title: Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators.
abstract: 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.
authors.affiliation: Scientific Institute for Quality of Health Care, Radboud University Nijmegen Medical Centre, the Netherlands. j.vanlieshout@iq.umcn.nl
authors.forename: Jan
authors.initials: J
authors.lastname: van Lieshout
authors.forename: Richard
authors.initials: R
authors.lastname: Grol
authors.forename: Stephen
authors.initials: S
authors.lastname: Campbell
authors.forename: Hector
authors.initials: H
authors.lastname: Falcoff
authors.forename: Eva Frigola
authors.initials: EF
authors.lastname: Capell
authors.forename: Mathias
authors.initials: M
authors.lastname: Glehr
authors.forename: Margalit
authors.initials: M
authors.lastname: Goldfracht
authors.forename: Esko
authors.initials: E
authors.lastname: Kumpusalo
authors.forename: Beat
authors.initials: B
authors.lastname: Künzi
authors.forename: Sabine
authors.initials: S
authors.lastname: Ludt
authors.forename: Davorina
authors.initials: D
authors.lastname: Petek
authors.forename: Veerle
authors.initials: V
authors.lastname: Vanderstighelen
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
mesh_terms: D000368:Aged; D003327:Coronary Disease / Q000628:therapy*; D003430:Cross-Sectional Studies; D019468:Disease Management; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D055502:Secondary Prevention / Q000379:methods / Q000706:statistics & numerical data*