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Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes
Jacob A Udell1, Arielle R Brickman2, Anna Chu3
1Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Insights
Primary care physician clinical volume impacts cardiovascular care. Higher physician patient volumes correlate with increased cholesterol testing and fewer major adverse cardiovascular events, improving preventive care outcomes.
Area of Science:
- Cardiology
- Primary Care Medicine
- Health Services Research
Background:
- The link between primary care physician (PCP) clinical volume and cardiovascular preventive care quality remains unclear.
- Assessing the relationship between PCP outpatient clinical volumes and cholesterol testing rates is crucial.
- Investigating the association between PCP clinical volumes and major adverse cardiovascular event (MACE) rates in eligible patients is needed.
Purpose of the Study:
- To examine the association between primary care physician (PCP) outpatient clinical volumes and cholesterol testing.
- To investigate the relationship between PCP clinical volumes and major adverse cardiovascular event (MACE) rates.
- To determine if higher PCP clinical volumes are linked to better cardiovascular preventive care.
Main Methods:
- Retrospective cohort study using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort (2008-2012).
- Included almost all adult residents of Ontario, Canada.
- Compared cholesterol testing and MACE rates across PCP clinical volume quintiles.
Main Results:
- Higher PCP clinical volumes were associated with increased cholesterol testing rates.
- A 10.5% relative increase in cholesterol testing probability for every doubling of clinical volume.
- Patients with lower volume PCPs had higher rates of major adverse cardiovascular events (adjusted HR 1.15).
Conclusions:
- Physicians with lower clinical volumes provided less frequent cholesterol testing.
- Patients treated by lower volume PCPs experienced higher rates of incident cardiovascular events.
- Further research is warranted to understand the drivers of this relationship and optimize cardiovascular preventive care.
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.
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