Prevalence and management of coronary heart disease in primary care: population-based cross-sectional study using a disease register

BACKGROUND: Patients with coronary heart disease are at high risk of further coronary events. Hence, one of the main priorities in the National Service Framework for Coronary Heart Disease strategy is the identification and treatment of patients with pre-existing coronary heart disease. We aimed to determine the prevalence of established coronary heart disease in a large primary care population and to compare the management of risk factors in these patients with the standards given in the National Service Framework. METHODS: A population-based cross-sectional study was carried out using data collected from primary care. Sixty-three general practices (total list size 378,021) in four primary care groups in SW London took part. Data collection was confined to 103,613 patients over 44 years of age. We calculated age- and sex-specific and age-standardized prevalence rates, and age-adjusted relative risks for men and women. RESULTS: A total of 6,778 patients with coronary heart disease were identified (8 per cent of men and 5 per cent of women over 44 years of age). There was a history of myocardial infarction in 30 per cent (1204/3991) of men and 22 per cent (613/2787) of women (relative risk 1.57; 1.37-1.81). Coronary revascularization procedures had been performed in 27 per cent (1068/3991) of men and 11 per cent (312/2787) of women (2.02; 1.73-2.35). Most patients had been assessed for hypertension (89 per cent (3538/3991) of men; 90 per cent (2500/ 2787) of women), but in many patients blood pressure was poorly controlled (26 per cent (902/3538) of men; 27 per cent (678/2500) of women). Total cholesterol had been recently measured in 51 per cent (2018/3991) of men and 44 per cent (1218/2787) of women and was elevated in 44 per cent (881/ 2018) of men and 59 per cent (716/1218) of women (0.74; 0.69-0.79). Statins were prescribed to 49 per cent (1967/3991) of men and 38 per cent (1064/2787) of women (1.06; 1.00-1.12). Aspirin was prescribed to 65 per cent (2586/3991) of men and 59 per cent (1631/2787) of women (1.08; 1.03-1.14). Beta-blockers were prescribed to 20 per cent (181/913) of men and 15 per cent (72/499) of women with a history of myocardial infarction (1.11; 0.85-1.44). CONCLUSIONS: Most patients with coronary heart disease in primary care were being treated with aspirin but less than half with statins or beta-blockers. More men than women were treated with aspirin and statins, even though women had higher cholesterol levels than men. Men were also more likely to have a confirmed diagnosis and to have undergone a coronary revascularization procedure. There is considerable scope for improving the secondary prevention of coronary heart disease and addressing gender inequalities in primary care.     

Cardiogenetics: the importance of identifying patients with hereditary heart disease

During the past decade, developments in the field of DNA diagnostics have resulted in the confirmation of the genetic nature of several cardiac diseases. In a cardiogenetics outpatient clinic, a cardiologist and a clinical geneticist together evaluate persons with a (possible) hereditary cardiac disease. It is of utmost importance that patients with hereditary cardiac diseases be recognised and subsequently referred for genetic counselling as several preventive and therapeutic options are available.     

Aspirin use for the primary prevention of coronary heart disease: a population-based study in Switzerland

OBJECTIVE: To determine the patterns of aspirin use for the primary prevention of coronary heart disease (CHD). Aspirin for primary prevention has a more favorable risk/benefit profile among adults with high CHD risk than among low-risk adults. METHOD: We studied 5725 adults aged 35-75 without cardiovascular disease in a population-based study in Switzerland in 2003-2006. We examined regular aspirin use for cardiovascular prevention according to 10-year CHD risk and other cardiovascular risk factors. RESULTS: One hundred seventy-four participants used aspirin. Aspirin use increased with 10-year CHD risk, from 2.6% in persons with risk <6% (low risk) to 9% in those with risk 6-20% (intermediate risk, p=0.001), but no adults with risk >or=20% used aspirin. Participants with cardiovascular risk factors were more likely to use aspirin. However, 1.9% adults with risk <6% and no diabetes used aspirin. Using a population perspective, a more appropriate aspirin use would reduce up to 2,348/24,310 CHD deaths expected over 10 years in Switzerland, and avoid about 700 gastrointestinal bleedings and hemorrhagic strokes among those not eligible. CONCLUSION: Individuals at intermediate CHD risk and diabetics are more likely to take aspirin, but there are significant opportunities for improvement. The underuse of aspirin for those at risk coexists with an overuse among those at low risk.     

