van Lieshout Jan, Frigola Capell Eva, Ludt Sabine, Grol Richard, Wensing Michel
Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Health Care, Nijmegen, The Netherlands.
BMJ Open. 2012 Aug 17;2(4). doi: 10.1136/bmjopen-2012-001344. Print 2012.
Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients.
Observational study.
273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain.
A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each.
We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic <140 and diastolic <90 mm Hg), and low-density lipoprotein cholesterol <2.5 mmol/l. Data from structured questionnaires were used to construct an overall measure and six domain measures of practice organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics.
Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, p<0.0001), antiplatelet therapy (OR 1.05, p=0.0245) and influenza vaccination (OR 1.12, p<0.0001). Overall practice organisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains 'self-management support' and 'use of clinical information systems' were linked to three CVRM indicators.
A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.
各国患者接受的心血管风险管理（CVRM）存在很大差异。在本研究中，我们探讨了与冠心病（CHD）患者CVRM关键组成部分相关的初级保健组织方面。
观察性研究。
奥地利、比利时、英格兰、芬兰、法国、德国、荷兰、斯洛文尼亚、瑞士和西班牙的273家初级保健机构。
基于处方清单并在八个国家各自的医疗机构就诊时，通过编码诊断确定的4563例CHD患者的随机样本。
我们在10个欧洲国家的初级保健机构进行了一项审计。我们使用六个指标来衡量CVRM的关键组成部分：危险因素记录、抗血小板治疗、流感疫苗接种、血压水平（收缩压<140且舒张压<90 mmHg）以及低密度脂蛋白胆固醇<2.5 mmol/L。来自结构化问卷的数据用于构建基于39个项目的实践组织的总体指标和六个领域指标。使用多水平回归分析，我们探讨了实践组织对CVRM的影响，并对患者特征进行了控制。
初级保健机构更好的总体组织与三个指标的更高得分相关：危险因素登记（B = 0.0307，p < 0.0001）、抗血小板治疗（OR 1.05，p = 0.0245）和流感疫苗接种（OR 1.12，p < 0.0001）。未发现总体实践组织与记录的血压或胆固醇水平相关。只有“自我管理支持”和“临床信息系统的使用”这两个组织领域与三个CVRM指标相关。
初级保健机构更好的组织与CHD患者CVRM过程指标的更好得分相关，但与中间患者结局指标无关。对患者和临床医生的直接支持似乎最具影响力。
