The SaM (Screening and Monitoring) Approach to Cardiovascular Risk-Reduction in Primary Care—Cyclic Monitoring and Individual Treatment of Patients at Cardiovascular Risk using the Electronic Medical Record

Abstract

Background

Cardiovascular disease (CVD) prevention suffers from a major gap between clinical evidence (information) and clinical practice (implementation). Insufficient control risk factor levels and under-utilization of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are well-known examples.

Methods

The SaM (Screening and Monitoring) approach was devised by a family physician in order to facilitate closure of this gap. It does so by providing solutions to problems in the fields of information and implementation. A simple manipulation of the electronic medical record used in the practice serves to facilitate cyclic monitoring of patients with cardiovascular risk factors. Technological and human resources available in the primary care setting are used. The approach is described in the first part of the article. The second part presents results obtained by employing the approach on one family physician's patient population.

Results

The final results demonstrate a marked improvement over time in risk factor levels and use of medications in accordance with Indications. The values achieved are superior to those reported in the literature. Blood pressure in hypertensive patients 134/75 mmHg; haemoglobin A1c 7.27%; low-density lipoprotein-cholesterol in patients with CVD or diabetes, 97mg/dl; patients with CVD receiving anti-thrombotic medication, 94%; dyslipidaemic patients with CVD or diabetes receiving lipid-lowering drugs, 90%; post myocardial infarction patients receiving beta-blockers, 76%; hypertensive diabetics or patients with chronic heart failure (CHF) receiving ACE-inhibitors/angiotensin receptor blockers, 86%.

Conclusions

In this one-practice pilot-study, the SaM approach was employed with marked improvement in risk factor levels and use of appropriate medications. This may translate into reductions in morbidity and mortality in a larger population. Eur J Cardiovasc Prev Rehabil 12:56-62 © 2005 The European Society of Cardiology

Keywords

cardiovascular disease prevention primary care cardiovascular risk factors

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References

World Health Report 1997–Executive Summary. http://www.who.int/whr/1997/exsum97e.htm.

Heart Disease. National Vital Statistics Reports, Vol. 49. No. 8 http://www.cdc.gov/nchs/fastats/heart.htm.

Stroke. National Vital Statistics Reports. Vol. 49. No. 12 http://www.cdc.gov/nchs/fastats/stroke.htm.

Brady

AJB

, Oliver

, Pittard

. Secondary prevention in 24,431 patients with coronary heart disease: survey in primary care. BMJ 2001; 322: 1463.

Sueta

, Chowdhury

, Boccuzzi

, Smith

, Alexander

, Londhe

. Analysis of the degree of under-treatment of hyperlipidaemia and congestive heart failure secondary to coronary artery disease. Am J Cardiol 1999; 83: 1303–1307.

Qureshi

, Suri

, Guterman

, Hopkins

. Ineffective secondary prevention in survivors of cardiovascular events in the US population: report from the Third National Health and Nutrition Examination Survey. Arch Intern Med 2001; 103: 38–44.

Shea

, Basch

. A review of five major community-based cardiovascular-disease-prevention programs. Part II: Intervention strategies, evaluation methods, and results. Am J Health Promot 1990; 4: 279–287.

Record

, Harris

, Record

, Gilbert-Arcari

, DeSisto

, Bunnell

. Mortality impact of an integrated community cardiovascular health program. Am J Prev Med 2000; 19: 30–38.

Murchie

, Campbell

, Ritchie

, Simpson

, Thain

. Secondary prevention clinics for coronary heart disease: four year follow up of a randomized controlled trial in primary care. BMJ 2003; 326: 84.

10.

The 33rd Bethseda Conference: preventive cardiology how can we do better?

J Am Coll Cardiol 2002; 4: 579–651.

11.

Cabana

, Rand

, Powe

, Wu

, Wilson

, Abboud

Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458–1465.

12.

Jackson

. Guidelines on preventing cardiovascular disease in clinical practice. BMJ 2000; 320: 659–661.

13.

Hyman

, Pavlik

. Self reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices and the role of guidelines and evidence-based medicine. Arch Intern Med 2000; 160: 2281–2286.

14.

Hayward

, Guyatt

, Moore

, McKibbon

, Carter

. Canadian physicians attitude about and preference regarding clinical practice guidelines. CMAJ 1997; 156: 1715–1723.

15.

Erhardt

. The essence effective treatment and compliance is simplicity. Am J Hypertension 1999; 12: 105s–110s.

16.

Mcwhinny Ian

. Textbook of family medicine. Second Edition. Oxford: Oxford University Press; 1997, pp. 44 and 413.

17.

National Guideline Clearing House. Lipid screening in adults. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); 18 Jan 2000.

18.

National Guideline Clearing House. Screening for diabetes. Diabetes Care Oct 2001; republished Jan 2001.

19.

National Guideline Clearing House. Preventive services for adults. Bloomington (MN): Institute For Clinical Systems Improvement (ICSI); Mar 2000.

20.

Standards of medical care in diabetes. Diabetes Care 2004; 27(Suppl 1): S15–S35.

21.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).

22.

National Cholesterol Education Program. Third Report of The Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. (Adult Treatment Panel III), 2001.

23.

Leibovitz

, Gavish

, Dicker

, Viskoper

, Yosefi

. Risk-factor profile and achievement of treatment goals among hypertensive patients in general practice in Israel: baseline results from the Israeli Blood Pressure Control (IBPC) Program. IMAJ 2003; 5: 696–701.

24.

Goldfracht

, Porath

. Nationwide program for improving the care of diabetic patients in Israeli primary care centers. Diabetes Care 2000; 23: 495–499.

25.

EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapy in coronary patients from 15 countries; principle results from the EUROASPIRE II Euro Heart Survey Program. Eur Heart J 2001; 22: 554–572.

26.

Rabinowitz I. The SaM approach to cardiovascular risk-reduction in primary care. http://www.samapproach.com.

27.

Stafford

, Radley

. The under-utilization of cardiac medications of proven benefit-1990 to 2002. J Am Coll Cardiol 2003; 41: 56–61.