Effectiveness of nurse-led clinics for patients with coronary heart disease A systematic review and meta-analysis

Abstract

Objective: Coronary heart disease (CHD) is a primary cause of cardiovascular disease and a critical public health concern with increased burden on health care. Nurse-led clinics (NLCs) can potentially contribute in providing effective secondary prevention in patients with CHD. This review aims to determine effectiveness of NLCs in managing patients with CHD compared to usual care. Nurse-led clinics offer a healthcare service that is staffed and coordinated primarily by registered nurses, advanced practice nurses and/or nurse practitioners. They provide specialised healthcare, comprising assessment and evaluation, counselling, education, empowerment, treatment and/or case management for a range of health conditions, including CHD. Introduction: This review presents the best available evidence in relation to NLCs for patients with CHD by updating an existing systematic review (SR) published in 2010. There is a growing evidence base of clinical trials with novel care components in NLCs that have not yet been incorporated into any of the more recent reviews in this area, which are consequently now outdated and/or have addressed different patient populations. Hence, there is a clear need to update the existing SR. Inclusion criteria: Randomised controlled trials examining patients aged 18 years and above with existing or newly diagnosed CHD such as angina pectoris and myocardial infarction were included in the review. The intervention is NLCs for cardiac patients, whereas usual care may be managed by medical practitioners such as General Practitioners (GPs) or specialists and any other non-nursing healthcare professional. Methods: Databases of unpublished and published literature have been searched for the period January 2008 until February 2022. Methodological quality assessment, data extraction and synthesis were undertaken using the SR management tools available through the Joanna Briggs Institute (JBI-SUMARI) and Revman. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence. Results: From 1390 records, 16 studies published between 2008 and 2022 were eligible for inclusion, in addition to the 13 studies from the previous review. Of the additional 16 studies, five evaluated all-cause mortality, two investigated symptoms such as chest pain exacerbations, including those requiring medical treatment. Twelve trials measured changes in risk factors for cardiac patients, eight trials provided self-reported measurements of health behaviour, 6 studies investigated patients’ compliance to the treatment. Ten trials provided self-reported measurements of quality of life for cardiac patients. Nurse-led clinics may slightly reduce all-cause mortality among cardiac patients in comparison to usual care at the 12 months follow-up (odds ratio (OR) of 0.78; 95% confidence interval (CI), 0.54-1.13, P=0.19). Attendance at NLCs may slightly reduce symptoms of chest pain in the long term (OR 0.81; 95% CI, 0.64-1.04; P=0.10). Mean systolic blood pressure (BP) in the medium term (6-11 months) was 10.96 mmHg lower in NLCs (95% CI -15.49, -6.43, P<0.00001). For diastolic BP in the medium term, the mean BP was 8.47 mmHg lower in NLCs (95% CI - 13.83, -3.12, P=0.002). There is little or no difference between NLCs and usual care in the likelihood of improving depression and anxiety. Patient satisfaction and utilisation of health service were not synthesised due to limited data. Conclusion: The evidence of this review suggests that NLCs may play a significant role in providing care to patients with CHD and may have similar or better effects on the prevention and treatment of CHD compared to usual care. The current analysis suggested a favourable effect of NLCs on mortality, chest pain, and some cardiac risk factors. However, transformations in health behaviours, compliance to medications and health-related quality of life were less evident. Nevertheless, NLCs should be considered for delivering care to patients with CHD and establishing specialised healthcare services in the community.