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Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators

Jan van Lieshout1*, Richard Grol1, Stephen Campbell2, Hector Falcoff3, Eva Frigola Capell14, Mathias Glehr5, Margalit Goldfracht6, Esko Kumpusalo7, Beat Künzi8, Sabine Ludt9, Davorina Petek10, Veerle Vanderstighelen11 and Michel Wensing1

Author affiliations

1 Scientific Institute for Quality of Health Care, Radboud University Nijmegen Medical Centre, PO Box 9101, 114, 6500 HB, Nijmegen, the Netherlands

2 Health Sciences - Primary Care Research Group, (National Primary Care Research & Development Centre), University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK

3 Université Paris Descartes, Faculté de Médecine, Département de Médecine Générale, 75015 Paris; Société de Formation Thérapeutique du Généraliste (SFTG), 233 bis rue de Tolbiac, 75013, Paris, France

4 Instituto Universitario Avedis Donabedian (FAD), Universitat Autònoma de Barcelona, Provença 293 pral, 08037, Barcelona, Spain

5 Department of Orthopedic Surgery, Medical University of Graz, Auenbruggerplatz 5-7, A-8036, Graz, Austria

6 Clalit Health Services, 101 Arlozorov Street, P.O. Box 16250, Tel Aviv, Israel

7 University of Eastern Finland, Department of Public Health and General Practice Kuopio Campus, P.O. Box 1627, FI-70211, Kuopio, Finland

8 Swisspep Institut für Qualität und Forschung im Gesundheitswesen, Postgasse 17, CH-3011, Bern, Switzerland

9 Department of General Practice and Health Services Research, University of Heidelberg, Voßstr 2, D-69115, Heidelberg, Germany

10 Zdravje Medical Center, Smoletova 18, 1000, Ljubljana, Slovenia

11 Domus Medica, Sint-Hubertusstraat 58, 2600, Berchem, Belgium

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Citation and License

BMC Family Practice 2012, 13:96  doi:10.1186/1471-2296-13-96

Published: 5 October 2012



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.