Randomised trials of secondary prevention programmes in coronary heart disease: systematic review
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F A McAlister1, F M Lawson, K K Teo
1Division of General Internal Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada. Finlay.McAlister@ualberta.ca
Insights
Multidisciplinary disease management programs for coronary heart disease patients improve care processes and quality of life. While reducing hospital admissions, their impact on survival and cost-effectiveness requires further investigation.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Coronary heart disease (CHD) poses a significant global health burden.
- Effective management strategies are crucial for improving patient outcomes and reducing healthcare costs.
- Multidisciplinary disease management programs aim to provide comprehensive care for CHD patients.
Purpose of the Study:
- To evaluate the effectiveness of multidisciplinary disease management programs for patients with coronary heart disease.
- To determine if these programs improve care processes, reduce morbidity, and decrease mortality.
Main Methods:
- A systematic review and meta-analysis of randomized clinical trials.
- Searched multiple databases including Medline, Embase, CINAHL, and Cochrane registers.
- Data extracted independently by two investigators; risk ratios calculated using random and fixed effects models.
Main Results:
- 12 trials involving 9803 CHD patients were analyzed.
- Programs significantly improved medication adherence (e.g., lipid-lowering drugs, beta-blockers) and risk factor profiles.
- Reduced hospital admissions (RR 0.84) and improved quality of life were observed; impact on mortality and recurrent myocardial infarction was uncertain.
Conclusions:
- Multidisciplinary disease management programs enhance care processes, reduce hospitalizations, and improve quality of life for CHD patients.
- Further research is needed to clarify the impact on survival, recurrent events, and cost-effectiveness.
- Optimal program components require further investigation.
Objective:
To determine whether multidisciplinary disease management programmes for patients with coronary heart disease improve processes of care and reduce morbidity and mortality.
Data Sources:
Randomised clinical trials of disease management programmes in patients with coronary heart disease were identified by searching Medline 1966-2000, Embase 1980-99, CINAHL 1982-99, SIGLE 1980-99, the Cochrane controlled trial register, the Cochrane effective practice and organisation of care study register, and bibliographies of published studies.
Data Extraction:
Studies were selected and data were extracted independently by two investigators, and summary risk ratios were calculated by using both the random effects model and the fixed effects model.
Data Synthesis:
A total of 12 trials (9803 patients with coronary heart disease) were identified. Disease management programmes had positive impacts on processes of care. Patients randomised to these programmes were more likely to be prescribed efficacious drugs (risk ratio 2.14 (95% confidence interval 1.92 to 2.38) for lipid lowering drugs, 1.19 (1.07 to 1.32) for beta blockers, and 1.07 (1.03 to 1.11) for antiplatelet agents). Five out of seven trials evaluating risk factor profiles showed significantly greater improvements with these programmes in comparison with usual care (with effect sizes in the moderate range). Summary risk ratios were 0.91 (0.79 to 1.04) for all cause mortality, 0.94 (0.80 to 1.10) for recurrent myocardial infarction, and 0.84 (0.76 to 0.94) for admission to hospital. Five of the eight trials evaluating quality of life or functional status reported better outcomes in the intervention arms. Only three of these trials reported the costs of the intervention-the interventions were cost saving in two cases.
Conclusions:
Disease management programmes improve processes of care, reduce admissions to hospital, and enhance quality of life or functional status in patients with coronary heart disease. The programmes' impact on survival and recurrent infarctions, their cost effectiveness, and the optimal mix of components remain uncertain.
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