Ferritin Cutoffs and Diagnosis of Iron Deficiency in Primary Care.

Importance: Ferritin is often measured by general practitioners, but the association of different cutoffs with the rates of iron deficiency diagnoses, particularly nonanemic iron deficiency, is unknown. Objective: To investigate the association of the ferritin cutoff choice with the incidence of nonanemic and anemic iron deficiency diagnoses in primary care. Design, Setting, and Participants: In this retrospective cohort study, patients 18 years or older with at least 1 consultation with a general practitioner participating in the Family Medicine Research Using Electronic Medical Records (FIRE) project, an electronic medical records database of Swiss primary care, from January 1, 2021, to November 30, 2023, were evaluated. Exposures: Sex, age, clinical patient characteristics, and professional general practitioner characteristics. Main Outcomes and Measures: Incidence of iron deficiency diagnoses (nonanemic and anemic) at ferritin cutoffs of 15, 30, and 45 ng/mL and ferritin testing itself. Time-dependent Cox proportional hazards regression was used to examine associations of patient and general practitioner characteristics with ferritin testing as adjusted hazard ratios (AHRs). Results: The study included 255 351 patients (median [IQR] age, 52 [36-66] years; 52.1% female). Per 1000 patient-years and at ferritin cutoffs of 15, 30, and 45 ng/mL, iron deficiency diagnoses had incidences of 10.9 (95% CI, 10.6-11.2), 29.9 (95% CI, 29.4-30.4), and 48.3 (95% CI, 47.7-48.9) cases, respectively; nonanemic iron deficiency diagnoses had incidences of 4.1 (95% CI, 3.9-4.2), 14.6 (95% CI, 14.3-15.0), and 25.8 (95% CI, 25.3-26.2) cases, respectively; and anemic iron deficiency diagnoses had incidences of 3.5 (95% CI, 3.3-3.7), 6.0 (95% CI, 5.8-6.2), and 7.5 (95% CI, 7.3-7.7) cases, respectively. Ferritin testing showed notable associations with fatigue (AHR, 2.03; 95% CI, 1.95-2.12), anemia (AHR, 1.75; 95% CI, 1.70-1.79), and iron therapy (AHR, 1.50; 95% CI, 1.46-1.54). Ferritin testing was associated with female sex in all age groups, including postmenopausal. Of the patients who received ferritin testing, 72.1% received concomitant hemoglobin testing, and 49.6% received concomitant C-reactive protein testing. Conclusions and Relevance: In this retrospective cohort study of primary care patients, ferritin cutoffs of 30 and 45 ng/mL were associated with a substantially higher incidence of iron deficiency compared with 15 ng/mL. These results provide a basis for health system-level evaluation and benchmarking of ferritin testing in high-resource settings and call for a harmonization of diagnostic criteria for iron deficiency in primary care.

Developing and testing a framework for coding general practitioners' free-text diagnoses in electronic medical records - a reliability study for generating training data in natural language processing.

BACKGROUND: Diagnoses entered by general practitioners into electronic medical records have great potential for research and practice, but unfortunately, diagnoses are often in uncoded format, making them of little use. Natural language processing (NLP) could assist in coding free-text diagnoses, but NLP models require local training data to unlock their potential. The aim of this study was to develop a framework of research-relevant diagnostic codes, to test the framework using free-text diagnoses from a Swiss primary care database and to generate training data for NLP modelling. METHODS: The framework of diagnostic codes was developed based on input from local stakeholders and consideration of epidemiological data. After pre-testing, the framework contained 105 diagnostic codes, which were then applied by two raters who independently coded randomly drawn lines of free text (LoFT) from diagnosis lists extracted from the electronic medical records of 3000 patients of 27 general practitioners. Coding frequency and mean occurrence rates (n and %) and inter-rater reliability (IRR) of coding were calculated using Cohen's kappa (Κ). RESULTS: The sample consisted of 26,980 LoFT and in 56.3% no code could be assigned because it was not a specific diagnosis. The most common diagnostic codes were, 'dorsopathies' (3.9%, a code covering all types of back problems, including non-specific lower back pain, scoliosis, and others) and 'other diseases of the circulatory system' (3.1%). Raters were in almost perfect agreement (Κ ≥ 0.81) for 69 of the 105 diagnostic codes, and 28 codes showed a substantial agreement (K between 0.61 and 0.80). Both high coding frequency and almost perfect agreement were found in 37 codes, including codes that are particularly difficult to identify from components of the electronic medical record, such as musculoskeletal conditions, cancer or tobacco use. CONCLUSION: The coding framework was characterised by a subset of very frequent and highly reliable diagnostic codes, which will be the most valuable targets for training NLP models for automated disease classification based on free-text diagnoses from Swiss general practice.

