Quality of cardiovascular disease preventive care and physician/practice characteristics

Kidney Transplantation Contraindications: Variation in Nephrologist Practice and Training Vintage

Introduction

Health system leaders aim to increase access to kidney transplantation in part by encouraging nephrologists to refer more patients for transplant evaluation. Little is known about nephrologists' referral decisions and whether nephrologists with older training vintage weigh patient criteria differently (e.g., more restrictively).

Methods

Using a novel, iteratively validated survey of US-based nephrologists, we examined how nephrologists assess adult patients' suitability for transplant, focusing on established, important criteria: 7 clinical (e.g., overweight) and 7 psychosocial (e.g., insurance). We quantified variation in nephrologist restrictiveness-proportion of criteria interpreted as absolute or partial contraindications versus minor or negligible concerns-and tested associations between restrictiveness and nephrologist age (proxy for training vintage) in logistic regression models, controlling for nephrologist-level and practice-level factors.

Results

Of 144 nephrologists invited, 42 survey respondents (29% response rate) were 85% male and 54% non-Hispanic White, with mean age 52 years, and 67% spent ≥1 day/wk in outpatient dialysis facilities. Nephrologists interpreted patient criteria inconsistently; consistency was lower for psychosocial criteria (intraclass correlation coefficient: 0.28) than for clinical criteria (intraclass correlation coefficient: 0.43; P < 0.01). With each additional 10 years of age, nephrologists' odds of interpreting criteria restrictively (top tertile) doubled (adjusted odds ratio [aOR] 1.96; 95% confidence interval [CI]: 0.95-4.07), with marginal statistical significance. This relationship was significant when interpreting psychosocial criteria (aOR: 3.18; 95% CI: 1.16-8.71) but not when interpreting clinical criteria (aOR: 1.12; 95% CI: 0.52-2.38).

Conclusion

Nephrologists interpret evaluation criteria variably when assessing patient suitability for transplant. Guideline-based educational interventions could influence nephrologists' referral decision-making differentially by age.

'Some of my patients only come to renew their prescriptions. They are not interested in any additional advice or support'. Physicians' perceptions on their roles in cardiovascular diseases risk reduction and management in Fiji

BACKGROUND

Primary health care (PHC) physicians' perceptions are vital to understand as they are the first-line health care providers in cardiovascular diseases (CVD) risk assessment and management. This study aims to explore PHC physicians' perceptions on their roles and their perceptions on management and risk reduction approaches on CVD risk reduction and management in Fiji.

METHODS

This is a qualitative study conducted in the Suva Medical area among 7 health centers from 1 August to 31 September, 2021. Purposive sampling was used to recruit physicians who worked in the Suva medical area as PHC physicians with at least 6 months' experience in the Special Outpatients Department clinics. In-depth interview were conducted using a semi-structured questionnaire over the telephone and recorded on a tablet device application. The interview content was then transcribed, and thematic analysis was done.

RESULTS

This study included 25 PHC physicians. From the thematic analysis, 2 major themes emerged with 6 subthemes. Theme 1 was CVD management skills with 3 subthemes including education, experience and trainings, beliefs and attitudes of physicians, self-confidence and effectiveness in CVD risk reduction and management. Theme 2 was roles and expectations with 3 subthemes including perceptions of effective treatment, perceptions of physicians' roles and perceptions of patients' expectations. Physicians generally see their role as central and imperative. They perceive to be important and leading toward combating CVDs.

CONCLUSIONS

Physicians' perceptions on their commitment to prevention and management of CVDs through their skills and knowledge, beliefs and motivation should be acknowledged. It is recommended that the physicians are updated on the current evidence-based medicine. Limitations include results that may not be the reflection of the entire physician and multidisciplinary community and the difficulties in face-to-face interviews due to the coronavirus diseases of 2019 pandemic.

General practitioners maintain a focus on blood pressure management rather than absolute cardiovascular disease risk management

BACKGROUND

Absolute cardiovascular disease (aCVD) risk assessment is recommended in CVD prevention guidelines. Yet, General Practitioners (GPs) often focus on single risk factors, including blood pressure (BP). Pathology services may be suitable to undertake high-quality automated unobserved BP (AOBP) measurement and aCVD risk assessment. This study explored GP attitudes towards AOBP measurement via pathology services and the role of BP in aCVD risk management.

METHODS

A brief survey was completed, after which a focus group (n = 8 GPs) and interviews (n = 10 GPs) explored attitudes to AOBP and aCVD risk via pathology services with an example pathology report discussed. Verbatim transcripts were thematically coded.

RESULTS

GPs predominantly used doctor-measured BP despite low levels of confidence. High BP measured by AOBP reported with aCVD risk via pathology services, would prompt a follow-up response. However, GPs focused on BP management. GPs were concerned about AOBP equivalency to routine BP measurements. After protocol explanation, GPs reported AOBP could value-add to care delivery.

CONCLUSION

GPs lacked familiarity of AOBP and maintained a focus on BP management in the context of absolute CVD risk. Targeted education on AOBP and BP management as part of absolute CVD risk is needed to support guideline-directed care in practice.

Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

Background

Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.

Methods

Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.

Results

7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.

Conclusions

Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

General practitioner perceptions of assessment and reporting of absolute cardiovascular disease risk via pathology services: a qualitative study

BACKGROUND

Guidelines for cardiovascular disease (CVD) prevention recommend assessment of absolute CVD risk to guide clinical management. Despite this, use among general practitioners (GPs) remains limited.

