Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

The POST study1 (BMJ 5th June 1999) indicates that there are
considerable deficiencies in the management of myocardial infarct and
angina patients discharged from a district hospital and, unfairly, implies
that it is the general practitioners who are failing.
Most GPs will continue hospital-initiated treatment for patients with
chronic diseases. The small proportion of patients in the POST study on
beta-blockers and lipid-lowerers must reflect hospital management which
may not include a cardiologist's input.

In most district hospitals acute
infarct patients are admitted under the general physician on call whose
main interest may be chest disease, endcrinology, renal disease,
gastroenterology or just possibly cardiology (and there are still
district hospitals without a cardiologist or physician with an interest in
cardiology). A proportion of these patients may never be seen by a
cardiologist.

We have investigated this problem by a survey of all the
coronary care units in the UK.
In January 1998 we circulated all the coronary care units (CCU) in the UK
with a questionnaire enquiring whether infarct patients were admitted to a
CCU, ITU or a general ward, under whose care they were admitted and
whether those admitted under a general physician were reviewed by the
cardiologist. We also asked whether patients had access to cardiac
rehabilitation and what routine follow-up arrangements were made.

325 CCUs were identified and 244 (75%) replied, 3 of which had ceased to
exist. The doctor in charge of the CCU was a cardiologist or physician
with an interest in cardiology in 206 (85%). In only 8 (3%) were patients
admitted to a general ward.

In 96 (40%) patients were admitted under the care of either the
cardiologist or physician with an interest in cardiology.

In 84 (35%)
admission was shared by the duty physician and the cardiologist and 60
(25%) was under the sole care of the general physician. In 18 (6%)
patients did not have access to a cardiologist's opinion.

Follow-up was provided by a cardiac clinic in 51 (21%), medical out-
patients in 103 (32%) and a specific cardiac rehabilitation clinic in 42
(17%). In 81 (34%) outpatient follow up was provided by the admitting
physician who was sometimes the cardiologist.
In those units which responded the great majority of infarct
patients were admitted under a cardiologist or had access to a
cardiological opinion (which is not the same thing as getting it), but
still an appreciable minority did not. If general practitioners are to
provide a high standard of long term care for their coronary patients they
need to start from the best vantage point. To ensure this we believe that
all infarct patients should have access to a cardiological opinion (and
where possible receive it) to ensure that they are discharged on the most
appropriate medication and receive further investigation when needed.

Hugh Bethell, Robin Graham & Marilyn Wallwork and the secondary
prevention & rehabilitation advisory committee.

1. Feder G, Griffiths C, Eldridge S, Spence M. Effect of postal
prompts to patients and general practitioners on the quality of primary
care after a coronary event (POST): randomised controlled trial. Brit Med
J 1999;318:1522-6.

24/6/1999

Editor,

Feder et al in their study examined postal prompts in secondary
prevention of coronary heart disease in primary care which is an important
issue. However the results of their study are not unexpected. As the
authors have stated in their introduction a multifaceted approach has
already been shown to be more effective than a single intervention. We
wondered why the authors then go on to test a single method.

Methods used in the study also leave some questions unanswered.
Firstly we recognise that the authors have adjusted for practice size,
number of partners, training status and number of practice nurses, and
have identified smoking, diabetes and beta blocker prescription as
variables between each practice. However cultural and socio-economic
factors have not been addressed. Since in an area such as Hackney there
are likely to be pockets of severe deprivation this may be related to
particular practices and influence results.

Secondly, the authors have excluded patients who died within six
months of discharge. We realise there may have been difficulties
obtaining data regarding these patients but it might have been useful to
know the distribution of deaths between the two groups.

We feel that the authors did achieve their objectives but were
unrealistic in the principle outcome measure that they specified. The
postal prompts were effective in increasing patient consultation rates but
the authors instead identified their principle outcome measure as beta-
blocker prescription. We feel this is a separate issue which may be more
related to GP training, awareness and availability of the pre-existing
East London guidelines.

Finally, the study showed the intervention group of GPs recorded
giving lifestyle advice more often than control group GPs. However this
did not have an effect on patients self-reported lifestyle changes.
Therefore we agree with the authors that this may be an implication for
future research into why GP consultations regarding lifestyle changes are
apparently ineffective.

Louise Li, Lesley Maher, Louisa Pollock, Claire Shevels, Ben White
(b.w.white@ncl.ac.uk)
3rd year medical students
Department of Epidemiology and Public Health
Medical School, University of Newcastle-upon-Tyne.