Preventive cardiology in primary care

Relationships between road-distance to primary care facilities and ischemic heart disease and stroke mortality in Hokkaido, Japan: A Bayesian hierarchical approach to ecological count data

Objective

Poor access to a primary care physician may lead to poor control of risk factors for disease. This study investigated whether geographic access to a primary care physician was related to ischemic heart disease and stroke mortality.

Methods

Road‐distances from the centroids of the basic unit blocks of the 2010 Japanese Census to the nearest primary care facilities in Hokkaido, northern Japan, were measured using geographic information system (GIS) software. Next, block population‐weighted mean road‐distances to primary care facilities in all municipalities were calculated. The numbers of deaths from ischemic heart disease and stroke were obtained from the Vital Statistics Bureau. A Bayesian spatial conditional autoregressive (CAR) model was used to analyze relative risk (RR) by road‐distance with the numbers of physicians in the municipality included as a covariate.

Results

Relative risk (per 1 kilometer increased) of death from ischemic heart disease to road‐distance to the nearest primary care facility was not significantly higher in men (1.108: 95% credible interval [CI] 0.999‐1.037) and women (1.023: 95% CI 1.000‐1.046). However, RR of death from stroke was significantly higher in men (1.019: 95% CI 1.005‐1.032) and women (1.019: 95% CI 1.006‐1.033).

Conclusion

Longer road‐distance to a primary care facility may increase the risk of stroke mortality.

Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews

OBJECTIVE

To identify, critically appraise and summarise existing systematic reviews on the impact of global cardiovascular risk assessment in the primary prevention of cardiovascular disease (CVD) in adults.

DESIGN

Systematic review of systematic reviews published between January 2005 and October 2016 in The Cochrane Library, EMBASE, MEDLINE or CINAHL databases, and post hoc analysis of primary trials.

PARTICIPANTS, INTERVENTIONS, OUTCOMES

Systematic reviews of interventions involving global cardiovascular risk assessment relative to no formal risk assessment in adults with no history of CVD. The primary outcomes of interest were CVD-related morbidity and mortality and all-cause mortality; secondary outcomes were systolic blood pressure (SBP), cholesterol and smoking.

RESULTS

We identified six systematic reviews of variable but generally of low quality (mean Assessing the Methodological Quality of Systematic Reviews 4.2/11, range 0/11 to 7/11). No studies identified by the systematic reviews reported CVD-related morbidity or mortality or all-cause mortality. Meta-analysis of reported randomised controlled trials (RCTs) showed small reductions in SBP (mean difference (MD) -2.22 mm Hg (95% CI -3.49 to -0.95); I²=66%; n=9; GRADE: very low), total cholesterol (MD -0.11 mmol/L (95% CI -0.20 to -0.02); I²=72%; n=5; GRADE: very low), low-density lipoprotein cholesterol (MD -0.15 mmol/L (95% CI -0.26 to -0.05), I²=47%; n=4; GRADE: very low) and smoking cessation (RR 1.62 (95% CI 1.08 to 2.43); I²=17%; n=7; GRADE: low). The median follow-up time of reported RCTs was 12 months (range 2-36 months).

CONCLUSIONS

The quality of existing systematic reviews was generally poor and there is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality. There are reductions in SBP, cholesterol and smoking but they may not be clinically significant given their small effect size and short duration. Resources need to be directed to conduct high-quality systematic reviews focusing on hard patient outcomes, and likely further primary RCTs.

TRIAL REGISTRATION NUMBER

CRD42015019821.

Physician Attitudes Regarding Cardiovascular Risk Reduction: The Gaps Between Clinical Importance, Knowledge, and Effectiveness

Reducing risk factors for patients with vascular disease can reduce the subsequent incidence of cerebro-cardiovascular disease. While physicians have had extensive training in the importance of atherosclerotic vascular disease risk factor modification, evidence suggests that they systematically miss opportunities for clinical prevention during routine practice. The aim of this study was to identify whether physicians felt confident in their knowledge and effectiveness regarding counseling patients to reduce cardiovascular risk and to determine barriers to prevention interventions in the office setting. Surveys were mailed to 509 physicians affiliated with an academic community hospital. Nonrespondents were sent reminders and a second survey. Comparisons were made using chi-square analysis. Two hundred and five surveys were returned (40.3%). Thirty-six percent of physicians felt knowledgeable about weight management techniques, compared to 3% who were confident that they succeeded in their practice (p < 0.001). Similar patterns were found for Tobacco Cessation (62% versus 14%, p = 0.001), Alcohol Reduction (46% versus 7%, p < 0.001), Stress Management (35% versus 5%, p < 0.001), Exercise (53% versus 10%, p < 0.001), Nutrition (36% versus 8%, p < 0.001), Diabetes Management (48% versus 23%, p < 0.001), Blood Pressure Management (57% versus 43%, p < 0.001) and Lipid Management (59% versus 38%, p < 0.001). We identified a significant gap between physician confidence in their knowledge about risk factors and their effectiveness at providing counseling and obtaining results in their office. Most physicians felt that the routine office follow-up visit was an ineffective method for instituting vascular risk factor reduction. Alternate settings for risk factor reduction may be needed for improving atherosclerosis prevention.