OBJECTIVE

Pathology services may provide an appropriate setting to assess and report absolute CVD risk in patients attending for cholesterol measurement. This study aimed to explore GPs perceptions of such a service.

METHODS

A focus group and semi-structured interviews were conducted with GPs (n = 18) in Tasmania, Australia, to identify perceptions of assessment and reporting of absolute CVD risk via pathology services. An example pathology report including absolute CVD risk was provided and discussed. Audio-recordings were transcribed and thematically coded by two researchers.

RESULTS

Almost all GPs identified that absolute CVD risk assessed and reported via pathology services could address deficits in practice. First, by reducing the number of appointments required to collect risk factors. Second, by providing a systematic (rather than opportunistic) approach for assessment of absolute CVD risk. Third, by reducing misclassification of patient CVD risk caused by overreliance on clinical intuition. All GPs reported they would order absolute CVD risk when issuing a cholesterol referral if such a service was offered. GPs recommended improving the service by providing information on methods used to measure risk factors on the pathology report.

CONCLUSIONS

Absolute CVD risk assessed and reported via pathology services may address challenges of screening CVD risk experienced by GPs in practice and encourage dedicated follow-up care for CVD prevention.

Differences based on patient gender in the management of hypertension: a multilevel analysis

The objective of our study was to investigate differences in the management of men and women treated for hypertension while considering the gender of their physicians. We used the data from the cross-sectional Paris Prevention in General Practice survey, where 59 randomly recruited general practitioners (42 men and 19 women) from the Paris metropolitan area enroled every patient aged 25-79 years taking antihypertensive medication and seen during a 2-week period (520 men and 666 women) in 2005-6. The presence in the medical files of six items recommended for hypertension management (blood pressure measurement, smoking status, cholesterol, creatinine, fasting blood glucose and electrocardiogram) was analysed with mixed models with random intercepts and adjusted for patient and physician characteristics. We found that the presence of all items was lower in the records of female than male patients (3.9 vs. 6.9%, p = 0.01), as was the percentage of items present (58.5 vs. 64.2%, p = 0.003). The latter gender difference was substantially more marked when the physician was a man (69.3 vs. 63.4%, p = 0.0002) rather than a woman (63.5 vs. 61.0%, p = 0.46). Although all guidelines recommend the same management for both genders, the practices of male physicians in hypertension management appear to differ according to patient gender although those of women doctors do not. Male physicians must be made aware of how their gender influences their practices.

Cardiometabolic medicine: a review of the current proposed approaches to revamped training in the United States

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, and the population of patients with cardiometabolic conditions, including obesity, metabolic syndrome and diabetes mellitus, continues to grow. There is a need for physicians with specific training in cardiometabolic medicine to provide a ‘medical home’ for patients with cardiometabolic disease, rather than the fractured care that currently exists in the United States. Cardiometabolic specialists will head multidisciplinary clinics, develop practice guidelines, and lead through research. Proposals for US training in cardiometabolic medicine include: maintain the current training model, a dedicated 2–3 year fellowship following internal medicine residency, a 1-year fellowship following either internal medicine residency or fellowship in cardiology or endocrinology, and certification available to any interested clinician. This review discusses the pros and cons of these approaches. The authors believe that a dedicated cardiometabolic training fellowship has significant advantages over the other options.

The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis

BACKGROUND

Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources.

METHODS

We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care.

DISCUSSION

Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.

Physicians' preventive practices: more frequently performed for male patients and by female physicians

Background

We sought to analyze gender differences in General Practitioners’ (GP) preventive practices: variations according to the GP’s and the patient’s genders, separately and combined, and the homogeneity of GPs’ practices according to gender.

Methods

Fifty-two general practitioners volunteered to participate in a cross-sectional study. A sample of 70 patients (stratified by gender) aged 40–70 years was randomly chosen from each GP’s patient panel. Information extracted from the medical files was used to describe the GPs’ preventive practices for each patient: measurements of weight, waist circumference, glucose, and cholesterol; inquiry and counseling about smoking, alcohol consumption, diet, and physical activity, and dates of cervical smears and mammographies. An aggregate preventive score was calculated to assess the percentage of these practices performed by each GP for patients overall and by gender. Mixed models were used to test for gender differences.

Results

Questionnaires were collected in 2008–2009 for 71% of the 3640 patients and analyzed in June 2017.

Male patients and female GPs were associated with the most frequent performance of many types of preventive care. The aggregate preventive score was higher for male patients (OR = 1.60, 95% CI 1.47–1.75) and female GPs (OR = 1.35, 95% CI 1.05–1.73). There was no combined effect of the genders of the two protagonists. Female patients of male GPs appeared to receive preventive care least frequently and female GPs to deliver preventive care more consistently than their male colleagues.

Conclusion

Physicians need to be aware of these differences, for both patient gender and their own.

Management of chronic spontaneous urticaria: a worldwide perspective

Background

The approaches to the diagnosis and treatment of chronic spontaneous urticaria (CSU) differ in various parts of the world. We sought to determine the adherence to international and national urticaria guidelines as well as the motives to deviate from the guidelines among physicians worldwide.

Methods

A web-based questionnaire was created and launched via e-mail by the World Allergy Organization (WAO) to representatives of all WAO Member Societies, the members of the American Academy of Allergy, Asthma & Immunology (AAAAI) and the members of the WAO Junior Members Group (JMG), regardless of the specialty, affiliation, or nationality in March 2017.

