心血管危险因素初级保健记录中的差距。

Gaps in primary care documentation of cardiovascular risk factors.

作者信息

Rafter Natasha, Wells Susan, Stewart Alistair, Selak Vanessa, Whittaker Robyn, Bramley Dale, Roseman Paul, Furness Sue, Jackson Rod T

机构信息

Clinical Trials Research Unit, University of Auckland, Auckland, New Zealand.

出版信息

N Z Med J. 2008 Feb 15;121(1269):24-33.

PMID:18278079

Abstract

BACKGROUND

New Zealand guidelines recommend that cardiovascular risk management should be informed by the absolute risk of a cardiovascular event. This requires knowledge of a person's age, sex, ethnicity, medical and family history, blood pressure, total and HDL cholesterol, diabetes, and smoking status.

AIM

To establish the extent of primary care documentation of cardiovascular risk factors.

METHODS

An audit of electronic patient records was conducted in practices affiliated with an Auckland primary care organisation (ProCare Health Ltd). The audited population were patients eligible for risk assessment (all Maori and a random sample of non-Maori) who had a consultation with their general practitioner during a four week study period (1 year before the doctor first used cardiovascular electronic clinical decision support software). Audit nurses searched for risk factors documented prior to the study period.

RESULTS

The records of 1680 individuals from 84 doctors were audited. The study periods prior to which the records were inspected ranged from August 2001 to June 2003. The proportions of records with risk factors documented were: blood pressure 81.8%, cholesterol 62.4%, smoking status 41.5%, diabetes status 16.1%, all these risk factors 6.8%. Recording of blood pressure and of cholesterol was higher in those with cardiovascular disease or diabetes. Recording of blood pressure increased with increasing age, then levelled off at about age 60 years. Documentation of cholesterol was lowest in the oldest and youngest age groups, and in women (at all ages) compared to men.

CONCLUSIONS

Primary care documentation of cardiovascular risk factors was incomplete. Whilst many doctors may know whether patients are smokers or have diabetes, systematic documentation of these factors in particular, is not occurring. In order to realise the large potential benefits associated with population-based cardiovascular risk assessment and management, a substantial investment by government, healthcare organisations, health professionals, and patients is required to collect and record this information.

摘要

背景

新西兰指南建议，心血管风险管理应以心血管事件的绝对风险为依据。这需要了解一个人的年龄、性别、种族、病史和家族史、血压、总胆固醇和高密度脂蛋白胆固醇、糖尿病及吸烟状况。

目的

确定初级保健中对心血管危险因素的记录程度。

方法

对隶属于奥克兰初级保健机构（ProCare Health Ltd）的医疗机构的电子病历进行审计。被审计人群为符合风险评估条件的患者（所有毛利人和非毛利人的随机样本），他们在为期四周的研究期间（医生首次使用心血管电子临床决策支持软件前一年）与全科医生进行了会诊。审计护士查找研究期间之前记录的危险因素。

结果

对来自84名医生的1680人的记录进行了审计。检查记录的研究期间从2001年8月至2003年6月。记录有危险因素的记录比例分别为：血压81.8%，胆固醇62.4%，吸烟状况41.5%，糖尿病状况16.1%，所有这些危险因素6.8%。心血管疾病或糖尿病患者中血压和胆固醇的记录率更高。血压记录率随年龄增长而增加，然后在约60岁时趋于平稳。胆固醇记录在最年长和最年轻年龄组以及女性（各年龄段）中最低，相比男性。