Health Care Delivery Fixes Somewhat Helpful in Heart Disease

Research has shown that heart disease patients who make lifestyle improvements, take recommended medications and control risk factors such as high cholesterol and high blood pressure can prevent heart disease from worsening.

A new review of studies looked at whether such patients would be more likely to reduce their risks if health care providers also made changes -- in appointment planning, patient education and monitoring of heart disease risk factors and medication use.

“Well-organized care certainly does work,” said lead author Brian Buckley, Ph.D.

However, in countries that already have well-established preventive care, making these changes might not make that much difference, the reviewers found.

Secondary preventive care “is care aimed at preventing disease that already exists from getting worse,” said Buckley, a researcher in the department of general practice at the National University of Ireland, in Galway. “In a lot of countries, the secondary preventive care that’s being provided for people with heart disease is already at quite a high standard. So when we looked at studies on methods to improve that, we found they often had little effect.”

None of the included studies took place in the United States, and “one has to be very careful about drawing any conclusions from system interventions in systems that are very different from one’s own system,” said Vera Bittner, M.D., medical director of the Cardiac Rehabilitation Program at the University of Alabama at Birmingham.

Bittner, who has no affiliation with the review, said that the way physicians educate patients is one area with room for improvement.

Buckley and his colleagues examined whether interventions to organize care affected cholesterol levels, blood pressure and other proven risk factors for heart disease. Eleven studies that included 12,074 participants with heart disease met the researchers’ criteria for inclusion.

Most of the interventions took place in the United Kingdom; other included studies came from China, Spain and Sweden. Almost all study participants were white, European males between the ages of 62 and 69.

This review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

In two studies, researchers found that patients of providers that offered organized care were almost twice as apt to have total cholesterol levels within the recommended range after a year. In one study in particular, 1,173 patients who had organized secondary care were two and a half times more prone to have total cholesterol levels within the target range.

However, “It seems that there may be a ceiling effect. In older studies, conducted when risk factors such as high cholesterol were more common amongst heart patients, small changes in the way physicians organized care for heart disease patients and the way they provided information to them could make significant improvements,” Buckley said.

Once care for people with heart disease has reached a certain level, making improvements — and reaching those last few patients —increasingly becomes difficult, Buckley said.

“But physicians must maintain the standards of care they are providing where they are high, and make improvements where they can, of course. And in countries or populations where effective, organized secondary preventive care isn’t in place, it’s well worth organizing,” Buckley said.

University of Alabama’s Bittner expressed reservations about the review’s focus on changes to existing interventions in primary care or community settings.

“Since patients interact with clinicians in the hospital setting, in subspecialty practices, and in primary care, it is pretty difficult to isolate the effect of an intervention to just one setting,” Bittner said. “It is, I believe, important not to generalize the findings here to all system interventions in other settings.”

Before physicians change their behaviors, more data on how to influence patient knowledge and behavior are necessary, Bittner says. “There are many barriers to patient adherence. Probably the biggest one I see is that patients don’t perceive themselves to be at risk and we need to get better at communicating this risk.”

More information: Buckley BS, Byrne MC, Smith SM. Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database of Systematic Reviews 2010, Issue 3.

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