Family Practice Vol. 20, No. 4, 420-424
© Oxford University Press 2003
Clinical Research |
Prevention and follow-up of cardiovascular disease among patients without a personal GP
Department of General Practice, Free University of Brussels (VUB), Laarbeeklaan 103, B-1090 Brussels, Belgium.
Correspondence to Dirk Devroey; E-mail: dirk.devroey{at}vub.ac.be
Devroey D, Coigniez P, Vandevoorde J, Kartounian J, Betz W. Prevention and follow-up of cardiovascular disease among patients without a personal GP. Family Practice 2003; 20: 420–424.
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Abstract |
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Objective. This paper describes the characteristics of Belgian people who declare that they have a personal GP (PGP) compared with those who do not. Furthermore, patterns of cardiovascular prevention and care are described for these two groups.
Methods. The data are derived from the 1997 Belgian Health Interview Survey (HIS) in which a representative sample (n = 10 221) of the Belgian population was questioned. The HIS data about physical activity, food, blood pressure, cholesterol, cardiovascular diseases, diabetes and stroke are analysed.
Results. After standardization for age and gender, 7.0% of the subjects declared that they did not have a PGP. The mean age of patients without a PGP (33.2 ± 20.4 years) is significantly lower than for those with a PGP (40.4 ± 22.7 years) (P < 0.001). More smokers (38.5% compared with 28.5%) were reported among the subjects without a PGP (P < 0.001). For 14.8% of the subjects without a PGP, their blood pressure had never been measured, and for 51.1% their cholesterol had never been measured (6.7% and 35.7%, respectively in subjects with a PGP). Among the subjects without a PGP, 3.8% had high blood pressure and 1.5% had a coronary heart disease. Among the hypertensive patients without a PGP, 43.6% are not treated by any physician.
Conclusion. Subjects without a PGP were less likely to have a healthy way of life. Having a PGP seemed to have a beneficial influence on the screening for and the follow-up of cardiovascular risk factors. However, it has never been confirmed that providing people who do not have a PGP with one would result in health improvements. In particular, cardiac patients without a PGP sought their medical treatment directly from specialists.
Keywords. Belgium, cardiovascular diseases, general practice, health survey, prevention.
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Introduction |
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For several decades, the prevention of cardiovascular diseases has involved more than follow-up of blood pressure alone. Many cardiovascular risk factors have been identified.1 The modifiable risk factors for cardiovascular disease can be divided into behavioural factors (smoking, obesity, physical activity) and non-behavioural factors (high blood pressure, diabetes, cholesterol). The Euroaspire survey demonstrated a high prevalence of such modifiable risk factors in coronary heart disease (CHD) patients.2 There is also absolute evidence about non-modifiable cardiovascular risk factors such as age, gender and family history.
GPs have a unique position in primary health care and cardiovascular prevention. Because of the high yearly encounter rate of patients with their GP, they are well placed to offer screening and a suitable cardiovascular follow-up. Adults who receive regular care from a GP are more likely to receive preventive services.3 However, not every subject seems to have a personal GP (PGP). According to previously published data from the Health Interview Survey (HIS), 93% of Belgians have a PGP.4 To understand these figures, one should know that Belgian patients are not registered with a GP. Patients are free to change their GP at any time and can consult a specialist without previous referral by a GP.
Little information is available on patients without a PGP because these patients are difficult to include in registrations in general practice. Using the data from the HIS, this paper describes the characteristics of Belgian people who declare that they have a PGP compared with those who do not. Furthermore, patterns of cardiovascular prevention and care are described for these two groups.
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Methods |
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Data from the 1997 Belgian HIS were analysed. In total, 10 221 subjects were questioned by 212 interviewers, recruited by the National Institute for Statistics. The representative sample of the Belgian population was constructed on the basis of the National Register using the household as sample unit, and was stratified per region, province and linguistic community.
The aim of the HIS was to determine the population’s health, its lifestyle and use of the health services. The investigated fields were: general health perception, perceived morbidity, functional status, chronic conditions, use of health services and consumption of care in general, as well as lifestyle and health behaviour, and socio-economic characteristics. The complete methods are described in the original report.4 All members of a household were questioned. Subjects who were not willing to participate were replaced by subjects of the same age, gender and social class.
For this subanalysis, questions about age, gender, schooling, smoking habits, physical activity, food, blood pressure, cholesterol, cardiovascular diseases, diabetes, stroke and recent hospitalization or consultations with a GP or a specialist were analysed. The reasons for encounter were also recorded. Because there are often multiple reasons for encounter, it was very difficult to interpret them, and therefore they were not analysed further in this study.
SPSS-PC 10® (SPSS Inc., Chicago, IL) was used for analysis and statistical processing. Significant differences between continuous variables were detected with the independent samples t-test. Differences between groups were detected by means of chi-square tests. Fisher’s exact two-tailed P-values were used if expected cell values were 
5.
