Law Tamryn K, Yan Andrew T, Gupta Aanika, Kajil Mahesh, Tsigoulis Michelle, Singh Narendra, Verma Subodh, Gupta Milan
Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Canada.
Faculty of Medicine, University of Ottawa, Ottawa, Canada.
Eur Heart J Qual Care Clin Outcomes. 2015 Jul 1;1(1):31-36. doi: 10.1093/ehjqcco/qcv002.
For the primary prevention of cardiovascular disease, the Framingham Risk Score (FRS) is the most well-known risk prediction method. However, there are limited data regarding physicians' method of risk assessment and guideline adherence in clinical practice.
In the PARADIGM (Primary cARe AuDIt of Global risk Management) study (March 2009-10), 105 primary care physicians across Canada prospectively collected data for 3015 patients (mean age 56 years, 59% men) without known cardiovascular disease, diabetes, or lipid-lowering medications at baseline. For each patient, the treating physician determined their cardiovascular risk, and reported the risk stratification method and subsequent treatment decisions. Kappa statistics assessed the agreement between the study-calculated FRS and the treating physician's reported risk assessment. The FRS was the most commonly reported risk assessment method, but was used in only 34.0% of patients. Regardless of the method used (even if the FRS was reportedly used), there was only fair agreement between the risk stratification as reported by the physician and the study-calculated FRS. Moreover, physicians recommended statin initiation in 92% of all patients that they identified as high risk; however, according to the study-calculated FRS, only 56% of the truly high-risk patients were recommended statin therapy.
For the primary prevention of cardiovascular disease, these findings indicate a need to improve risk assessment and stratification, as misclassification directly contributes to suboptimal risk factor management in real-world clinical practice. Future studies should establish the optimal risk stratification method with quality improvement strategies for its subsequent implementation.
http://clinicaltrials.gov/ct2/show/NCT00950703; NCT00950703.
对于心血管疾病的一级预防，弗雷明汉风险评分（FRS）是最著名的风险预测方法。然而，关于临床实践中医生的风险评估方法和对指南的遵循情况的数据有限。
在PARADIGM（全球风险管理初级保健审计）研究（2009年3月至2010年）中，加拿大的105名初级保健医生前瞻性地收集了3015例患者（平均年龄56岁，59%为男性）的数据，这些患者在基线时无已知心血管疾病、糖尿病或降脂药物治疗史。对于每位患者，主治医生确定其心血管风险，并报告风险分层方法及后续治疗决策。kappa统计量评估研究计算的FRS与主治医生报告的风险评估之间的一致性。FRS是最常报告的风险评估方法，但仅在34.0%的患者中使用。无论使用何种方法（即使据报告使用了FRS），医生报告的风险分层与研究计算的FRS之间的一致性仅为中等。此外，医生在所有他们认定为高危的患者中，有92%推荐开始使用他汀类药物；然而，根据研究计算的FRS，只有56%的真正高危患者被推荐接受他汀类药物治疗。
对于心血管疾病的一级预防，这些发现表明需要改进风险评估和分层，因为分类错误直接导致现实临床实践中危险因素管理欠佳。未来的研究应建立最佳风险分层方法及其后续实施的质量改进策略。
