Website of the Department of Health

(The ASSIST trial)

Executive Summary

Project findings

Objective
To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care.

Design
Pragmatic unblinded cluster-randomised controlled trial.

Setting
Warwickshire, England.

Patients/participants
21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease.

Interventions:
(i) Audit: audit of notes with summary feedback to primary health care team
(ii) Recall to general practitioner (GP): assistance with setting up a disease register and systematic patient recall to GP
(iii) Recall to nurse: assistance with setting up a disease register and systematic patient recall to practice nurse clinic.

Main outcome measures at 18 months follow-up:

(i) 'adequate assessment' of blood pressure, cholesterol, and smoking status
(ii) prescribing of hypotensives, lipid lowering agents, and antiplatelets
(iii) blood pressure, serum cholesterol, and cotinine levels.

Results
Adequate assessment of all three risk factors was much more common in the Nurse and General Practitioner recall groups (85%, 76%) than the Audit group (52%). The advantage in the Nurse recall compared with the Audit group was 33% (95% confidence interval 19 to 46); in the General Practitioner recall compared with the Audit group 23% (10 to 36) and in the Nurse recall compared with the general practitioner recall group 9% (-3 to 22). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mmHg), total cholesterol (5.4, 5.5, 5.5 mmol/l) and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the Nurse recall, General Practitioner recall and Audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the Nurse recall group (85%) than the general practitioner recall or Audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the Nurse recall compared with the Audit group was 10% (3 to 17), in the Nurse recall compared with the General Practitioner recall group 8% (1 to 15) and in the General Practitioner recall compared with the Audit group 2% (-6 to 10).

Conclusions
Setting up a register and recall system improved patient assessment at 18-month follow-up, but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease.

Relevance to the NHS
Achieving optimal management and treatment for patients with established CHD in primary care is a priority for the development of clinical governance in relation to the National service Framework for CHD. The results of the trial show that by setting up more active strategies, important improvements in monitoring and management of CHD patients can be achieved.

Dissemination

Target audience
General practitioners and practice nurses

Publications

Papers accepted for publication:

Moher M, Yudkin P, Turner R, Schofield T, Mant D for the ASSIST (Assessment of Implementation STrategies) trial collaborative Group. An assessment of morbidity registers for coronary heart disease in primary care. Br J Gen Pract 2000;50:706-709.

Yudkin P, Moher M. Putting theory into practice: a cluster-randomised trial with a small number of clusters Statist. Med 2001;20:341-349.

Wright F.L, Wiles R, Moher M for the ASSIST (Assessment of Implementation STrategies) trial collaborative Group. Patients' and practice nurses perceptions of secondary preventive care for established ischaemic heart disease: A qualitative study. Journal of Clinical Nursing 2001;10:180-188.

Moher M, Yudkin P, Wright L, Turner R, Schofield T, Mant D for the ASSIST (Assessment of Implementation STrategies) trial collaborative Group. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care (BMJ 2001 - in press).

Conference presentations

How to ASSIST primary care

This oral presentation by Dr Michael Moher took place at:

An assessment of morbidity registers for coronary heart disease in primary care.

This oral presentation by Dr Michael Moher took place at:

Randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care.

This oral presentation by Dr Michael Moher took place at the AUDGP annual scientific meeting in Bournemouth, 12-14 July 2000.

Poster presentations

Pat Yudkin, Michael Moher
Design and analysis of cluster-randomised trials with a small number of clusters at the AUDGP annual scientific meeting in Bournemouth, 12-14 July 2000. (this poster presentation received special commendation by the judges at the prize giving)

Lucy Wright, Rose Wiles
Patients' and practice nurses perceptions of secondary preventive care for established IHD:A qualitative study.