June 28, 2015Open Access

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

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Ischaemic heart disease (IHD) (n=4005). Intervention: Organisational interventions for secondary prevention vs. Usual care. Primary outcome: All-cause mortality at 4.7-6 years (RR 0.79, 95% CI 0.66 to 0.93, p=0.006).

Key Result

Cardiac secondary prevention programmes targeting organisational change in primary care reduced all-cause mortality by approximately 20% (RR 0.79) at 4.7 to 6 years of follow-up.

Study Design

Type

Meta-Analysis (n=4,005)

Structured PICO

Do primary care organisational interventions reduce long-term mortality in patients with established ischaemic heart disease?

Population

4,005 patients with established ischaemic heart disease from 5 randomized controlled trials, followed for 4.7 to 10 years to evaluate primary care organisational interventions.

Intervention

Cardiac secondary prevention programmes targeting organisational change in primary care or community settings (components included patient/clinician education, pre-planned appointments, nurse-led interventions, risk-factor management) lasting 1-3 years.

Comparator

Usual care.

Outcome

All-cause mortality and cardiac-related mortality at 4.7-6 years follow-up.hard clinical

Cardiac secondary prevention programmes targeting organisational change in primary care are associated with a reduced risk of death for at least 4-6 years after the formal cessation of the original programmes.

Main Result

Relative Risk: 0.79 (95% CI 0.66–0.93)

Absolute Event Rate: 14.2% vs 18.1%

p-value: p=0.006

Limitations

Small number of included studies did not allow for sensitivity analysis based on risk of contamination of controls
Populations included in the trials were predominantly males from Western Europe, limiting generalisability
Considerable clinical heterogeneity in the intervention components across studies
Insufficient evidence to determine how long the intervention impact persists after formal cessation

Abstract

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(®), 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.

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