The therapeutic gap--compliance with medication and guidelines

Cross-sectional analysis of the prevalence and predictors of statin utilisation in Ireland with a focus on primary prevention of cardiovascular disease

OBJECTIVE

To describe the prevalence of statin utilisation by people aged over 50 years in Ireland and the factors associated with the likelihood of using a statin, focusing particularly on those using statins for primary prevention of cardiovascular disease (CVD).

METHODS

This is a cross-sectional analysis of cardiovascular risk and sociodemographic factors associated with statin utilisation from wave 1 of The Irish Longitudinal Study on Ageing. A hierarchy of indications for statin utilisation, consisting of eight mutually exclusive levels of CVD-related diagnoses, was created. Participants were assigned one level of indication. The prevalence of statin utilisation was calculated. The likelihood that an individual was using a statin was estimated using a multivariable logistic regression model, controlling for cardiovascular risk and sociodemographic factors.

RESULTS

In this nationally representative sample (n=5618) of community-dwelling participants aged 50 years and over, 1715 (30.5%) were taking statins. Of these, 65.0% (57.3% of men and 72.7% of women) were doing so for the primary prevention of CVD. Thus, almost two-thirds of those taking statins did so for primary prevention and there was a notable difference between women and men in this regard. We also found that statin utilisation was highest among those with a prior history of CVD and was significantly associated with age (compared with the base category 50-64 years; 65-74 years OR 1.38 (95% CI 1.16 to 1.65); 75+ OR 1.33 (95% CI 1.04 to 1.69)), living with a spouse or partner (compared with the base category living alone; OR 1.35 (95% CI 1.10 to 1.65)), polypharmacy (OR 1.74 (95% CI 1.39 to 2.19)) and frequency of general practitioner visits (compared with the base category 0 visits per year; 1-2 visits OR 2.46 (95% CI 1.80 to 3.35); 3-4 visits OR 3.24 (95% CI 2.34 to 4.47); 5-6 visits OR 2.98 (95% CI 2.08 to 4.26); 7+ visits OR 2.51 (95% CI 1.73 to 3.63)), even after controlling for clinical need. There was no association between using statins and gender, education, income, social class, health insurance status, location or Systematic Coronary Risk Evaluation (SCORE) risk in the multivariable analysis.

CONCLUSION

Statin utilisation among those with no history of CVD accounted for almost two-thirds of all statin use, in part reflecting the high proportion of the population with no history of CVD, although utilisation rates were highest among those with a history of CVD.

The Return of Lombroso? Ethical Aspects of (Visions of) Preventive Forensic Screening

The vision of legendary criminologist Cesare Lombroso to use scientific theories of individual causes of crime as a basis for screening and prevention programmes targeting individuals at risk for future criminal behaviour has resurfaced, following advances in genetics, neuroscience and psychiatric epidemiology. This article analyses this idea and maps its ethical implications from a public health ethical standpoint. Twenty-seven variants of the new Lombrosian vision of forensic screening and prevention are distinguished, and some scientific and technical limitations are noted. Some lures, biases and structural factors, making the application of the Lombrosian idea likely in spite of weak evidence are pointed out and noted as a specific type of ethical aspect. Many classic and complex ethical challenges for health screening programmes are shown to apply to the identified variants and the choice between them, albeit with peculiar and often provoking variations. These variations are shown to actualize an underlying theoretical conundrum in need of further study, pertaining to the relationship between public health ethics and the ethics and values of criminal law policy.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

OBJECTIVES

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

SELECTION CRITERIA

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

MAIN RESULTS

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

Combined survival analysis of cardiac patients by a Cox PH model and a Markov chain

The control and treatment of dyslipidemia is a major public health challenge, particularly for patients with coronary heart diseases. In this paper we propose a framework for survival analysis of patients who had a major cardiac event, focusing on assessment of the effect of changing LDL-cholesterol level and statins consumption on survival. This framework includes a Cox PH model and a Markov chain, and combines their results into reinforced conclusions regarding the factors that affect survival time. We prospectively studied 2,277 cardiac patients, and the results show high congruence between the Markov model and the PH model; both evidence that diabetes, history of stroke, peripheral vascular disease and smoking significantly increase hazard rate and reduce survival time. On the other hand, statin consumption is correlated with a lower hazard rate and longer survival time in both models. The role of such a framework in understanding the therapeutic behavior of patients and implementing effective secondary and primary prevention of heart diseases is discussed here.

