How accurately do general practitioners and students estimate coronary risk in hypercholesterolaemic patients?

Abstract

Recent guidelines on hyperlipidaemia recommend the calculation of individual coronary risk, at least for patients without previous cardiovascular disease. Although tables and computer programs exist, the estimates are often made on an intuitive basis. The aim of the present work was to study Swedish general practitioners' (GPs) and medical students' ability to estimate the 10-year risk of coronary events for hypercholesterolaemic patients. Two hundred randomly selected Swedish GPs and 73 medical students in their nal year of medical school were asked to estimate coronary risk for 10 written case descriptions with different cholesterol levels (at least 5.5 mmol/l) and combinations of other risk factors. Both primary and secondary prevention cases were represented. The risk estimates were compared with the estimates from the Framingham equation and a Swedish equation. The interindividual differences in estimated risk were remarkable for both GPs and students. Both GPs and students underestimated coronary risk, especially for high-risk patients. GPs tended to be more accurate than students in ranking the cases. Cases with previous coronary heart disease were not recommended treatment to the extent that the guidelines recommend. Both GPs and students were quite accurate in estimating absolute risk increase attributable to successive cholesterol increases in a scenario with other risk factors kept constant. It was concluded that GPs and medical students need help to differentiate more accurately between patients at high and low coronary risk, and greater effort should be made to communicate the advantages and dif culties involved in multiple risk assessment. The requirements for decision support are discussed. More evidence is needed on the validity of the Framingham equation for new population samples.

The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia

“…This is in line with a previous study [4] where the task was to make numerical risk estimates of patient cases with elevated cholesterol values and different patterns of other risk factors: there was a tendency to underestimate risk, especially so for high-risk patients. However, other studies have shown a tendency for doctors to underestimate the absolute risk for coronary events when they make intuitive judgements [12,13].…”

“…Even if the guidelines were well known and/or easily retrievable, adherence to them could vary due to different opinions and values on the part of doctors. We can also assume that tools for risk estimates are not always available or used when indicated [4,5]. The consequences can be over- and undertreatment as compared with the guidelines, which has been shown by a review of medical records [6], and an inefficient use of quite costly cholesterol-lowering drugs.…”

GPs' decisions on drug treatment for patients with high cholesterol values: A think-aloud study

“…The reason for studying decisions without access to written guidelines is that as experienced GPs (in the case of three of us), we have found that this is how decisions on cholesterol treatment are usually made. Furthermore, in a previous study concerning the ability of GPs to make numerical estimates of future cardiovascular risks, we asked the GPs if they had access to any tool for making numerical risk estimates at their clinic [8]. Only nine out of 84 respondents said they had such a tool.…”

Trends in coronary heart disease mortality and statin utilization in two European areas with different population risk levels: Stockholm and Sicily

“…despite the development of specific tools for risk assessment, their use in clinical practice is limited and the risk estimate for a single patient is usually made subjectively 78 . In our previous study of risk estimates made by primary care doctors from stockholm and sicily we found that the risk estimates tended to be inversely related to the average cardiovascular risk in the population 26 , and that swedish doctor tended to underestimate high-risk patients 79 . Moreover, doctors in stockholm were less likely to start lipid-lowering treatment even when their estimate of the risk was above the threshold at which guidelines recommend that pharmacological treatment should start 26 .…”