Study Evaluates Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting
BACKGROUND:
Collaborative models of care are multi-faceted interventions that typically include planned, interactive communication between primary care providers and specialists. The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers (PCPs) ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Between 7/05 and 3/07, project investigators recruited 703 Veterans with symptomatic IHD from primary care clinics at four VAMCs (344 intervention patients and 359 control patients); 183 PCPs also participated in the study. At each site, a collaborative care team, including a cardiologist, general internist, and clinical nurse or pharmacist, met twice monthly to review patients’ records, develop diagnostic and treatment plans, and conduct progress evaluations. Recommendations were then forwarded to PCPs via the electronic medical record as unsigned orders that PCPs could sign, modify, or reject. Veterans in the control group received usual care. All Veterans were mailed follow-up questionnaires at 4, 8, and 12 months to assess symptoms and self-perceived health.
FINDINGS:
- The collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina.
- Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications.
- The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins.
LIMITATIONS:
- Concordance with guidelines at baseline was relatively high, limiting opportunities for improvement (ceiling effect).
- There was a substantial non-response to the invitation to participate in this study, which was related to the two-stage, mail-in consent process mandated by the Institutional Review Boards.
- Although classification of angina was based on the Seattle Angina Questionnaire ? a reliable, responsive, and validated measure of angina ? misclassification of angina pain may have occurred.
IMPACT:
- This collaborative care intervention is potentially applicable to other chronic illnesses and is being evaluated as part of VHA’s transformational initiative related to new models of care.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IHI 02-062). Dr. Fihn is currently with VA’s Office of Analytics and Information, but was at HSR&D’s Northwest Center for Outcomes Research in Older Adults during this study.
Fihn S, Bucher J, McDonell M, et al. A Collaborative Care Intervention for Stable Ischemic Heart Disease. Archives of Internal Medicine September 12, 2011;171(16):1471-79.
