A Case-Management System for Coronary Risk Factor Modification after Acute Myocardial Infarction

Objective: To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification. Design: Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction. Setting: 5 Kaiser Permanente Medical Centers in the San Francisco Bay area. Patients: 585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction. Intervention: In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy. Outcome: Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction. Results: In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 ± 0.69 mmol/L and 3.41 ± 0.90 mmol/L (107 ± 30 mg/dL and 132 ± 30 mg/dL) (P = 0.001), and functional capacities were 9.3 ± 2.4 METS and 8.4 ± 2.5 METS (P = 0.001), respectively. Conclusion: In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.