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QUESTION: In patients with coronary heart disease (CHD), do multidisciplinary disease management programmes (DMPs) improve processes of care and reduce morbidity and mortality?
Data sources
Studies were identified by searching Medline (1966 to 2000), EMBASE/Excerpta Medica (1980 to 1999), CINAHL (1982 to 1999), SIGLE (1980 to 1999), the Cochrane Controlled Trials Register, and the Cochrane Effective Practice and Organization of Care Study Register with the terms case management, health services research, home care services, clinical protocols, patient care planning, quality of health care, rehabilitation, nurse-led clinics, special clinics, and myocardial ischemia. Bibliographies of identified studies were scanned, and experts were contacted.
Study selection
Studies were selected if they were randomised controlled trials in any language investigating the effect of DMPs on death, myocardial infarction (MI), or hospital admission in patients with CHD. Exclusion criteria were primary prevention studies, single modality interventions, inpatient interventions, or < 50 patients.
Data extraction
Data were extracted by 2 independent reviewers on study quality, duration of intervention, length of follow up, and key components of the intervention.
Main results
12 trials (n=9803) were included. Patients who received the DMP intervention did not have greater reductions in recurrent MI (7 trials) {p=0.44}* or all-cause mortality (10 trials) {p=0.40}* than did those who received usual care (table). Admissions to hospitals were reduced among patients who received the DMP intervention (6 trials) {p=0.01}* (table). 5 of 7 trials showed that DMPs reduced cardiovascular risk factors (cholesterol level, smoking, and blood pressure). 5 of 7 trials showed increased prescriptions of efficacious drugs (antiplatelet agents, β-blockers, or lipid lowering drugs).
Multidisciplinary disease management program (DMP) v usual care for coronary heart disease at 0.5 to 48 months†
Conclusion
In patients with coronary heart disease, multidisciplinary disease management programmes increase prescription of efficacious drugs and reduce admission to hospital but do not reduce recurrent myocardial infarction or all-cause mortality in the short term.
QUESTION: In patients with coronary heart disease (CHD), do multidisciplinary disease management programmes (DMPs) improve processes of care and reduce morbidity and mortality?
Commentary
Assessment of risk in patients with CHD is often incomplete, and many patients do not receive optimal treatment.1 Systematic approaches to care are central to all quality improvement initiatives. It is reassuring that the meta-analysis by McAlister et al found that DMPs have a positive effect on processes of care (better risk factor profiles and more prescribing of effective drugs) and on quality of life and hospital admission rates.
Should we be disappointed or even interested that the investigators did not detect statistically significant effects on mortality and reinfarction rates? Not really, as long as the treatments that were targeted for enhanced delivery were themselves known to be efficacious. The organisational interventions tested in the included trials were diverse. Not all conformed to the definition of a comprehensive DMP suggested by McAlister et al. For example, the largest trial contributing to the meta-analysis evaluated psychological rehabilitation after MI.2 Furthermore, individual trials were small (98 to 2328 participants) compared with the original efficacy studies (which often had many more participants), and the duration of follow up was short in most of the studies reviewed (as short as 2 wk) compared with years of follow up in the efficacy studies. Clearly, these studies were underpowered to detect benefits in morbidity and mortality.
What we should mainly require of an organisational intervention is that it enhance delivery of evidence-based interventions. But we certainly need evidence from other sources that the component interventions (such as lifestyle counselling, medication, and psychological support) can improve outcomes.
Another important reason to study organisational interventions is to determine which components and combinations of treatments and delivery improve the processes of care. We cannot easily judge this from the trials included in this review. To analyse complex interventions, other forms of inquiry are needed, particularly those that explore the experiences of patients and professionals.3 Qualitative studies, surveys, time-series analyses, and economic studies can all help in interpreting data on effectiveness from trials.
Footnotes
↵* p Values calculated from data in article
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Source of funding: Alberta Heritage Foundation for Medical Research.
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For correspondence: Dr F A McAlister, University of Alberta Hospital, Edmonton, Alberta, Canada. Finlay.McAlister{at}ualberta.ca.
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A modified version of this abstract also appears in Evidence-Based Nursing.