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Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes

  • Author Footnotes
    ∗ Co-primary authors.
    Jacob A. Udell
    Correspondence
    Address for Correspondence: Jacob A. Udell, Peter Munk Cardiac Centre, Toronto General Hospital and Women’s College Hospital, 76 Grenville Street, Toronto, ON M5S 1B1. Tel: 416-351-3732; Fax: 416-351-3746;
    Footnotes
    ∗ Co-primary authors.
    Affiliations
    Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    ICES, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Division, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    ∗ Co-primary authors.
    Arielle R. Brickman
    Footnotes
    ∗ Co-primary authors.
    Affiliations
    Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    ICES, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Division, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
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  • Anna Chu
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada
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  • Laura E. Ferreira-Legere
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada
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  • Maya S. Sheth
    Affiliations
    Dalla Lana School of Public Health, University of Toronto, University of Toronto, Toronto, Ontario, Canada
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  • Dennis T. Ko
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada

    Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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  • Peter C. Austin
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
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  • Husam Abdel-Qadir
    Affiliations
    Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    ICES, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Division, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
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  • Noah M. Ivers
    Affiliations
    Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    ICES, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada

    Department of Family Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
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  • R. Sacha Bhatia
    Affiliations
    Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    ICES, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Division, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
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  • Michael E. Farkouh
    Affiliations
    Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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  • Thérèse A. Stukel
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
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  • Jack V. Tu
    Affiliations
    ICES, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada

    Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    ∗ Co-primary authors.
Published:December 23, 2022DOI:https://doi.org/10.1016/j.cjca.2022.12.016
Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes
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      ABSTRACT

      Background

      It is unknown whether the annual number of primary care physician (PCP) unique outpatient assessments, hereto termed clinical volume, translates into better cardiovascular preventive care. We examined the relationship between PCP outpatient clinical volumes and cholesterol testing and major adverse cardiovascular event rates among guideline recommended eligible patients.

      Methods

      This was a retrospective cohort study conducted as part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, a population-based cohort of almost all adult residents of Ontario, Canada, followed between 2008 and 2012. For each clinical volume quintile, we compared cholesterol testing and major adverse cardiovascular events, defined as time to first event of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke.

      Results

      The 10,037 PCPs evaluated had an annualized median volume of 2303 clinical encounters (IQR, 1292-3680). Among 4,740,380 patients, 84% underwent guideline-concordant cholesterol testing at least once over 5 years, ranging from 73% among the lowest clinical volume quintile physicians to 86% among the highest. After multivariable adjustment, there was a 10.5% relative increase in the probability of cholesterol testing for every doubling of clinical volumes (95% CI, 9.7-11.4, P<0.001). Patients treated by the lowest volume physicians had the highest rate of major adverse cardiovascular outcomes, compared with the highest quintile volume physicians (adjusted HR 1.15; 95% CI, 1.10-1.21; P<0.001).

      Conclusions

      Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing and had the highest rate of incident cardiovascular events. Further research investigating the drivers of this relationship is warranted.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Keywords

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      References

      1. Public Health Agency of Canada. Heart Disease in Canada. 2017. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/heart-disease-canada.html.

        View in Article
        • Benjamin E.J.
        • Blaha M.J.
        • Chiuve S.E.
        • et al.
        Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association.
        Circulation. 2017; 135: e146-e603
        View in Article
        • Jollis J.G.
        • Peterson E.D.
        • DeLong E.R.
        • et al.
        The relation between the volume of coronary angioplasty procedures at hospitals treating Medicare beneficiaries and short-term mortality.
        N Engl J Med. 1994; 331: 1625-1629
        View in Article
        • Tu J.V.
        • Austin P.C.
        • Chan B.T.
        Relationship between annual volume of patients treated by admitting physician and mortality after acute myocardial infarction.
        JAMA. 2001; 285: 3116-3122
        View in Article
        • Joynt K.E.
        • Orav E.J.
        • Jha A.K.
        The association between hospital volume and processes, outcomes, and costs of care for congestive heart failure.
        Ann Intern Med. 2011; 154: 94-102
        View in Article
        • Joynt K.E.
        • Orav E.J.
        • Jha A.K.
        Physician volume, specialty, and outcomes of care for patients with heart failure.
        Circulation. Heart failure. 2013; 6: 890-897
        View in Article
        • Tung Y.C.
        • Chang G.M.
        • Chien K.L.
        • Tu Y.K.
        The relationships among physician and hospital volume, processes, and outcomes of care for acute myocardial infarction.
        Medical care. 2014; 52: 519-527
        View in Article
        • Kumbhani D.J.
        • Fonarow G.C.
        • Heidenreich P.A.
        • et al.
        Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure: Insights From Get With The Guidelines-Heart Failure.
        Circulation. 2018; 137: 1661-1670
        View in Article
        • Alabousi M.
        • Abdullah P.
        • Alter D.A.
        • et al.
        Cardiovascular Risk Factor Management Performance in Canada and the United States: A Systematic Review.
        Can J Cardiol. 2017; 33: 393-404
        View in Article
        • Tu J.V.
        • Chu A.
        • Maclagan L.
        • et al.
        Regional variations in ambulatory care and incidence of cardiovascular events.
        CMAJ. 2017; 189: E494-E501
        View in Article
        • Cheung A.
        • Stukel T.A.
        • Alter D.A.
        • et al.
        Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study.
        Ann Intern Med. 2017; 166: 240-247
        View in Article
        • Dahrouge S.
        • Hogg W.
        • Younger J.
        • Muggah E.
        • Russell G.
        • Glazier R.H.
        Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada.
        Ann Fam Med. 2016; 14: 26-33
        View in Article
        • Doherty P.
        • Harrison A.S.
        • Knapton M.
        • Dale V.
        Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.
        Open Heart. 2015; 2e000304
        View in Article
        • Fleming L.M.
        • Jones P.
        • Chan P.S.
        • Andrei A.C.
        • Maddox T.M.
        • Farmer S.A.
        Relationship of Provider and Practice Volume to Performance Measure Adherence for Coronary Artery Disease, Heart Failure, and Atrial Fibrillation: Results From the National Cardiovascular Data Registry.
        Circ Cardiovasc Qual Outcomes. 2016; 9: 48-54
        View in Article
        • Bhatia R.S.
        • Bouck Z.
        • Ivers N.M.
        • et al.
        Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination.
        JAMA Intern Med. 2017; 177: 1326-1333
        View in Article
        • National Cholesterol Education Program (NCEP)
        Expert Panel on Detection Ea, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report.
        Circulation. 2002; 106: 3143-3421
        View in Article
        • McPherson R.
        • Frohlich J.
        • Fodor G.
        • Genest J.
        • Cardiovascular Society Canadian
        Canadian Cardiovascular Society position statement--recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease.
        Can J Cardiol. 2006; 22: 913-927
        View in Article