Results

We received 1140 completed surveys from participating physicians from 99 countries. Virtually all participants (96%) were aware of at least one urticaria guideline and reported that they follow a guideline. However, one in five physicians who follow a guideline (22%) reported to deviate from it. Reliance on own clinical experience is the most frequent reason for deviation from guidelines or not following them (44%). Young (< 40 years) and less experienced physicians more often follow a guideline and less often deviate than older and experienced ones. Physicians who follow a urticaria guideline showed higher rates of routinely ordering a complete blood count, the erythrocyte sedimentation rate, C-reactive protein, anti-thyroid antibodies, and thyroid-stimulating hormone and of performing the autologous serum skin test as compared to those who do not. Physicians who follow a urticaria guideline showed higher rates of using second generation antihistamines as their first-line treatment of CSU (p = 0.001) and more frequently observed higher efficacy of these drugs (or had more confidence that it would work, p < 0.019) as compared to those who do not follow the guidelines.

Conclusions

Physicians’ characteristics (e.g. age, clinical experience, and specialty) and country specifics and regional features (e.g. availability of drugs for CSU treatment) importantly influence adherence to urticaria guidelines and CSU patient care and should be addressed in more detail in future research.

Electronic supplementary material

The online version of this article (10.1186/s40413-018-0193-4) contains supplementary material, which is available to authorized users.

Patient, Physician, and Practice Characteristics Associated with Cardiovascular Disease Preventive Care for Women

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death for American women. Although CVD preventive care has the potential to reduce a significant number of these deaths, the degree to which healthcare providers deliver such care is unknown. The purpose of this study was to identify patient, physician, and practice characteristics that significantly influence the provision of CVD preventive care during ambulatory care visits for female patients.

METHODS

The National Ambulatory Medical Care Survey datasets from 2005 to 2010 were utilized. The study sample included female patients ≥20 years of age whose healthcare provider performed CVD preventive care and who had visits for a new health problem, a routine chronic problem, management of a chronic condition, and preventive care. Binary logistic regression models estimated the association of patient, physician, and practice characteristics and CVD preventive care; cholesterol testing, body mass index (BMI) screening, and tobacco education.

RESULTS

Of the 32,009 visits, 15.9% involved cholesterol testing, 50.3% involved BMI screening, and 3.20% involved tobacco education. Obstetricians/gynecologists were less likely to perform cholesterol testing (aOR: 0.39; 95% CI: 0.25-0.61) and tobacco education (aOR: 0.56; 95% CI: 0.32-0.98) than general/family physicians.

CONCLUSION

The delivery of CVD preventive care varied by healthcare provider type, with obstetricians/gynecologists having lower odds of providing two of the three services. The amount of time a physician spent with a patient was a significant predictor for the provision of all three services. These findings demonstrate the need to implement multifaceted approaches to address predicting characteristics of CVD preventive care.

General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

BACKGROUND

Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older.

METHOD

25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.

RESULTS

Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.

CONCLUSION

Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

Primary prevention of cardiovascular disease: More patient gender-based differences in risk evaluation among male general practitioners

OBJECTIVE

Our objective was to analyse general practitioner (GP) cardiovascular risk assessment of patients for primary prevention while considering the gender of both the GP and the patient.

METHODS

This study consisted of an observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire regarding their own characteristics and randomly selected 70 patients from their patient list. Dependent variables from the patient files included the presence of information about risk factors necessary to assess the patient's cardiovascular risk according to the French scale and the Systematic COronary Risk Evaluation (SCORE) scale. Analyses used mixed logistic models with a random intercept and adjusted for patient and physician characteristics.

RESULTS

Both cardiovascular risk scales could be assessed less frequently in women than in men (odds ratio (OR) = 0.64 (95% confidence interval (CI): 0.5-0.8) for the French scale and OR = 0.63 (95% CI: 0.5-0.8) for the SCORE scale). These gender differences were less substantial when the patients were seen by female (for the SCORE scale OR = 0.72 (95% CI: 0.5-1.01)) compared with male physicians (OR = 0.56 (95% CI: 0.4-0.7)). The patients who were least well assessed for cardiovascular risk were women seen by male physicians.

CONCLUSION

Even before the onset of cardiovascular disease, women patients receive less satisfactory preventative management than men do, and these differences are even more marked when the physician is a man. More attention to the influence of gender stereotypes is needed in medical training in order to combat the inequalities that they cause.

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

BACKGROUND

Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

METHODS

We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient's most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

RESULTS

We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72-1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient's condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39-8.42] d for most experienced quartile; 7.63 [95% CI 7.13-8.14] d for least experienced quartile).

INTERPRETATION

For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.

Reducing stroke in women with risk factor management: blood pressure and cholesterol

Stroke is a major cause of death and disability in adults worldwide. Prevention focused on modifiable risk factors, such as hypertension and hyperlipidemia, has shown them to be of significant importance in decreasing the risk of stroke. Multiple studies have brought to light the differences between men and women with regards to stroke and these risk factors. Women have a higher prevalence of stroke, mortality and disability and it has been shown that preventive and treatment options are not as comprehensive for women. Hence, it is of great necessity to evaluate and summarize the differences in gender and stroke risk factors in order to target disparities and optimize prevention, especially because women have a higher lifetime risk of stroke. The purpose of this review is to summarize sex differences in the prevalence of hypertension and hyperlipidemia. In addition, we will review the sex differences in stroke prevention effectiveness and adherence to blood pressure and cholesterol medications, and suggest future directions for research to reduce the burden of stroke in women.

