NIHR Signal Clinics and activities in primary care can reduce heart disease deaths

Published on 20 October 2015

This review found that primary care interventions at an organisational level for people with coronary heart disease reduced death rates for up to six years after the intervention, compared to usual care. The structured interventions lasted between one and three years and included activities like organising dedicated clinics to monitor and adjust medication to meet recommended blood pressure and cholesterol levels or drop-in sessions to encourage healthy lifestyle. The results are in line with 2012 NICE guidance that encourages organisations to take action to help people with known heart disease take their medicines as prescribed, and reduce risk factors through lifestyle changes.

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Why was this study needed?

Coronary heart disease is the leading cause of death in the UK and worldwide. As well as chest pain (angina), the main symptoms are heart attacks and heart failure. In the UK, there are about 2.3 million people living with coronary heart disease costing the NHS over a billion pounds in hospital care and primary care alone in 2012.

Primary care interventions to prevent heart disease from progressing typically include medication to keep blood pressure and cholesterol within recommended limits, and lifestyle advice such as stopping smoking, being physically active and eating a healthy diet. This study aimed to see whether delivering primary care interventions in a structured way improved long-term health outcomes. This review updates a 2010 Cochrane systematic review of randomised controlled trials. This found weak evidence that structured primary care interventions led to short-term reductions in progression of ischaemic heart disease.

What did this study do?

The systematic review identified five trials with 4,005 participants comparing organised ischaemic heart disease interventions (lasting one to three years) with usual care, which was not described. Participants were tracked for up to 10 years to monitor their long-term health outcomes. The trials took place in Scotland, Ireland, Sweden and Spain.

The review followed best practice standards for conducting and reporting systematic reviews and most trials were scored at a low risk of bias suggesting the underlying evidence is reliable. Trial participants were mainly men in their mid-sixties limiting the applicability of the results to other age groups and women. There was a lack of detail on the interventions used, and from the limited information available, interventions varied over time and between countries: this is a barrier to replicating the most promising interventions in other contexts.

What did it find?

  • Pooled results from four trials showed that the interventions were associated with a 20% reduction in death from any cause during six years follow up after the end of the intervention, relative risk (RR) 0.79 (95% confidence interval (CI) 0.66 to 0.93).
  • Pooled results from the same four trials showed that the relative risk of death from coronary heart disease was also reduced by 26% for the intervention groups compared with usual care during six years follow-up, RR 0.74 (95% CI 0.58 to 0.94).
  • Two studies did not find any difference in death rate from any cause or coronary heart disease between the intervention and control groups, followed up for six years in one trial and ten in the other.
  • There were no significant differences in hospital admissions, medication prescribing or risk factor management by at least 4.7 years of follow up, though findings for each were based on only one to three studies.

What does current guidance say on this issue?

The current 2012 NICE guidance broadly supports the importance of providing preventative interventions in a structured way in primary care for people with coronary heart disease. It recommends that commissioners take an integrated approach to preventing heart disease, including providing services that encourage people to take their medicines as prescribed, and that reduce risk factors within an individuals’ control, such as being more active and eating a healthy diet. The 2015 General Medical Services Quality Outcomes Framework sets targets for secondary prevention care, such as maintaining a register of people with coronary heart disease and a record of the percentages of people with blood pressure in the target range. The framework does not say how activities should be organised and this review provides some indications of what might be useful.

What are the implications?

Structured primary care interventions for coronary heart disease have the potential to save lives up to six years after the intervention. There is also potential for large cost savings. In 2011, a study on the effectiveness and cost effectiveness of cardiovascular disease prevention found that the reducing cardiovascular disease events – such as heart attacks - by just 1% a year in England and Wales could save the health service at least £30 million a year compared with no additional care. This current systematic review provides further evidence to support existing 2012 NICE guidance. Both support regular review and disease management for people with coronary heart disease to prevent subsequent disease-related deaths.

Bibliography

Barton P, Andronis L, Briggs A et al. (2011). Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ. 2011;343:d4044.

BMA, NHS Employers, NHS England. 2015/16 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). BMA, NHS Employers, NHS England; 2015.

Buckley BS, Byrne MC, Smith SM. Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database Syst Rev. 2010;(3):CD006772.

NICE. Services for the prevention of cardiovascular disease. CMG45. London; National Institute for Health and Care Excellence; 2012.

NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. CG181. London; National Institute for Health and Care Excellence; 2014.

NICE. Prevention of cardiovascular disease. PH25. London; National Institute for Health and Care Excellence; 2010.

Why was this study needed?

Coronary heart disease is the leading cause of death in the UK and worldwide. As well as chest pain (angina), the main symptoms are heart attacks and heart failure. In the UK, there are about 2.3 million people living with coronary heart disease costing the NHS over a billion pounds in hospital care and primary care alone in 2012.

Primary care interventions to prevent heart disease from progressing typically include medication to keep blood pressure and cholesterol within recommended limits, and lifestyle advice such as stopping smoking, being physically active and eating a healthy diet. This study aimed to see whether delivering primary care interventions in a structured way improved long-term health outcomes. This review updates a 2010 Cochrane systematic review of randomised controlled trials. This found weak evidence that structured primary care interventions led to short-term reductions in progression of ischaemic heart disease.

What did this study do?

The systematic review identified five trials with 4,005 participants comparing organised ischaemic heart disease interventions (lasting one to three years) with usual care, which was not described. Participants were tracked for up to 10 years to monitor their long-term health outcomes. The trials took place in Scotland, Ireland, Sweden and Spain.