Changes in the attractiveness of medical careers and career determinants during the bachelor's program at Zurich medical schools.

BACKGROUND: Monitoring the career intentions of medical students during their undergraduate studies could help to address the shortage of physicians, particularly in general practice. This study aimed to investigate changes in medical students' career openness, attractiveness and determinants of medical career choice during their bachelor's studies. METHODS: The design was cross-sectional, recruiting all medical students who started a bachelor's program in one of the four different educational tracks in Zurich, Switzerland, in the fall of 2019 (first survey) and completed it in the summer of 2022 (second survey). Students' perceptions of the attractiveness and determinants of different medical career options were assessed using a structured online questionnaire. Absolute changes between the two-time points were reported in percentage points overall and by educational track. Regression analysis was used to examine the association of student characteristics and determinants of career options with the attractiveness of each option. RESULTS: We surveyed 354 medical students at the beginning and 433 at the end of the bachelor's program (participation rate: 71.1% and 86.9%, respectively). Overall, the proportion of students open to all proposed medical career options decreased (from 52.8% to 43.8%, p = 0.004). The attractiveness of outpatient gynecology or pediatrics increased (from 27.4% to 43.4%, p < 0.001), whereas the attractiveness of both general and specialized inpatient care decreased (from 47.8% to 40.3%, p = 0.05 and from 71.1% to 61.1%, p = 0.006 respectively). There was an increase in the proportion of students who perceived part-time work, autonomy and relationships with patients as important career determinants (from 47.3% to 64.7%, p < 0.001; from 63.3% to 77.8%, p < 0.001; from 80.8% to 89.3%, p = 0.002 respectively), while the importance of reputation and career opportunities decreased (from 42.6% to 26.2%, p < 0.001; from 79.2% to 63.6%, p < 0.001 respectively). The importance of part-time work and relationships with patients were positively associated with the attractiveness of general practice. CONCLUSIONS: During the bachelor's program, the attractiveness of a career in general practice tended to decrease, but the importance of part-time work, autonomy and relationships with patients as career determinants increased. Helping students understand how these determinants relate to general practice may increase their interest in the profession. TRIAL REGISTRATION: Not applicable.

Elevated TSH Levels: A Database Study of General Practitioners' Course of Action.

OBJECTIVE: To investigate general practitioners' course of action after detection of elevated thyroid stimulating hormone (TSH) levels regarding repeat testing, direct levothyroxine replacement, or neither. METHODS: We conducted a retrospective study of adults without prior evidence of thyroid disease and with a first detection of elevated TSH levels from January 1, 2015, to December 31, 2020, using data from electronic medical records of a Swiss primary care database. We determined the occurrence of either repeat TSH testing or direct levothyroxine initiation in primary care during 12-month follow-up and determined associations with demographic and clinical factors. RESULTS: Of the 1 591 patients included (median age 65 years, 64.4% female, median TSH 5.7 mIU/L), 34.3% received repeat TSH testing and 12.4% received direct levothyroxine replacement in primary care during follow-up. Repeat TSH testing showed the strongest association with overt hypothyroidism and was more common among patients with high primary care utilization and among patients aged 40-64 years compared to patients aged <40 years. Direct levothyroxine initiation was more likely for TSH levels >7 mIU/L, overt hypothyroidism, female patients, and nonurban practices. CONCLUSIONS: While the degree of thyroid dysfunction was the main driver of follow-up, we identified important gaps in the primary care-based monitoring of elevated TSH levels in young patients and in patients with infrequent consultations. We also observed potential overtreatment of women and patients in nonurban areas. Our findings highlight the need for standardization and dissemination of guidelines for the management of elevated TSH levels among general practitioners.