Physician perceived market competition associated with barriers to delivery of quality care: Evidence from a national cross-sectional survey of physicians in the USA

While quality is of paramount concern in health care, there has been little research done examining physician attitudes towards quality of health care and their perceived competitiveness in the market place. Utilizing the national physician survey data ( n = 4720), we undertook a bivariate and multivariate regression analysis to explore the association between physician perceived competition and barriers to quality of care. After adjusting personal and organizational factors, two quality care measures were found to be related to increased physician perceived market competition: (1) inadequate mechanism (patient’s inability to pay for care); (2) variations in practice (medical errors and untimeliness of medical reports). Overall our findings suggest the association between perceived market competition and barriers to quality of care. In physicians’ views the current managed care market system appears to be competitive but this market competition may not benefit practicing physicians in improving quality of patient care.

Gender, race and cardiac rehabilitation in the United States: is there a difference in care?

Coronary heart disease is the leading cause of death within the United States, involving both genders and among all races and ethnic populations. Cardiac rehabilitation (CR) has been shown to significantly improve morbidity and mortality, and these benefits extend to individuals of both genders and all ages with coronary heart disease. Despite this, referral and participation rates remain surprisingly low. Furthermore, women and minorities have even lower referral rates than do their male and white counterparts. Over the course of this article, we will review CR referral and participation among women, as well as racial and ethnic minorities in the United States. We will also examine barriers to CR participation among these subgroups.

Communicating cardiovascular disease risk: an interview study of General Practitioners' use of absolute risk within tailored communication strategies

BACKGROUND

Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs' descriptions of their CVD risk communication strategies, including the role of absolute risk.

METHODS

Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour.

RESULTS

GPs used absolute CVD risk within three different communication strategies: 'positive', 'scare tactic', and 'indirect'. A 'positive' strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A 'scare tactic' strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to 'scare' them into taking action. An 'indirect' strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations.

CONCLUSIONS

This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.

Gender differences in achieving optimal lipid goals in patients with coronary artery disease

To investigate gender differences in lipid goal attainment, we conducted a retrospective analysis of outpatient electronic health records from a large cardiology practice from September 2008 to September 2009. The most recent lipid profile and lipid-lowering medications and doses were extracted from electronic medical record. We identified 9,950 patients with coronary artery disease of whom 3,366 (34%) were women. Women were less likely to achieve a low-density lipoprotein (LDL) cholesterol goal of <70 mg/dl compared with men (30.6% vs 38.4%, p <0.001) and less likely to achieve a non-high-density lipoprotein cholesterol goal of <100 mg/dl (37.1% vs 48.2%, p <0.001). Irrespective of age, women were less likely to achieve their LDL cholesterol goals. Compared with men, women were more likely to be on no statin (16.9% vs 11.6%, p <0.001) or any lipid-lowering therapy (12.8% vs 7.8%, p <0.001) and less likely to be on high-potency statin (14.9% vs 18.0%, p <0.001) or combination therapy (22.2% vs 30.1%, p <0.001). There exists a major difference in the use of lipid-lowering therapy between men and women with coronary artery disease. In conclusion, women with coronary artery disease are prescribed insufficient doses of statins and combination lipid-lowering therapy and are less likely to achieve their optimal LDL and non-high-density lipoprotein cholesterol goals.

Organization of Primary Care Practice for Providing Energy Balance Care

Purpose.

Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care.

Design.

The study design was a nationally representative survey conducted in 2008.

Setting.

The study setting was U.S. primary care practices.

Subjects.

A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%).

Measures.

The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care.

Analysis.

Descriptive statistics and logistic regression modeling were used.

Results.

More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care.

Conclusion.

PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

General practitioners' use of different cardiovascular risk assessment strategies: a qualitative study

OBJECTIVES

To identify factors that influence the extent to which general practitioners use absolute risk (AR) assessment in cardiovascular disease (CVD) risk assessment.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews with 25 currently practising GPs from eight Divisions of General Practice in New South Wales, Australia, between October 2011 and May 2012. Data were analysed using framework analysis.

RESULTS

The study identified five strategies that GPs use with patients in different situations, defined in terms of the extent to which AR was used and the reasons given for this: the AR-focused strategy, used when AR assessment was considered useful for the patient; the AR-adjusted strategy, used to account for additional risk factors such as family history; the clinical judgement strategy, used when GPs considered that their judgement took multiple risk factors into account as effectively as AR; the passive disregard strategy, used when GPs lacked sufficient time, access or experience to use AR; and the active disregard strategy, used when AR was considered to be inappropriate for the patient. The strategies were linked with different opportunity, capability and motivation barriers to the use of AR.

CONCLUSIONS

This study provides an in-depth insight into the factors that influence GPs' use of AR in CVD risk assessment. The results suggest that GPs use a range of strategies in different situations, so different approaches may be required to improve the use of AR guidelines in practice.

Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study

BACKGROUND

Guidelines indicate eligibility for lipid lowering drugs, but it is not known to what extent GPs' follow guidelines in routine clinical practice or whether additional clinical factors systematically influence their prescribing decisions.

METHODS

A retrospective cohort analysis was undertaken using electronic primary care records from 421 UK general practices. At baseline (May 2008) patients were aged 30 to 74 years, free from cardiovascular disease and not taking lipid lowering drugs. The outcome was prescription of a lipid lowering drug within the next two years. The proportions of eligible and ineligible patients prescribed lipid lowering drugs were reported and multivariable logistic regression models were used to investigate associations between age, sex, cardiovascular risk factors and prescribing.

