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Nurse-led clinics to reduce modifiable cardiac risk factors in adults.

Information Source

This Best Practice information sheet updates and supersedes the Joanna Briggs Institute (JBI) information sheet published in 20092. This Best Practice information sheet has been derived from a systematic review published in the JBI Library of Systematic Reviews in 2010. The full text of the report3 is available from the Joanna Briggs Institute (www.joannabriggs.edu.au)

Objectives

The purpose of this information sheet is to present the best available evidence for the effectiveness of nurse-led clinics in reducing cardiac risk factors in adults (aged > 18 years) with newly diagnosed or existing CHD.

Background

Nurse-led clinics were first established in the United Kingdom and the United States in the 1980s in the primary care setting to improve continuity of care after patient discharge while attempting to contain costs. The differentiation between a nurse-led clinic and other forms of clinics such as physician clinics or hospital clinics, lies in the fact that nurse-led clinics are run independently by nurses and that their focus is more holistic, preventive and educative rather than therapeutic or medicinal. The major interventions in such clinics are assessment, evaluation and monitoring of patients' health status, as well as health counselling and education prior to therapy, diagnosis and case management. By providing psychosocial support, promoting secondary prevention strategies and a holistic approach to patients' needs, nurse-led clinics may represent one way of tackling the problem of the rising number of older and chronically ill patients and address issues of consumer satisfaction with their care. Coronary Heart Disease (CHD) is the major cause of illness and death in Western countries, an effect that is likely to increase as the population ages. Individuals with established CHD are at the highest risk of experiencing further coronary events. Establishing and maintaining a healthy lifestyle may contribute significantly in reducing cardiovascular mortality in these individuals. Providing nurse-led services to divert patients from busy hospital and general practice settings has been suggested as one way of maintaining quality care of patients with chronic illness, such as CHD. Nurses have the potential to contribute to risk factor reduction as a result of their familiarity with the patient, availability for sustained consultation and the potential to apply interventions when patients are ready to initiate change rather than during a period of acute crisis.

Types of Intervention

Interventions of interest are those related to the common role of staff in a nurse-run cardiac clinic, including education, assessment and monitoring, consultation, referral and administrative duties.

Quality of the research

There were 13 articles included in the systematic review, describing seven different studies comprising the period of 1998 to 2007, three of them implemented in England and the others located in Scotland, Australia, China and Canada respectively. The studies are all randomised controlled trials, two of them having a cluster design. The nurse-led clinics in the included RCTs were mostly implemented in a general practice setting; one was hospital based with follow-up at home. Follow-up duration ranged from three months to ten years; the majority concluded at one year. Methodological quality of the studies was very good, apart from the randomisation, which was only exactly described and truly randomised in one Chinese study.

Outcomes measures

Six of the seven included studies assessed blood lipids, five studies focused on blood pressure, BMI and medication treatment; and four studies evaluated physical activity, health status, quality of life and smoking behaviour. Further outcomes were diet adherence, anxiety, depression and angina symptoms. Less frequently considered outcomes were clinic attendance, patient satisfaction, readmission rates and total mortality.

Systematic review results

Blood pressure outcomes

Five studies included blood pressure as an outcome. The random effects meta-analysis of two studies revealed no statistically significant benefits from nurse-led clinics on blood pressure reduction in the time period 6 to 8 months. When measuring blood pressure management by calculating patients who reached a certain target level, there was a significant improvement between intervention and control group having blood pressure less than 140/85 mmHg after one year. In one study there was a significant improvement of blood pressure management after one year attending a nurse-led clinic but those benefits were not sustained in the four-year follow-up. Small improvements of blood pressure in the long-term are likely which favours the treatment of a nurse-led clinic. No effect is shown in the long-term of more than one year, though there were only two studies included.

Blood lipid outcomes

Meta-analysis was possible for total cholesterol (TC) and high-density lipoprotein (HDL) values. Six studies had TC as an outcome. Data from two studies reveal a positive, though not statistically significant result for six and eight months follow up respectively. However the random effects meta-analysis of two studies for long-term TC values found that after 12 months and 18 months the effects of the nurse-led clinics decrease. However, patients still significantly benefit from the nurse-led clinics related to risk factor management. This was assessed by calculating the number of patients who attained a target level of total cholesterol less than 5 mmol/l. The meta-analysis found that after one year there was a significantly higher number of patients in the intervention group achieving this target level. Results of the meta-analysis did not reveal significant differences between the groups in terms of the HDL level, neither long term nor short term. In summary, the meta-analysis of TC and HDL did not reveal advantages related to the nurse-led clinics, but the single results for LDL and Triglycerides showed that nurse-led clinics improved these blood lipids in the short term. No long-term effect for blood lipids was achieved with the nurse-led clinics except for the management of achieving blood lipid levels.

Smoking

The studies included in the systematic review found that nurse-led clinics did not influence smoking cessation rates in patients in either the short term or long term. The number of patients not smoking was not reduced after one year attending a nurse-led clinic.

Body weight

Studies found that the nurse-led clinics had no statistically significant effect on the patients' behaviour related to reduce body weight, in either the short or long-term.

Compliance

Compliance is an important part of health behaviour because it is related to the degree to which patients are able to change their lifestyle. One Canadian study evaluated compliance in medication intake with a medication compliance index. The index gives the proportion of days when medication was taken according to the plan and is expressed in percentages. The authors report that no significant difference between the groups was detectable.