[Vaccination against the Infodemic].

INTRODUCTION: Misinformation about vaccination leads to vaccination hesitancy. During the SARS-CoV-2 pandemic, different patterns were observed in how misinformation spread on social media, which coined the term "infodemic." There are different approaches to counter misinformation in vaccination, some of which can be implemented in medical practice. This article is an introduction and overview of the phenomenon of misinformation in social media. The article also aims to uncover individual mechanisms that make misinformation appear credible and thus the article aims to function as an "inoculation against the infodemic."

Importance of different electronic medical record components for chronic disease identification in a Swiss primary care database: a cross-sectional study.

BACKGROUND: Primary care databases collect electronic medical records with routine data from primary care patients. The identification of chronic diseases in primary care databases often integrates information from various electronic medical record components (EMR-Cs) used by primary care providers. This study aimed to estimate the prevalence of selected chronic conditions using a large Swiss primary care database and to examine the importance of different EMR-Cs for case identification. METHODS: Cross-sectional study with 120,608 patients of 128 general practitioners in the Swiss FIRE ("Family Medicine Research using Electronic Medical Records") primary care database in 2019. Sufficient criteria on three individual EMR-Cs, namely medication, clinical or laboratory parameters and reasons for encounters, were combined by logical disjunction into definitions of 49 chronic conditions; then prevalence estimates and measures of importance of the individual EMR-Cs for case identification were calculated. RESULTS: A total of 185,535 cases (i.e. patients with a specific chronic condition) were identified. Prevalence estimates were 27.5% (95% CI: 27.3-27.8%) for hypertension, 13.5% (13.3-13.7%) for dyslipidaemia and 6.6% (6.4-6.7%) for diabetes mellitus. Of all cases, 87.1% (87.0-87.3%) were identified via medication, 22.1% (21.9-22.3%) via clinical or laboratory parameters and 19.3% (19.1-19.5%) via reasons for encounters. The majority (65.4%) of cases were identifiable solely through medication. Of the two other EMR-Cs, clinical or laboratory parameters was most important for identifying cases of chronic kidney disease, anorexia/bulimia nervosa and obesity whereas reasons for encounters was crucial for identifying many low-prevalence diseases as well as cancer, heart disease and osteoarthritis. CONCLUSIONS: The EMR-C medication was most important for chronic disease identification overall, but identification varied strongly by disease. The analysis of the importance of different EMR-Cs for estimating prevalence revealed strengths and weaknesses of the disease definitions used within the FIRE primary care database. Although prioritising specificity over sensitivity in the EMR-C criteria may have led to underestimation of most prevalences, their sex- and age-specific patterns were consistent with published figures for Swiss general practice.

[Why Switzerland needs evidence-based guidelines for its general practice medicine].

INTRODUCTION: Medical guidelines summarize evidence based knowledge and give helpful recommendations for diagnostics and therapy in daily practice. Most Swiss medical societies therefore adapt international guidelines for the Swiss setting. In primary care this adaption must not only take into account the specific Swiss healthcare system, but also the specific setting of primary care, which is characterized by a low prevalence of most diseases as well as by chronic conditions and multimorbidity. Exactly these multimorbid patients are underrepresented in the studies, which underline the current guidelines of medical societies. The institute of primary care at the university of Zurich, IHAMZ, therefore creates evidence based guidelines according to international established quality criteria for the Swiss primary care setting.

[Implementation of an electronic clinical decision aid to support quality of care for COPD in family medicine]. / Implementierung einer elektronischen Entscheidungshilfe zur Unterstützung der Behandlungsqualität der COPD in der Hausarztmedizin.