RESULTS

Of 365,718 patients with complete data, 13.8% (50,558) were prescribed lipid lowering drugs: 28.5% (21,101/74,137) of those eligible and 10.1% (29,457/291,581) of those ineligible. Only 41.7% (21,101/50,558) of those prescribed lipid lowering drugs were eligible. In multivariable analysis prescribing was most strongly associated with increasing age (OR for age ≥ 65 years 4.21; 95% CI 4.05-4.39); diabetes (OR 4.49; 95% CI 4.35-4.64); total cholesterol level ≥ 7 mmol/L (OR 2.20; 95% CI 2.12-2.29); and ≥ 4 blood pressure measurements in the past year (OR 4.24; 95% CI 4.06-4.42). The predictors were similar in eligible and ineligible patients.

CONCLUSIONS

Most lipid lowering drugs for primary prevention are prescribed to ineligible patients. There is underuse of lipid lowering drugs in eligible patients.

Which practice characteristics are associated with the quality of cardiovascular disease prevention in European primary care?

BACKGROUND

Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care.

METHODS

An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM.

RESULTS

The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001).

CONCLUSIONS

There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology.

General Practitioners' coronary risk estimates, decisions to start lipid-lowering treatment, gender and length of clinical experience: their interactions in primary prevention

AIM

We investigated whether the risk estimates of General Practitioners (GPs) and their treatment decisions mutually influence each other and whether factors not related to the patient's risk, such as the gender and length in clinical practice, interact.

BACKGROUND

The quantitative assessment of the absolute risk of developing coronary heart disease (CHD) and the decision to start treatment with lipid-lowering drugs are crucial tasks in the primary prevention of CHD.

METHODS

Nine clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to three groups of 90 randomly selected GPs in Stockholm. One group (R) was asked to estimate the risk of CHD within 10 years on a visual analogue scale. A second group (R1D) was asked to estimate the risk and to specify whether they would recommend a pharmacological lipid-lowering treatment. A third group (D) only to indicate whether they would recommend treatment.

RESULTS

Response rate ranged from 42.2% to 45.6%. The median risk estimates were higher in the R group than in the R1D group (difference not statistically significant). R1D group showed higher proportions of correct decisions to start treatment compared with the R group (86.2% versus 77.5%, P50.19). More correct decisions were made by female doctors (OR 1.77, 95% CI 1.19-2.61, P50.004) and by less experienced doctors (OR 0.97, 95% CI 0.95-0.99, P50.016).

CONCLUSIONS

The task of making CHD risk estimates and the task of making decisions whether to start lipid-lowering treatment do not seem to influence each other. The gender of physicians and the length of clinical experience seem to affect treatment decisions. Female GPs and less experienced GPs are more likely to make correct decisions. However, the relatively low response rate to the questionnaires may limit the generalizability of these results.

Single-case experimental designs: a systematic review of published research and current standards

This article systematically reviews the research design and methodological characteristics of single-case experimental design (SCED) research published in peer-reviewed journals between 2000 and 2010. SCEDs provide researchers with a flexible and viable alternative to group designs with large sample sizes. However, methodological challenges have precluded widespread implementation and acceptance of the SCED as a viable complementary methodology to the predominant group design. This article includes a description of the research design, measurement, and analysis domains distinctive to the SCED; a discussion of the results within the framework of contemporary standards and guidelines in the field; and a presentation of updated benchmarks for key characteristics (e.g., baseline sampling, method of analysis), and overall, it provides researchers and reviewers with a resource for conducting and evaluating SCED research. The results of the systematic review of 409 studies suggest that recently published SCED research is largely in accordance with contemporary criteria for experimental quality. Analytic method emerged as an area of discord. Comparison of the findings of this review with historical estimates of the use of statistical analysis indicates an upward trend, but visual analysis remains the most common analytic method and also garners the most support among those entities providing SCED standards. Although consensus exists along key dimensions of single-case research design, and researchers appear to be practicing within these parameters, there remains a need for further evaluation of assessment and sampling techniques and data analytic methods.

Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT

BACKGROUND

A pilot project cardiovascular prevention was implemented in Sandwell (West Midlands, UK). This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice. Those found to be eligible for treatment were offered treatment. During the pilot a higher proportion of high risk patients were started on treatment in the intervention practices than in control practices. Following the apparent success of the prevention project, it was intended to extend the service to all practices across the Sandwell area. However the pilot project was not a robust evaluation. There was a need for an efficient evaluation that would not disrupt the planned rollout of the project.

METHODS/DESIGN

Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practices, with the sequence of general practices determined randomly. This is a stepped wedge randomised controlled trial design. The target population is patients aged 35 to 74, without diabetes or cardiovascular disease whose ten-year cardiovascular risk, (determined from data in their electronic records) is ≥ 20%. The primary outcome is the number of high risk patients started on treatment, because these data could be efficiently obtained from electronic primary care records. From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practices before and after implementation of targeted case finding. Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs. Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians. Practical considerations meant that 26 practices in Sandwell could be randomised, including about 6,250 patients at high risk of cardiovascular disease. This gives sufficient power for evaluation.

DISCUSSION

It is possible to design a stepped wedge randomised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme.

Cardiac rehabilitation for women across the lifespan

Cardiac rehabilitation improves function and compliance and also reduces morbidity and mortality in female and male cardiovascular disease patients but remains significantly underutilized. At every age, and especially in their senior years, female cardiovascular disease patients are under-referred relative to men. Lack of standardized referral processes, misconceptions by physicians and patients, and idiosyncrasies of female pathophysiology contribute to this pattern. Moreover, confounding factors of age, socioeconomic status, and sex-specific roles and responsibilities exacerbate the problem. This review summarizes barriers to cardiac rehabilitation for female cardiac patients, and highlights opportunities for increased participation and benefit.

