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- Title
The effect of a nurse-led telephone-based care coordination program on the follow-up and control of cardiovascular risk factors in patients with coronary artery disease.
- Authors
NINGYAN WONG; SIANG JIN TERRANCE CHUA; FEI GAO; SOK TIANG ROSALIND SIM; MATCHAR, DAVID; SUNG LUNG AARON WONG; KHUNG KEONG YEO; WEI CHIEH JACK TAN; CHEE TANG CHIN; Wong, Ningyan; Chua, Siang Jin Terrance; Gao, Fei; Sim, Sok Tiang Rosalind; Wong, Sung Lung Aaron; Yeo, Khung Keong; Tan, Wei Chieh Jack; Chin, Chee Tang
- Abstract
<bold>Objective: </bold>We sought to analyse the impact of a care coordination protocol on transiting patients with coronary artery disease who had undergone percutaneous coronary intervention (PCI) to primary care and its effect on cardiovascular risk factor control.<bold>Design: </bold>A prospective observational study involving 492 patients who had undergone PCI either electively or after an acute coronary syndrome.<bold>Setting: </bold>A tertiary institution in Singapore.<bold>Participants: </bold>Patients who had undergone a PCI either electively or after an acute coronary syndrome.<bold>Interventions: </bold>The SCORE (Standardized Care for Optimal Outcomes, Right-Siting and Rapid Re-evaluation) program was a nurse-led, telephone-based, care coordination protocol.<bold>Main Outcome Measures: </bold>Transition to primary care within 1 year of enrolment, the achievement of low-density lipoprotein (LDL) level of <2.6 mmol/l within 1 year and hospital admissions related to cardiovascular causes within 1 year were studied.<bold>Results: </bold>Under the SCORE protocol, a significantly higher number of patients transited to primary care and achieved the LDL target within 1 year, as compared with non-SCORE patients. Discharge to primary care and achievement of target LDL continued to be higher among those under the SCORE protocol even after multivariate analysis. Rates of hospital admission due to cardiovascular causes were not significantly different.<bold>Conclusions: </bold>Care coordination improved the rate of transition of post-PCI patients to primary care and improved LDL control, with no difference in the rate of hospital admissions due to cardiovascular causes. These findings support the implementation of a standardized follow-up protocol in patients who have undergone PCI.
- Subjects
SINGAPORE; TELEMEDICINE; CARDIOVASCULAR diseases risk factors; NURSING care facilities; PERCUTANEOUS coronary intervention; TERTIARY care; FOLLOW-up studies (Medicine); CARDIOVASCULAR disease prevention; CORONARY heart disease treatment; CARDIOVASCULAR system; CORONARY disease; HOSPITAL care; PATIENT aftercare; LONGITUDINAL method; LOW density lipoproteins; MEDICAL care; NURSES; PRIMARY health care; ACUTE coronary syndrome
- Publication
International Journal for Quality in Health Care, 2016, Vol 28, Issue 6, p758
- ISSN
1353-4505
- Publication type
journal article
- DOI
10.1093/intqhc/mzw103