title: Secondary prevention in patients with coronary heart diseases: what factors are associated with health status in usual primary care?
abstract: BACKGROUND
  For patients with coronary heart diseases a substantial part of secondary prevention is delivered in primary care. Along with the growing importance of prevention, health-related quality of life (HRQoL) is an indicator of patient-centered care that has gained increased attention. Different approaches for reorganization in primary care have been associated with improvements in HRQoL. However, these are often results of complex interventions. Evidence on aspects concerning usual primary care that actually have an impact on HRQoL remains scarce. Therefore, this observational study aimed to identify factors which are associated with HRQoL in usual primary care at practice and patient-level.
  
  
  METHODS
  This observational study was conducted in eight European countries. We were able to match data from survey instruments for 3505 patients with coronary heart disease (CHD) in 228 practices. A multilevel analysis was performed to identify associations of EQ-5D scores at patient and practice-level.
  
  
  RESULTS
  After dropping patients with missing information, our cohort consisted of 2656 patients. In this sample, 30.5% were female and the mean age was 67.5 years (SD 10.1). The final model included a total set of 14 potential explanatory variables. At practice-level no variable was associated with EQ-5D. At patient-level, lower education (r = -0.0381, p<0.0001), female gender (r = -0.0543, p<0.0001) and a higher number of other conditions (r = -0.0340, p<0.0001), had a strong negative effect on HRQoL. Strong positive associations with HRQoL were found for a good medication adherence (Morisky) (r = 0.0195, p<0.0001) and more positive evaluations of physicians' clinical behavior (r = 0.0282, p = 0.002). In terms of HRQoL no differences between single-handed and group practices exist.
  
  
  CONCLUSIONS
  The results of our study suggest that a better patient-physician relationship rather than organization of CHD care is associated with higher HRQOL in the primary care setting. The results may imply that interventions to improve HRQoL require a strong patient-centered approach.
authors.affiliation: University Hospital of Heidelberg, Department of General Practice and Health Services, Heidelberg, Germany. dominik.ose@med.uni-heidelberg.de
authors.forename: Dominik
authors.initials: D
authors.lastname: Ose
authors.forename: Justine
authors.initials: J
authors.lastname: Rochon
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Campbell
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
authors.forename: Jan
authors.initials: J
authors.lastname: van Lieshout
authors.forename: Lorenz
authors.initials: L
authors.lastname: Uhlmann
authors.forename: Tobias
authors.initials: T
authors.lastname: Freund
authors.forename: Joachim
authors.initials: J
authors.lastname: Szecsenyi
authors.forename: Sabine
authors.initials: S
authors.lastname: Ludt
mesh_terms: D003327:Coronary Disease / Q000453:epidemiology / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D005060:Europe / Q000453:epidemiology; D005260:Female; D006304:Health Status; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D011788:Quality of Life; D055502:Secondary Prevention; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires