Abstract
Aim: To describe the standard of secondary prevention received by individuals with a history of ischaemic heart disease (IHD) in Spanish rural areas, and the factors associated with low standards of quality. Methods: Medical audit of patients with a history of IHD, whose data were provided by 72 rural physicians in 12 autonomous regions (1030 cases). Quality criteria were used based on international guidelines. Multivariate analysis was employed to assess the variables associated with poor-quality attention. Results: 30.9% of patients gave target low-density lipoprotein (LDL) readings, and 68.1% reached target blood pressure (BP). Beta-blockers were taken by 48.5%. Twenty-nine per cent of patients had not visited a specialist within the previous year. The fact that patients had visited a specialist within the previous year was associated with their having followed the types of treatments recommended in the guidelines (p < 0.01) and with obtaining target LDL and BP readings (p < 0.05). Patients from the smallest villages had the lowest probability of having LDL controls and also of receiving hypolipidaemic therapy (p<0.01). Those with a past history of isolated angina had lower probability of being treated with antiaggregants than those who had experienced previous acute myocardial infarction (p < 0.01).
Conclusion: The quality of secondary prevention for these patients shows there is room for improvement. Problems of accessibility exist for some groups, which may be improved with the involvement of rural primary healthcare teams.
Introduction
Cardiovascular diseases make up the leading cause of death in Spain Citation[1]. Despite the fact that patients with a past history of ischaemic heart disease form the group with highest cardiovascular risk and are considered a priority group in preventive cardiology Citation[2], the process of secondary prevention (SP) of ischaemic heart disease has never traditionally formed part of the services offered in primary healthcare in our country. Such care is carried out by specialists, with variable involvement from general practitioners (GPs).
Several studies Citation[3–6] have pointed out numerous problems in the quality of attention received by these patients, including those in Spain Citation[7]. In this context, our group, the rural research network (REDIMER)—an organization of the Rural Medicine Work Group of the Spanish Society for Family and Community Medicine, made up of Spanish doctors working in rural areas—set about the task of describing specific aspects related to the quality of SP of ischaemic heart disease in rural and semi-rural areas in Spain, and analysing those factors associated with differences in its management.
Methods
This was an observational study of quality standards and variables potentially associated with shortcomings in quality.
Participating doctors
Seventy-eight GPs working in rural and semi-rural areas in 12 autonomous regions of Spain participated in the study. According to the Spanish National Institute of Statistics criteria, villages/towns with fewer than 2000 inhabitants are considered rural, and towns with between 2000 and 10 000 inhabitants as semi-rural.
The participating doctors constituted a convenience sample; they were recruited by members of the Rural Group at national conferences, local meetings or in their workplaces. They were offered the opportunity to participate in a network whose aim is to bring to light information from the rural environment. Seventy-eight interested doctors were sent a letter inviting them to participate in this first project, and all accepted.
Study units
Patients under 85 years of age with diagnosed ischaemic heart disease, from the practices of the participating doctors, were identified by registering those that came to renew their prescriptions for cholesterol-lowering drugs, antiaggregants/anticoagulants, beta-blockers, calcium-channel blockers or nitrates between September and December 2002. Included in the study were cases, entered by the participating doctors, which fulfilled the following criteria: 1) existence in the patient's medical records of a hospital report diagnosing ischaemic heart disease prior to 1 December 2001; 2) patient under 85 years of age; and 3) patient did not die or move in the year 2002.
Attention received between 1 December 2001 and 1 December 2002 was analysed.
Criteria for quality assessment
The following were used as fulfilment criteria for intermediate result targets. The time frame used was the previous 12 months.
The mean of the last two BP readings of the year was to be lower than 140/90 mmHg.
The last LDL reading of the year was to be lower than 100 mg/dl (2.6 mmol/l).
The last body-mass index (BMI) reading of the year was to be lower than 25 kg/m2.
Patients were to walk at least 2 hours per week. This was ascertained by telephone survey using a Likert scale of five categories (from “always” to “never”). Exceptions were physical or psychological disability.
Patients on the programme were not to smoke. This was ascertained by telephone survey.
Cases of LDL < 130 mg/dl (3.4 mmol/l)—and likewise total cholesterol < 200 mg/dl (5.2 mmol/l)—and BMI < 30 kg/m2 were also considered. Fulfilment criteria were inspired by international guidelines on SP, SP in elderly patients, and chronic angina Citation[8–10]. We chose the target BP reading of 140/90 mmHg in order to be able to compare results with previous studies Citation[3], Citation[5], Citation[11].
