Scientific Institute for Quality of Health Care, Radboud University Nijmegen Medical Centre, the Netherlands.
BMC Fam Pract. 2012 Oct 5;13:96. doi: 10.1186/1471-2296-13-96.
Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size.
In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex.
We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries.
CVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.
初级保健在心血管风险管理 (CVRM) 中发挥着重要作用，可能需要初级保健实践的最小规模来有效提供 CVRM。我们检查了初级保健中冠心病 (CHD) 患者的 CVRM，并探讨了实践规模的影响。
在 8 个国家的观察性研究中，我们在初级保健实践中抽样 CHD 患者，并从电子患者记录中收集数据。实践样本根据实践规模和城市化程度进行分层；当有可用的编码诊断时，使用编码诊断选择患者。CVRM 是基于国际认可的质量指标来衡量的。在分析中，实践规模是根据注册或访问实践的患者数量来定义的。我们进行了多水平回归分析，控制了患者的年龄和性别。
我们纳入了 181 个实践（目标数量的 63%）。两个国家纳入了实践的便利样本。共获得 2960 例 CHD 患者的数据。一些国家使用了补充编码诊断或其他纳入方法的方法，可能会引入潜在的纳入偏倚。我们发现，各国之间的所有 CVRM 指标都存在显著差异。我们计算了作为所有患者阳性结果比例的综合实践得分。危险因素记录率从所有实践的平均实践得分（标准差 32%）的 55%（标准差 32%）到血压的 94%（标准差 10%）不等。达到收缩压、舒张压和 LDL 胆固醇治疗目标的比率分别为 46%（标准差 21%）、86%（标准差 12%）和 48%（标准差 22%）。推荐使用降胆固醇和抗血小板药物的比率约为 80%，70%的患者接受了流感疫苗接种。除了一个例外，实践规模与指标得分无关：在斯洛文尼亚，较大的实践表现更好。变异更多地与实践之间的差异有关，而不是与国家之间的差异有关。
通过质量指标衡量的 CVRM 在各国之间和内部表现出广泛的差异，可能所有参与国家都有改进的空间。很少发现绩效评分与实践规模之间存在关联。