An educational intervention to improve data recording in the management of ischaemic heart disease in primary care

BACKGROUND: Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality standards in primary care difficult to demonstrate. The aim of this study was to examine the effect of an educational intervention on data quality in primary care. METHODS: A before-and-after study of key data quality measures was carried out in 87 general practices in eight primary care organizations in England in phase 1 and 84 general practices in phase 2. The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2. The main outcome measures were improvement in the completeness and quality of the computerized medical record. Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice. Data quality workshops were arranged, in which reflection can take place, backed up by summary statistics. Practice visits provided training and personalized feedback of patients needing intervention. RESULTS: In the patients with heart disease, nearly 16,000 new clinical entries were made in the key improvement areas. The percentage of patients advised to quit smoking increased by 49.3 per cent, from 23.6 per cent to 61.9 per cent. There were also significant improvements in many other aspects of management. CONCLUSION: Focused interventions that provide targeted and relevant clinical information can be implemented in primary care. Such interventions can lead to a rise in data quality in primary care, but their effectiveness needs to be further tested in more rigorous research settings such as randomized controlled trials.     

Improvement of primary care for patients with chronic heart failure: a pilot study

Background  

Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.     

Assessing family history of heart disease in primary care consultations: a qualitative study

BACKGROUND: Current primary prevention guidelines recommend the assessment of family history of coronary heart disease (CHD) to identify at-risk individuals. OBJECTIVE: To examine how clinicians and patients understand and communicate family history in the context of CHD risk assessment in primary care. METHODS: A qualitative study. Patients completed a validated family history questionnaire. Consultations with clinicians were video recorded, and semi-structured interviews conducted with patients after consultation. The participants were 21 primary care patients and seven primary care clinicians (two practice nurses, five GPs). Four practices in South West England. RESULTS: Patients and clinicians usually agreed about the patient's level of risk and how to reduce it. Patients were mostly satisfied with their consultations and having their family history assessed. However, three issues were identified from the consultations which contributed to concerns and unanswered questions for patients. Problems arose when there were few modifiable risk factors to address. Firstly, patients' explanations of their family history were not explored in the consultation. Secondly, the relationship between the patient's family history and their other risk factors, such as smoking or cholesterol, was rarely discussed. Thirdly, clinicians did not explain the integration of family history into the patient's overall cardiovascular disease risk. CONCLUSIONS: Clinicians appeared to lack a rhetoric to discuss family history, in terms of capturing both genetic and environmental factors and its relation to other risk factors. This created uncertainties for patients and carries potential clinical and social implications. There is a need for better guidance for primary care clinicians about family history assessment.     

Management of ischaemic heart disease in primary care: towards better practice. STaRNet. South Thames Region Network.

BACKGROUND: Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia. METHODS: A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600). RESULTS: Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l). CONCLUSIONS: Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.     

Selenium in ischaemic heart disease

Ecological between-area comparisons, hospital-based case-control studies and cross-sectional angiography studies have provided data on the role of selenium (Se) deficiency in the aetiology of ischaemic heart disease (IHD), but this evidence is, at best, suggestive because of the potential selection biases and the lack of certainty of the temporal direction of the observed associations. Out of the four cohort-based population studies published so far, one observed a moderate association between a reduced serum Se and an increased risk of IHD and all cardiovascular (CVD) deaths, one was equivocal and two did not find any association between serum Se and IHD. There are, however, several potential sources of biases acting towards the null hypothesis in these studies. In the pooled data of the two separate cohorts from eastern Finland including 377 people who experienced a CVD death or a non-fatal myocardial infarction and equally many event-free risk-factor matched controls, people with serum Se of less than 45 micrograms/l had a 1.7-fold (95% confidence interval 1.2-2.7) risk of an CVD event compared to those with higher serum Se. This association could, however, be explained by the covariation of Se with other nutrients, as for example n-3 polyunsaturated fatty acids. As the evidence concerning the role of serum Se in IHD is inconclusive, we need new epidemiological studies to test the association and experiments exploring the possible mechanisms.     

Continuity of primary care and prenatal care adequacy among women with disabilities in Ontario: A population-based cohort study