Fulfilment of the above-mentioned criteria was valued (fulfils/does not fulfil/exception). The criterion of sedentarism—“Do you walk at least 2 hours per week?”—was considered fulfilled if the reply was “always” or “nearly always”.
Process variables
Dichotomized variables, created with the aim of standardizing the intensity of patient monitoring by health centres, were formulated by consensus among professionals from the Rural Group. We estimated the existence of an entry in the patients’ medical records within the previous 6 months of: 1) at least two visits with blood pressure readings; 2) at least one LDL cholesterol reading (patients with hypertriglyceridaemia were excluded); and 3) at least two visits with weight measurements (patients who received home visits were excluded).
Other variables
Other variables studied were age, gender, diabetes, population of the patient's town/village of residence, and distance, in minutes, from the patient's village/town of residence to the town where the referred cardiologist's surgery was located and the town/village where the health centre was located. In cases where the patient resided in the same locality as the health centre/referred cardiologist's surgery, a value of 0 was given.
Data were also collected on visits made to the referred cardiologist in the previous year (question in telephone survey) (yes, no); type of ischaemic heart disease: record of acute myocardial infarction (AMI) (yes, no) or of angina (yes, no); and consumption of prophylactic drugs: antiaggregants/anticoagulants, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists (ARBs), and cholesterol-lowering drugs.
Source of data
Data were retrieved from medical records for all variables except for physical activity, smoking and visits made to a referred cardiologist in the previous year, which were obtained by telephone survey.
Analysis
The percentage of fulfilment of the referred quality criteria was determined. We had to accept a lack of data for some criteria results (BP, LDL and BMI) for certain patients owing to the fact that medical records were used as the source of data. Data were missing in 198 cases (19%) for the BP criterion, 243 cases (23%) for LDL < 100 mg/dl, and the same figure for BMI. A descriptive study was carried out of the characteristics of the missing case data.
For the bivariate analysis of factors associated with standard of assistance (patient characteristics and place of residence), chi-square, Student's t, ANOVA, Mann-Whitney U, and Kruskal-Wallis tests were used.
In the study of the association between diverse individual factors and the poor quality of assistance, the odds ratio of each variable was calculated and adjusted for the rest by means of logistic regression. Independent variables were sex, age group (under 65 years, over 65 years), population of place of residence (fewer than 294, 295–3400, 3401 and over), distance from patient's town/village of residence to primary healthcare centre, distance from patient's town/village of residence to cardiologist's surgery, diabetes (yes, no), visits to a specialist in the previous 12 months (yes, no), history of AMI (yes, no), and history of angina (yes, no). The dependent variable was the existence or not of a quality assistance process, adjusted to the model as “0” if it fulfilled the criterion and “1” if it did not. Also, by means of logistic regression, factors associated with the consumption of drugs recommended by guidelines (antiaggregants/anticoagulants, beta-blockers, hypolipidaemic agents and ACE inhibitors) were explored using the same independent variables.
In all of the analyses, the regression model was adjusted for possible dependence between observations of individuals belonging to the same physician (physician cluster effect).
Results
There were 1030 patients, of whom 69.6% were males. Mean age (±SD) was 70.3±9.7 (range 33–85) years, and 75.6% were over 65 years of age. Further, 55.6% had a history of AMI and 62% angina. Telephone surveys could not be conducted with 12 patients (1.2%). Sample characteristics are shown in .
Table I. Sample characteristics.
From among the target range criteria (), those that were met least were LDL < 100 mg/dl (30.9%) and BMI < 25 kg/m2 (19.6%). Beta-blockers were not used by 51.5% of cases, and 34.7% did not use any hypolipidaemic agents at all ().
Table II. Results.
Among the three variables most affected by lack of information (BP < 140/90 mmHg, LDL < 100 mg/dl, and obesity) the missing cases showed, in relation to the study total, a lower proportion of diabetic patients (18, 15 and 21%, respectively) and of patients visited by a specialist (39, 39 and 37%, respectively).
Factors associated with non-fulfilment of quality criteria
and give the factors that showed a statistically significant association (p<0.05) with the studied criteria. The variables that were more frequently associated with quality criteria were the fact of having visited a specialist in the previous year, diabetes, age, and population of the patient's town/village of residence.