Promoting lifestyle self-awareness among the medical team by the use of an integrated teaching approach: a primary care experience

OBJECTIVES

Healthy lifestyle is recommended in clinical guidelines for the prevention and treatment of chronic diseases such as cardiovascular disease and diabetes. Research previously identified a gap between lifestyle recommendations and their implementation in clinical practice. In this paper, we describe a pilot educational program aimed to promote providers' awareness of their own lifestyles, and to explore whether increased personal awareness enhances providers' willingness to engage in lifestyle-change discussion with patients.

METHODS

Two primary-care urban clinics in Northern Israel participated in the program, which consisted of a series of six biweekly educational sessions, each lasting 2-4 hours. Each session included both knowledge-based and experiential learning based on complementary medicine modalities. Surveys at the end of the program and a year later provided the program evaluation.

RESULTS

Thirty-five personnel participated in the program. Thirteen (13) of the 20 participants (65%) reported an attitude change regarding eating habits after the program. At 1-year follow up, 24 of the 27 respondents (89%) stated that they were more aware of their eating habits and of their physical activity compared with precourse status. Twenty-three (23) of 27 respondents (85%) stated that after the program they were better prepared to initiate a conversation with their patients about lifestyle change.

CONCLUSIONS

An integrated educational approach based on knowledge-based and complementary and alternative medicine experiential modalities, aimed to facilitate self-awareness, may enhance learners' attitude change. The findings demonstrate readiness of learners to reexamine their lifestyles. Increased self-awareness helped participants to make a positive attitude change regarding eating habits and physical activity and was associated with participants' increased engagement in lifestyle-change discussions with patients. The teaching approach had longstanding effect, noted in the one-year follow-up.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

Pharmaceuticals, while central to medical therapy, pose a significant burden to health care budgets. Therefore regulations to control prescribing costs and improve quality of care are implemented increasingly. These include the use of financial incentives for prescribers, namely increased financial accountability using budgets and performance based payments.

OBJECTIVES

To determine the effects on drug use, healthcare utilisation, health outcomes and costs (expenditures) of policies, that intend to affect prescribers by means of financial incentives.

SEARCH STRATEGY

We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (August 2003), Cochrane Central Register of Controlled Trials (October 2003), MEDLINE (October 2005), EMBASE (October 2005), and other databases.

SELECTION CRITERIA

Policies were defined as laws, rules, financial and administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes, and costs. The study had to be a randomised or non-randomised controlled trial, interrupted time series analysis, repeated measures study or controlled before-after study evaluating financial incentives for prescribers introduced for a jurisdiction or healthcare system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study limitations.

MAIN RESULTS

Thirteen evaluations of budgetary policies and none of performance based payments met our inclusion criteria. Ten studies evaluated general practice fundholding in the UK, one the Irish Indicative Drug Target Savings Scheme (IDTSS) and two evaluated German drug budgets for physicians in private practice. The interrupted time series analyses had some limitations. All the controlled before-after studies (all from the UK) had serious limitations. Drug expenditure (per item and per patient) and prescribed drug volume decreased with budgets in all three countries. Evidence indicated increased use of generic drugs in the UK and Ireland, but was inconclusive on the use of new and expensive drugs. We found no clear evidence of increased health care utilisation and no studies reporting effects on health. Administration costs were not reported. No studies on the effects of performance-based payments or other policies met our inclusion criteria.

AUTHORS' CONCLUSIONS

Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.

Determinants of poor adherence in hypertensive patients: development and validation of the "Maastricht Utrecht Adherence in Hypertension (MUAH)-questionnaire"

OBJECTIVES

(1) To help identify patients with poor adherence and (2) to identify potential reasons that impede or facilitate adherence.

METHODS

Seventeen patients who used antihypertensive drugs participated in semi-standardized interviews. Interviews were recorded and reviewed by two investigators. Forty-four items were selected. An exploratory factor analysis was performed. Convergent validity was assessed by evaluating the association between sum scores on the identified subscales and three other adherence measures: (1) the Brief Medication Questionnaire (BMQ), (2) pharmacy refill records and (3) electronic monitoring. Regression analysis was used to evaluate the magnitude of associations.

