46d24d2e7d4d3bd89273441eaacd1e1a pmc_31694294.pdf 60774151e8eab059585996c7e496087d3d2fcc74 pmc_31694294.pdf 86bda1ef7bd52dfb34342faaf3b07045b6a3a5ebce52f632f923b88489a64673 pmc_31694294.pdf Title: Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors Subject: Current improvement strategies for the control of cardiovascular risk factors (CRFs) in Europe are based on quality management policies. With the aim of understanding the effect of interventions delivered by primary healthcare systems, we evaluated the impact of clinical governance on cardiovascular health after ten years of implementation in Catalonia. A cohort study that included 1878 patients was conducted in 19 primary care centres (PCCs). Audits that comprised 13 cardiovascular health indicators were performed and general practitioners received periodic (annual, biannual or monthly) feedback about their clinical practice. We evaluated improvement in screening, diagnosis and control of the main CRFs and the effects of the feedback on cardiovascular risk (CR), incidence of cardiovascular disease (CVD) and mortality, comparing baseline data with data at the end of the study (after a 10-year follow-up). The impact of the intervention was assessed globally and with respect to feedback frequency. General improvement was observed in screening, percentage of diagnoses and control of CRFs. At the end of the study, few clinically significant differences in CRFs were observed between groups. However, the reduction in CR was greater in the group receiving high frequency feedback, specifically in relation to smoking and control of diabetes and cholesterol (Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL)). A protective effect of having a cardiovascular event (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.44–0.94) or death (HR = 0.55, 95% CI = 0.35–0.88) was observed in patients from centres where general practitioners received high frequency feedback. Additionally, these PCCs presented improved cardiovascular health indicators and lower incidence and mortality by CVD, illustrating the impact of this intervention. Keywords: cardiovascular diseases; primary health care; clinical audit; feedback; clinical governance; incidence; mortality Author: Carina Aguilar Martín, Alessandra Queiroga Gonçalves, Carlos López-Pablo, José Fernández-Sáez, Emma Forcadell Drago, Zojaina Hernández Rojas, Josep Maria Pepió Vilaubí, Dolores Rodríguez Cumplido, Josep Lluis Piñol, Jordi Bladé-Creixenti and Maria Rosa Dalmau Llorca Creator: LaTeX with hyperref package Producer: pdfTeX-1.40.18 CreationDate: Tue Nov 5 12:32:30 2019 CET ModDate: Tue Nov 5 12:32:30 2019 CET Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 11 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 338294 bytes Optimized: no PDF version: 1.5 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- TYEIXS+URWPalladioL-Ital Type 1 Custom yes yes no 70 0 HKIZFP+URWPalladioL-Bold Type 1 Custom yes yes no 71 0 JYPLJJ+VnURWPalladioL-Bold Type 1 Custom yes yes no 72 0 QTLELQ+Pxbsy Type 1 Builtin yes yes no 73 0 HALZTA+URWPalladioL-Roma Type 1 Custom yes yes no 74 0 XEFGQJ+VnURWPalladioL Type 1 Custom yes yes no 75 0 FATHTC+Rpxr Type 1 Builtin yes yes no 76 0 XJETPQ+Pxsy Type 1 Builtin yes yes no 77 0 IRWHZX+TimesNewRomanPSMT Type 1C WinAnsi yes yes no 82 0 LWQXII+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 83 0 MCBCCI+SourceSansRoman-Regular Type 1C Custom yes yes no 102 0 MCBCCM+SourceSansRoman.613wght Type 1C Custom yes yes no 103 0 MCBCCO+SourceSansRoman-Bold Type 1C Custom yes yes no 104 0 FAECIJ+URWPalladioL-BoldItal Type 1 Custom yes yes no 188 0 VUPETJ+Rpxb Type 1 Builtin yes yes no 189 0 VSHNAE+Rpcxr Type 1 Builtin yes yes no 304 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2020-08-10 12:21:56 CEST RepresentationInformation: pmc_31694294.