setting : 52 general practice s in east London , 44 of which had received facilitation of local guidelines for coronary heart disease . Participants : 328 patients admitted to hospital for myocardial infa rct ion or unstable angina . Interventions : Postal prompts sent 2 weeks and 3 months after discharge from hospital . The prompts contained recommendations for lowering the risk of another coronary event , including changes to lifestyle , drug treatment , and making an appointment to discuss these issues with the general practitioner or practice nurse . Main outcome measures : Proportion of patients in whom serum cholesterol concentrations were measured;proportion of patients prescribed β blockers ( 6 months after discharge ) ; and proportion of patients prescribed cholesterol lowering drugs ( 1 year after discharge ) . Results : Prescribing of β bockers ( odds ratio 1.7,95 % confidence interval 0.8 to 3.0 , P>0.05 ) and cholesterol lowering drugs ( 1.7 , 0.8 to 3.4 , P>0.05 ) did not differ between intervention and control groups . A higher proportion of patients in the intervention group ( 64 % ) than in the control group ( 38 % ) had their serum cholesterol concentrations measured ( 2.9 , 1.5 to 5.5 , P<0.001 ) . Secondary outcomes were significantly improved for consultations for coronary heart disease , the recording of risk factors , and advice given . There were no significant differences in patients ' self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event . Conclusions : Postal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle . The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practice s. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines Health promotion programmes for patients with coronary heart disease are valuable,1 2 but there is little evidence on their lasting effect.3 A r and omised controlled trial in which patients who received personalised health promotion for two years showed significant benefits in lifestyle and quality of life.2 4 We investigated whether the differences in lifestyle , quality of life , and risk factors persisted between the two groups five years after enrolment . Patients aged under 75 who had had angina ( all grade s included ) for at least six months and no other concurrent serious illness were identified by 18 general practice s in Belfast . Their diagnosis was confirmed at interview , and they were r and omly allocated to receive either usual NHS care and personal health promotion from a trained nurse every four months for two years or usual NHS care alone . Sealed envelopes opened at interview showed group allocations . Both groups were review ed PURPOSE Despite demonstrated benefits of cardiac rehabilitation and risk factor reduction , only 11 % to 38 % of eligible patients with cardiovascular disease ( CVD ) participate in cardiac rehabilitation programs .  Women and older adults are particularly less likely to participate in cardiac rehabilitation . In an effort to broaden access to cardiac rehabilitation , the authors developed an alternative Internet-based program that allows nurse case managers to provide risk factor management training , risk factor education , and monitoring services to patients with CVD . METHODS The evaluation consisted of a r and omized , clinical trial involving 104 patients with CVD , 53 of whom used the program as a special intervention ( SI ) for 6 months and 51 of whom received usual care ( UC ) .  RESULTS The results indicate that fewer cardiovascular events occurred among the SI subjects ( 15.7 % ) than among the UC subjects ( 4.1 % ) ( P = .053 ) , result ing in a gross cost savings of $ 1418 US dollars per patient . With a projected program cost of $ 453 USD per patient , the return on investment is estimated at 213 % . More weight loss occurred in the SI group ( -3.68 pounds ) than in the UC group ( + .47 pounds ) ( P = .003 ) . The differences between the two groups in terms of blood pressure , lipid levels , depression scores , minutes of exercise , and dietary habits were not statistically significant . CONCLUSION An Internet-based case management system could be used as a cost-effective intervention for patients with CVD , either independently or in conjunction with traditional cardiac rehabilitation Background : After the cardiovascular events of myocardial infa rct ion ( MI ) and coronary artery bypass surgery ( CABS ) , unpartnered older adults are a vulnerable group that may benefit from interventions to improve health outcomes . The purpose of this analysis is to determine if a community-based collaborative peer advisor/advanced practice nurse intervention increased participation in cardiac rehabilitation programs and reduced hospital readmissions after MI and CABS and determine whether the type of cardiovascular event influenced rehospitalization . Subjects and Methods : This study was a r and omized clinical trial that enrolled 247 unpartnered older adults who were single , widowed , or divorced . Subjects were r and omized into 4 groups : st and ard of care group for MI and for CABS and st and ard of care plus the treatment groups for MI and for CABS , for 12 weeks after discharge . There were 163 women/84 men , with a mean age of 76.4 years , who were admitted for MI ( n = 93 ) or CABS ( n = 154 ) and who were enrolled from 5 academic medical centers . The treatment consisted of a community-based intervention of a home visit within 72 hours and telephone calls at 2 , 6 , and 10 weeks from an advanced practice nurse and 12 weekly telephone calls from a peer advisor .  