Assessment of coronary risk in general practice in relation to the use of guidelines: a survey in Denmark

BACKGROUND

There is a considerable gap between recommended and actually conducted preventive cardiology in general practice. The effect of guidelines is not fully evaluated.

METHODS

A questionnaire containing 10 questions on preventive cardiology, including the use of clinical guidelines, together with four case stories for cardiovascular risk estimation was mailed to 205 general practitioners (GPs).

RESULTS

Response rate was 81%. Twenty-five percent of the GPs had consultations in preventive cardiology at least once a day and 60% of the GPs thought lifestyle intervention had significant effect on cardiovascular risk. Approximately two-thirds of the GPs were regular users of national guidelines on prevention of cardiovascular disease. While the majority of GPs correctly assigned a patient with multiple risk factors to the high-risk category there was a much larger variation in risk estimations if fewer risk factors were present. GPs who reported use of guidelines overestimated coronary risk twice as frequently as nonusers of guidelines.

CONCLUSION

Preventive cardiology in general practice is common and the effect of lifestyle intervention is well accepted. Poor discrimination between high- and low-risk patients may, however, lead to suboptimal preventive care. The use of guidelines does not seem to improve risk estimation and further dissemination of better tools for risk estimation is needed.

Effectiveness of a cardiovascular health promotion education intervention on the attitudes of urban African American school-age children

African American children are at risk for high rates of morbidity and mortality associated with cardiovascular (CV) disease as they become adults, yet little is known about the effectiveness of CV risk-reduction interventions in African American children. This study explored the effectiveness of a concentrated CV health promotion educational program on health-related attitudes of 76 African American children enrolled in a mid-southern school system. The Children's Cardiovascular Health Promotion Attitude Scale was used to examine differences in attitude prior to and 2 weeks following a focused health education intervention. Results demonstrate that children have preconceived attitudes regarding practice of health behaviors and that these attitudes are modifiable with age and developmental level specific educational interventions. Findings indicate the need for health care providers to assume more active roles in reducing the risk of future CV disease and death in African Americans through health promotion education of individuals who influence the development of children's attitudes.

[Diagnosis of dyslipidemia in primary care: a service to be improved. Results of a multicenter evaluation]

OBJECTIVE

The variability of the quality of care in the primary care procedures to diagnose lipaemia was evaluated.

DESIGN

Observation, multi-centred and retrospective study.

SETTING

Random sample of 10 primary care centres in the Murcia region.

PATIENTS AND OTHER PARTICIPANTS

Patients over 19 with lipaemia detected over the previous twelve months in the general medical clinics at health centres. 500 cases in all were studied (50 per centre).

MEASUREMENTS AND MAIN RESULTS

Compliance with criteria of good clinical practice was evaluated. These criteria were formulated by health centre doctors and included: adequate diagnosis, classification into primary or secondary, phenotype, recording of cardiovascular risk factors and assessment of cardiovascular (CV) risk. The differences between the centres studied and the effect of the centre's characteristics (teaching, location, existence of lipaemia programme) and of the patients' (age and gender) were also examined. We found that none of the cases evaluated satisfied the five quality criteria at the same time. Assessment of CV risk and the aetiopathogenic classification were the criteria least complied with (1.5% +/- 1.0). Centres varied considerably. Their characteristics affected the quality of the procedure evaluated, which in all centres had a lot of room for improvement.

CONCLUSIONS

The quality of the procedures for diagnosing lipaemia can be considerably improved. It varies a lot from centre to centre.

Management of hypercholesterolemia: practice patterns for primary care providers and cardiologists

This retrospective study, conducted as part of a private practice quality assurance process for patients with coronary artery disease (CAD), compares practice patterns in the LIFEHELP lipid clinic and non-lipid clinic settings at the Heart Institute of St. Petersburg. Quality assurance parameters included documentation of low-density lipoprotein (LDL) cholesterol, initiation of lipid-lowering therapy, and achievement of the Second National Cholesterol Education Program (NCEP II) goal for CAD patients of LDL cholesterol < or =100 mg/dL. A total of 934 patient charts with ICD-9 codes of 410-414 for ischemic heart disease were randomly selected and reviewed by a utilization review nurse. A higher level of documentation and treatment of elevated LDL cholesterol to NCEP II goal in CAD patients was found for those followed in the lipid clinic. Among non-lipid clinic physicians, cardiologists documented and treated elevated LDL cholesterol more frequently than primary care physicians. Women and the elderly subgroups received improved care in the lipid clinic setting. Screening activities and risk-factor management by cardiologists within a lipid clinic, therefore, demonstrated an improved standard of care that came closer to achieving national guidelines in the secondary prevention of CAD.