Evaluation of strategies of care in the secondary prevention of heart disease: critical appraisal of a cluster randomized trial.

Evaluation of: Murphy AW, Cupples ME, Smith SM, Byrne M, Myrne MC, Newell J; for the SPHERE study team: Effect of tailored practice and patients care plans on secondary prevention of heart disease in general practice: cluster randomized controlled trial. BMJ 339, B4220 (2009). Coronary heart disease is the main cause of morbidity/mortality in developed countries and the costs of this epidemic are a major concern and a focus of public health policies. The cornerstone in controlling the incidence of coronary heart disease is the management of risk factors and an evaluation of the best strategy is of the greatest importance. Murphy et al. conducted a cluster randomized trial to evaluate the strategies of tailored practice and patient care plans on secondary prevention of heart disease in general practice. The study found that at 18 months of follow-up, there were no significant differences between intervention and control groups in the proportion of patients above the recommended limits of systolic blood pressure, diastolic blood pressure and total cholesterol concentrations. The number of patients admitted to hospital significantly decreased in the intervention group. Although secondary prevention programs have positive impacts on the process of care, the benefit was clear after a longer period of follow-up in many studies. The practice of preventive cardiology in patients with coronary heart disease is difficult to achieve, particularly when the population already had a lower prevalence of uncontrolled risk factors, as Murphy et al. found in their study. It is possible that the patients included in this and other studies were at a sufficiently low risk that the likelihood of detecting a beneficial effect in a short period of time was small. There is good evidence that healthcare professionals can help patients; nonetheless, they also need guidance and programs to help them. Some questions regarding these multidisciplinary programs also remain to be answered, and their cost-effectiveness remains unclear. The incremental benefit of secondary prevention programs may be very small in the settings in which those trials were performed, but they certainly will be beneficial in settings where usual care is less optimal; these scenarios are often found around the world.