BACKGROUND: Electronic clinical decision aids (eCDAs) have the potential to improve the quality of chronic disease management (CDM) and, therefore, patient relevant outcomes. However, eCDAs are only sparsely implemented in primary care for chronic obstructive pulmonary disease (COPD). The aim of this pilot study was to develop and implement of an eCDA for COPD primary care in two Swiss primary care practices. METHOD: Two primary care practices, each with five primary care physicians and their assistants, participated in the study. The eCDA was developed in collaboration with one of the two GP practices (Practice 1) following a development cycle encompassing alpha- and beta-testing stages. Long-term testing for one year was conducted in both practices. The implementation of the eCDA was evaluated according to the RE-AIM framework counting occurrences as follows: Reach: the number of patients included in the CDM using the eCDA. EFFECTIVENESS: the number of treatment processes initiated per patient. Adoption: practice utilization of the diverse functions featured in the eCDA. Implementation and Maintenance: health care professionals' attitudes towards the impact of the eCDA on the quality of care and their willingness to continue using the eCDA after long-term testing. Data were collected by the eCDA itself, which was programmed to track user data, and from practice staff using questionnaires. RESULTS: Reach: After the long-term test, the number of patients recorded in the eCDA was 28 in practice 1, and 12 in practice 2. EFFECTIVENESS: The number of evidence-based treatment processes per patient was 14 (IQR 6 to 22) in Practice 1 and 6 (IQR 5 to 8) in Practice 2. Adoption: The utilization profiles of the eCDA differed greatly between practices. Implementation and Maintenance: After the long-term test, respondents were more critical of the quality of the CDM for patients with COPD, and attitudes consistent with interprofessional care were more prevalent compared to baseline. Respondents were optimistic regarding both the potential of the eCDA to improve the quality of CDM and their motivation to continue using the eCDA after long-term testing. CONCLUSION: This pilot study is a roadmap for future projects aiming to develop and implement eCDAs for the CDM of COPD in primary care. Future larger implementation studies in this domain should place greater emphasis on the measurement of structural practice characteristics as potential determinants of patient-relevant outcomes. The modifiable determinants should then be tested for their effects on patient-relevant outcomes in a randomized controlled design.

[New/direct oral anticoagulants (DOAK)].

INTRODUCTION: Due to their advantageous benefit-risk-profile, direct oral anticoagulants (DOACs) are preferred over vitamin-K-antagonists for stroke prevention in atrial fibrillation as well as therapy and secondary prevention of venous thromboembolism. This guideline provides information on the practical use of DOACs, their advantages and disadvantages and limitations. It is based on recommendations from international guidelines (ESC, EHRA, DGA) and adapts them for the general practitioner setting in Switzerland.

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study.

BACKGROUND: Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013-2019. METHODS: We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs). RESULTS: We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2-3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2). CONCLUSION: This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

Attractiveness of medical disciplines amongst Swiss first-year medical students allocated to different medical education tracks: cross-sectional study.

BACKGROUND: As most countries, Switzerland is experiencing a shortage of physicians especially in general practice and new medical education tracks with respective focusses have been started in response. This study investigated Swiss medical students' career openness and attractiveness of different medical disciplines as well as the concordance of students' career intentions with assigned medical education tracks. METHODS: Cross-sectional study surveying first year medical students assigned to four different Swiss medical education tracks with distinctive additional education focuses (ETH Zurich: medical technology and engineering, University of St. Gallen and University of Lucerne: primary healthcare and University of Zurich: no distinctive focus). RESULTS: We surveyed 354 medical students (response rate across all included medical education tracks 71.1%), 64.8% female, mean age 20 years. Regarding career openness, we found that 52.8% of medical students had neither a strong commitment nor a strong reservation for any of the proposed career options and 17.0% had a strong commitment. Among medical disciplines, medical subspecialties were attractive to the largest part of students (inpatient subspecialties attractive for 71%, outpatient for 58%), attractiveness of general practice was moderate (30%), academic (22%) and industrial sector (17%) careers were least attractive. Proportions of medical students attracted to general practice were similar at medical education tracks with focus on primary healthcare compared to other medical education tracks (32.2% vs. 25.8%, p = 0.391). Conversely, proportions of medical students attracted to academic or industry careers were significantly higher at the ETH Zurich compared to other medical education tracks (37.2%, vs. 13.1%, p < 0.001 and 31.9%, vs. 8.8%, p < 0.001 respectively). CONCLUSION: While most first-year medical students were open to careers in many medical disciplines, attractiveness of disciplines varied strongly. Students attracted to academic or industrial careers accumulated at the medical education track with concordant teaching focus but students attracted to general practice did not accumulate at medical education tracks focused on primary healthcare. For medical education tracks with primary care teaching focus this is both a challenge and an opportunity to specifically counteract the shortage of general practitioners in Switzerland.