Table III. Factors associated with fulfilment of quality criteria (multivariate analysis).
Table IV. Factors associated with prescription of recommended drugs (multivariate analysis).
With regard to pathology type, patients with a history of AMI had greater probability of being treated with antiaggregants (multivariate adjusted odds ratio [aOR] 2.41), hypolipidaemic agents (aOR 1.8) or ACE inhibitors (aOR 1.7) than those who had only experienced angina.
The variable of distance from a patient's town/village of residence to that of a specialist's surgery or health centre was not associated with either having visited the specialist or fulfilment of process variables, respectively.
Discussion
The results presented are subject to limitations derived from the representativeness of the doctors and patients involved. At the outset of the study, few primary care (PC) practices had computerized records (11%) and there were problems with access to the computerized diagnostic records of district hospitals. For these reasons, we decided to create new diagnostic records with the collaboration of volunteer doctors. The new register was made up of patients coming to health centres to renew prescriptions, taking into account the fact that in the Spanish National Health Service almost all prescriptions for chronic disease are issued in PC. The sample, therefore, is not necessarily representative of IHD management in the rural environment. On the other hand, this study deals with the largest number of cases and the greatest number of locations of those carried out to date in PC, rural or urban, in Spain. In any case, our initial hypothesis was that the problems in quality that we would encounter in the patients of these doctors would not be less important than those encountered by the general group of rural physicians.
The inclusion criteria for patients who came to renew their prescriptions in a period of 4 months may have excluded the less regular or non-attending patients. This could cause an overestimation in the consumption of medication, and, at the same time, introduce selection bias if the inverse care law Citation[12] were fulfilled and excluded patients had a higher burden of CVD risk factors. However, we consider this bias, which would again underestimate quality problems, to be minimal in a public health system such as ours that requires compulsory registration with one doctor, and which subsidizes the full cost of medication for pensioners. With the exception of one, all SP quality studies carried out in PC in Spain following hospital discharge have been cross-sectional Citation[7].
As no tradition exists of specific SP programmes in PC, the quality of follow-up is greatly influenced by actions taken by specialists and hospitals. Previous studies have focused on very localized catchment areas and therefore may be influenced by the quality of attention in one particular hospital. This is not the case in our study, given that it includes patients from 12 autonomous regions with a number of different tertiary referral hospitals.
Comparison with other studies ()
We also consulted recent prospective studies Citation[3], Citation[6]. The range of BP figures in our study was higher than that obtained in all of the studies consulted Citation[3], Citation[6], Citation[11], including the prospective ones. However, our study did not include the use of antihypertensives, a factor which might help to explain the difference.
Table V. Comparison of certain variables with studies published in Spain between 2001 and 2002.
Target LDL fulfilment was unsatisfactory, although it was better than results obtained in the consulted cross-sectional studies carried out in Spain Citation[11], Citation[13].
The percentage of smokers was much lower than reflected in studies where a breath carbon monoxide monitor was used. There is likely to have been bias in the gathering of this information, as it was the patient's doctor who conducted the telephone survey.
Our results concerning recommended drug prescriptions are in line with other studies in Spain () Citation[6], Citation[11], Citation[13], Citation[14], with moderately higher ACE inhibitor/ARB consumption. The Euroaspire study Citation[3] makes note of the infrequent use of beta-blockers in Spanish patients, data that are corroborated in all of the studies carried out in Spain, as well as in ours. The results of our study for LDL also suggest that increased effort should be made to extend the use of cholesterol-lowering treatments.
Associations found
We found that patients from the smallest villages had the least probability of having recorded LDL readings, unlike those from intermediate and larger towns. Although no association was found for the variable “distance (in minutes by car) from patient's town/village of residence to the town/village where the health centre is located” (place where blood samples were taken), this paradox could be explained by the fact that a large number patients had no access to a private vehicle or to public transport to reach the place where their health centre is located, factors not considered in the study. People resident in the smallest villages also had a lower probability of being on cholesterol-lowering treatments.
For older patients (over 65 years), it so happened that there was a lower probability of being on hypolipidaemic therapy, yet they reached target LDL levels of < 100 mg/dl better than younger patients. It is possible that there is a bias here owing to survival.
Women appeared to be more sedentary and obese than men, who reached target blood pressure on more occasions than women. In contrast, women visited the health centre more often. These associations have also been pointed out by another study in Spain Citation[11].
