GP-led research finds management of CVD ‘suboptimal’

The research, published in the Medical Journal of Australia (MJA), has found around four in 10 people with cardiovascular disease (CVD) are not being prescribed the guideline-recommended treatments.
 
Lead author Associate Professor Charlotte Hespe, Head of General Practice and General Practice Research at the University of Notre Dame and Chair of RACGP NSW&ACT, told newsGP the findings are ‘disappointing’.
 
‘We’ve certainly got room for improvement and I think that those conversations need to be had and everybody needs to be on the same page,’ she said.
 
‘I liken it … to my eyes being opened to antibiotic prescribing. I thought I did a good job until I did an audit and then it was like, “Oh, okay, I probably prescribed more than I thought I did”.
 
‘It’s the same with blood pressure management; I probably don’t meet the guidelines as much as I thought I did, and why is that?’
 
Researchers examined the implementation of the 2012 Guidelines for the management of Absolute cardiovascular disease risk in general practice by analysing the baseline electronic medical record (eMR) data of 102,225 patients from 95 general practices used in the INTEGRATE and Q Pulse clinical trials during 2015–18.
 
Of the 10,631 people who had established CVD, 6038 (56.8%) had been prescribed the guideline-recommended treatments, blood pressure targets had been achieved by 4114 patients (38.7%), and low-density lipoproteins cholesterol (LDL-C) targets had been met by 5645 (53.1%).
 
Among the 15,743 patients at high CVD risk, 6486 (41.2%) were prescribed recommended treatments, 8988 (57.1%) had achieved blood pressure targets and 5714 (36.3%) LDL-C targets.
 
‘Our findings indicate that primary care management of patients with CVD is suboptimal,’ Associate Professor Hespe and colleagues concluded.
 
‘Adopting the absolute risk assessment approach has not improved adherence to management guidelines, similar to the experience in Europe, Canada, and the United Kingdom.’
 
While more qualitative research is needed to confirm why there is not greater adherence to the CVD guidelines, as a GP herself, Associate Professor Hespe suspects there is a combination of factors.
 
‘One is around the patient themselves, about what they will or won’t do,’ she said. ‘Then there’s the doctor and the patient, and the conversations about what they will and won’t do.
 
‘I was struck when I first started doing a lot of this audit work back in 2008 that the guidelines are very black and white. But as GPs we can’t be black and white, because if my result is 2.1 but I’m aiming for two, am I going to put your medication up and increase the risk of you having side effects and then stopping taking it? Probably not. I’m going to have that conversation, but be pragmatic and say 2.1 is probably good enough.
 
‘Then the conversation is at what point would I recommend to the patient to change the medication, and at what point would they?
 
‘Again, the data is very black and white, but the way in which we prescribe medication is not. Hence I don’t think you’re ever going to – and you never should – get 100%, because if you’re getting 100% you’re certainly not being person-centred.’
 
While GPs are increasingly involved in the development of guidelines, Associate Professor Hespe notes they are primarily the outcome of single-disease experts mostly familiar with a hospital setting.
 
‘None of my patients are like that at the end of the day; they are real people, leading real lives with multimorbidity, and so [as a GP] you have to do this sort of juggle about getting the best outcome for it,’ she explains.
 
‘But until we’ve got a bit more research around, “how do we have that conversation in the real world of complex patients?”, rather than just using numbers that are around one single disease, I think it’s difficult.’
 
CVD remains the leading cause of death in Australia.
 
While the research reasserts GPs’ essential role in identifying patients at risk of CVD and managing their treatment, it also notes that health system barriers need to be overcome for progress to be made.
 
Associate Professor Hespe says ‘GPs are not the problem, it’s the system’, starting with the lack of financial incentive. Recognising GPs as experts in multimorbidity and equipping them with the resources they need, she says, would be a step in the right direction.
 
‘Having guidelines is not the way to solve the problem,’ Associate Professor Hespe said.
 
‘What we need is a framework and a model of care that actually supports general practice to be able to deliver the guidelines in a patient-centred way that actually allows us to improve what we’re doing. It needs to be supported and funded.
 
‘Making a small amount of difference in cardiovascular disease output will actually make a huge difference for the whole of our community. So how do we do that? We increasingly think taking a tablet is the answer when, really, let’s look at our increased obesity, our increased sitting on our bottoms.
 
‘Cardiovascular disease is a great model because improving eating, improving exercise, decreasing weight, stopping smoking, as well as those medications, are all the things that will decrease the effects.’
 
To assist GPs, Associate Professor Hespe says greater government investment into practice nurses, particularly in an urban setting, is a practical option.
 
‘Nurses are the perfect people to assist us in doing that work,’ she said.
 
‘That work would beautifully align with being able to do some of this population health quality improvement work.
 
‘It’s not about the funding of the heart health assessment – that’s not the answer, that’s just another volume-based thing. It doesn’t actually do anything to highlight the broad need to review what it is that we do.
 
‘It’s a wicked problem, and wicked problems need complex implementation solutions, not just another health assessment tick.’
 
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cardiovascular disease chronic disease guideline-recommended treatments heart disease