Gaps in primary care documentation of cardiovascular risk factors

Abstract

Abstract Background New Zealand guidelines recommend that cardiovascular risk management should be informed by the absolute risk of a cardiovascular event. This requires knowledge of a person’s age, sex, ethnicity, medical and family history, blood pressure, total and HDL cholesterol, diabetes, and smoking status. Aim To establish the extent of primary care documentation of cardiovascular risk factors. Methods An audit of electronic patient records was conducted in practices affiliated with an Auckland primary care organisation (ProCare Health Ltd). The audited population were patients eligible for risk assessment (all Māori and a random sample of non-Māori) who had a consultation with their general practitioner during a four week study period (1 year before the doctor first used cardiovascular electronic clinical decision support software). Audit nurses searched for risk factors documented prior to the study period. Results The records of 1680 individuals from 84 doctors were audited. The study periods prior to which the records were inspected ranged from August 2001 to June 2003. The proportions of records with risk factors documented were: blood pressure 81.8%, cholesterol 62.4%, smoking status 41.5%, diabetes status 16.1%, all these risk factors 6.8%. Recording of blood pressure and of cholesterol was higher in those with cardiovascular disease or diabetes. Recording of blood pressure increased with increasing age, then levelled off at about age 60 years. Documentation of cholesterol was lowest in the oldest and youngest age groups, and in women (at all ages) compared to men. Conclusions Primary care documentation of cardiovascular risk factors was incomplete. Whilst many doctors may know whether patients are smokers or have diabetes, systematic documentation of these factors in particular, is not occurring. In order to realise the large potential benefits associated with population-based cardiovascular risk assessment and management, a substantial investment by government, healthcare organisations, health professionals, and patients is required to collect and record this information.