We also found in the multivariate analysis that diabetic patients receive more regular monitoring than other patients in this study (). We believe this could be due to the fact that diabetes is a disease whose monitoring is programmed in primary healthcare. Nevertheless, this greater frequency of control in the health centre has not resulted in any association at all with the fulfilment of target criteria. These data could be related to what has been termed in previous studies Citation[15]record of activities without clinical purpose, i.e. the frequent orientation of monitoring programmes for chronic patients centred on the carrying out and recording of activities, with scant emphasis on obtaining target results.
Patients who did not visit their specialist in the previous year satisfied to a lesser degree target figures included in the criteria, with worse fulfilment of target LDL and BP. They also had greater probability of not following prophylactic treatments, and went to fewer check-ups in PC. While we are aware of the restraints set by the cross-sectional design of our study, we cannot rule out this information as being an example of the inverse care law Citation[12], as it is commonly observed that there is no direct connection between the use of services and necessity.
Conclusion
Our data show that there is room for improvement in a number of areas in particular. It has been said that one of the reasons for the current validity of the inverse care law Citation[16] within a public health system is that specific groups within the population are less represented in studies that involve the general population owing to the difficulty in obtaining good rates of response. This, in turn, has consequences within the process of policy making. This could be the case in the rural sector. The present work, with all the outlined limitations, aims to bring to light information that might improve this situation.
We need to find an effective and feasible organizational strategy that will allow SP to be introduced with participation of primary care in rural areas. There are successful experiences in the literature Citation[17–19] based on the involvement of primary healthcare. A strategy based on process management and the wider use of information technology in the rural environment would be a good starting point.
REDIMER group: José María Turón Alcaine, Gabriel J. Diaz Grávalos, Rafael Alonso Roca, Jose Luis Rodríguez Yeste, Josep Cañellas Isern, Ana Vazquez Torguet, Beatriz Solans Aisa, Teofilo Lorente Aznar Ma José González Bouzo, José Luis Romero Limia, Luis A. Vázquez Fernandez, Gerardo Palmeiro Fernández, Ana Rodríguez Fernández, Celso Sánchez González, José Manuel Quintáns, Margarita Arandia García, Ma Adoración Juiz Crespo, Enrique López Vázquez, Isabel Monreal Aliaga, Lourdes Enciso Ciriano, Javier Citoler Perez, José María Millat Medina, Ana Carmen Gimenez Baratech, Ana Ma Fernandez García, Salvador Gestoso Gayá, David Medina i Bombardó, Laura Romero Fernandez, Jasone Basterretxea Oiarzabal, Daniel Domínguez Tristancho, Mercedes Martinez Gonzalez, Inmaculada Casado Gorriz, Jaume Banqué Vidiella, Juan José García Díaz, Tomás García Martinez, Esteban Gracia Gil, Rosana Arribas Garcia, José Tomás Gomez Saenz, Maria Salud Hernández Juanes, José Antonio Morales Ruiz, Emiliano Rodríguez Sánchez, Maria José Gamero Samino, Eva Gomez Iglesias, Miguel Angel Mercader Mercadé, Pere Farrás Serra, Rodolfo Montoya Barquet, Jose Manuel Lopez de Goicoechea, Francisco Abal Ferrer, Joaquín Cuetos Alvarez, Aurora Suarez Reguera, Pablo Belderrain Belderrain, Lina Belenguer Carreras, Lucía Sierra Santos, José María Rubio Ruiz, Carlos Del Valle Hernández, Javier Martín Fuertes, Sagrario Lausín Marín, José Alcubierre Cura, Eva Rua Portu, Antón Aldanondo Gabilondo, Jesús Ubalde Saenz, Francisco José Fagundez Santiago, Pilar Del Rio, Luis García Burriel, Sara Fanlo Abellá, Javier Marzo Arana, Luis Angel Florez, Amelia Rojas Marín, Mercé Fuentes Pujol, Dolors García i Perez, Antonio Morales Jiménez, Albert Clapés Roca, Carme Beltral Lopez, Ramón Barberá Reus, Jordi Espinás Boquet, Rafael Gracia Ballarin, Maria Angeles Gutierrez Stampa and Esteban Gonzalez Lopez.
We are grateful to the Aragonese branch of REDIAPP and the Instituto Aragonés de Ciencias de la Salud for their collaboration on this project.
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