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2020-03-02 03:51:24 CET Size: 338294 Format: PDF Version: 1.5 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 0 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: ViewerPreferences: HideToolbar: false HideMenubar: false HideWindowUI: false FitWindow: true CenterWindow: false DisplayDocTitle: false NonFullScreenPageMode: UseNone Direction: L2R ViewArea: CropBox ViewClip: CropBox PrintArea: CropBox PageClip: CropBox PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: ぉのぴひはつふっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸲ Item: Title: きちぴづひどちぬぜ〴ぜ〰ちのつぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮ㄩ‾㸊⡜㌷㙜㌷㝜〰こぴふつべぜ〴ぜ〰いづびどでのぜ〴ぜ〰ちのつぜ〴ぜ〰ぐちひぴどっどばちのぴびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㈩‾㸊⡜㌷㙜㌷㝜〰こちねばぬづぜ〴ぜ〰こどぺづぜ〴ぜ〰ちのつぜ〴ぜ〰ぐちぴどづのぴぜ〴ぜ〰こづぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰いちぴちぜ〴ぜ〰ぃはぬぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Children: Item: Title: こぴふつべぜ〴ぜ〰いづびどでのぜ〴ぜ〰ちのつぜ〴ぜ〰ぐちひぴどっどばちのぴびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㈩‾㸊⡜㌷㙜㌷㝜〰こちねばぬづぜ〴ぜ〰こどぺづぜ〴ぜ〰ちのつぜ〴ぜ〰ぐちぴどづのぴぜ〴ぜ〰こづぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰いちぴちぜ〴ぜ〰ぃはぬぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: こちねばぬづぜ〴ぜ〰こどぺづぜ〴ぜ〰ちのつぜ〴ぜ〰ぐちぴどづのぴぜ〴ぜ〰こづぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰いちぴちぜ〴ぜ〰ぃはぬぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: いちぴちぜ〴ぜ〰ぃはぬぬづっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: ざちひどちぢぬづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: ぅぴとどっびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: げづびふぬぴびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Item: Title: いどびっふびびどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸵ Item: Title: ぃはのっぬふびどはのびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸵ Item: Title: げづてづひづのっづび Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: VSHNAE+Rpcxr FontSubset: true FirstChar: 169 LastChar: 169 FontDescriptor: FontName: VSHNAE+Rpcxr Flags: Symbolic FontBBox: -212, -286, 1344, 973 FontFile: true Font: BaseFont: TYEIXS+URWPalladioL-Ital FontSubset: true FirstChar: 46 LastChar: 122 FontDescriptor: FontName: TYEIXS+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: HKIZFP+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 241 FontDescriptor: FontName: HKIZFP+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: JYPLJJ+VnURWPalladioL-Bold FontSubset: true FirstChar: 161 LastChar: 226 FontDescriptor: FontName: JYPLJJ+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: QTLELQ+Pxbsy FontSubset: true FirstChar: 121 LastChar: 121 FontDescriptor: FontName: QTLELQ+Pxbsy Flags: Symbolic FontBBox: 5, -978, 1382, 913 FontFile: true Font: BaseFont: HALZTA+URWPalladioL-Roma FontSubset: true FirstChar: 1 LastChar: 241 FontDescriptor: FontName: HALZTA+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: XEFGQJ+VnURWPalladioL FontSubset: true FirstChar: 160 LastChar: 226 FontDescriptor: FontName: XEFGQJ+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: FATHTC+Rpxr FontSubset: true FirstChar: 11 LastChar: 61 FontDescriptor: FontName: FATHTC+Rpxr Flags: Symbolic FontBBox: -40, -283, 904, 728 FontFile: true Font: BaseFont: FAECIJ+URWPalladioL-BoldItal FontSubset: true FirstChar: 78 LastChar: 112 FontDescriptor: FontName: FAECIJ+URWPalladioL-BoldItal Flags: Symbolic FontBBox: -170, -300, 1073, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: XJETPQ+Pxsy FontSubset: true FirstChar: 0 LastChar: 121 FontDescriptor: FontName: XJETPQ+Pxsy Flags: Symbolic FontBBox: -21, -994, 1292, 912 FontFile: true Font: BaseFont: VUPETJ+Rpxb FontSubset: true FirstChar: 61 LastChar: 61 FontDescriptor: FontName: VUPETJ+Rpxb Flags: Symbolic FontBBox: -57, -266, 932, 729 FontFile: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 75, 757, 221, 793 Annotation: Subtype: Link Rect: 474, 757, 519, 793 Annotation: Subtype: Link Rect: 362, 621, 373, 634 Annotation: Subtype: Link Rect: 471, 621, 482, 634 Annotation: Subtype: Link Rect: 175, 607, 186, 621 Annotation: Subtype: Link Rect: 466, 284, 518, 303 Annotation: Subtype: Link Rect: 255, 38, 338, 50 Annotation: Subtype: Link Rect: 410, 38, 519, 50 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 417, 579, 424, 588 ActionDest: 247 Annotation: Subtype: Link Rect: 219, 566, 226, 575 ActionDest: 247 Annotation: Subtype: Link Rect: 148, 552, 155, 561 ActionDest: 247 Annotation: Subtype: Link Rect: 281, 512, 288, 521 ActionDest: 247 Annotation: Subtype: Link Rect: 289, 511, 296, 521 ActionDest: 247 Annotation: Subtype: Link Rect: 358, 498, 365, 507 ActionDest: 247 Annotation: Subtype: Link Rect: 280, 471, 287, 480 ActionDest: 274 Annotation: Subtype: Link Rect: 116, 444, 123, 453 ActionDest: 274 Annotation: Subtype: Link Rect: 311, 417, 318, 426 ActionDest: 274 Annotation: Subtype: Link Rect: 363, 376, 375, 386 ActionDest: 274 Annotation: Subtype: Link Rect: 378, 376, 390, 386 ActionDest: 274 Annotation: Subtype: Link Rect: 460, 363, 472, 372 ActionDest: 274 Annotation: Subtype: Link Rect: 472, 363, 484, 372 ActionDest: 274 Annotation: Subtype: Link Rect: 115, 309, 127, 318 ActionDest: 274 Annotation: Subtype: Link Rect: 121, 282, 133, 291 ActionDest: 274 Annotation: Subtype: Link Rect: 136, 282, 148, 291 ActionDest: 274 Annotation: Subtype: Link Rect: 452, 268, 464, 277 ActionDest: 274 Annotation: Subtype: Link Rect: 465, 268, 477, 277 ActionDest: 274 Annotation: Subtype: Link Rect: 286, 241, 298, 250 ActionDest: 274 Annotation: Subtype: Link Rect: 301, 241, 313, 250 ActionDest: 301 Annotation: Subtype: Link Rect: 174, 201, 186, 210 ActionDest: 274 Annotation: Subtype: Link Rect: 466, 187, 478, 196 ActionDest: 274 Annotation: Subtype: Link Rect: 104, 174, 115, 183 ActionDest: 301 Annotation: Subtype: Link Rect: 294, 147, 306, 156 ActionDest: 301 Annotation: Subtype: Link Rect: 402, 147, 414, 156 ActionDest: 301 Annotation: Subtype: Link Rect: 115, 93, 127, 102 ActionDest: 301 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 322, 702, 329, 711 ActionDest: 247 Annotation: Subtype: Link Rect: 329, 702, 336, 711 ActionDest: 247 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 339, 382, 346, 394 ActionDest: 178 Annotation: Subtype: Link Rect: 410, 90, 417, 102 ActionDest: 185 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 122, 271, 129, 283 ActionDest: 196 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 108, 344, 115, 356 ActionDest: 204 Annotation: Subtype: Link Rect: 135, 344, 142, 356 ActionDest: 204 Annotation: Subtype: Link Rect: 172, 263, 179, 274 ActionDest: 204 Annotation: Subtype: Link Rect: 169, 196, 176, 207 ActionDest: 204 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 144, 190, 156, 199 ActionDest: 274 Annotation: Subtype: Link Rect: 254, 136, 266, 145 ActionDest: 301 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 126, 688, 138, 