Participation in a cardiac rehabilitation program and rehospitalizations were collected at 6 weeks and 3 , 6 , and 12 months by telephone interview . Results and Conclusions : There were significantly more participants in cardiac rehabilitation programs after 3 months in the treatment group , and this increase was seen up to 1 year after MI and CABS . There were no statistical differences , although there were fewer rehospitalizations between 3 and 6 months after MI and CABS in the treatment group compared with the st and ard of care group . Overall , the evidence from this study suggests that a community-based collaborative peer advisor/advanced practice nurse intervention can play a role in promoting active participation in cardiac rehabilitation programs and fewer rehospitalizations in unpartnered older adults after MI and CAGS BACKGROUND Local opinion leaders are educationally and socially influential physicians . Although they can accelerate the adoption of new evidence in hospitals , their impact on the quality of prescribing for out patients has only been examined by a few studies . We hypothesized that an intervention consisting of patient-specific one-page evidence summaries , generated and endorsed by local opinion leaders , would improve prescribing of angiotensin-converting enzyme ( ACE ) inhibitors or angiotensin receptor blockers ( ARBs ) in heart failure ( HF ) and that of statins in ischemic heart disease ( IHD ) . METHODS We conducted a community-based r and omized controlled trial in patients with HF ( not receiving ACE inhibitors or ARBs ) and those with IHD ( not receiving statins ) who were recruited from 40 pharmacies and allocated either to the opinion leader intervention or to usual care based on r and omization of their primary care physician . The primary outcome was an increase in the use of efficacious therapies ( ACE inhibitors or ARBs in HF and statins in IHD ) within 6 months ; the secondary outcomes were prescribing changes for HF or IHD . RESULTS A total of 171 patients participated in the study ; 87 were allocated to the intervention , whereas 84 were assigned to the  control group .  The median age of the participants was 75 years ; 103 ( 60 % ) were female , 54 ( 32 % ) had HF , and 117 ( 68 % ) had IHD . Overall , 21 ( 24 % ) intervention patients started receiving an efficacious medication within 6 months , as compared with 15 ( 18 % ) control subjects ( relative risk of improvement 1.32 , 95 % CI 0.73 - 2.40 , P = .31 ) . In the HF subgroup , 38 % of the intervention patients started receiving an ACE inhibitor or ARB therapy , as compared with 20 % of control subjects ( relative risk of improvement 1.90 , 95 % CI 0.76 - 4.72 , P = .15 ) . In the IHD subgroup , 17 % of the intervention patients and 17 % of the control subjects started receiving  statin therapy  ( P = .97 ) . CONCLUSIONS The influence of local opinion leaders may be useful for improving the quality of cardiovascular prescribing in the community , but the benefits are likely modest and may be disease specific . Further studies on this method are warranted The effects of a nurse-managed secondary prevention program for patients after acute cardiac events were examined . Special interest was given to gender-specific results . The design was a prospect i ve , r and omized , controlled trial involving 343 patients following 3 weeks of inpatient cardiac rehabilitation , r and omly assigned to either of two study groups . Patients in the treatment group were contacted monthly by phone over 1 year . The main goals of the intervention were the reduction of behavioural coronary risk factors and enhancing quality of life . The program was conducted by specially trained nurses . The control group received written information only . Primary outcome was the Framingham risk score . Follow-up examination after 12 months was completed by 297 patients . Patients in the intervention group showed lower Framingham risk scores as compared to controls . Separate analyses by sex revealed that this was mostly due to the men in the sample . Women , on the other h and , showed a significant rise of clinical ly relevant anxiety/depressiveness in the control but not in the intervention group ; in males there were no differences between study conditions . In conclusion , telephone counselling by specially trained nurses seems a cost-effective way to achieve a lasting reduction in cardiac risk factors and to maintain the effects of cardiac rehabilitation . Effekte eines von Pflegepersonal durchgefuehrten Nachsorgeprogramms fuer Koronarpatienten wurden untersucht . Besondere Aufmerksamkeit galt moeglichen Gendereffekten . Es h and elt sich um eine prospektive , r and omisierte , kontrollierte Studie . 