Sinclair Gary, Kerr Andrew
The Doctors Systems, Mangere, South Auckland.
N Z Med J. 2006 Nov 17;119(1245):U2312.
To develop a series of system changes in primary care to facilitate cardiovascular risk screening of all eligible patients identified according to the current New Zealand Cardiovascular Guidelines (NZGG), and to provide the ability to measure and track clinical management of high risk patients.
Several system changes were developed within primary care practice management software to identify the patient cohort eligible for cardiovascular risk screening, to calculate cardiovascular disease risk (CVR), and to extract the data for reporting on screening outcomes and clinical management indicators in high risk patients. Following a baseline audit, the system changes were piloted over 12 months in three general practices with a combined enrolled patient population of 30,963.
A total of 6570 NZGG eligible patients were identified; 20.1% of these were Maori and 19.7% were Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin). Over 12 months, screening rates for cardiovascular risk assessment increased from 4.7% to 53.5% for the cohort. Of the 3516 patients screened, 482 (13.7%) had established cardiovascular disease. A further 230 (6.5%) had diabetes without CVD and 646 (18.4%) had a 5-year CVD risk of > or = to 15% Management data was available in 232 (48.1%) of those with CVD, 74%, 65%, and 79% were on aspirin, statins, and blood pressure-lowering medication, respectively. Fifty-five percent exceeded the low density lipoprotein (LDL) target of 2.5 mmol/L, 62% had a systolic blood pressure (BP) above the target of 130 mmHg, 18% were still smoking, and only 9% met all clinical targets recommended in the guideline. Of 646 with a 5-year CVD risk > or = to 15%, management data was available in 347 (53.7%). Only 34% were prescribed aspirin, 40% were prescribed statins, and 57% were on blood pressure lowering medication. Forty percent of this group had a systolic BP >140 mmHg, 36% an LDL >3.5 mmol/L, with only 7% of patients meeting all the guideline clinical targets.
The system changes comprising this intervention have dramatically increased cardiovascular risk assessment rates in a primary care setting, and will facilitate appropriate targeting of intensive cardiovascular prevention measures to close the treatment gap observed.
在初级医疗保健中进行一系列系统变革，以促进对所有根据现行新西兰心血管指南（NZGG）确定的符合条件患者进行心血管风险筛查，并具备测量和跟踪高危患者临床管理情况的能力。
在初级医疗保健实践管理软件中进行了多项系统变革，以识别符合心血管风险筛查条件的患者群体，计算心血管疾病风险（CVR），并提取数据以报告高危患者的筛查结果和临床管理指标。在进行基线审核后，在三家综合诊所对系统变革进行了为期12个月的试点，这些诊所的登记患者总数为30963人。
共识别出6570名符合NZGG条件的患者；其中20.1%为毛利人，19.7%为太平洋岛民（主要是萨摩亚、汤加、纽埃或库克群岛血统）。在12个月内，该队列的心血管风险评估筛查率从4.7%提高到了53.5%。在接受筛查的3516名患者中，482人（13.7%）已确诊患有心血管疾病。另有230人（6.5%）患有糖尿病但无心血管疾病，646人（18.4%）的5年心血管疾病风险≥15%。在患有心血管疾病的患者中，232人（48.1%）有管理数据，其中分别有74%、65%和79%的患者正在服用阿司匹林、他汀类药物和降压药物。55%的患者低密度脂蛋白（LDL）超过2.5 mmol/L的目标值，62%的患者收缩压（BP）高于130 mmHg的目标值，18%的患者仍在吸烟，只有9%的患者达到了指南中推荐的所有临床目标。在5年心血管疾病风险≥15%的646名患者中，347人（53.7%）有管理数据。只有34%的患者被开了阿司匹林，40%的患者被开了他汀类药物，57%的患者正在服用降压药物。该组中40%的患者收缩压>140 mmHg，36%的患者低密度脂蛋白>3.5 mmol/L，只有7%的患者达到了指南中的所有临床目标。
构成该干预措施的系统变革显著提高了初级医疗保健环境中的心血管风险评估率，并将有助于有针对性地采取强化心血管预防措施，以缩小观察到的治疗差距。
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