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A Case-Management System for Coronary Risk Factor Modification after Acute Myocardial Infarction

Robert F. DeBusk, MD; Nancy Houston Miller, RN; H. Robert Superko, MD; Charles A. Dennis, MD; Randal J. Thomas, MD, MS; Henry T. Lew, MD; Walter E. Berger, MD; Robert S. Heller, MD; Jonathan Rompf, MD; David Gee, MD; Helena C. Kraemer, PhD; Albert Bandura, PhD; Ghassan Ghandour, PhD; Mia Clark, RD, MPH; Raksha V. Shah, RD, MS; Lynda Fisher; and C. Barr Taylor, MD
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From the Stanford University School of Medicine, Stanford, California; Kaiser Permanente Medical Care Program in Santa Clara, Redwood City, Hayward, San Jose, and Walnut Creek, California; Deborah Heart and Lung Institute, Browns Mills, New Jersey; Northwestern University School of Medicine, Chicago, Illinois; Lawrence Berkeley Laboratory, Berkeley, California. Requests for Reprints: Robert DeBusk, MD, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite 106, Palo Alto, CA 94304-1517. Acknowledgments: The authors thank research nurses Mary Adornato, RN, MS, Nancy Fitch, RN, MS, Liz Frazier, BSN, MS, Vicki Hacker, RN, MS, Sherry Novak, RN, MBA, Teresa Picchi, RN, BSN, Deborah Senneca, RN, BSN, Sue Swope, RN, MS, and Robin Wedell, RN, BSN for their excellent performance; the medical staffs of the participating Kaiser Permanente Medical Centers for referring patients to the study; the Stanford-based research staff Debi Hooke, BA, Diane Garcia, BS, and Cheryl Leong, BA, for their excellent technical support; and Steven Sidney, MD, for coordination of the project with the Kaiser Permanente Medical Care Program of Northern California. Grant Support: By HL38874 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland and a Shannon Award from the National Institutes of Health, Bethesda, Maryland. Dr. Thomas participated as a Clinical Scholar of the Robert Wood Johnson Foundation.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(9):721-729. doi:10.7326/0003-4819-120-9-199405010-00001
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Objective: To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification.

Design: Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction.

Setting: 5 Kaiser Permanente Medical Centers in the San Francisco Bay area.

Patients: 585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction.

Intervention: In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy.

Outcome: Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction.

Results: In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 ± 0.69 mmol/L and 3.41 ± 0.90 mmol/L (107 ± 30 mg/dL and 132 ± 30 mg/dL) (P = 0.001), and functional capacities were 9.3 ± 2.4 METS and 8.4 ± 2.5 METS (P = 0.001), respectively.

Conclusion: In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.





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