343 Patienten wurden nach stationaerer kardiologischer Rehabilitation auf eine von zwei Studiengruppen r and omisiert . Patienten in der Interventions gruppe wurden über ein Jahr ca . einmal i m Monat telephonisch kontaktiert . Hauptziele der Intervention waren die effektive und nachhaltige Reduktion verhaltensgebundener Risikofaktoren sowie die Verbesserung der Lebensqualitaet . Das Programm wurde von speziell dafuer fortgebildetem Pflegepersonal durchgefuehrt . Die Kontrollgruppe erhielt nur schriftliches Informations material . Primaerer Endpunkt war das globale koronare Risiko ( Framingham Score ) . Von 297 Patienten wurden komplette Date n bei der Abschlussuntersuchung nach 12 Monaten erhalten . Patienten in der Interventions gruppe zeigten niedrigere Framingham-Scores als Kontrollpatienten . Getrennte Analysen nach Geschlecht ergaben , dass dieser Effekt hauptsaechlich auf die Maenner zurueckzufuehren ist ; bei den Frauen zeigten sich keine Unterschiede zwischen den Studiengruppen . Auf der and eren Seite zeigte sich bei den Frauen in der Kontrollgruppe eine deutliche Zunahme an Angst bzw . Depressivitaet ; ein entsprechender Effekt f and sich bei den Maennern nicht . Telefonische Nachsorge durch speziell fortgebildetes Pflegepersonal scheint ein kostenguenstiger Weg zu sein , koronare Risikofaktoren zu reduzieren und die Effekte von kardiologischer Rehabilitation aufrechtzuerhalten . Se evaluaron los result ados de un programa secundario de prevención dirigido por el personal de enfermería para pacientes que han sufrido un trastorno cardiovascular agudo . Se dio una especial importancia a los result ados específicos para cada sexo . Se trata de un estudio prospect ivo , aleatorizado , comparativo , en el que participaron 343 pacientes tras 3 semanas de haber recibido rehabilitación cardiovascular , a quienes se dividieron en dos grupos , de manera aleatoria . Los pacientes del grupo que recibió tratamiento fueron contactados por teléfono una vez al mes durante 1 año . Los principales objetivos de la intervención fueron reducir los factores de riesgo de las cardiopatías arterioscleróticas relacionados con el actuar de los pacientes , y mejorar la calidad de vida de éstos . La realización del programa estuvo a cargo de un grupo de enfermeras y enfermeros especialmente entrenados para ello . El grupo de referencia recibió información sólo por escrito . Los result ados iniciales se obtuvieron aplic and o la escala de riesgo de Framingham . En las valoraciones de seguimiento , realizadas tras 12 meses , participaron 292 pacientes . Los valores en la escala de riesgo de Framingham fueron más bajos en los pacientes del grupo que recibió la intervención que en el grupo de referencia . Los análisis según el sexo revelaron que el aporte mayor a este result ado provino de los varones de la muestra . Por su parte , las mujeres del grupo de referencia presentaron un aumento importante de la ansiedad/depresión relacionada con el proceso de enfermedad , lo cual no se apreció en el grupo que recibió tratamiento . Entre los varones no se apreciaron diferencias relacionadas con las condiciones del estudio . En conclusión , el apoyo emocional por vía telefónica brindado por el personal de enfermería especialmente entrenado para ello parece ser una manera rentable de disminuir de forma perdurable los factores de riesgo para las cardiopatías arterioscleróticas , así como de perpetuar los result ados de la rehabilitación cardiovascular . Cette étude examine les effets d'un programme de prévention secondaire sous surveillance du personnel infirmier pour les patients ayant souffert d'incidents cardiaques aigus . Une attention toute particulière a été donnée aux résultats selon le sexe . L'essai était de type prospect if , r and omisé et contrôlé , avec la participation de 343 patients après 3 semaines de rééducation cardiaque dans des conditions d'hospitalisation , affectés de manière aléatoire à l'un ou l'autre des deux groupes d'étude . Les patients appartenant au groupe de traitement ont été contactés tous les mois par téléphone sur une période de 1 an . Les principaux objectifs de l'intervention étaient la réduction des facteurs comportementaux de risque coronaire et l'amélioration de la qualité de vie . Le programme était administré par des infirmiers spécialement formés . Le groupe témoin recevait simplement des informations écrites . Le principal résultat était le score de risque de Framingham .  