What components of chronic care organisation relate to better primary care for coronary heart disease patients? An observational study

OBJECTIVES: Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients. DESIGN: Observational study. SETTING: 273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain. PARTICIPANTS: A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each. MAIN OUTCOME MEASURE: We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic <140 and diastolic <90 mm Hg), and low-density lipoprotein cholesterol <2.5 mmol/l. Data from structured questionnaires were used to construct an overall measure and six domain measures of practice organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics. RESULTS: Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, p<0.0001), antiplatelet therapy (OR 1.05, p=0.0245) and influenza vaccination (OR 1.12, p<0.0001). Overall practice organisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains ‘self-management support’ and ‘use of clinical information systems’ were linked to three CVRM indicators. CONCLUSIONS: A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.