(Circulation. 1996;93:4-6.)
© 1996 American Heart Association, Inc.
Articles |
Compliance Enhancement
A Call for Multidisciplinary Team Approaches
From the Johns Hopkins University, Baltimore, Md (M.N.H.), and Stanford Cardiac Rehabilitation Program, Stanford University School of Medicine, Palo Alto, Calif (N.H.M.).
Correspondence to Martha N. Hill, RN, PhD, Associate Professor, Nursing, Medicine and Public Health, The Johns Hopkins University, 1830 E Monument St, Room 233, Baltimore, Md 21205-2100.
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Introduction |
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Concern about the cost and quality of health care has stimulated an interest in documenting improved patient outcomes. Large multisite clinical trials, such as MRFIT,1 HDFP,2 SHEP,3 and 4S,4 used multidisciplinary educational and behavioral interventions to demonstrate dramatic reductions in cardiovascular morbidity and mortality through the modification of risk factors. Other large multisite clinical trials, such as TOHP I5 and TOMS,6 used similar strategies to demonstrate significant differences in lifestyle modification and quality of life associated with effective risk reduction. But similar outcomes have not been achieved in clinical practice.
Why are we not achieving the same results in clinical practice that we see in randomized controlled clinical trials? We believe one major reason is that the multidisciplinary team approach used in clinical trials to reduce risk is insufficiently incorporated into standard clinical practice.
In the case of secondary prevention for coronary artery disease, improved outcomes depend on patients' following appropriate risk reduction plans. The recent American Heart Association consensus statement "Preventing Heart Attack and Death in Patients With Coronary Disease"7 outlines a set of risk reduction recommendations for clinicians and emphasizes the central role of patient compliance (or "adherence") in achieving improved medical outcomes. The statement says that "attention to enhancing patient compliance is an integral part of any risk reduction program," adding that the proportion of patients who continue risk factor interventions over the long term "can be significantly increased by a team approach in which healthcare professionals-including physicians, nurses, and dietitians- manage risk reduction therapy by using follow-up techniques that include office or clinic visits and telephone contact. In many healthcare settings, the team approach will be the preferred technique for optimizing risk reduction."
The need for improved patient compliance extends well beyond those with established coronary artery disease. For example, for more than 20 years, a blood pressure level of 140/90 mm Hg has been arbitrarily established as the cutoff point for defining high blood pressure. Since 1972, the Coordinating Committee of the National Heart, Lung, and Blood Institute's High Blood Pressure Education Program (to which the American Heart Association belongs) has spearheaded extensive professional education programs and mass media campaigns about control of high blood pressure. Yet the recently published NHANES III data indicate that of all people in the United States with hypertension, only 24%, or 29% after adjustment, now have blood pressures controlled to <140/90 mm Hg.8 9 Fewer than 50% of those treated for hypertension were controlled (<140/90 mm Hg) in each of the six age, sex, and race groups analyzed.9 In the editorial10 accompanying the release of the NHANES III prevalence data,9 Hypertension editor-in-chief E.D. Frohlich says, "This is a totally unacceptable number. ... We can still do better in hypertension control."
The evidence is clear, not only for blood pressure but for smoking, exercise, obesity, and lipids, that optimal risk factor management will benefit very large numbers of people. Statements and consensus reports providing guidance for detection, evaluation, and treatment, including strategies for behavior change and compliance for healthy adults and those with disease, have been widely circulated.11 12 13 14 15 16 17 18 19 Nonetheless, despite progress in controlling some risk factors, evidence indicates that overweight and sedentary activity are increasing.19 20 Further improvement in risk factor reduction is needed if potential beneficial outcomes are to be achieved and costs reduced.
Managing cardiovascular risk factors is a complex, multifactorial process. It requires the management over many decades of single or multiple risk factors within the context of coexisting biological, psychological, and social factors. And it requires that patients not only adopt health-promoting behaviors but also sustain these behaviors indefinitely, adhering both to medication regimens and lifestyle modifications. Monitoring the effects of treatment, including drug-induced side effects or worsened symptoms, and taking appropriate action are other patient responsibilities. Effective risk factor management requires not only that patients participate fully in their care in these ways but also that healthcare professionals be trained in behavioral science and make multiple contacts with their patients. If this is understood, why hasn't standard practice incorporated these approaches?