297 patients ont subi des examens de suivi après 12 mois . Les patients appartenant au groupe d'intervention ont affiché des scores de risque de Framingham inférieurs à ceux du groupe témoin . Les analyses séparées par sexe révèlent que la différence porte principalement sur les hommes . Les femmes , par contre , affichent une augmentation significative des tendances dépressives/à l'anxiété , cliniquement pertinente dans le groupe témoin , contrairement au groupe d'intervention ; chez les hommes , on ne note aucune différence entre les conditions d'étude . En conclusion , le conseil téléphonique administré par des infirmiers spécialement formés semble constituer un mode économique et efficace pour parvenir à une réduction durable des facteurs de risques cardiaques et préserver les effets de la rééducation cardiaque BACKGROUND There have been recent moves to extend the role of the community pharmacist to include medicine management . METHODS A r and omized controlled trial was conducted in nine sites in Engl and . Patients with coronary heart disease were identified from general practice computer systems , recruited and r and omized ( 2:1 ) to intervention or control . The 12-month intervention comprised an initial consultation with a community pharmacist to review appropriateness of therapy , compliance , lifestyle , social and support issues . Control patients received st and ard care .  The primary outcome measures were appropriate treatment [ derived from the National Service Framework ( NSF ) ] , health status ( SF-36 , EQ-5D ) and an economic evaluation . Secondary outcome measures were patient risk of cardiovascular death and satisfaction . RESULTS The study involved 1493 patients ( 980 intervention and 513 control ) , 62 pharmacists and 164 GPs . No statistically significant differences between intervention and control groups were shown at follow-up for any of the primary outcome measures such as numbers on aspirin or lifestyle measures . There were few differences in quality of life ( SF-36 ) between the intervention and control groups at baseline or follow-up or with overall EQ-5D score over time . The total National Health Service cost increased between baseline and at 12 months in both groups but to a greater extent in the intervention group . Significant improvements were found in the satisfaction score for patients ' most recent pharmacy visit for prescription medicines among the intervention group , compared with control group . Self-reported compliance was good for both groups at baseline and no significant differences were shown at follow-up . CONCLUSION There was no change in the proportion of patients receiving appropriate medication as defined by the NSF . The pharmacist-led service was more expensive than st and ard care BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms 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 PURPOSE Because limited audit/feedback of health status information has yielded mixed results , we evaluated the effects of a sustained program of audit/feedback on patient health and satisfaction . METHODS We conducted a group-r and omized effectiveness trial in which firms within Veterans Administration general internal medicine clinics served as units of r and omization , intervention , and analysis . Respondents to a baseline health inventory were regularly mailed the 36-Item Short Form ( SF-36 ) and , as relevant , question naires about six chronic conditions ( ischemic heart disease , diabetes , chronic obstructive pulmonary disease , depression , alcohol use , and hypertension ) and satisfaction with care . Data were reported to primary providers at individual patient visits and in aggregate during a 2-year period . RESULTS Baseline forms were mailed to 34,050 patients ; of the 22,413 respondents , 15,346 completed and returned follow-up surveys . Over the 2-year study , the difference between intervention and control groups ( as measured by difference in average slope ) was -0.26 ( 95 % confidence interval [ CI ] : -0.79 to 0.27 ; P=0.28 ) for the SF-36 Physical Component Summary score and -0.53 ( 95 % CI : -1.09 to 0.03 ; P=0.06 ) for the SF-36 Mental Component Summary score . No significant differences emerged after adjusting for deaths . There were no significant differences in condition-specific measures or satisfaction between groups after adjustment for provider type , panel size , and number of intervention visits , or after analysis of patients who completed all forms . CONCLUSION An elaborate , sustained audit/feedback program of general and condition-specific measures of health/satisfaction did not improve outcomes . To be effective , such data probably should be incorporated into a comprehensive chronic disease management program BACKGROUND Previous research indicates that patients exiting a 12-week cardiac rehabilitation program ( CRP )  have difficulty maintaining an adequate exercise program . Thus , the authors ' purpose was to