6 October 2020

Room for GPs to improve CVD care

Cardio Clinical Evidence Based General Practice

Despite established treatment guidelines to manage patients with cardiovascular disease and mitigate risk, many GPs are not applying them in clinical practice, a study has found.

According to a research letter, published in the Medical Journal of Australia this week, less than 60% of patients with established cardiovascular disease were receiving the guideline recommended treatments, which included the prescribing of blood-pressure, lipid-lowering and antiplatelet or anticoagulant medications.

The researchers reviewed more than 100,000 de-identified electronic medical records generated from 95 Australian general practices. At baseline, about 10% of patients had a recorded diagnosis of cardiovascular disease, 13% were found to have clinically high-risk conditions for developing cardiovascular disease, 3% were deemed high risk and 45% were considered low or intermediate risk.

“Our findings indicate that primary care management of patients with CVD is sub-optimal,” the study authors said.

The adherence to treatment guidelines was even lower among patients classified as at high risk of developing cardiovascular disease, with only about 40% of patients prescribed recommended treatments.

The RACGP-endorsed treatment guidelines were adopted in 2012, but the study authors say that adopting this absolute risk assessment approach has not improved adherence to the management guidelines.

“GPs play essential roles in identifying patients at risk of CVD and managing their treatment but ensuring their adherence to evidence-based recommendations is challenging,” they said.

The authors admitted that their study didn’t gather any free text, so it was possible the electronic data they analysed omitted patient records that showed they were already receiving medications to mitigate their cardiovascular disease risk.

Additionally, rural and Aboriginal Medical Service practice data was under-represented in the sample used. Associate Professor Charlotte Hespe, GP co-author and head of general practice at the University of Notre Dame in Sydney, said some GPs might be implementing the guidelines, but not putting it in the patient notes.

“It also points to the pressure of time [and] because we’re so poorly remunerated, it is very difficult,” she said.

And while risk assessment tools are important, there remains systemic barriers for GPs to effectively deliver preventative healthcare across their patient base.

“There’s many reasons why GPs don’t implement guidelines but from my perspective, it’s around systems of care and the way we as GPs often offer reactive care to patients,” Professor Hespe said.

“The Medicare system was designed in the 70s to be reactive care, and you get rewarded as a GP for volume.

“And the way we have been taught medicine is to deal with the problem of the patient in front of us. Even the way you interview a patient is about [asking] what’s the problem, and then sorting out the issue.

“But where our power is [as GPs] is actually around preventive healthcare, because as we all know, reactive care can be done in an emergency but there’s bang for buck in preventive healthcare.”

The development of the Primary Health Care 10-Year Plan, initiated last year by the federal government, is expected to help in redesigning a system where primary care is front and centre in preventative care.

Professor Hespe said the value of prevention in primary care is becoming increasingly apparent through these studies, which show the potential healthcare savings of early intervention.

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