This information sheet first published as the Joanna Briggs Institute.

Nurse-led clinics to reduce modifiable cardiac risk factors in adults.

Best Practice: evidence-based information sheets for health professionals. 2010; 14(2):1-4

Evidence-based information sheets for health professionals

Nurse-led clinics to reduce modifiable

cardiac risk factors in adults
Recommendations
Nurse-led clinics offer some support
for adult patients with newly
diagnosed or existing CHD in
achieving certain target treatment
levels such as total cholesterol and
blood pressure, but seem to be less
effective in improving absolute values
of risk factors in the short- and longterm, except for LDL-cholesterol and
triglycerides. (Grade B)
Nurse-led clinics offer some support
for adult patients with newly
diagnosed or existing CHD to
maintain their lifestyle changes and
influence patients willingness to
comply with the prevention of CHD in
the first year following the clinic
attendance. (Grade B)
Nurse-led clinics may positively
influence perceived quality of life and
general health status, especially
physical functioning in adults with
newly diagnosed or existing CHD.
(Grade B)

Information Source
This Best Practice information sheet
updates and supersedes the Joanna Briggs
Institute (JBI) information sheet published
in 20092. This Best Practice information
sheet has been derived from a systematic
review published in the JBI Library of
Systematic Reviews in 2010. The full text
of the report3 is available from the Joanna
Briggs Institute (www.joannabriggs.edu.au)

Objectives
The purpose of this information sheet is to
present the best available evidence for the
effectiveness of nurse-led clinics in reducing
cardiac risk factors in adults (aged > 18 years)
with newly diagnosed or existing CHD.

Background
Nurse-led clinics were first established in the
United Kingdom and the United States in
the 1980s in the primary care setting to
improve continuity of care after patient
discharge while attempting to contain costs.
The differentiation between a nurse-led
clinic and other forms of clinics such as
physician clinics or hospital clinics, lies in
the fact that nurse-led clinics are run
independently by nurses and that their focus
is more holistic, preventive and educative

rather than therapeutic or medicinal. The

major interventions in such clinics are
assessment, evaluation and monitoring of
patients health status, as well as health
counselling and education prior to therapy,
diagnosis and case management. By
providing psychosocial support, promoting
secondary prevention strategies and a
holistic approach to patients needs, nurseled clinics may represent one way of
tackling the problem of the rising number of
older and chronically ill patients and address
issues of consumer satisfaction with their
care. Coronary Heart Disease (CHD) is the
major cause of illness and death in Western
countries, an effect that is likely to increase
as the population ages. Individuals with
established CHD are at the highest risk of
experiencing further coronary events.
Establishing and maintaining a healthy
lifestyle may contribute significantly in
reducing cardiovascular mortality in these
individuals. Providing nurse-led services to
divert patients from busy hospital and
general practice settings has been
suggested as one way of maintaining quality
care of patients with chronic illness, such as
CHD. Nurses have the potential to
contribute to risk factor reduction as a result
of their familiarity with the patient, availability
for sustained consultation and the potential
to apply interventions when patients are
ready to initiate change rather than during a
period of acute crisis.

Grades of Recommendation
These Grades of Recommendation have been based on the JBI-developed 2006
Grades of Effectiveness1
Grade A Strong support that merits application
Grade B Moderate support that warrants consideration of application
Grade C Not supported

JBI Nurse-led clinics to reduce modifiable cardiac risk factors in adults

JBI Nurse-led clinics to reduce modifiable cardiac risk factors in adultsBest
BestPractice
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Definition of terms
For the purposes of this information
sheet the following definitions were
used:
Nurse-led clinic a term used for
clinics defined as clinics providing a
service for the customer that is
managed and staffed solely by nurses,
with the ability to assess, treat and
consult or refer the consumer to other
health disciplines as required.
Cardiac risks factors health or
lifestyle influences that increase the
chances of CHD. Known modifiable risk
factors include being overweight,
smoking, elevated cholesterol levels,
high blood pressure, suffering from
depression, sedentary lifestyle and
having a high intake of alcohol.
Compliance defined as the
willingness to follow treatment.

Types of Intervention

Systematic review results

Interventions of interest are those related to

the common role of staff in a nurse-run
cardiac clinic, including education,
assessment and monitoring, consultation,
referral and administrative duties.