RESULTS

Two hundred and fifty-five (90%) patients completed the questionnaire. Factor analysis resulted in a four-factor solution, explaining 30% of cumulative variance among respondents. The factors (scales) were labeled: positive attitude towards health care and medication (I), lack of discipline (II), aversion towards medication (III) and active coping with health problems (IV). Chronbach's alpha coefficient was 0.75, 0.80, 0.63 and 0.76 for scales I, II, III and IV, respectively. Convergent validity was partly supported by statistically significant associations that were found between sum scores of subscales 1 and II and the BMQ and electronic monitoring, respectively.

CONCLUSION

The MUAH-questionnaire has excellent psychometric properties and may be useful to identify factors that impede or facilitate adherence. However, it is not clear to what extent the questionnaire measures actual adherence.

PRACTICE IMPLICATIONS

Validation of the MUAH-questionnaire in other studies is needed.

Cardiac disease in the non-cardiac surgical population: effect on survival

Mortality from cardiac disease is decreasing, yet the prevalence of ischemic heart disease, diabetes and hypertension is increasing. This, combined with an aging population, affects the characteristics of the surgical population. Survival in this subgroup of the non-cardiac surgical population has not been studied in a UK setting. This study aimed to determine the mortality rate at 1, 6 and 24 months for patients with underlying cardiac risk factors undergoing elective non-cardiac surgery, and to identify independent risk factors associated with 1-year mortality (death within 365 days of original operation date). Following ethical approval, 1622 patients were included in the study. Demographic, pre-, peri- and postoperative variables were collected from medical and nursing notes. Follow-up was completed using the National Office of Statistics tracking system. Copies of death certificates were obtained on all patients who had died within 12 months of surgery. Risk factors for 1-year mortality were identified using multiple regression modelling. Survival at 12 months was 89%. The majority of cardiac-related deaths occurred within the first 6 months of surgery. Independent risk factors associated with 1-year mortality were advanced age, preoperative angina, odds ratio=1.59 (1.02-2.47), surgery type, perioperative blood transfusion and a prolonged hospital stay. A significant portion of the non-cardiac surgical population who have underlying cardiac disease risk factors are at risk of a cardiac-related death within 1 year of surgery. Patients with angina had nearly a 60% greater risk of death compared with asymptomatic patients. In the hospital setting, nurses with the appropriate pre-assessment and critical care competencies are pivotal to the successful management of this group of patients. In the long term, careful follow-up by the primary care team can help modify cardiac risk factors and potentially reduce cardiac-related mortality.

The influence of guidelines on the use of statins: analysis of prescribing trends 1998-2002

AIMS

To monitor statin prescribing trends over time in order to determine whether prescribers were influenced by study results and/or clinical guidelines in terms of type and dosage of statin prescribed.

METHODS

The GMS (General Medical Services) prescription database in Ireland was used to identify a cohort of patients, prescribed statins, in order to investigate prescribing trends from January 1998-December 2002. Statin prescribing rates for patients with ischaemic heart disease and diabetes were compared with rates in the general GMS population. Logistic regression analysis was used in patients with ischaemic heart disease and diabetes and adjusted odds ratios and 95% confidence intervals presented.

RESULTS

Increased statin prescribing over time was noted (test for linear trend P < 0.0001). Pravastatin was the most frequently prescribed, followed by atorvastatin; simvastatin and fluvastatin showed lower rates of prescribing. Atorvastatin showed the greatest increased rate over time. An increase in the overall dose prescribed (test for trend P < 0.01) was chiefly due to increases in pravastatin dose, but doses were still below those recommended from clinical trials. Statins were prescribed more frequently in patients with ischaemic heart disease and diabetes, 44% (95% CI 43-45%) compared with the total GMS population, 7.7% (95% CI 7.6-7.8%), by December 2002. However, statins were only prescribed to 52% (95% CI 51-53%) of ischaemic heart disease patients and 40% (95% CI 39-41%) of patients with diabetes by December 2002. Patients aged 45-64 years were more likely to receive statins, compared with those aged 65 years and older.

CONCLUSION

These findings suggest that the beneficial effects of statins shown in clinical studies may not be achieved in practice.

