Collaborative Care for Patients with Ischemic Heart Disease

Collaborative care is one of the components of the patient-centered medical home, a care model promoted as part of the Patient Protection and Affordable Care Act of 2010. Studies have demonstrated that for patients with depression or diabetes mellitus, collaborative care, including planned interactive communication between primary care providers (PCPs) and specialists, has improved processes and treatment outcomes. Another condition that requires complex pharmacotherapy and management using evidence-based guidelines is ischemic heart disease (IHD). According to researchers, “although treatments for IHD decrease mortality and improve quality of life, many patients are not treated according to well-publicized guidelines.” To determine whether an intervention directed through PCPs using the collaborative care model would improve symptoms of angina, self-perceived health, and utilization of practice guidelines for managing chronic stable angina among patients with IHD who reported angina or sublingual nitroglycerin use at least once a week, researchers recently conducted a randomized prospective trial. They reported results in Archives of Internal Medicine [2011;171(16):1471-1479]. The trial was randomized by provider; it involved patients with symptomatic IHD recruited from primary care clinics at 4 academically affiliated Department of Veterans Affairs (VA) healthcare systems. Providers were enrolled from October 7, 2004, through March 30, 2005, and patients agreed to participate in the study between July 29, 2005, and March 9, 2007. The primary end points were changes over 12 months in symptoms on the Seattle Angina Questionnaire (SAQ), self-perceived health, and concordance with practice guidelines. The collaborative care intervention utilized collaborative care teams that included a cardiologist, general internist, research assistant, and a clinical nurse specialist or pharmacist. The team met twice a month to review patients’ records, develop plans for diagnosis and treatment, and report progress evaluations. The research assistants conducted telephone interviews with the patients to gather data on symptoms and medications, including adherence, activities, and care received outside of the VA. The final study cohort included 183 PCPs; of those, 91 were randomized to the collaborative care group and 92 to the control group. The researchers identified 17,484 patients with IHD who were being treated by the consenting providers; study eligibility was determined by questionnaires sent to those patients. Of the 7033 patients who responded to the eligibility questionnaire, 703 met inclusion and exclusion criteria; there were 344 patients in the collaborative care group and 359 in the control group. Mean age was 68 years, 97.7% were male, 87.6% received most of their care through the VA, and 18.9% received at least some non-VA cardiology care. Baseline characteristics, including SAQ anginal frequency score, were similar in the 2 groups (52.8 in the collaborative care group vs 53.8 in the control group). There were 701 recommendations made by the collaborative care teams; of those, providers accepted and implemented 91.6%. Forty-seven percent of the recommendations were related to medications; adjustments to beta-blockers, long-acting nitrates, and statins were the most frequent recommendations. Other recommendations were for referrals, consultations, or other assessments (21.8%); cardiac diagnostic testing (8.7%); and laboratory tests (8.7%). The remainder included a call from the PCP or follow-up visit with the patient to review symptoms or compliance. The collaborative care model was favored in 10 of 13 study measures, but the intervention did not significantly improve either the symptoms of angina or self-perceived health. Between baseline and 12 months, patients in the intervention group improved 0.18 more points (4.5%) than those in the control group on the guideline concordance score (P<.01). There was no difference between the groups in change in provider satisfaction from baseline to 12 months. Limitations to the study cited by the researchers include substantial nonresponse to the mail invitation to participate, possible misclassification of anginal pain, and a limited ability to generalize the findings beyond integrated care systems similar to the VA. In summary, the researchers said, “A collaborative care intervention was well accepted by primary care providers and modestly improved receipt of guideline-concordant care, but not symptoms or self-perceived health in patients with stable angina.”