Blood pressure outcomes

Quality of the research

There were 13 articles included in the
systematic review, describing seven
different studies comprising the period of
1998 to 2007, three of them implemented
in England and the others located in
Scotland, Australia, China and Canada
respectively. The studies are all
randomised controlled trials, two of them
having a cluster design. The nurse-led
clinics in the included RCTs were mostly
implemented in a general practice setting;
one was hospital based with follow-up at
home. Follow-up duration ranged from
three months to ten years; the majority
concluded at one year. Methodological
quality of the studies was very good, apart
from the randomisation, which was only
exactly described and truly randomised in
one Chinese study.

Outcomes measures
Six of the seven included studies assessed
blood lipids, five studies focused on blood
pressure, BMI and medication treatment;
and four studies evaluated physical activity,
health status, quality of life and smoking
behaviour. Further outcomes were diet
adherence, anxiety, depression and angina
symptoms. Less frequently considered
outcomes were clinic attendance, patient
satisfaction, readmission rates and total
mortality.

Five studies included blood pressure as an

outcome. The random effects metaanalysis of two studies revealed no
statistically significant benefits from nurseled clinics on blood pressure reduction in
the time period 6 to 8 months. When
measuring blood pressure management by
calculating patients who reached a certain
target level, there was a significant
improvement between intervention and
control group having blood pressure less
than 140/85 mmHg after one year. In one
study there was a significant improvement
of blood pressure management after one
year attending a nurse-led clinic but those
benefits were not sustained in the four-year
follow-up. Small improvements of blood
pressure in the long-term are likely which
favours the treatment of a nurse-led clinic.
No effect is shown in the long-term of more
than one year, though there were only two
studies included.

Blood lipid outcomes

Meta-analysis was possible for total
cholesterol (TC) and high-density
lipoprotein (HDL) values. Six studies had
TC as an outcome. Data from two studies
reveal a positive, though not statistically
significant result for six and eight months
follow up respectively. However the random
effects meta-analysis of two studies for
long-term TC values found that after
12 months and 18 months the effects of the
nurse-led clinics decrease. However,
patients still significantly benefit from the
nurse-led clinics related to risk factor
management. This was assessed by
calculating the number of patients who
attained a target level of total cholesterol
less than 5 mmol/l. The meta-analysis
found that after one year there was a
significantly higher number of patients in
the intervention group achieving this target
level. Results of the meta-analysis did not
reveal significant differences between the
groups in terms of the HDL level, neither
long term nor short term. In summary, the
meta-analysis of TC and HDL did not
reveal advantages related to the nurse-led
clinics, but the single results for LDL and
Triglycerides showed that nurse-led clinics
improved these blood lipids in the short
term. No long-term effect for blood lipids
was achieved with the nurse-led clinics
except for the management of achieving
blood lipid levels.

2 | JBI Nurse-led clinics to reduce modifiable cardiac risk factors in adults Best Practice 14(2) 2010

Smoking

Physical function

Depression and anxiety

The studies included in the systematic

review found that nurse-led clinics did not
influence smoking cessation rates in
patients in either the short term or long
term. The number of patients not smoking
was not reduced after one year attending a
nurse-led clinic.

The results significantly favour nurse-led

clinics to improve physical skills and
function in CHD patients.

Depression and anxiety were only included

in a Scottish study. These outcomes
showed no difference between the groups
at one-year and four-year follow-up.

Body weight
Studies found that the nurse-led clinics had
no statistically significant effect on the
patients behaviour related to reduce body
weight, in either the short or long-term.

Compliance
Compliance is an important part of health
behaviour because it is related to the
degree to which patients are able to
change their lifestyle. One Canadian study
evaluated compliance in medication intake
with a medication compliance index. The
index gives the proportion of days when
medication was taken according to the plan
and is expressed in percentages. The
authors report that no significant difference
between the groups was detectable.
One Scottish study evaluated compliance
with aspirin intake. At one-year follow up
adherence to correct aspirin intake was
significantly higher in the intervention
group. Similarly there were significant
benefits in continuing physical exercise and
diet after one year, but none of these
effects were maintained at the four-year
follow-up. The results strongly recommend
a nurse-led clinic for supporting patients to
maintain their lifestyle changes and to
influence patients willingness to comply
with the prevention of CHD in the first year
following the clinic attendance. However,
studies included in this review measured
compliance with medication intake only, so
that compliance with other health promotion
strategies is unknown.

Quality of life and general

health status
Outcomes on health status and perceived
quality of life were measured in most of the
studies using the Short Form 36 (SF36)
questionnaire with scores ranging from
zero to 100 and higher scores indicating a
better outcome. Results of three studies at
one-year follow-up were pooled in a metaanalysis. Unfortunately, none of the articles
presented an overall score for the eight
domains of the SF 36 and it could not be
calculated, so each domain of the SF 36 is
evaluated and interpreted separately.

