Laurie J. Goldsmith

Screening for hypercholesterolaemia in primary care: randomised controlled trial of postal questionnaire appraising risk of coronary heart disease

Abstract Objectives: To validate a self administered postal questionnaire appraising risk of coronary heart disease. To determine whether use of this questionnaire increased the percentage of people at high risk of coronary heart disease and decreased the percentage of people at low risk who had their cholesterol concentration measured. Design: Validation was by review of medical records and clinical assessment. The questionnaire appraising risk of coronary heart disease encouraged those meeting criteria for cholesterol measurement to have a cholesterol test and was tested in a randomised controlled trial. The intervention group was sent the risk appraisal questionnaire with a health questionnaire that determined risk of coronary heart disease without identifying the risk factors as related to coronary heart disease; the control group was sent the health questionnaire alone. Setting: One capitation funded primary care practice in Canada with an enrolled patient population of about 12 000. Subjects: Random sample of 100 participants in the intervention and control groups were included in the validation exercise. 5686 contactable patients aged 20 to 69 years who on the basis of practice records had not had a cholesterol test performed during the preceding 5 years were included in the randomised controlled trial. 2837 were in the intervention group and 2849 were in the control group. Main outcome measures: Sensitivity and specificity of assessment of risk of coronary heart disease with risk appraisal questionnaire. Rate of cholesterol testing during three months of follow up. Results: Sensitivity of questionnaire appraising coronary risk was 87.5% (95% confidence interval 73.2% to 95.8%) and specificity 91.7% (81.6% to 97.2%). Of the patients without pre-existing coronary heart disease who met predefined screening criteria based on risk, 45 out of 421 in the intervention group (10.7%) and 9 out of 504 in the control group (1.8%) had a cholesterol test performed during follow up (P<0.0001). Of the patients without a history of coronary heart disease who did not meet criteria for cholesterol testing, 30 out of 1128 in the intervention group (2.7%) and 18 out of 1099 in the control group (1.6%) had a cholesterol test (P=0.175). Of the patients with pre-existing coronary heart disease, 1 out of 15 in the intervention group (6.7%) and 1 out of 23 in the control group (4.3%) were tested during follow up (P=0.851, one tailed Fishers exact test). Conclusions: Although the questionnaire appraising coronary risk increased the percentage of people at high risk who obtained cholesterol testing, the effect was small. Most patients at risk who received the questionnaire did not respond by having a test. Key messages Of patients at high risk of coronary heart disease, 10.7% who received a risk appraisal questionnaire with a general health questionnaire and 1.8% of those who received the general health questionnaire alone had a cholesterol test within the following three months Of patients at low risk, 2.7% of patients receiving the risk appraisal questionnaire and 1.6% of control subjects had a cholesterol test Most patients at risk who received the risk appraisal questionnaire did not seek a test Further research is needed to identify factors contributing to low uptake of cholesterol testing among people at high risk of coronary heart disease even when encouragement is given

Selective Opportunistic Screening for Hypercholesterolemia in Primary Care Practice

OBJECTIVES To assess the performance of selective opportunistic screening in a primary care group practice. DESIGN Cross-sectional survey of coronary heart disease risk factors and retrospective chart audit of cholesterol testing. SETTING Capitation-funded primary care group practice in Ontario, Canada. SUBJECTS 7785 enrolled patients between the ages of 20 and 69 years. INTERVENTION Protocol-based selective opportunistic screening program for hypercholesterolemia of 45 months duration. MAIN OUTCOME MEASURES Targeting (proportion of screening tests that were appropriate), coverage (proportion of those meeting screening criteria who had a screening test performed), over-screening (proportion of those not meeting screening criteria who had a screening test performed), and screening ratio (likelihood that a screening test was performed on an individual who met screening criteria rather than one who failed to meet screening criteria). RESULTS 64.7% of patients tested met the practice criteria for screening. 37.7% of patients who met the practice screening criteria were tested and 24.9% of those not meeting practice screening criteria had a cholesterol test performed. The screening ratio was 1.52. CONCLUSION Our findings bring into question the effectiveness of opportunistic approaches to preventive care.

Physician impact analysis predictions in Ontario hospitals: does the emperor have clothes?

Physician impact analysis (PIA) is a human resource planning tool used to predict the impact on hospital resources of adding a new or replacement physician to a hospitals medical staff. This article describes the findings of a study which examined the extent to which PIAs are used in Ontario acute care hospitals and the accuracy of PIA predictions. The results suggest that although PIA appears to be widely used, there is no evidence that it meets the intended policy objective of accurately predicting physician hospital resource use.