When trying to compare indicators among patients with and without a PGP, differences in age structure and gender ratio between both groups could affect the comparison. For example, when the group of patients with a PGP is older, it is quite difficult to compare indicators such as physical activity, blood pressure, cardiovascular disease, etc. For that reason, all results were standardized for age and gender. The direct standardization method was used choosing the 1997 Belgian population as the standard population. The number of people in the standard population for each age/gender group was multiplied by the crude rates for that age/gender group to calculate an ‘expected’ number of cases for each age/gender group. The expected numbers of all age groups were added together to reach a total number of ‘expected’ people in the total population. This total was then divided by the total standard population. The standardization made it possible to compare groups which have a different age structure or gender ratio. Without standardization, the observed differences between patients with and without a PGP could be related to the fact that the patients in one group were older or belonged to the male gender. Standardized numbers have no absolute meaning but are only useful for comparison of groups.
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Results |
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General information on patients without PGP
From the 10 221 completed questionnaires, 10 079 were suitable for analysis. In total, 1040 subjects declared that they did not have a PGP. After standardization for age and gender, 7.0% of the subjects did not have a PGP (6.0% of women and 8.1% of men) (P < 0.005). The proportions of patients without a PGP per age group are displayed for both genders in Table 1
. In the age groups 25–34 years and 45–54 years, the proportion of subjects without a PGP is higher among men than women. The proportion of patients without a PGP varies between 6.8 and 10.2% for the subjects younger than 45 years and between 2.5 and 6.4% for the subjects aged over 45 years. The mean age of patients without a PGP (33.2 ± 20.4 years) is significantly lower than for those with a PGP (40.4 ± 22.7 years) (P < 0.001). Among the subjects without a PGP, 58.7% were aged <35 years. The proportion of subjects without a PGP is higher among the subjects with at least a high school degree (9.3%) compared with those without a high school degree (5.8%) (P < 0.001).
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Concerns about health—health behaviour
More smokers (38.5%) were found among the subjects without a PGP than among those with a PGP (28.5%) (P < 0.001). Among the subjects without a PGP, only 10.9% were concerned about physical activity compared with 27.7% of those with a PGP (P < 0.001). Subjects without a PGP were less concerned about selecting healthy food (23.6%) compared with those with a PGP (62.2%) (P < 0.001). Subjects without a PGP were also less concerned about the calories in their food (15.7%) than those with a PGP (41.8%) (P < 0.001). Five percent of all subjects without a PGP eat eggs daily compared with 2.8% of those with a PGP (P < 0.001), and 17.5% of the subjects without a PGP do not eat vegetables daily compared with 12.1% of those with a PGP (P < 0.001).
For 14.8% of the subjects without a PGP, their blood pressure had never been measured, compared with 6.7% of those with a PGP (P < 0.001). For 51.1%, their cholesterol level was never measured, compared with 35.7% of those with a PGP (P < 0.001). For 12.9% of the subjects without a PGP, blood pressure was last measured 
2 years ago, compared with 4.2% of those with a PGP (P < 0.001). For 13.0%, the last cholesterol measurement was 2 years ago, compared with 9.5% of those with a PGP (P < 0.001). In all age groups separately, the proportion of subjects whose blood pressure was never measured was higher among the subjects without a PGP than those with a PGP (Table 2). The difference between both groups is most important among the elderly. The blood pressure of 15.9% of the patients aged 55 years without a PGP was never measured.
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In the age group between 25 and 34 years and from the age of 55 years, the proportion of subjects whose cholesterol was never measured was higher among the subjects without a PGP than among those with a PGP (Table 3
). The cholesterol level of 33.4% of the patients aged 55 or more without a PGP was never measured.
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The proportion of subjects having had contact with a GP during the last 2 months was significantly higher among the patients with a PGP (47.0%) than among those without (12.6%) (P < 0.001). The latter consulted any GP, who was not considered to be a PGP by the patient. Although the difference is small, it is not surprising that the proportion of subjects having consulted a specialist within the last year is higher among those without a PGP (25.7%) compared with those with a PGP (22.0%) (P = 0.006). No significant differences were found concerning hospitalizations or contacts with alternative healers within both groups.
Follow-up of patients with high blood pressure or cardiac events
Among the subjects without a PGP, 3.8% (n = 39) stated that they had high blood pressure compared with 11.7% of those with a PGP (P < 0.001), and 1.5% (n = 15) stated that they had a CHD compared with 4.3% of those with a PGP (P < 0.001). Only 0.6% (n = 6) declared that they had diabetes compared with 3.2% of those with a PGP (P < 0.001), and 0.5% (n = 5) had had a stroke compared with 0.8% of those with a PGP (P = 0.004).
