Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators

Background

Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size.

Methods

In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex.

Results

We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries.

Conclusions

CVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.

What components of chronic care organisation relate to better primary care for coronary heart disease patients? An observational study

OBJECTIVES

Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients.

DESIGN

Observational study.

SETTING

273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain.

PARTICIPANTS

A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each.

MAIN OUTCOME MEASURE

We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic <140 and diastolic <90 mm Hg), and low-density lipoprotein cholesterol <2.5 mmol/l. Data from structured questionnaires were used to construct an overall measure and six domain measures of practice organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics.

RESULTS

Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, p<0.0001), antiplatelet therapy (OR 1.05, p=0.0245) and influenza vaccination (OR 1.12, p<0.0001). Overall practice organisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains 'self-management support' and 'use of clinical information systems' were linked to three CVRM indicators.

CONCLUSIONS

A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.