PubMed · 10378214
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G Fitzmaurice. 1999. Confidence intervals.. https://doi.org/10.1016/s0899-9007(99)00063-5
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OBJECTIVE: To study the efficacy of case method learning, for general practitioners, on patients' lipid concentrations in the secondary prevention of coronary artery disease. DESIGN: Prospective controlled trial. SETTING: Södertälje, Stockholm County, Sweden. PARTICIPANTS: 255 consecutive patients with coronary artery disease. INTERVENTION: Guidelines were mailed to all general practitioners (n=54) and presented at a common lecture. General practitioners who were randomised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period. A locally well known cardiologist served as a facilitator. MAIN OUTCOME MEASURE: Concentration of low density lipoprotein cholesterol at baseline and after two years. Analysis according to intention to treat (intervention and control groups (n=88)) was based on group affiliation at baseline. RESULTS: Low density lipoprotein cholesterol was reduced by 0.5 mmol/l (95% confidence interval 0.2 to 0.8 mmol/l) (9.3% (2.9% to 15.8%)) from baseline in patients in the intervention group and by 0.5 (0.1 to 0.9) mmol/l compared with controls (P<0.05). No change occurred in the control group (0.0 (-0.2 to 0.2) mmol/l). Low density lipoprotein cholesterol decreased by 0.6 (0.4 to 0.8) mmol/l in a group of patients who received specialist care. CONCLUSION: Case method learning resulted in a lowering of low density lipoprotein cholesterol in the primary care patients with coronary artery disease comparable to that achieved at a specialist clinic. Conventional presentation of practice guidelines had no effect.
In 2001 the National Cholesterol Education Program (NCEP) released its Adult Treatment Panel (ATP) III report. This was an evidence-based report that upgraded cholesterol management guidelines. The update was made possible by a series of large, cholesterol-lowering clinical trials. These trials demonstrated strongly the efficacy and safety of cholesterol reduction in both primary and secondary prevention of coronary heart disease (CHD). The major recommendations of the report were several. Low-density lipoprotein (LDL) cholesterol continued to be identified as the major target of cholesterol-lowering therapy. However, more emphasis was given to HDL cholesterol and triglycerides as important targets for management. The concept of CHD risk equivalents was introduced. A CHD risk equivalent represents an absolute risk for future CHD events equal to that in persons with established CHD. Diabetes was identified as a CHD risk equivalent, requiring more intensive LDL-lowering therapy. Finally, the report placed more emphasis on the metabolic syndrome as a major, multiplex risk factor requiring increased clinical attention.
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