Knowledge, attitudes and current practice of Jordanian family physicians about prescribing aspirin in primary and secondary prevention of vascular diseases: a self-reported survey

BACKGROUND

Long-term aspirin therapy is crucial for patients with increased risk of occlusive vascular diseases. However, inconsistencies in the methods for risk assessment and the perception among health care providers are major contributing factors for challenges in risk assessment.

METHODS

A questionnaire was distributed to a total of 124 family physicians working at two university teaching centers and Ministry of Health primary health care centers in Jordan.

RESULTS

A majority of the physicians reported prescribing aspirin for patients if they have peripheral vascular disease (93%), post-coronary artery bypass graft (92%), stroke (90%), or stable angina (95%). A smaller percentage of physicians reported that they prescribe aspirin if patients have atrial fibrillation (81%) or acute myocardial infarction (85%). The percentage of physicians who prescribe aspirin markedly declined when patients have potential bleeding disorder (52%) or asthma (52%). For patients without cardiovascular diseases but with one or more risk factors, the prophylactic use of aspirin was reported by 85% to 95% of family physicians.

CONCLUSIONS

The presence of co-morbidity along with vascular diseases tended to hinder physicians from prescribing aspirin even when it is indicated. A majority of family physicians recommends the use of aspirin in primary prevention in spite of its questionable or even negative benefits. Furthermore, self-reported aspirin prescribing rates among physicians in Jordan are higher than those reported by physicians in the U.S. and Europe. Therefore, we believe that proper dissemination of updated evidence-based treatment guidelines is required to ensure appropriate and efficient preventive services for cardiovascular diseases.

Patient and other factors influencing the prescribing of cardiovascular prevention therapy in the general practice setting with and without nurse assessment

BACKGROUND

Although guidelines indicate when patients are eligible for antihypertensives and statins, little is known about whether general practitioners (GPs) follow this guidance.

OBJECTIVE

To determine the factors influencing GPs decisions to prescribe cardiovascular prevention drugs.

DESIGN OF STUDY

Secondary analysis of data collected on patients whose cardiovascular risk factors were measured as part of a controlled study comparing nurse-led risk assessment (four practices) with GP-led risk assessment (two practices).

SETTING

Six general practices in the West Midlands, England.

PATIENTS

Five hundred patients: 297 assessed by the project nurse, 203 assessed by their GP.

MEASUREMENTS

Cardiovascular risk factor data and whether statins or antihypertensives were prescribed. Multivariable logistic regression models investigated the relationship between prescription of preventive treatments and cardiovascular risk factors.

RESULTS

Among patients assessed by their GP, statin prescribing was significantly associated only with a total cholesterol concentration ≥ 7 mmol/L and antihypertensive prescribing only with blood pressure ≥ 160/100 mm Hg. Patients prescribed an antihypertensive by their GP were five times more likely to be prescribed a statin. Among patients assessed by the project nurse, statin prescribing was significantly associated with age, sex, and all major cardiovascular risk factors. Antihypertensive prescribing was associated with blood pressures ≥ 140/90 mm Hg and with 10-year cardiovascular risk.

LIMITATIONS

Generalizability is limited, as this is a small analysis in the context of a specific cardiovascular prevention program.

CONCLUSIONS

GP prescribing of preventive treatments appears to be largely determined by elevation of a single risk factor. When patients were assessed by the project nurse, prescribing was much more consistent with established guidelines.

The achievement of target cholesterol level differs between coronary heart disease and diabetic patients

BACKGROUND

Guidelines recommend that LDL-C level should be <100mg/dl among diabetes mellitus (DM) and coronary heart disease (CHD) patients.

OBJECTIVE

To evaluate how patients with DM and CHD differ in attaining the target level and to examine the association between goal achievement, demographic and clinical parameters.

METHODS

The study was conducted in Maccabi Healthcare Services, the second largest health maintenance organization in Israel. All patients with DM (n=54,261), CHD (n=24,083) or DM and CHD (n=15,370) who were listed in the computerized database and had at least one LDL-C level measurement between January 1, 2007 and July 15, 2008 were eligible. The percentage of patients who attained LDL-C level <100mg/dl and its association with demographic and clinical parameters were analyzed.

RESULTS

The rate of reaching the LDL-C target level was higher among the CHD and CHD and DM patients than DM ones (67% vs. 57% vs. 50%, p<0.001, respectively). Male gender; 5th socioeconomic status quintile; underlying disease i.e. CHD, CHD and DM; high statins compliance; and revascularization by percutaneous coronary intervention predicted for reaching target level. DM; absence of renal function evaluation; hospitalizations; HbA1C>7% or missing its measurements had a negative predictive value.

CONCLUSIONS

The rate of reaching LDL-C target level should be increased in all high risk patients, mainly diabetic ones. Efforts should include educational programs to physicians and patients regarding the importance, the need to adhere and to intensify the cholesterol lowering treatment.

Does the academic performance of psychiatrists influence success in the NHS Clinical Excellence Award Scheme?

Objectives

Given the uncertainty about factors that influence receipt of Clinical Excellence Awards (CEA) and recent availability of advanced research metrics, we examined the factors that predict CEA success using a convenience sample of English psychiatrists.

Design

Observational study examining region, subspecialty, H-index, M-index, number of publications, years since registration and years in specialty.

Setting

ACCEA Nominal Roll, cross-referenced with data from the GMC's list of registered medical practitioners and Thompson's Web of Science database.

Participants

A total of 494 psychiatrists including 245 with national levels awards and a random sample with local level awards.