BackgroundWomen with disabilities experience elevated risks for pregnancy complications and report barriers accessing prenatal care. Emerging evidence highlights the significant role primary care providers play in promoting preventive services like prenatal care.ObjectiveTo examine the relationship between continuity of primary care (COC) and prenatal care adequacy among women with disabilities.MethodsWe conducted a population-based study using health administrative data in Ontario, Canada. The study population included 15- to 49-year-old women with physical (n = 106,555), sensory (n = 32,194), intellectual/developmental (n = 1515), and multiple (n = 6543) disabilities who had a singleton livebirth or stillbirth in 2003–2017 and ≥ 3 primary care visits < 2 years before conception. COC was measured using the Usual Provider of Care Index. Nominal logistic regression was used to compute adjusted odds ratios (aOR) for prenatal care adequacy, measured using the Revised-Graduated Prenatal Care Utilization Index, for women with low versus moderate/high COC, controlling for other social and medical characteristics.ResultsWomen with disabilities with low COC, versus those with moderate/high COC, had increased odds of no (aOR 1.42, 95% CI 1.29–1.56), inadequate (aOR 1.19, 95% CI 1.16–1.23), and intensive prenatal care (aOR 1.22, 95% CI 1.19–1.25) versus adequate. In additional analyses, women with low COC and no/inadequate prenatal care were the most socially disadvantaged among the cohort, and those with low COC and intensive prenatal care had the greatest medical need.ConclusionImproving primary care access for women with disabilities, particularly those experiencing social disadvantage, could lead to better prenatal care access.     

Costs of informal care for patients in advanced home care: a population-based study

OBJECTIVES: Several studies have sought to analyze the cost-effectiveness of advanced home care and home rehabilitation. However, the costs of informal care are rarely included in economic appraisals of home care. This study estimates the cost of informal care for patients treated in advanced home care and analyses some patient characteristics that influence informal care costs. METHODS: During one week in October 1995, data were collected on all 451 patients in advanced home care in the Swedish county of Osterg?tland. Costs were calculated by using two models: one including leisure time, and one excluding leisure time. Multiple regression analysis was used to analyze factors associated with costs of informal care. RESULTS: Severity percent of the patients in the study had informal care around the clock during the week investigated. The patients had, on average, five formal care visits per week, each of which lasted for almost half an hour. Thus, the cost of informal care constituted a considerable part of the cost of advanced home care. When the cost of leisure time was included, the cost of informal care was estimated at SEK 5,880 per week per patient, or twice as high as total formal caregiver costs. When leisure time was excluded, the cost of informal care was estimated at SEK 3,410 per week per patient, which is still 1.2 times higher than formal caregiver costs (estimated at SEK 2,810 per week per patient). Informal care costs were higher among patients who were men, who were younger, who had their own housing, and who were diagnosed with cancer. CONCLUSIONS: Studies of advanced home care that exclude the cost of informal care substantially underestimate the costs to society, regardless of whether or not the leisure time of the caregiver is included in the calculations.     

Practice size,caseload, deprivation and quality of care of patients with coronary heart disease,hypertension and stroke in primary care: national cross-sectional study

Background  

Reports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.     

Physical health care of patients with schizophrenia in primary care: a comparative study

BACKGROUND: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care. OBJECTIVE: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia. METHODS: Design: Case-matched retrospective case note review. Setting: Twenty-two general practices in the Birmingham area (UK). Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients. Main outcome measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups. RESULTS: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 1.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05). CONCLUSIONS: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.     

Identifying factors associated with experiences of coronary heart disease patients receiving structured chronic care and counselling in European primary care

ABSTRACT: BACKGROUND: Primary care for chronic illness varies across European healthcare systems. In patients suffering from coronary heart disease (CHD), factors associated with patients' experiences of receiving structured chronic care and counselling at the patient and practice level were investigated. METHODS: In an observational study comprising 140 general practices from five European countries (Austria, Germany, the Netherlands, Switzerland and the United Kingdom), 30 patients with Coronary Heart Disease (CHD) per practice were chosen at random to partake in this research. Patients were provided with a questionnaire and the Patient Assessment of Chronic Illness Care (PACIC-5A) - instrument. Practice characteristics were assessed through a practice questionnaire and face to face interviews. Data were aggregated to obtain two practice scores representing quality management and CHD care, respectively. A hierarchical multilevel analysis was performed to examine the impact of patient and practice characteristics on PACIC scores. RESULTS: The final sample included 1745 CHD-patients from 131 general practices with a mean age of 67.8 (SD 9.9) years. The overall PACIC score was 2.84 (95%CI: 2.79; 2.89) and the 5A score reflecting structured lifestyle counselling was 2.75 (95% CI: 2.69; 2.79). At the patient level, male gender, more frequent practice contact and fewer related or unrelated conditions were associated with higher PACIC scores. At the practice level, performance scores reflecting quality management (p = 0.013) and CHD care (p = 0.009) were associated with improved assessment of the structured chronic care and counselling received. CONCLUSIONS: Patients' perceived quality of care varies. However, good practice management and organisation of care were positively reflected in patients' assessments of receiving structured chronic illness care. This highlights the importance of integrating patient experiences into quality measurements to provide feedback to health care professionals.