The review followed best practice standards for conducting and reporting systematic reviews and most trials were scored at a low risk of bias suggesting the underlying evidence is reliable. Trial participants were mainly men in their mid-sixties limiting the applicability of the results to other age groups and women. There was a lack of detail on the interventions used, and from the limited information available, interventions varied over time and between countries: this is a barrier to replicating the most promising interventions in other contexts.

What did it find?

  • Pooled results from four trials showed that the interventions were associated with a 20% reduction in death from any cause during six years follow up after the end of the intervention, relative risk (RR) 0.79 (95% confidence interval (CI) 0.66 to 0.93).
  • Pooled results from the same four trials showed that the relative risk of death from coronary heart disease was also reduced by 26% for the intervention groups compared with usual care during six years follow-up, RR 0.74 (95% CI 0.58 to 0.94).
  • Two studies did not find any difference in death rate from any cause or coronary heart disease between the intervention and control groups, followed up for six years in one trial and ten in the other.
  • There were no significant differences in hospital admissions, medication prescribing or risk factor management by at least 4.7 years of follow up, though findings for each were based on only one to three studies.

What does current guidance say on this issue?

The current 2012 NICE guidance broadly supports the importance of providing preventative interventions in a structured way in primary care for people with coronary heart disease. It recommends that commissioners take an integrated approach to preventing heart disease, including providing services that encourage people to take their medicines as prescribed, and that reduce risk factors within an individuals’ control, such as being more active and eating a healthy diet. The 2015 General Medical Services Quality Outcomes Framework sets targets for secondary prevention care, such as maintaining a register of people with coronary heart disease and a record of the percentages of people with blood pressure in the target range. The framework does not say how activities should be organised and this review provides some indications of what might be useful.

What are the implications?

Structured primary care interventions for coronary heart disease have the potential to save lives up to six years after the intervention. There is also potential for large cost savings. In 2011, a study on the effectiveness and cost effectiveness of cardiovascular disease prevention found that the reducing cardiovascular disease events – such as heart attacks - by just 1% a year in England and Wales could save the health service at least £30 million a year compared with no additional care. This current systematic review provides further evidence to support existing 2012 NICE guidance. Both support regular review and disease management for people with coronary heart disease to prevent subsequent disease-related deaths.

Bibliography

Barton P, Andronis L, Briggs A et al. (2011). Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ. 2011;343:d4044.

BMA, NHS Employers, NHS England. 2015/16 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). BMA, NHS Employers, NHS England; 2015.

Buckley BS, Byrne MC, Smith SM. Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database Syst Rev. 2010;(3):CD006772.

NICE. Services for the prevention of cardiovascular disease. CMG45. London; National Institute for Health and Care Excellence; 2012.

NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. CG181. London; National Institute for Health and Care Excellence; 2014.

NICE. Prevention of cardiovascular disease. PH25. London; National Institute for Health and Care Excellence; 2010.

Primary care organisational interventions for secondary prevention of ischaemic heart disease: a systematic review and meta-analysis

Published on 30 June 2015

Murphy, E.,Vellinga, A.,Byrne, M.,Cupples, M. E.,Murphy, A. W.,Buckley, B.,Smith, S. M.

Br J Gen Pract Volume 65 , 2015

BACKGROUND: Ischaemic heart disease (IHD) is the most common cause of death worldwide. AIM: To determine the long-term impact of organisational interventions for secondary prevention of IHD. DESIGN AND SETTING: Systematic review and meta-analysis of studies from CENTRAL, MEDLINE((R)), Embase, and CINAHL published January 2007 to January 2013. METHOD: Searches were conducted for randomised controlled trials of patients with established IHD, with long-term follow-up, of cardiac secondary prevention programmes targeting organisational change in primary care or community settings. A random-effects model was used and risk ratios were calculated. RESULTS: Five studies were included with 4005 participants. Meta-analysis of four studies with mortality data at 4.7-6 years showed that organisational interventions were associated with approximately 20% reduced mortality, with a risk ratio (RR) for all-cause mortality of 0.79 (95% confidence interval [CI] = 0.66 to 0.93), and a RR for cardiac-related mortality of 0.74 (95% CI = 0.58 to 0.94). Two studies reported mortality data at 10 years. Analysis of these data showed no significant differences between groups. There were insufficient data to conduct a meta-analysis on the effect of interventions on hospital admissions. Additional analyses showed no significant association between organisational interventions and risk factor management or appropriate prescribing at 4.7-6 years. CONCLUSION: Cardiac secondary prevention programmes targeting organisational change are associated with a reduced risk of death for at least 4-6 years. There is insufficient evidence to conclude whether this beneficial effect is maintained indefinitely.

Coronary heart disease – also called ischaemic heart disease or coronary artery disease - is the term used for conditions where there is a restricted blood supply to heart muscle, due to narrowed arteries. Symptoms may include angina (chest pain), heart attacks or heart failure.

“Secondary prevention” is health care that aims to prevent worsening of conditions such as ischaemic heart disease, that a person is already known to have.

Organisational change in primary or community care settings was defined as interventions to improve clinician and patient adherence with recommendations on secondary prevention of heart disease. They included the following components:

  • Patient education
  • Clinician education
  • Pre-planned appointments
  • Nurse-led interventions
  • Risk factor management

Expert commentary

This systematic review included five moderate quality randomised trials of organisational changes in primary care for patients with coronary heart disease. The results equate to approximately 4 (95% CI, 1 to 6) lives saved per 100 patients treated over a six year period. Much of what is proposed in the intervention - education, risk factor management and structured use of resources - forms part of current routine general practice in the UK. The review further highlights the need for long term follow up trials and the need for a sustained approach to engaging with hard to reach individuals, particularly those with on-going elevated risk.

Carl Heneghan, General Practitioner and Professor of Evidence Based Medicine, University of Oxford