title: Case-based training of evidence-based clinical practice in primary care and decreased mortality in patients with coronary heart disease.
abstract: OBJECTIVE
  We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD).
  
  
  METHODS
  A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention.
  
  
  RESULTS
  At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20-0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist.
  
  
  CONCLUSIONS
  Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.
authors.affiliation: Department of Clinical Sciences, Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden. anna.kiessling@ki.se
authors.forename: Anna
authors.initials: A
authors.lastname: Kiessling
authors.forename: Moira
authors.initials: M
authors.lastname: Lewitt
authors.forename: Peter
authors.initials: P
authors.lastname: Henriksson
mesh_terms: D000924:Anticholesteremic Agents / Q000627:therapeutic use; D002983:Clinical Competence; D016001:Confidence Intervals; D003324:Coronary Artery Disease / Q000188:drug therapy / Q000401:mortality*; D004522:Educational Status; D019317:Evidence-Based Medicine / Q000379:methods*; D005260:Female; D058005:General Practitioners; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods*; D018794:Problem-Based Learning / Q000379:methods*; D011787:Quality of Health Care / Q000592:standards; D013223:Statistics as Topic; D013548:Sweden
chemical_list: D000924:Anticholesteremic Agents