Primary Care as an Arena For Primary, Secondary, and Tertiary Vardiovascular Disease Prevention

University dissertation from Ingvar Ovhed, Grytstigen 1, SE-37160 Lyckeby

Abstract: Cardiovascular disease prevention has been a challenge for research for decades. The studies of this thesis were designed to investigate the role of health professionals in everyday clinical work based upon the concept of comprehensive primary care consultation. Routine check-up of blood pressure was the basis for the inclusion in an opportunistic screening for hyperchol-esterolaemia. Additionally, advice on smoking cessation was given. The doctor was the initiator, and could control the rate of inclusion. The nurses administered and performed the individual follow-ups. A telephone survey was used to investigate awareness and treatment of cardiovascular risk in the population. The value of local guidelines and responsi-bilities of the nurse on quality of care was studied in two populations of diabetics defined by their primary health care center (PHCC) listing. Finally, a randomized study of follow-up 15 months of post acute myocardial infarction (AMI) was used to compare quality of care in primary and in hospital clinic care. Opportunistic screening integrated in day-to-day patient care during three years with inclusion controlled by the physi-cian included one third of the population aged 40 - 59 years. There was increased awareness of individual risks factors among those aware of but not included in the project, indicating a population impact of the opportunistic screening. The net result of smoking cessation at the two year follow-up was negative. Smokers frequently make long-lasting quitting attempts. There was a higher quality of care of non-insulin-dependent diabetes mellitus (NIDDM) in a PHCC having a structured management with nurses using local guidelines and check-lists. A randomised one-year follow-up in primary care and at the department of internal medicine post AMI did not show any statistically significant differences in the proportion of readmitted patients, coronary by pass surgery, or secondary preventive medication. Opportunistic screening is most feasible in ages 40-59 years. If integrated with regular case-finding and treatment for hypertension, few extra resources are needed for implementation. Smoking cessation must be recognized as a long-lasting process with patients leaving and entering the ?risk-zone?. Finding quick-relapsing former smokers among current non-smokers may be of importance when planning smoking cessation activities. Screening activities may rise the awareness of cardiovascular risk factors in the population. The diabetes educated practice nurse is a valuable contribution to the PHC organization, provided that guide-lines are implemented to guide day-to-day work with these patients. About 40 per cent of patients younger than 75 years discharged after an AMI should require the specialized resources of hospital. Most re-maining patients can use a low resource follow-up in general practice as safely as at the specialized out-patient clinic.

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