Abstract
Background
It is unknown whether the annual number of primary care physician (PCP) unique outpatient
assessments, which we refer to as 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 from 2008 to 2012. For each clinical
volume quintile, we compared cholesterol testing and major adverse cardiovascular
events, defined as time to first event of cardiovascular death, nonfatal myocardial
infarction, or nonfatal 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% with the lowest clinical volume
quintile physicians to 86% with 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 quintile physicians had the highest
rate of major adverse cardiovascular outcomes (compared with the highest volume quintile
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.
Résumé
Contexte
On ne sait pas si un lien peut être établi entre le nombre annuel d’évaluations de
patients effectuées en consultation externe (ci-après « volume clinique ») par les
médecins de premier recours (MPR) et la qualité des soins cardiovasculaires préventifs.
Nous avons examiné la relation entre, d’une part, les volumes cliniques des MPR et,
d’autre part, les bilans lipidiques réalisés et les taux de manifestations cardiovasculaires
graves chez les patients admissibles selon les lignes directrices.
Méthodologie
Il s’agissait d’une étude de cohorte rétrospective menée à partir de la cohorte populationnelle
utilisée par l’équipe de recherche sur la santé cardiovasculaire et les soins ambulatoires
CANHEART (Cardiovascular Health in Ambulatory Care Research Team), qui comprend presque
tous les adultes résidant en Ontario (Canada) ayant fait l’objet d’un suivi entre
2008 et 2012. Pour chaque quintile de volume clinique, nous avons comparé la réalisation
de bilans lipidiques et les manifestations cardiovasculaires graves, soit le temps
écoulé avant la première manifestation (décès d’origine cardiovasculaire, infarctus
du myocarde non mortel ou accident vasculaire cérébral non mortel).
Résultats
Au total, les 10 037 MPR évalués avaient rencontré un nombre médian de 2303 patients
(intervalle interquartile : 1292 à 3680) par année. Sur les 4 740 380 patients, 84
% se sont fait prescrire un bilan lipidique conforme aux lignes directrices au moins
une fois tous les 5 ans, la proportion allant de 73 % pour les médecins du quintile
de volume clinique inférieur, à 86 % pour les médecins du quintile supérieur. Après
ajustement multivarié, la probabilité qu’un bilan lipidique soit réalisé affichait
une hausse relative de 10,5 % chaque fois que le volume clinique doublait (intervalle
de confiance [IC] à 95 % : 9,7 à 11,4; p < 0,001). Les patients traités par les médecins
du quintile de volume clinique inférieur étaient ceux chez qui on observait le taux
de manifestations cardiovasculaires graves le plus élevé, comparativement aux patients
des médecins du quintile supérieur (rapport des risques instantanés corrigé : 1,15;
IC à 95 % : 1,10 à 1,21; p < 0,001).
Conclusions
Les patients dont les médecins avaient les volumes cliniques les moins élevés étaient
ceux chez qui les bilans lipidiques étaient moins fréquents et qui affichaient le
taux le plus élevé de manifestations cardiovasculaires. D’autres études sont nécessaires
pour déterminer les facteurs qui sous-tendent cette relation.
Graphical abstract
Graphical Abstract
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Article info
Publication history
Published online: December 23, 2022
Accepted:
December 20,
2022
Received:
May 13,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
See page 9 for disclosure information.
Identification
Copyright
© 2022 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
