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.
OBJECTIVE
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.


METHODS
A prospective observational study involving 492 patients who had undergone PCI either electively or after an acute coronary syndrome.


METHODS
A tertiary institution in Singapore.


METHODS
Patients who had undergone a PCI either electively or after an acute coronary syndrome.


METHODS
The SCORE (Standardized Care for Optimal Outcomes, Right-Siting and Rapid Re-evaluation) program was a nurse-led, telephone-based, care coordination protocol.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.
Ningyan
N
Wong
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.|Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
Siang Jin Terrance
SJT
Chua
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.
Fei
F
Gao
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.
Sok Tiang Rosalind
STR
Sim
Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
David
D
Matchar
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.|Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
Sung Lung Aaron
SLA
Wong
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.|Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
Khung Keong
KK
Yeo
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.|Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
Wei Chieh Jack
WCJ
Tan
Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, 169609 Singapore.|Health Services and Systems Research, Duke-NUS Medical School Singapore, 8 College Road, 169857 Singapore.
Chee Tang
CT
Chin
D054058:Acute Coronary Syndrome; D000359:Aftercare / Q000379:methods*; D000368:Aged; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D008078:Cholesterol, LDL / Q000097:blood; D003324:Coronary Artery Disease / Q000097:blood / Q000451:nursing* / Q000628:therapy; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009726:Nurses; D062645:Percutaneous Coronary Intervention; D011320:Primary Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012307:Risk Factors; D012846:Singapore; D017216:Telemedicine
D008078:Cholesterol, LDL
cardiovascular diseases; care pathways/disease management; cholesterol; coronary artery disease; percutaneous coronary intervention