The delivery of medical care can be conceptualized as three domains: the cognitive (delineating what should be done), the executive (specifying how it should be done and who should do it), and the organizational (determining where to do it). We suggest that deficiencies within each of these domains impede progress in risk reduction needed for successful secondary prevention.
Practice guidelines, for example, are increasingly used by government agencies and healthcare delivery systems to standardize treatment practice. Caring for individuals, however, requires patient-specific data not only about comorbid conditions, symptoms, concurrent medications, and laboratory findings but also about prior experiences with healthcare providers, life-style modification, and readiness to adopt new habits and change behavior patterns. Acquiring such data is central to the cognitive process.
Conveying these data and the resulting recommendations to other providers as well as to the patients and their family and caregivers is an important executive task for which little provision has been made in the current healthcare delivery system. Currently, the system focuses almost exclusively on the hospital and physician's office settings. During hospitalization, physicians and nurses acquire this information, document it, and implement decisions that result from it. But after discharge, the physician caring for the patient may not have the hospital information and thus may have to acquire information and execute decisions with a less well-developed database.
A related deficiency in the long-term care of patients is the almost exclusive reliance on repeated face-to-face visits with the physician, either in the office or in an outpatient clinic. However, it is what happens between these visits that determines whether even the best treatment recommendations will yield improved outcomes. Face-to-face visits with the physician have deep historical roots, but they are less efficient and less effective in improving outcomes than multidisciplinary team approaches that use numerous management strategies during and between office visits. Ultimately, the patient is in charge.21 Our challenge, particularly for those of us who practice in settings delivering care in this era of increasing cost constraints, is to help patients take care of themselves, day in and day out.
Many of the deficiencies that conspire against risk factor management in conventional settings can be corrected by systems that rely on nurses and other nonphysicians. These care providers use the telephone to gather information from patients, communicate treatment decisions, and provide surveillance and support. They can supplement that phone contact with both office and home visits. Other organizational deficiencies can be overcome with computer databases and other forms of decision support.
A case management system applying these strategies was used recently with patients recovering from acute myocardial infarction. The program demonstrated that nurses can effectively manage multiple risk factors simultaneously.22 Known as MULTIFIT, the system relies on specially trained nurses to provide interventions for smoking cessation, exercise training, diet and drug management of hyperlipidemia, and control of other risk factors. In a year-long randomized clinical trial conducted through a health maintenance organization, the MULTIFIT nursing intervention proved to be significantly more effective than conventional care. For example, MULTIFIT patients achieved plasma LDL cholesterol values of 107±30 mg/dL at 1 year, bringing them close to the benchmark value of 100 mg/dL established for regression of atherosclerotic lesions and reduction of clinical events.23 24 Of patients treated under MULTIFIT, 85% were still receiving lipid-lowering medications at 1 year compared with 21% in usual care.22
Why was this approach so effective? The investigators used a single caregiver, the nurse case manager, to provide multidisciplinary services. The nurse referred 5% of the participants, only as needed, to nutrition consultation. By substituting telephone and mail contact for some office visits, the nurse-coordinated program made care more convenient for patients, saved money, and enabled nurses to provide personal instruction, support, and surveillance for individual patients. A computerized database and standardized algorithms were used to facilitate data gathering and medical decision-making. This permitted administration of the kind of high-quality care that has been shown to improve patient outcomes.
For some, these findings are not surprising. Nurse-supervised outreach workers, direct nursing care, and nurse case management have been effective approaches for decades. In a variety of settings with consultation and referral access to physicians, pharmacists, and dietitians, nurses have been shown to be effective in improving outcomes for persons with hypertension,25 26 27 28 29 30 31 hypercholesterolemia,32 diabetes,33 and smoking.34 Moreover, research has shown that nurse-practitioners can provide care within their areas of competence at levels of quality equivalent to or better than that provided by physicians.35
The potential of secondary prevention to improve the clinical course of coronary artery disease is well established. The role of interdisciplinary education and teamwork in practice and research is well recognized.36 37 We can no longer afford to ignore the evidence. Achieving that potential requires addressing the problems that block effective risk factor modification by changing the delivery of patient care and both provider and patient behavior. The consensus statement developed by the Secondary Prevention Panel of the American Heart Association7 calls for action. Now is the time to respond.