determine if a home-based exercise program would enable patients to maintain/improve their blood lipids , body composition , and functional capacity after exiting the CRP . METHODS Thirty-one patients exiting an initial 12-week CRP were assigned r and omly to the home-based ( HB ) intervention or the st and ard care ( SC ) condition . After one home visit , the HB participants ( n = 16 ) were contacted by telephone every other week by CRP staff and completed and returned weekly exercise logs . The SC participants ( n = 15 ) had no contact with the CRP other than to schedule follow-up tests . A third group ( n = 17 ) , r and omly selected from patients that elected to remain in the center-based CRP ( CB ) for the same duration , also were examined . All groups underwent  exercise testing , fasting blood lipid analysis , and body composition assessment before starting CRP ( 0 M ) , after 3 months ( 3 M ) in a st and ard CRP , and after 9 months ( 12 M ) in either HB , SC , or CB condition ( 12 months after starting CRP ) . RESULTS Analysis of variance indicated that there were significant increases in metabolic equivalents and high-density lipoprotein , in all three groups , over time . However , analysis of covariance revealed no significant differences between the HB , SC , and CB groups at 12 M for any variable . CONCLUSIONS These data indicate that the HB program was as effective as the CB program at improving/maintaining functional capacity , blood lipids , and body weight/composition . The similar success of the SC group is likely due to their prior experience in CRP and knowledge of follow-up testing . Home-based maintenance program could be offered as a low-cost alternative to CB programs Cardiac rehabilitation and subsequent intensified aftercare is capable , of increasing the rate of occupational reintegration not only over the short-term , but also over a period of two years . In addition to improving physical performance , this enhances the patient 's self-confidence , decreases anxiety and reduces depression . Since , two years after completion of cardiac rehabilitation and aftercare , the percentage of those lost to gainful employment and in need of an early pension is appreciably less in the interventional group as compared with controls , this program would appear to be of particular economic importance for social security/national insurance carriers . For this reason , the Westphalian Social Security Carrier has initiated the regular use of this concept in its cardiological hospitals Abstract Objectives : To evaluate the effects of nurse led clinics in primary care on secondary prevention , total mortality , and coronary event rates after four years . Design : Follow up of a r and omised controlled trial by postal question naires and review of case notes and national data sets . Setting : Stratified , r and om sample of 19 general practice s in north east Scotl and . Participants : 1343 patients ( 673 intervention and 670 control ) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound . Intervention : Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year . Main outcome measures : Components of secondary prevention ( aspirin , blood pressure management , lipid management , healthy diet , exercise , non-smoking ) , total mortality , and coronary events ( non-fatal myocardial infa rct ions and coronary deaths ) . Results : Mean follow up was at 4.7 years . Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year , and these were sustained after four years except for exercise . The control group , most of whom attended clinics after the initial year , caught up before final follow up , and differences between groups were no longer significant . At 4.7 years , 100 patients in the intervention group and 128 in the control group had died : cumulative death rates were 14.5 % and 18.9 % , respectively ( P=0.038 ) . 100 coronary events occurred in the intervention group and 125 in the control group : cumulative event rates were 14.2 % and 18.2 % , respectively ( P=0.052 ) . Adjusting for age , sex , general practice , and baseline secondary prevention , proportional hazard ratios were 0.75 for all deaths ( 95 % confidence intervals 0.58 to 0.98 ; P=0.036 ) and 0.76 for coronary events ( 0.58 to 1.00 ; P=0.049 ) Conclusions : Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events .  