One Scottish study evaluated compliance with aspirin intake. At one-year follow up adherence to correct aspirin intake was significantly higher in the intervention group. Similarly there were significant benefits in continuing physical exercise and diet after one year, but none of these effects were maintained at the four-year follow-up. The results strongly recommend a nurse-led clinic for supporting patients to maintain their lifestyle changes and to influence patients' willingness to comply with the prevention of CHD in the first year following the clinic attendance. However, studies included in this review measured compliance with medication intake only, so that compliance with other health promotion strategies is unknown.

Quality of life and general health status

Outcomes on health status and perceived quality of life were measured in most of the studies using the Short Form 36 (SF36) questionnaire with scores ranging from zero to 100 and higher scores indicating a better outcome. Results of three studies at one-year follow-up were pooled in a meta-analysis. Unfortunately, none of the articles presented an overall score for the eight domains of the SF 36 and it could not be calculated, so each domain of the SF 36 is evaluated and interpreted separately.

Physical function

The results significantly favour nurse-led clinics to improve physical skills and function in CHD patients.

Social functioning

Nurse-led clinics have a comparable impact on social functioning for CHD patients to other clinics. No difference was found between the groups at 12 and 18 months follow-up or at 4 years.

Physical and emotional role limitation

Results show that the overall effect on the patient's ability to fulfil their physical an emotional roles is improved in nurse led clinics.

Bodily pain

There was no effect on pain relief at one-year follow-up.

Energy and vitality

The patients' perception on energy and vitality did not improve significantly in the intervention groups attending a nurse-led clinic at one-year follow-up. One study, a cluster RCT, detected benefits for experienced vitality after one year. However, in studies with longer follow-up periods this effect was not seen.

Mental health

The results on mental health did not show significant improvement after one year attendance to nurse-led clinics. Apart from one study (cluster design) the clinics' effect was not beneficial for the long-term at the 18 months evaluation and the four-year follow-up.

General health perception

Perceived general health was significantly better in the intervention group after one year follow-up. This result was not supported at 18 months follow-up and the four-year follow-up.

Summarising the results of the SF 36, statistically significant improvements at the first year follow-up were only achieved in physical functioning, physical and emotional role limitation and general health perception. For all other domains outcomes of the nurse-led clinics were equal to other clinics.

Depression and anxiety

Depression and anxiety were only included in a Scottish study. These outcomes showed no difference between the groups at one-year and four-year follow-up.

Angina symptoms

One study focused on angina symptoms, using the Seattle Angina Questionnaire. The statistically significant differences between the groups at one year follow-up were found in exertional capacity and angina frequency, where the intervention group scored higher and therefore had less angina symptoms. The Angina TyPe[R] questionnaire, used in one Scottish study to assess angina pain, identified no significant difference between the groups at one-year and four-year follow-up, except that worsening chest pain was experienced significantly less frequently in the intervention group after attending a nurse-led clinic for one year.

Hospital admissions

One Scottish study evaluated hospital admissions. At the 10-year follow-up there was no difference between the groups for this outcome. Data are not sufficient for statements on the short and middle-term follow-up.

Coronary events, coronary mortality and total mortality

In one Scottish study total mortality was significantly reduced in the intervention group at four-year follow-up and the occurrence of coronary events shows a borderline difference. No significant differences occurred between the groups concerning all cause mortality, coronary events or deaths due to coronary events at 10-year follow-up.

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Recommendations

* Nurse-led clinics offer some support for adult patients with newly diagnosed or existing CHD in achieving certain target treatment levels such as total cholesterol and blood pressure, but seem to be less effective in improving absolute values of risk factors in the short-and long-term, except for LDL-cholesterol and triglycerides. (Grade B)

* Nurse-led clinics offer some support for adult patients with newly diagnosed or existing CHD to maintain their lifestyle changes and influence patients' willingness to comply with the prevention of CHD in the first year following the clinic attendance. (Grade B)

* Nurse-led clinics may positively influence perceived quality of life and general health status, especially physical functioning in adults with newly diagnosed or existing CHD. (Grade B)

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006

Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Definition of terms

For the purposes of this information sheet the following definitions were used:

Nurse-led clinic--a term used for clinics defined as clinics providing a service for the customer that is managed and staffed solely by nurses, with the ability to assess, treat and consult or refer the consumer to other health disciplines as required.

Cardiac risks factors--health or lifestyle influences that increase the chances of CHD. Known modifiable risk factors include being overweight, smoking, elevated cholesterol levels, high blood pressure, suffering from depression, sedentary lifestyle and having a high intake of alcohol.

Compliance--defined as the willingness to follow treatment.

Acknowledgments

This Best Practice information sheet was developed by The Joanna Briggs Institute.

References

(1.) The Joanna Briggs Institute. Levels of Evidence and Grades of Recommendations. http://www.joannabriggs.edu.au/pubs/approach.php

(2.) The Joanna Briggs Institute. Nurse-led interventions to reduce cardiac risk factors in adults. Best Practice: evidence-based information sheets for health professionals 2009; 13(5):1-4.

(3.) Schadewaldt V, Schultz T. A systematic review on the effectiveness of nurse-led cardiac clinics for adult patients with coronary heart disease. JBI Library of Systematic Reviews 2010;8(2):53-89.

(4.) Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.
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Date:Feb 1, 2010
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