      18. Genest J, McPherson R, Frohlich J, et al. 2009 Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult - 2009 recommendations. Can J Cardiol. 2009;25:567-579.

        View in Article

      19. Anderson TJ, Grégoire J, Hegele RA, et al. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol. 2013;29:151-167.

        View in Article

      20. Anderson TJ, Gregoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol. 2016;32:1263-1282.

        View in Article

      21. Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults. Can J Cardiol. 2021;37:1129-1150.

        View in Article

      22. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889-2934.

        View in Article

      23. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73:e285-e350.

        View in Article
        • Tran D.T.
        • Palfrey D.
        • Lo T.K.T.
        • Welsh R.
        Outcome and Cost of Optimal Control of Dyslipidemia in Adults With High Risk for Cardiovascular Disease.
        Can J Cardiol. 2021; 37: 66-76
        View in Article
        • Tu J.V.
        • Chu A.
        • Donovan L.R.
        • et al.
        The Cardiovascular Health in Ambulatory Care Research Team (CANHEART): using big data to measure and improve cardiovascular health and healthcare services.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 204-212
        View in Article
        • Shah B.R.
        • Chiu M.
        • Amin S.
        • Ramani M.
        • Sadry S.
        • Tu J.V.
        Surname lists to identify South Asian and Chinese ethnicity from secondary data in Ontario, Canada: a validation study.
        BMC Med Res Methodol. 2010; 10: 42
        View in Article
        • Schultz S.E.
        • Glazier R.H.
        Identification of physicians providing comprehensive primary care in Ontario: a retrospective analysis using linked administrative data.
        CMAJ Open. 2017; 5: E856-E863
        View in Article
        • Stukel T.A.
        • Glazier R.H.
        • Schultz S.E.
        • et al.
        Multispecialty physician networks in Ontario.
        Open medicine : a peer-reviewed, independent, open-access journal. 2013; 7: e40-55
        View in Article
        • Fernandes K.A.
        • Sutradhar R.
        • Borkhoff C.M.
        • et al.
        Small-area variation in screening for cancer, glucose and cholesterol in Ontario: a cross-sectional study.
        CMAJ Open. 2015; 3: E373-381
        View in Article

      30. Statistics Canada. Canadian Community Health Survey (CCHS). Vol 2018. Ottawa, ON: Statistics Canada; Jan 11, 2016.

        View in Article
        • D'Agostino R.B.
        • Vasan R.S.
        • Pencina M.J.
        • et al.
        General cardiovascular risk profile for use in primary care: the Framingham Heart Study.
        Circulation. 2008; 117: 743-753
        View in Article
        • Tu J.V.
        • Chu A.
        • Rezai M.R.
        • et al.
        The Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada: The CANHEART Immigrant Study.
        Circulation. 2015; 132: 1549-1559
        View in Article
        • Panageas K.S.
        • Schrag D.
        • Russell Localio A.
        • Venkatraman E.S.
        • Begg C.B.
        Properties of analysis methods that account for clustering in volume-outcome studies when the primary predictor is cluster size.
        Stat Med. 2007; 26: 2017-2035
        View in Article
        • Sterne J.A.
        • White I.R.
        • Carlin J.B.
        • et al.
        Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.
        BMJ. 2009; 338: b2393
        View in Article
        • Austin P.C.
        • Lee D.S.
        • Fine J.P.
        Introduction to the Analysis of Survival Data in the Presence of Competing Risks.
        Circulation. 2016; 133: 601-609
        View in Article
        • Kiran T.
        • Glazier R.H.
        • Campitelli M.A.
        • Calzavara A.
        • Stukel T.A.
        Relation between primary care physician supply and diabetes care and outcomes: a cross-sectional study.
        CMAJ open. 2016; 4: E80-87
        View in Article

      Article info

      Publication history

      Accepted: December 20, 2022
      Received in revised form: December 7, 2022
      Received: May 13, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Brief Summary:

      We examined the relationship between primary care provider clinical volumes and cholesterol testing and major adverse cardiovascular event (MACE) rates among guideline recommended eligible patients. Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing, with a 10.5% significant increase in relative rate of cholesterol testing for every doubling of clinical volumes. Patients treated by the lowest volume physicians had the highest risk of MACE, compared with the highest quintile volume physicians.

      Identification

      DOI: https://doi.org/10.1016/j.cjca.2022.12.016

      Copyright

      © 2022 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.

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