Secondary prevention clinics should be started sooner rather than later . What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease , but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary This paper presents findings from the evaluation of a self-management education program based on self-regulation principles . Older men and women ( N = 324 ) were r and omly assigned to program and control groups . Outcomes were measured using the Sickness Impact Profile . Twelve months following baseline data collection , psychosocial functioning of program participants was significantly better than that of controls . Different program effects were noted when results were analyzed by participant gender BACKGROUND We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease ( CAD ) . METHODS We performed a controlled r and om group assignment trial in 4 community outpatient clinics . The Dietary Intervention and Evaluation Trial r and omized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program 's Step II-III diet plan ( n=48 ) or an experimental group that received meal plans , recipes , and nutritional information during monthly group office sessions ( n=49 ) . Both groups received lipid-lowering medications and were followed-up over 12 months . We assessed dietary intake , fasting lipid profiles , hemoglobin A1C levels , and per member per month ( PMPM ) expense data . RESULTS Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year ( P=.0072 ; P=.0001 ; P=.0004 ) . The total PMPM expenses decreased for both groups ( 38 % for the experimental group and 10 % for the control group ) , but the cost difference was statistically nonsignificant ( P=.2975 ) . Both groups noted low-density lipoprotein reductions , significant only in the experimental group ( P=.0035 ) . CONCLUSIONS Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels .  Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary , family-based preventive cardiology programme could improve st and ards of preventive care in routine clinical practice . METHODS In a matched , cluster-r and omised , controlled trial in eight European countries , six pairs of hospitals and six pairs of general practice s were assigned to an intervention programme ( INT ) or usual care ( UC ) for patients with coronary heart disease or those at high risk of developing cardiovascular disease . The primary endpoints-measured at 1 year-were family-based lifestyle change ; management of blood pressure , lipids , and blood glucose to target concentrations ; and prescription of cardioprotective drugs . Analysis was by intention to treat . The trial is registered as IS RCT N 71715857 . FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC , respectively . In patients with coronary heart disease who smoked in the month before the event , 136 ( 58 % ) in the INT and 154 ( 47 % ) in the UC groups did not smoke 1 year afterwards ( difference in change 10.4 % , 95 % CI -0.3 to 21.2 , p=0.06 ) . Reduced consumption of saturated fat ( 196 [ 55 % ] vs 168 [ 40 % ] ; 17.3 % , 6.4 to 28.2 , p=0.009 ) , and increased consumption of fruit and vegetables  ( 680 [ 72 % ] vs 349 [ 35 % ] ; 37.3 % , 18.1 to 56.5 , p=0.004 ) , and  oily fish  ( 156 [ 17 % ] vs 81 [ 8 % ] ; 8.9 % , 0.3 to 17.5 , p=0.04 ) at 1 year were greatest in the INT group . High-risk individuals and partners showed changes only for fruit and vegetables ( p=0.005 ) . Blood-pressure target of less than 140/90 mm Hg was attained by both coronary ( 615 [ 65 % ] vs 547 [ 55 % ] ; 10.4 % , 0.6 to 20.2 , p=0.04 ) and high-risk ( 586 [ 58 % ] vs 407 [ 41 % ] ; 16.9 % , 2.0 to 31.8 , p=0.03 ) patients in the INT groups . Achievement of total cholesterol of less than 5 mmol/L did not differ between groups , but in high-risk patients the difference in change from baseline to 1 year was 12.7 % ( 2.4 to 23.0 , p=0.02 ) in favour of INT . In the hospital group , prescriptions for statins  were higher in the INT group ( 810 [ 86 % ] vs 794 [ 80 % ] ; 6.0 % , -0.5 to 11.5 , p=0.04 ) . In general practice s in the intervention groups ,  angiotensin-converting enzyme inhibitors  ( 297 [ 29 % ] INT vs 196 [ 20 % ] UC ; 8.5 % , 1.8 to 15.2 , p=0.02 ) and  statins  ( 381 [ 37 % ] INT vs 232 [ 22 % ] UC ; 14.6 % , 2.5 to 26.7 , p=0.03 ) were more frequently prescribed . INTERPRETATION To achieve the potential for cardiovascular prevention , we need local preventive cardiology programmes adapted to individual countries , which are accessible by all hospitals and general practice s caring for coronary and high-risk patients abstract Objective To determine whether a nurse led smoking cessation intervention affects smoking cessation rates in patients admitted for coronary heart disease . Design R and omised controlled trial . Setting Cardiac ward of a general hospital , Norway . Participants 240 smokers aged under 76 years admitted for myocardial infa rct ion , unstable angina , or cardiac bypass surgery . 118 were r and omly assigned to the intervention and 122 to usual care  ( control group ) . Intervention The intervention was based on a booklet and focused on fear arousal and prevention of relapses .  