698 ActionDest: 301 Annotation: Subtype: Link Rect: 188, 688, 200, 698 ActionDest: 274 Annotation: Subtype: Link Rect: 253, 688, 265, 698 ActionDest: 301 Annotation: Subtype: Link Rect: 103, 661, 115, 671 ActionDest: 301 Annotation: Subtype: Link Rect: 115, 661, 127, 671 ActionDest: 301 Annotation: Subtype: Link Rect: 427, 553, 439, 562 ActionDest: 274 Annotation: Subtype: Link Rect: 439, 553, 451, 562 ActionDest: 274 Annotation: Subtype: Link Rect: 432, 526, 444, 535 ActionDest: 274 Annotation: Subtype: Link Rect: 445, 526, 457, 535 ActionDest: 274 Annotation: Subtype: Link Rect: 457, 526, 469, 535 ActionDest: 301 Annotation: Subtype: Link Rect: 198, 418, 210, 427 ActionDest: 301 Annotation: Subtype: Link Rect: 503, 391, 515, 400 ActionDest: 301 Annotation: Subtype: Link Rect: 354, 324, 366, 333 ActionDest: 301 Annotation: Subtype: Link Rect: 464, 175, 476, 184 ActionDest: 301 Annotation: Subtype: Link Rect: 503, 161, 515, 171 ActionDest: 301 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 369, 460, 451, 471 Annotation: Subtype: Link Rect: 499, 440, 519, 450 Annotation: Subtype: Link Rect: 75, 429, 233, 440 Annotation: Subtype: Link Rect: 172, 320, 210, 330 Annotation: Subtype: Link Rect: 216, 320, 252, 330 Annotation: Subtype: Link Rect: 395, 293, 433, 304 Annotation: Subtype: Link Rect: 439, 293, 475, 304 Annotation: Subtype: Link Rect: 286, 255, 323, 265 Annotation: Subtype: Link Rect: 329, 255, 365, 265 Annotation: Subtype: Link Rect: 371, 126, 409, 136 Annotation: Subtype: Link Rect: 150, 74, 187, 84 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 100, 702, 137, 712 Annotation: Subtype: Link Rect: 365, 675, 402, 686 Annotation: Subtype: Link Rect: 358, 650, 395, 661 Annotation: Subtype: Link Rect: 460, 637, 497, 648 Annotation: Subtype: Link Rect: 176, 612, 214, 622 Annotation: Subtype: Link Rect: 218, 586, 255, 596 Annotation: Subtype: Link Rect: 278, 559, 315, 570 Annotation: Subtype: Link Rect: 159, 521, 196, 531 Annotation: Subtype: Link Rect: 202, 521, 238, 531 Annotation: Subtype: Link Rect: 247, 495, 285, 506 Annotation: Subtype: Link Rect: 291, 495, 327, 506 Annotation: Subtype: Link Rect: 100, 470, 137, 480 Annotation: Subtype: Link Rect: 143, 470, 179, 480 Annotation: Subtype: Link Rect: 196, 444, 233, 454 Annotation: Subtype: Link Rect: 239, 444, 276, 454 Annotation: Subtype: Link Rect: 307, 366, 344, 376 Annotation: Subtype: Link Rect: 288, 327, 325, 338 Annotation: Subtype: Link Rect: 217, 289, 255, 299 Annotation: Subtype: Link Rect: 371, 224, 409, 234 Annotation: Subtype: Link Rect: 475, 198, 513, 209 Annotation: Subtype: Link Rect: 418, 133, 455, 144 Annotation: Subtype: Link Rect: 307, 82, 344, 92 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 452, 727, 489, 738 Annotation: Subtype: Link Rect: 262, 650, 300, 661 Annotation: Subtype: Link Rect: 150, 612, 187, 622 Annotation: Subtype: Link Rect: 193, 612, 229, 622 Annotation: Subtype: Link Rect: 473, 598, 509, 609 Annotation: Subtype: Link Rect: 223, 573, 261, 583 Annotation: Subtype: Link Rect: 267, 573, 303, 583 Annotation: Subtype: Link Rect: 437, 534, 474, 544 Annotation: Subtype: Link Rect: 481, 534, 516, 544 Annotation: Subtype: Link Rect: 258, 456, 296, 467 Annotation: Subtype: Link Rect: 435, 430, 472, 441 Annotation: Subtype: Link Rect: 100, 392, 137, 402 Annotation: Subtype: Link Rect: 76, 350, 166, 381 Annotation: Subtype: Link Rect: 234, 345, 407, 355 Checksum: 3bf3b2fc Type: CRC32 Checksum: 46d24d2e7d4d3bd89273441eaacd1e1a Type: MD5 Checksum: 60774151e8eab059585996c7e496087d3d2fcc74 Type: SHA-1