Bridging the Treatment Gap: Improving Compliance With Lipid-Modifying Agents and Therapeutic Lifestyle Changes

Despite the large burden of cardiovascular disease on society, abnormal lipid levels, which are associated with an increase in coronary heart disease mortality, are not being adequately managed in many individuals. Poor patient compliance with therapeutic lifestyle changes and lipid-modifying therapies contribute to this treatment gap. If management of lipid levels is to reduce cardiovascular mortality effectively, poor compliance with treatment needs to be understood and addressed. Educating and motivating patients to understand the need for compliance with continued therapy is an important step for ensuring that the benefits of lipid management cited in clinical trials are translated to the general population. This will require a proactive approach from both patients and physicians. Well-tolerated and effective therapies may also help compliance by reducing the incidence of side effects and the need for complex dosing regimens. Suboptimal treatment of lipid levels is currently limiting the effectiveness of primary and secondary prevention of coronary heart disease; methods for improving compliance should be a key strategy to overcoming this problem.

Achievement of low-density lipoprotein cholesterol goals: new strategies to address new guidelines

Evidence that CHD morbidity and mortality can be reduced with reduction of LDL-C to less than 100 mg/dL (2.6 mmol/L) is rapidly accumulating. NCEP-ATP III guidelines should be considered minimal goals of therapy. Regarding the prevention and treatment of CHD, health care providers need to recognize the wide therapeutic gap between evidence-based medicine and customary clinical practice. Aggressive pharmacologic therapy is probably required to achieve optimal LDL-C levels in many hyperlipidemic patients. Novel agents, including selective cholesterol absorption inhibitors, will provide clinicians with a tool to safely and effectively target the exogenous pathway of cholesterol metabolism. Combination therapy with cholesterol-lowering agents that have complementary mechanisms of action and can be safely co-administered may be a new option to achieve broader lipid control.

Status of practice guidelines in the United States: CDC guidelines as an example

BACKGROUND

Clinical practice guidelines have proliferated in the past several decades, starting with only a handful in the 1980s to over 1000 approved through The National Guideline Clearinghouse in 2002.

METHODS

The purposes of this article to review research related to guideline adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example.

RESULTS

Despite the national movement toward standardization of evidence-based practice, few studies have been conducted to assess the costs of guideline development and implementation, and some practice guidelines have been implemented without concomitant assessment on patient outcomes and costs and benefits of changes in care.

CONCLUSIONS

An immediate mandate is to ensure that when guidelines are promulgated, they include an evaluation plan, developed by the implementer of the guideline, which takes advantage of existing qualitative and quantitative data and programs (e.g., patient-centered care, quality assurance, risk management) not limited to expensive and sophisticated clinical trials.

Under-prescribing of cardiovascular therapies for diabetes in primary care

OBJECTIVE

To determine the extent to which cardiovascular therapies are prescribed in primary care for those with diabetes, compared with those without diabetes.

METHODS

Population study of patients with and without diabetes identified using a national primary care prescribing database. All patients receiving a prescription for any diabetes therapy, including insulin and oral hypoglycaemic drugs, or diagnostic test kit for glucose ( n=8523) and those receiving no such therapies ( n=145,756) during a 1-year period (September 1999-August 2000) in the Eastern Regional Health Authority of Ireland were identified. In addition, a sub-set of patients receiving a nitrate prescription, a marker for ischaemic heart disease (IHD), were also identified ( n=14,826). Odds ratios and 95% confidence intervals for prescribing of cardiovascular therapies between those with diabetes and those without, adjusted for age and gender, were calculated using logistic regression.

RESULTS

The proportion of those (and 95% CES) with diabetes and IHD prescribed secondary preventative therapies was 37.3% (35.0, 39.6) for statins, 55.3% (53.0, 57.6) for angiotension converting enzyme inhibitors, 34.7% (32.5, 36.9) for beta blockers, 73.3% (71.2, 75.4) for aspirin, 4.4% (3.4, 5.4) for angiotensin-II antagonists and 2.5% (1.8, 3.2) for fibrates. The adjusted odds ratios for prescribing in those with diabetes compared with those without are 1.44 (1.30, 1.61) for statins, 3.09 (2.79, 3.42) for angiotension converting enzyme inhibitors, 0.82 (0.74, 0.91) for beta blockers, 1.23 (1.09, 1.38) for aspirin, 1.47 (1.13, 1.87) for angiotensin-II receptor blockers and 4.23 (2.88, 6.14) for lipid-lowering fibrates.

