The Enhancing Secondary Prevention in Coronary Artery Disease trial

Abstract

Background: Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease. Methods:We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization. Results:We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n = 316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71-1.94, p = 0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94-2.42, p = 0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p = 0.48) and 2.19 (SD 0.68) in the unsigned statement group (p = 0.32).Interpretation: Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240. AbstractPreviously published at www.cmaj.ca

A Cluster Randomized Trial of an Enhanced eGFR Prompt in Chronic Kidney Disease

“…Data are urgently needed to clarify how routinely incorporating information on eGFR into routine care could improve outcomes rather than simply increasing physician workload. Because the effect of treatment recommendations delivered at point of care may be increased by accompanying them with endorsements from respected local physicians (22,36), future use of automated reminders should consider incorporating opinion leaders as signatories or other enabling strategies such as patient activation mechanisms and the involvement of allied health professionals (37).…”

“…However, no prior studies have evaluated the effect of an enhanced managementbased eGFR prompt. Moreover, whether point-of-care reminders improve processes of care and clinical outcomes is uncertain (21)(22)(23).…”

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

“…Conclusion Although primary care physicians and specialists have made great inroads in the control of cardiovascular risk factors for patients with coronary disease over the past decade, 31 stroke prevention strategies need to extend beyond the current emphasis on antithrombotic agents and evaluation for carotid endarterectomy. We found that a nurse-led case management program based on monthly evaluation of risk factors, patient counselling and feedback to primary care physicians improved control of key risk factors for stroke (hypertension and dyslipidemia) by 6 months.…”

Delayed educational reminders for long-term medication adherence in ST-elevation myocardial infarction (DERLA-STEMI): Protocol for a pragmatic, cluster-randomized controlled trial

“…Another important caveat is that we will be using patient self-report for main outcome measurements—an approach which has previously been used in a similar trial [38]. We are planning to evaluate the validity of self-report data in our study by comparing patient reported medication use (including the MMAS) with data recorded in administrative databases for a subsample of participants above age 65 (for whom data are accessible using the Ontario Drug Database).…”

“…Three other trials have evaluated the role of reminder letters to the primary care provider (with or without patient reminders) to improve adherence to evidenced-based cardiovascular therapies: one in the USA, one in the UK, and one in Canada [36-38]. The American trial focused on beta-blocker use post-MI and found a small increase in compliance (proportion of days covered), with a number needed to treat of 16 for achieving high adherence, but no change in the proportion who discontinued their beta-blocker.…”