The follow-up of hypertensive patients with a PGP is performed mostly by the GP only (66.7%) and in 17.8% by the GP and a specialist together. Among the hypertensive patients without a PGP, 43.6% were treated by no physician at all and 38.5% were treated by a specialist only (Table 4).
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The follow-up of cardiac patients with a PGP is performed mostly by the specialist together with the PGP (52.5%). The follow-up of cardiac patients without a PGP was done in 53.3% by a specialist only, in 20.0% by a GP only and in 20.0% by both. Seven percent of the cardiac patients were not treated by a physician. Because of the small number of patients with diabetes and stroke, their treatment was not analysed.
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Discussion |
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The study is limited because we analysed data reported by the patients themselves. From other health interview surveys, we learned that the prevalence of self-reported cardiovascular risk factors and diseases is often under-reported for hypertension, hypercholesterolaemia, obesity and smoking.5
Although Belgians are not obliged to register with a GP, only 7.0% of the subjects of this representative sample of the Belgian population did not have a PGP. More men than women did not have a PGP. The elderly had a PGP more often than the younger subjects. Subjects with a higher education were less likely to have a PGP.
Subjects without a PGP tended to consult a specialist rather than a GP, but the difference was rather small. In total, they consumed less medical care than patients with a PGP.
Subjects without a PGP seemed to have a less healthy way of life. They smoke more, and were less concerned about physical activity, about the kind of food they ate in general and about calories in their food in particular. The daily consumption of eggs was higher and the daily consumption of vegetables was lower. All of these factors have proved to be important protective factors in maintaining good health, and it has been proved that health education and promotion in general practice had a beneficial effect on the patient’s diet and daily physical activity.6
GPs are in a unique position to initiate preventive interventions in this risk group. A stable relationship with a PGP could contribute to a better prevention of cardiovascular diseases by regular cholesterol measurements and acceptable dietary advice. It has been proven that dietary advice can result in a sustained reduction in cholesterol levels, but requires the stimulus of a prior cholesterol measurement.7 On the other hand, there have been several relevant systematic reviews which minimize the effectiveness of behavioural interventions in reducing CHD risk.8,9
In our study, the proportions of patients whose blood pressure or cholesterol level had never been measured were higher among those without a PGP. This was confirmed in all age groups for blood pressure and in the group aged 55 or more for cholesterol. Especially in this age group, the prevention of cardiovascular disease is becoming increasingly important. However, also among the young, GPs have proven their ability to detect and treat hypertension.10 Our figures concerning screening for hypertension and hypercholesterolaemia are comparable with those from an Australian study. They found 10% of patients not screened for hypertension and 49% not screened for hypercholesterolaemia within the past 5 years.11
Another study proved that health checks in general practice help patients to modify their diet and cholesterol level.12 More intensive effort in lifestyle modification and health promotion, with more active involvement of GPs, could produce significant health benefit.13
Only a small proportion of subjects without a PGP reported high blood pressure or a CHD, or they may not have been aware of their disease. The follow-up of hypertensive patients by a PGP is mostly done by the GP only. It is remarkable that >40% of the patients without PGP, who state that they have high blood pressure, are not treated by a physician. Some questions arise about the treatment and the follow-up of these patients. The follow-up of subjects without a PGP and suffering from a CHD was done mostly by specialists. The lack of a PGP can hamper the continuity and the cohesion of treatment for these patients. Having a PGP might contribute to improvements in their lifestyle and better treatment and follow-up of cardiovascular diseases. However, it is likely that the type of patient that chooses not to have a PGP would be one that would choose not to benefit from the services available from that GP. Therefore, providing these people with a PGP might make no difference to their health. Further studies would be needed to assess whether providing these patients with a PGP would result in health improvements.
In order to limit medical shopping and to provide better health care, the federal government has encouraged registration with a GP since 1999 by increasing the health insurance reimbursement for patients who register with a GP. This system is called the General Medical File (GMF). The role of the GP has probably evolved since that time.
During 2001, a new HIS was performed. Comparison of our data with the 2001 data will provide interesting information about the effect of the GMF on the use of health services in general and GPs in particular. Unfortunately, the 2001 data will only be available for analysis later this year.
In conclusion, only 7% of Belgians have no PGP. Having no PGP seemed to be correlated with a less healthy way of life. Patients without a PGP smoke more and are less concerned about healthy food. Having a PGP seems to be correlated with concern for better health. Patients without a PGP solicit more specialists for their medical care. In particular, cardiac and hypertensive patients without a PGP seek their medical treatment among specialists. The high proportion of hypertensive patients who are treated by no physician at all is at the least surprising. The conclusions of this study should not be restricted to cardiovascular risk factors, but can probably also be extended to the management of other risk factors.
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Acknowledgments |
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We thank Herman Van Oyen, Johan Van Der Heyden and Stefaan Demarest for the conception and the design of the HIS, and Karolien Vantomme, Marianne van Winden and Neeltje Blommaert for their comments on this manuscript.
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