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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TopIntroductionReferences |
|---|
1. Multiple Risk Factor Intervention Trial Research Group. Multiple risk factor intervention trial: risk factor changes and mortality results. JAMA. 1982;248:1465-1477.
2.
Hypertension Detection and Follow-up Program
Cooperative Group. Five-year findings of the Hypertension Detection
and Follow-up Program, I: reduction in mortality of persons with
high blood pressure, including mild hypertension. JAMA. 1979;242:2562-2571.
3.
SHEP Cooperative Research Group. Prevention of stroke
by antihypertensive drug treatment in older persons with isolated
systolic hypertension. JAMA. 1991;265:3255-3264.
4. Pedersen TR, Kjekshus J, Berg K, Haghfelt T, Faegeman O, Thorgeirsson G, Pyorala K, Miettinen T, Wilhelmsen L, Olsson AG, Wedel H. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383-1389. [Medline] [Order article via Infotrieve]
5.
Treatment of Mild Hypertension Study Research Group.
Treatment of mild hypertension study: final results. JAMA. 1993;270:713-724.
6.
The Trials of Hypertension Prevention Collaborative
Research Group. The effects of nonpharmacological interventions on
blood pressure of persons with high normal levels: results of the
Trials of Hypertension Prevention, phase I. JAMA. 1992;267:1213-1220.
7. Consensus Panel Statement. Preventing heart attack and death in patients with coronary disease. Circulation. 1995;92:2-4.
8.
Burt VL, Cutler JA, Higgins M, Horan M, Labarthe D,
Whelton PK, Brown C, Rocella EJ. Trends in prevalence,
awareness, treatment and control of hypertension in the adult US
population: data from the health examination surveys 1960-1991.
Hypertension. 1995;26:60-69.
9.
Burt VL, Whelton PK, Rocella EJ, Brown C, Cutler JA,
Higgins M, Horan M, Labarthe D. Prevalence of hypertension in
the US adult population: results from the third national health and
nutrition examination surveys, 1988-1991.
Hypertension. 1995;25:305-313.
10.
Frohlich ED. There's good news and not so good
news. Hypertension. 1995;25:303-304. Editorial.
11. Grundy SM, Greenland P, Herd A, Huebsch JA, Jones RJ, Mitchell JH, Schlant RC. Cardiovascular and risk factor evaluation of healthy American adults: a statement for physicians by an ad hoc committee appointed by the Steering Committee of the American Heart Association. Circulation. 1987;75:1340A-1362A.
12. Working Group on Health Education and High Blood Pressure Control. Improving Adherence Among Hypertensive Patients: The Physician's Guide. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1987.
13.
Joint National Committee. The Fifth Report of the Joint
National Committee on the Detection, Evaluation and Treatment of High
Blood Pressure (JNC V). Arch Intern Med. 1993;153:154-183.
14. Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Summary of the Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP II). JAMA. 1993;269:3017-3023.
15.
Fletcher GF, Blair SN, Blumenthal J, Casperson C,
Chaitman B, Epstein S, Falls H, Froelicher ES, Froelicher VF, Pina
IL. Statement on exercise: benefits and recommendations for
physical activity programs for all Americans: a statement for health
professionals by the Committee on Exercise and Cardiac Rehabilitation
of the Council on Clinical Cardiology, American Heart
Association. Circulation. 1992;86:340-344.
16. National Institutes of Health Consensus Development Panel on the Health Implications of Obesity. Health implications of obesity: National Institutes of Health Consensus Development Conference. Ann Intern Med. 1985;103:977-1077.
17. US Public Health Service, Office of the Surgeon General, Center for Health Promotion and Education, Office on Smoking and Health. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health; 1988. DHHS publication (CDC) 88-8406.
18.
Pearson T, Rapaport E, Criqui M, Furberg C, Fuster V,
Hiratzka L, Little W, Ockene I, Williams G. Optimal risk factor
management in the patient after coronary
revascularization: a statement for healthcare
professionals from an American Heart Association writing group.
Circulation. 1994;90:3125-3133.
19.
Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA,
Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, Kriska A, Leon
AS, Marcus BH, Morris J, Paffenbarger RS, Patrick K, Pollock ML, Rippe
JM, Sallis J, Wilmore JH. Physical activity and public health: a
recommendation from the Centers for Disease Control and Prevention and
the American College of Sports Medicine. JAMA. 1995;273:402-407.
20. Stephens T. Secular trends in adult physical activity. Res Q Exerc Sport. 1987;58:94-105.
21.
Working Group to Define Critical Behaviors in High
Blood Pressure Control. Patient behavior for blood pressure control:
guidelines for professionals. JAMA. 1979;241:2534-2537.
22.
DeBusk RF, Miller NH, Superko R, Dennis CA, Thomas
RJ, Lew HT, Berger WE III, Heller RS, Rompf J, Gee D, Kraemer HC,
Bandura A, Ghandour G, Clark M, Shah RV, Fisher L, Taylor CB. A
case-management system for coronary risk factor
modification after acute myocardial infarction. Ann
Intern Med. 1994;120:721-729.
23. Watts GF, Lewis B, Brunt JN, Lewis ES, Coltart DJ, Smith LDR, Mann JI, Swan AV. Effects on coronary artery disease of lipid-lowering diet, or diet plus cholestyramine in the St. Thomas Atherosclerosis Regression Study (STARS). Lancet. 1992;339:563-569. [Medline] [Order article via Infotrieve]
24.
Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF,
Supenko R,Williams PT, Johnstone IM, Champagne M, Krauss RM, Farquhar
JW. Effects of intensive multiple risk factor reduction on
coronary atherosclerosis and clinical cardiac
events in men and women with coronary artery disease: the
Stanford Coronary Risk Intervention Project
(SCRIPT). Circulation. 1994;89:975-990.
25.
Finnerty FA Jr, Shaw LW. Hypertension in the
inner city, II: detection and follow-up.
Circulation. 1973;47:76-78.
26.
Runyon JW Jr. The Memphis Chronic Disease Program:
comparison in outcome and the nurse's extended role. JAMA. 1975;231:264-267.
27. Schoenbaum EE, Alderman MH. Organization for long-term management of hypertension: the recruitment, training, and responsibilities of the health team. Bull N Y Acad Med. 1976;52:699-708. [Medline] [Order article via Infotrieve]
28. Hill MN, Reichgott MJ. Achievement of standards for quality care of hypertension by physicians and nurses. Clin Exp Hypertens. 1979;1:665-684.
29.
Morisky DE, Levine DM, Green LW, Shapiro S, Russell RP,
Smith CR. Five-year blood pressure control and mortality
following health education for hypertensive patients. Am
J Public Health. 1983;73:153-162.
30. Bone LR, Mamon J, Levine DM, Walrath JM, Nanda J, Gurley HT, Noji EK, Ward E. Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers. Am J Emerg Med. 1989;7:16-20. [Medline] [Order article via Infotrieve]
31. Perry HM, Sambhi MP, Cushman WC, Frieds ED, Rutan G, Bingham SF, Carmody S, Meyer G. The VA Hypertension Screening and Treatment Program. VA Practitioner. 1992;November:54-60.
32.
Blair TP, Bryant J, Bocuzzi S. Treatment of
hypercholesterolemia by a clinical nurse using
a stepped-care protocol in a non volunteer population.
Arch Intern Med. 1988;148:1046-1048.
33. Peters AL, Davidson MB, Ossorio CR. Management of patients with diabetes by nurses with support of subspecialists. HMO Pract. 1995;9:8-12. [Medline] [Order article via Infotrieve]
34. Taylor CB, Houston-Miller N, Killen JC, DeBusk R. Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Intern Med. 1990;113:118-123.
35. Pew Health Professions Commission. Nurse Practitioners: Doubling the Graduates by the Year 2000. San Francisco, Calif: UCSF Center for the Health Professions; 1994.
36. O'Neil EH. Health Professions Education for the Future: Schools in Service to the Nation. San Francisco, Calif: Pew Health Professions Commission; 1993.
37. Baldwin DC. The Role of Interdisciplinary Education and Teamwork in Primary Care and Health Care Reform. Washington, DC: Department of Health and Human Services; 1994.
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