Main outcome measures

Receipt of local or national CEA awards in 2008 and 2009.

Results

Of those with national awards, 126 had university contracts and 119 NHS contracts. Across all staff, years since qualification in medicine and H-index were the dominant influences. For local awards we found that years worked in the specialty was the main predictor of a CEA award with a smaller contribution from H-index. For national awards to university staff (academics) years on the medical register and publication rate were significant predictors. For national awards to NHS staff (non-academics) H-index and total cites were predictive, but these were themselves related to age.

Conclusions

Progression in CEAs among psychiatrists is strongly influenced by age (years spent in specialty and years on the medical register) with an additional contribution from research productivity. Currently, research impact is crudely assessed in the CEA process. We suggest that CEA committees formally assess the impact of NHS-related research using standardized research metrics which are openly available. We also suggest that supporting organizations and local trusts adhere to the rules mandated by the ACCEA.

Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians

Purpose:

Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines.

Patients and methods:

A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage.

Results:

Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response.

Conclusions:

Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.

Gender and microvascular angina

There are gender differences in the presentation, diagnosis, and treatment of chest pain. When compared to men, women may have more atypical presentations of chest pain. In addition, current diagnostic tools are often not definitive regarding cardiac etiology for chest pain in women. The current diagnostic model of chest pain focuses on significant obstructions within the large coronary arteries as the cause for angina. Microvascular angina (MVA) represents an under-recognized pathophysiologic mechanism that may explain the apparent disparities and elucidate an etiology for the common finding in women of chest pain, ischemia on stress testing, and no obstructive coronary artery disease (CAD) on angiography in the presence of abnormal coronary reactivity testing. Endothelial dysfunction, estrogen deficiency, and abnormal nociception play a role in the pathophysiology of MVA. Treatments are targeted toward these underlying mechanisms. Recognizing the role gender and other pathophysiologic models of chest pain can play in the work-up and treatment of angina may identify a treatable cardiac condition, that would otherwise be discounted as non-cardiac in origin.

Stroke prevention in women: challenges and opportunities

Women have a 20% lifetime risk of stroke. In addition, the majority of stroke-related deaths occur in women. Reducing the burden of stroke in women through prevention would positively affect public health. Unfortunately, most of the data used to develop specific evidence-based guidelines for stroke prevention in women were derived from coronary heart disease studies. Stroke was a secondary and less common outcome, if it was included at all. In addition, women have traditionally been underrepresented in stroke prevention trial cohorts. Stroke prevention in women offers many challenges, not only related to data extrapolated from clinical trials primarily composed of men, but also because physicians may underestimate cardiovascular risk in women, and therefore prevention strategies may not be appropriately undertaken. The opportunities to improve stroke prevention in women include increasing patient and physician awareness of risk and optimizing management of key modifiable risk factors (eg, hypertension, hyperlipidemia, physical inactivity, obesity, and diabetes).

Evaluation of the American Heart Association cardiovascular disease prevention guideline for women

BACKGROUND

The 2007 update to the American Heart Association (AHA) guidelines for cardiovascular disease prevention in women recommend a simplified approach to risk stratification. We assigned Women's Health Initiative participants to risk categories as described in the guideline and evaluated clinical event rates within and between strata.

METHODS AND RESULTS

The Women's Health Initiative enrolled 161 808 women ages 50 to 79 years and followed them prospectively for 7.8 years (mean). Applying the 2007 AHA guideline categories, 11% of women were high risk, 72% at-risk, and 4% at optimal risk; 13% of women did not fall into any category, that is, lacked risk factors but did not adhere to a healthy lifestyle (moderate intensity exercise for 30 minute most days and <7% of calories from saturated fat). Among high risk, at-risk, and optimal risk women, rates of myocardial infarction/coronary death were 12.5%, 3.1%, and 1.1% per 10 years (P for trend <0.0001); the event rate was 1.3% among women who could not be categorized. We observed a graded relationship between risk category and cardiovascular event rates for white, black, Hispanic, and Asian women, although event rates differed among ethnic groups (P for interaction=0.002). The AHA guideline predicted coronary events with accuracy similar to current Framingham risk categories (area under receiver operating characteristic curve for Framingham risk, 0.665; for AHA risk, 0.664; P=0.94) but less well than proposed Framingham 10-year risk categories of <5%, 5% to 20%, and >20% (area under receiver operating characteristic curve for Framingham risk, 0.724; for AHA risk, 0.664; P<0.0001).

CONCLUSIONS

Risk stratification as proposed in the 2007 AHA guideline is simple, accessible to patients and providers, and identifies cardiovascular risk with accuracy similar to that of the current Framingham algorithm. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00000611.

Decision making and physician prescribing characteristics: a pilot study of Japanese physicians

The factors that affect physicians' prescribing remain unclear. Although previous reports suggest that prescription decisions are associated with various clinical situation, most of these studies analyzed simulated patient models rather than actual clinical practice. Here, we retrospectively analyzed actual cases of statin prescription for hyperlipidemia at Tohoku University Hospital between Apr 1, 2004 and Mar 31, 2008. Twelve physicians (6 cardiologists, 3 nephrologist, and 3 diabetologist) made decisions on whether to prescribe statins to 187 patients in 788 visits. As expected, cardiologists started prescribing statins at significantly lower serum total cholesterol levels than other specialists (221.7mg/dL vs. 244.7mg/dL, P<0.05). Interestingly, the total cholesterol levels that triggered prescribing differed significantly among cardiologists (p<0.05). These results suggested that prescription decisions differed not only among specialties but also among individuals.