Social functioning
Nurse-led clinics have a comparable impact
on social functioning for CHD patients to
other clinics. No difference was found
between the groups at 12 and 18 months
follow-up or at 4 years.

Angina symptoms

There was no effect on pain relief at oneyear follow-up.

One study focused on angina symptoms,

using the Seattle Angina Questionnaire.
The statistically significant differences
between the groups at one year follow-up
were found in exertional capacity and
angina frequency, where the intervention
group scored higher and therefore had less
angina symptoms. The Angina TyPe
questionnaire, used in one Scottish study
to assess angina pain, identified no
significant difference between the groups at
one-year and four-year follow-up, except
that worsening chest pain was experienced
significantly less frequently in the
intervention group after attending a nurseled clinic for one year.

Energy and vitality

Hospital admissions

Physical and emotional

role limitation
Results show that the overall effect on the
patients ability to fulfil their physical an
emotional roles is improved in nurse led
clinics.

Bodily pain

The patients perception on energy and

vitality did not improve significantly in the
intervention groups attending a nurse-led
clinic at one-year follow-up. One study, a
cluster RCT, detected benefits for
experienced vitality after one year.
However, in studies with longer follow-up
periods this effect was not seen.

Mental health
The results on mental health did not show
significant improvement after one year
attendance to nurse-led clinics. Apart from
one study (cluster design) the clinics effect
was not beneficial for the long-term at the
18 months evaluation and the four-year
follow-up.

General health perception

One Scottish study evaluated hospital

admissions. At the 10-year follow-up there
was no difference between the groups for
this outcome. Data are not sufficient for
statements on the short and middle-term
follow-up.

Coronary events, coronary

mortality and total mortality
In one Scottish study total mortality was
significantly reduced in the intervention
group at four-year follow-up and the
occurrence of coronary events shows a
borderline difference. No significant
differences occurred between the groups
concerning all cause mortality, coronary
events or deaths due to coronary events at
10-year follow-up.

Perceived general health was significantly

better in the intervention group after one
year follow-up. This result was not
supported at 18 months follow-up and the
four-year follow-up.
Summarising the results of the SF 36,
statistically significant improvements at the
first year follow-up were only achieved in
physical functioning, physical and
emotional role limitation and general health
perception. For all other domains outcomes
of the nurse-led clinics were equal to other
clinics.

JBI Nurse-led clinics to reduce modifiable cardiac risk factors in adults Best Practice 14(2) 2010 | 3

Nurse-led interventions to reduce cardiac risk factors in adults

Newly diagnosed or
existing CHD

Nurse-led clinics

Support for achieving

target level for total
cholesterol

Support for compliance

with CHD prevention

Support for Lifestyle

changes

Support for achieving

target level for blood
pressure

Reduced
Cardiac risk
factors

Acknowledgments
This Best Practice information sheet was
developed by The Joanna Briggs Institute.

References
1. The Joanna Briggs Institute. Levels of Evidence
and Grades of Recommendations. http://www.
joannabriggs.edu.au/pubs/approach.php
2. The Joanna Briggs Institute. Nurse-led
interventions to reduce cardiac risk factors in
adults. Best Practice: evidence-based information
sheets for health professionals 2009; 13(5):1-4.
3. Schadewaldt V, Schultz T. A systematic review on
the effectiveness of nurse-led cardiac clinics for
adult patients with coronary heart disease. JBI
Library of Systematic Reviews 2010;8(2):53-89.
4. P
 earson A, Wiechula R, Court A, Lockwood C.
The JBI model of evidence-based healthcare.
Int J of Evid Based Healthc 2005; 3(8):207-215.

Evidencebased Practice

evidence, context,
client preference
judgement

This Best Practice information sheet presents the best available evidence on
this topic. Implications for practice are made with an expectation that health
professionals will utilisethis evidence with consideration of their context, their
clients preference and theirclinical judgement.4

The Joanna Briggs Institute

The University of Adelaide
South Australia 5005
AUSTRALIA
www.joannabriggs.edu.au
The Joanna Briggs Institute 2011
ph: +61 8 8303 4880
fax: +61 8 8303 4881
email: jbi@adelaide.edu.au
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4 | JBI Nurse-led clinics to reduce modifiable cardiac risk factors in adults Best Practice 14(2) 2010