Quality of cardiovascular disease care in Ontario, Canada: missed opportunities for prevention - a cross sectional study

Abstract

BackgroundPrimary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients.MethodsWe conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c.ResultsAdherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c.ConclusionsThere remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.Trial RegistrationNCT00574808

Missed opportunities in prevention of cardiovascular disease in primary care: a cross-sectional study

“…The under-treatment of patients at high risk of CVD observed in the present study is consistent with the findings of other studies conducted in Canada, 15 Belgium, 10 Italy, 11,12 Switzerland, 13 and across Europe 14 ( Table 3). The present study is the first conducted in the UK and the first to examine adherence to guidelines for both primary and secondary prevention of CVD in a complete primary care population.…”

“…[3][4][5][6][7][8][9] Despite these guidelines, previous studies have identified under-treatment of patients for CVD prevention in specific at-risk groups. [10][11][12][13][14][15] In the UK, an attempt has been made to address missed opportunities in CVD prevention by introducing a programme of 'vascular health checks' for all patients aged 40-74 years with no previous history of CVD. 16,17 A recent Cochrane review of general health checks suggested that there is no existing evidence to support their implementation or indicate that such a programme might be effective at reducing cardiovascular morbidity or total mortality.…”

Measuring Physician Adherence With Gout Quality Indicators: A Role for Natural Language Processing

“…Given the recent expansion of the gout therapeutic armamentarium, subsets of patients once limited in treatment options can now achieve target uric acid levels, and thereby disease control (). Yet, too few gout patients receive adequate treatment to achieve target sUA levels in spite of the establishment of treatment guidelines and recommendations for its quality of care focusing on the appropriate use of medications ().…”

“…Manual review of medical records is the traditional method utilized for evaluating quality of care, but is tedious and costly, restricting analyses to only a fraction of available charts (). The advent of electronic medical records (EMRs) allows for analyses of large administrative pharmacy data, as in the evaluation of quality of medical care of myocardial infarction following use of aspirin and statins, and of diabetes mellitus (DM) (). EMR analyses of the initiation of allopurinol in gout care have also been studied (), but as BM counseling is documented in the narrative portion of the EMR, it is not easily accessible for quantitative analysis without manual review ().…”

“…The advent of electronic medical records (EMRs) allows for analyses of large administrative pharmacy data, as in the evaluation of quality of medical care of myocardial infarction following use of aspirin and statins, and of diabetes mellitus (DM) (). EMR analyses of the initiation of allopurinol in gout care have also been studied (), but as BM counseling is documented in the narrative portion of the EMR, it is not easily accessible for quantitative analysis without manual review (). Therefore, while an EMR lends itself to data extraction of numerical values (as in laboratory assays and medication doses), BM counseling, because it is in the EMR narrative, does not.…”