Prescription Rates, Polypharmacy and Prescriber Variability in Swiss General Practice-A Cross-Sectional Database Study.

Purpose: The frequency of medication prescribing and polypharmacy has increased in recent years in different settings, including Swiss general practice. We aimed to describe patient age- and sex-specific rates of polypharmacy and of prescriptions of the most frequent medication classes, and to explore practitioner variability in prescribing. Methods: Retrospective cross-sectional study based on anonymized electronic medical records data of 111 811 adult patients presenting to 116 Swiss general practitioners in 2019. We used mixed-effects regression analyses to assess the association of patient age and sex with polypharmacy (≥5 medications) and with the prescription of specific medication classes (second level of the Anatomical Therapeutic Chemical Classification System). Practitioner variability was quantified in terms of the random effects distributions. Results: The prevalence of polypharmacy increased with age from 6.4% among patients aged 18-40 years to 19.7% (41-64 years), 45.3% (65-80 years), and 64.6% (81-92 years), and was higher in women than in men, particularly at younger ages. The most frequently prescribed medication classes were antiinflammatory and antirheumatic products (21.6% of patients), agents acting on the renin-angiotensin system (19.9%), analgesics (18.7%), and drugs for acid related disorders (18.3%). Men were more often prescribed agents targeting the cardiovascular system, whereas most other medications were more often prescribed to women. The highest practitioner variabilities were observed for vitamins, for antiinflammatory and antirheumatic products, and for mineral supplements. Conclusion: Based on practitioner variability, prevalence, and risk potential, antiinflammatory drugs and polypharmacy in older patients appear to be the most pressing issues in current drug prescribing routines.

Testing and Prescribing Vitamin B12 in Swiss General Practice: A Survey among Physicians.

Testing and prescribing vitamin B12 (also known as cobalamin) is increasing in Switzerland but substantial variation among general practitioners (GPs) with respect to testing has been noted. In this study, we aimed at exploring GPs' mindsets regarding vitamin B12 testing and prescribing. A cross-sectional study was conducted using an online survey distributed by e-mail to Swiss GPs. The questionnaire explored mindsets related to testing and prescribing vitamin B12 in specific clinical situations, as well as testing and prescribing strategies. The questionnaire was sent to 876 GPs and 390 GPs responded (44.5%). The most controversial domains for testing and prescribing vitamin B12 were idiopathic fatigue (57.4% and 43.4% of GPs agreed, respectively) and depressive symptoms (53.0% and 35.4% of GPs agreed, respectively). There was substantial variation among GPs with regard to testing strategies (89.5% of GPS used a serum cobalamin test, 71.3% of GPS used holotranscobalamin, and 27.6% of GPs used homocysteine or methylmalonic acid). Intramuscular injection was the predominantly prescribed route of application (median of 87.5% of the prescriptions). In this study, we focus on discordant mindsets that can be specifically targeted by using educational interventions, and research questions that still need answering specifically about the effectiveness of vitamin B12 for idiopathic fatigue.

Potentially inappropriate proton-pump inhibitor prescription in the general population: a claims-based retrospective time trend analysis.

