A leading Auckland cardiologist has described the results of cardiovascular disease (CVD) research published recently as “staggering”.
Professor Ralph Stewart, a cardiologist with the Green Lane Cardiovascular Service and an Honorary Professor of Medicine at the University of Auckland, was commenting on findings published in The New Zealand Medical Journal, which found that 39 per cent of patients who had previous hospitalisations for major CVD events had ‘no’ indicated for prior CVD in the PREDICT algorithm.
“Sue Wells and colleagues report on what initially seems a mundane question; ‘Is general practice identification of prior cardiovascular disease at the time of CVD risk assessment accurate and does it matter?’. The answer is staggering and the consequences substantial,” he writes.
“During the last 10 years, thousands of New Zealanders have had a cardiovascular risk assessment completed in primary care using simple risk algorithms such as PREDICT,” explains Professor Stewart. “When completing this risk score, the most important ‘box’ is ‘prior cardiovascular disease’.
“This identifies patients who usually have a much higher risk, compared with people with risk factors alone, and who almost always have a clear indication for preventive medication.”
The University of Auckland research team lead by Sue Wells and including Rod Jackson found that among 454,369 people aged 35–74 years who had CVD risk assessments, 30,924 (6.8 per cent) had previously been admitted with ischaemic CVD. Of these, only 61 per cent were recorded as having prior CVD during risk assessments.
Inaccurate primary care recording was more likely for younger people (<55 years), women, Māori, Pacific, Indian and Asian ethnic groups, whereas smokers and people with diabetes were more likely to have prior CVD correctly identified. Over more than a decade, the odds of inaccurate recording during risk assessment increased.
“The mistake was most common for patients with an admission for peripheral arterial disease, whose risk for recurrent CV events is particularly high,” observes Professor Stewart. “This apparently simple error translated to more than double the failure to dispense appropriate evidence-based treatment during the next six months.”
‘Swiss cheese’ system failure
The researchers say the findings suggest a classic ‘Swiss cheese’ system failure where information is lost through one or more process steps. These steps include: preparing and sending hospital discharge letters (via secure portal, fax or paper-based); transmitting discharge summaries to the right GPs at the right general practices; filing in general practice electronic health records (EHRs) after receipt; coding events in the EHRs; using codes compatible with the integrated risk assessment template; and accurately entering CVD history at the time of CVD risk assessments in primary care.
“This study highlights the need for ‘whole of system’ clinical information to be available to better support primary care. It is timely that the Ministry of Health is investigating the implementation of a unified national electronic health record,” conclude the researchers.
Professor Stewart agrees. “The study … shows how easy it is to make simple mistakes during busy consultations, and doctors and patients can both ‘forget’ important medical events.
“Improved systems which automatically link electronic records and lab results to decision support tools and then check and guide decisions may reduce these types of mistakes.”
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