The intervention was delivered by cardiac nurses without special training . The intervention was initiated in hospital , and the participants were contacted regularly for at least five months . Main outcome measure Smoking cessation rates at 12 months determined by self report and biochemical verification . Results 12 months after admission to hospital , 57 % ( n = 57/100)of patients in the intervention group and 37 % ( n = 44/118 ) in the control group had quit smoking ( absolute risk reduction 20 % , 95 % confidence interval 6 % to 33 % ) . The number needed to treat to get one additional person who would quit was 5 ( 3 to 16 ) . Assuming all dropouts relapsed at 12 months , the smoking cessation rates were 50 % in the intervention group and 37 % in the control group ( absolute risk reduction 13 % , 0 % to 26 % ) . Conclusion A smoking cessation programme delivered by cardiac nurses without special training , significantly reduced smoking rates in patients 12 months after admission to hospital for coronary heart disease BACKGROUND Lowering plasma lipid levels in patients in the months following hospital discharge for a myocardial infa rct ion ( MI ) is clearly beneficial if recurrent cardiac events and mortality are to be prevented ; traditionally , however , there has been a large gap between guidelines and levels achieved in routine practice . OBJECTIVES AND METHODS A r and omized , open-label clinical trial was conducted to assess the impact of nurse-centred surveillance and treatment in achieving nationally recognized lipid targets in post-MI patients . This program had the following features : systematic telephone follow-up of patients discharged from the University of Sherbrooke ( Sherbrooke , Quebec ) after an MI ;  systematic lipid testing three months after discharge ; close liaison with , and guidance of , patients ' primary care physicians to intervene on results of this test if targets were not obtained ; and continued monitoring of patients until lipid profiles consistent with consensus targets were achieved . The impact of this approach was tested and compared with that of a control group that continued to be followed by a primary care physician for up to 18 months . RESULTS A total of 127 patients were r and omly assigned into an intervention group ( n=64 ) or a control group ( n=63 ) . The intervention group was followed by telephone for an average ( + /-SD ) of 4.4+/-2.0 months post-MI . At this point , when intervention was optimized , the mean low-density lipoprotein cholesterol ( LDL-C ) level was 2.19+/-0.65 mmol/L in the intervention group , and 87.3 % of patients had LDL-C levels of less than 2.5 mmol/L. Patients from both experimental groups returned at 12 months and 18 months post-MI for a new blood lipid assessment . In total , 12.5 % of patients in each group were lost to follow-up . At 12 months and 18 months , the mean LDL-C level was not different between the two groups , nor was there a significant difference in the proportion of patients achieving LDL-C levels of less than 2.5 mmol/L ( 51.6 % in the intervention group and 65 % in the control group at 18 months ; P>0.05 ) . When the combined end point of an LDL-C level of less than 2.5 mmol/L , a triglyceride level of less than 2.0 mmol/L and a total cholesterol to high-density lipoprotein cholesterol ratio of less than 4.0 was considered , the proportion of patients achieving this composite at 18 months was low and not different between the two groups ( 23.4 % in the intervention group and 38.3 % in the control group ; P>0.05 ) . Over 95 % of patients in both groups were on a lipid-lowering medication , and more than 90 % had complied with their medication regimen at 18 months . CONCLUSIONS This trial did not support the role of nurse-managers and a system of telephone-based contacts to ensure the continuity of care and aggressive intervention when considering cardiovascular risk factors in post-MI patients . This trial also re-emphasized the important remaining treatment gap in secondary prevention of coronary artery disease , particularly if composite lipid end points are to be targeted
target: There were no significant effects of interventions on mean blood pressure or cholesterol levels , prescribing , smoking status or body mass index .
  There was some suggestion of a " ceiling effect " whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached .
  There is weak evidence that regular planned recall of patients for appointments , structured monitoring of risk factors and prescribing , and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure .
background: BACKGROUND Ischaemic heart disease ( IHD ) is a major cause of mortality and morbidity and its prevalence is set to increase .
  Secondary prevention aims to prevent subsequent acute events in people with established IHD .
  While the benefits of individual medical and lifestyle interventions is established , the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community setting s is less so .
  OBJECTIVES To assess the effectiveness of service organisation interventions , identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring ( blood pressure , cholesterol and lifestyle factors such as diet , exercise , smoking and obesity ) and appropriate prophylactic medication .