CONCLUSION

The greater rate of prescribing of cardiovascular therapies in those with diabetes relative to those without is not unexpected given the higher risk of coronary heart disease in those with diabetes. However, the proportion of patients with diabetes, particularly those with established IHD, prescribed cardiovascular therapies is considerably below that recommended in local and international guidelines.

Practice guidelines and measurement: state-of-the-science

BACKGROUND

Restructuring of the health care system has exposed widespread evidence of practice variability and has highlighted the benefits associated with nurses embracing interdisciplinary, best practice solutions to health care delivery. Clinical practice guidelines have emerged as a valuable interdisciplinary evidenced-based tool.

PURPOSE

This article explores the state of the science of guideline measurement and evaluates the strengths and weaknesses of measurement approaches.

METHOD

A computerized search of Cumulative Index of Nursing and Allied Health Literature, Health and Psychosocial Instruments, Medline, and PubMed for the search term "practice guidelines" was combined with the following key words: attitudes, adherence, effect, impact, instrument, and measurement.

DISCUSSION

Measurement issues identified in this analysis are related to the manner in which guidelines are written and the lack of a standard methodology for measurement.

CONCLUSIONS

The challenge remains to establish sound measures of adherence and impact while controlling for confounding variables. Questions remain as to the format of practice guidelines to best grant autonomy while offering recommendations that are clear and measurable.

Lipid-lowering medication for secondary prevention of coronary heart disease in a German outpatient population: the gap between treatment guidelines and real life treatment patterns

BACKGROUND

Few published data in particular from the United States indicate that the implementation of guidelines for prevention of coronary heart disease (CHD) is far from optimal. The objective of our study was to identify the type and prevalence of lipid-lowering medications in a German outpatient CHD population and to examine the impact of applied treatment regimens on serum lipid levels.

METHODS

Retrospective analysis of the washout phase of 2,856 CHD patients requiring lipid-lowering medication. Data are derived from a multicenter, randomized, open-label, parallel group clinical trial comparing the safety and efficacy of atorvastatin versus simvastatin in 591 centers in Germany. Medical history, physical examination, and serum lipid levels were obtained at the beginning of the washout phase (Week -6) and at the end of the washout phase (Week -1, i.e., 5 weeks after the discontinuation of all prior lipid-lowering medications). The data at Week -6 represented the lipid levels under real life conditions. The difference from the data at Week -1 reflected the therapeutic effects achieved by the previous lipid-lowering treatment.

RESULTS

The mean low-density lipoprotein cholesterol (LDL-C) level at Week -6 was 173.4 +/- 42.5 mg/dl. Only 176 (6.2%) of 2,856 CHD patients were found to meet the target LDL-C level of <115 mg/dl at Week -6, only 76 (2.7%) patients had LDL-C levels <100 mg/dl, and 363 (12.7%) patients had LDL-C levels <130 mg/dl. After discontinuation of all prior lipid-lowering medications, mean LDL-C increased to 187.2 +/- 44.0 mg. This means that only a marginal 7.4% reduction in LDL-C level was achieved under real life treatment conditions. This limited LDL-C reduction was due mainly to the low prevalence of lipid-lowering treatment (65.5% of patients did not receive any medication at all) and inadequate dosing. With respect to the effect on LDL-C and total cholesterol, statins alone were superior to fibrates.

CONCLUSION

The study shows that there is a wide gap between treatment guidelines and real life treatment patterns in Germany. Awareness of the risks of high cholesterol levels has to be increased among both patients and physicians. Available treatment guidelines should be better implemented.

A randomized controlled trial of an extensive lifestyle management intervention (ELMI) following cardiac rehabilitation: study design and baseline data

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 randomized intervention to prevent these adverse changes.

METHODS

Patients with ischemic heart disease (IHD) were randomized following a standard CRP to the ELMI or to usual care. The ELMI program is a case-managed intervention aimed 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 randomized. 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 infarction, 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 standard CRP. Results of the ELMI trial will provide valuable information for the future design of CRPs.