Coronary risk estimates and decisions on lipid-lowering treatment in primary prevention: comparison between general practitioners, internists, and cardiologists

BACKGROUND

Quantitative assessment of an individual's absolute cardiovascular risk is essential for primary prevention. Although risk-scoring tools have been developed for this task, risk estimates are usually made subjectively. We investigated whether general practitioners (GPs), internists and cardiologists differ in their quantitative estimates of cardiovascular risk and their recommendations about lipid-lowering treatment for the same set of patients.

METHODS

Mail survey. Nine written clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to 90 randomly selected GPs and to the same number of internists and cardiologists in Sicily. The doctors were then asked to estimate the 10-year coronary risk in each case and to decide whether they would recommend a lipid-lowering treatment.

RESULTS

In the majority of the nine cases, the cardiologists' risk estimates were significantly lower than those of the other two groups. A higher proportion of internists (mean value 0.68) decided to start treatment than GPs (0.54) or cardiologists (0.57). In all three groups, the doctors' willingness to begin treatment was over 90% when their risk estimate was above 20%, and less than 50% when it fell below this level. Internists were more prone to treat than the other two groups even when their patients' estimated risk was below 20%.

CONCLUSION

When presented with the same set of clinical cases, GPs, internists and cardiologists make different quantitative risk estimates and come to different conclusions about the need for lipid-lowering treatment. This may result in over- or under-prescription of lipid-lowering drugs and inconsistencies in the care provided by different categories of doctors.

Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events

Background

Adherence to clinical practice guidelines for management of cardiovascular disease (CVD) is suboptimal. The purposes of this study were to identify practice patterns and barriers among U.S. general internists and family physicians in regard to cardiovascular risk management, and examine the association between physician characteristics and cardiovascular risk management.

Methods

A case vignette survey focused on cardiovascular disease risk management was distributed to a random sample of 12,000 U.S. family physicians and general internists between November and December 2006.

Results

Responses from a total of 888 practicing primary care physicians who see 60 patients per week were used for analysis. In an asymptomatic patient at low risk for cardiovascular event, 28% of family physicians and 37% of general internists made guideline-based preventive choices for no antiplatelet therapy (p < .01). In a patient at high risk for cardiovascular event, 59% of family physicians and 56% of general internists identified the guideline-based goal for serum fasting LDL level (< 100 mg/dl). Guideline adherence was inversely related to years in practice and volume of patients seen. Cost of medications (87.7%), adherence to medications (74.1%), adequate time for counseling (55.7%), patient education tools (47.1%), knowledge and skills to recommend dietary changes (47.8%) and facilitate patient adherence (52.0%) were cited as significant barriers to CVD risk management.

Conclusion

Despite the benefits demonstrated for managing cardiovascular risks, gaps remain in primary care practitioners' management of risks according to guideline recommendations. Innovative educational approaches that address barriers may facilitate the implementation of guideline-based recommendations in CVD risk management.

A global survey of physicians' perceptions on cholesterol management: the From The Heart study

AIMS

Guidelines for cardiovascular disease (CVD) prevention cite high levels of low-density lipoprotein cholesterol (LDL-C) as a major risk factor and recommend LDL-C goals for various risk groups. Lifestyle changes are advised as first-line treatment for patients with high cholesterol, and statins are recommended in high-risk patients. The From The Heart study investigated current practice for the diagnosis and treatment of high cholesterol, and attitudes towards management of the condition.

METHODS

Physicians were randomly selected from 10 countries, and completed a confidential, semi-structured questionnaire.

RESULTS

Of 2790 physicians agreeing to participate, 750 (27%) responded. Physicians rated CVD as the leading cause of death, although physicians (80%) perceived that cancer was the most feared illness among patients. Physicians (71%) believed smoking to be the greatest CVD risk factor, while only 50% thought high cholesterol was the greatest risk. Most physicians (81%) used guidelines to set cholesterol goals, primarily their national guidelines (34%) or the National Cholesterol Education Program Adult Treatment Panel III guidelines (24%). Although only 47% of patients reached and maintained their cholesterol goals, 61% of physicians believed that a sufficient number of patients achieved goals, and 53% did not feel frustrated that they could not always effectively treat patients with CVD.

CONCLUSION

Results indicate discrepancies between guideline recommendations and clinical practice. Although physicians appreciate the risk of CVD, the importance of achieving healthy cholesterol levels for CVD prevention does not seem to be widely endorsed. There is a need for improved communication regarding the importance of cholesterol lowering and investigation of initiatives to improve goal achievement among physicians.

A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations

Antimicrobial resistance is a growing crisis in healthcare. Various antimicrobial stewardship strategies have been used to control antibiotic use in efforts to reduce antibiotic resistance. We conducted a systematic review of antimicrobial stewardship programs in pediatric settings. Twenty-eight published studies met inclusion criteria. The majority (21 of 28) of studies had positive outcomes, but only 6 measured the impact of interventions on antimicrobial resistance. Prescriber education for a specific diagnosis (eg, otitis media) was the most effective intervention in the outpatient setting. Ancillary laboratory tests (eg, rapid diagnostic assays for viral pathogens) were most effective in the inpatient setting. Most studies had moderate to high risk of bias, mainly because of selection bias, inadequate preintervention data for time series analysis, and contamination between treatment groups. To date, there are a limited number of studies assessing antimicrobial stewardship in pediatric settings and these have heterogeneous study designs. Thus, it is difficult to determine the most effective interventions. Future studies should be designed to overcome the biases encountered in current publications.