BACKGROUND: Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations. AIMS: We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI. METHODS: This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate. RESULTS: Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), (p = <0.001), and the incidence of PIPPI increased from 4.8% (2013) to 6.4% (2017), (p = <0.001). Age, male gender, drugs with bleeding risk and multimorbidity were independent determinants of PIPPI (p = <0.001 for all). CONCLUSIONS: This study provides evidence that one of the most prescribed drug groups is commonly prescribed inappropriately in the general population and that this trend is increasing. Multimorbidity and drugs with bleeding risks were strong determinants of PIPPI. Addressing PPI prescriptions exceeding guideline recommendations could reduce polypharmacy and improve patient safety.

Effects of Vitamin B12 Supplementation on Cognitive Function, Depressive Symptoms, and Fatigue: A Systematic Review, Meta-Analysis, and Meta-Regression.

Vitamin B12 is often used to improve cognitive function, depressive symptoms, and fatigue. In most cases, such complaints are not associated with overt vitamin B12 deficiency or advanced neurological disorders and the effectiveness of vitamin B12 supplementation in such cases is uncertain. The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) is to assess the effects of vitamin B12 alone (B12 alone), in addition to vitamin B12 and folic acid with or without vitamin B6 (B complex) on cognitive function, depressive symptoms, and idiopathic fatigue in patients without advanced neurological disorders or overt vitamin B12 deficiency. Medline, Embase, PsycInfo, Cochrane Library, and Scopus were searched. A total of 16 RCTs with 6276 participants were included. Regarding cognitive function outcomes, we found no evidence for an effect of B12 alone or B complex supplementation on any subdomain of cognitive function outcomes. Further, meta-regression showed no significant associations of treatment effects with any of the potential predictors. We also found no overall effect of vitamin supplementation on measures of depression. Further, only one study reported effects on idiopathic fatigue, and therefore, no analysis was possible. Vitamin B12 supplementation is likely ineffective for improving cognitive function and depressive symptoms in patients without advanced neurological disorders.

Trends in Micronutrient Laboratory Testing in Switzerland: A 7-Year Retrospective Analysis of Healthcare Claims Data.

BACKGROUND: Micronutrient laboratory tests (MLT) are increasing in many healthcare systems. This study assessed time trends of annual MLT incidence in the Swiss population and examined the frequency of specific MLT, defined as the number of yearly tests performed in individual persons. METHODS: For annual time trends, we used a longitudinal design with a seven-year observation period (2012-2018) and for yearly testing frequency we used a cross-sectional design (2018 only). The database consisted of nationwide insurance claims from adult persons. RESULTS: Persons with MLT compared to persons without were older (mean age 57.1 years vs 48.6 years) and to a higher proportion female (65.1% vs 45.5%). Between 2012 and 2018, we included 6.7 million person years and found an increase in the proportion of persons receiving any MLT from 24.5% to 35.0%. Tests with strongest absolute increase during the observation period were vitamin D (from 7.4% of persons to 20.4%), vitamin B12 (from 9.0% to 17.6%) and ferritin (from 17.4% to 26.6%). In 2018, vitamin D and vitamin B12 tests were performed more than once in 4.5% and 3.3% of the population, respectively. CONCLUSION: We found that the Swiss population undergoes MLT with high and increasing frequency. Testing for vitamin D, vitamin B12 and ferritin is very common and of questionable appropriateness.

Guideline Concordance of Statin Treatment Decisions: A Retrospective Cohort Study.

Guidelines recommend initiation of statins depending on cardiovascular risk and low-density lipoprotein cholesterol (LDL-C) levels. In this retrospective cohort study, we aimed to assess guideline concordance of statin treatment decisions and to find determinants of undertreatment in Swiss primary care in the period 2016-2019. We drew on electronic medical records of 8060 statin-naive patients (50.0% female, median age 59 years) with available LDL-C levels and cardiovascular risk. Guideline concordance was assessed based on the recommendations of the European Society of Cardiology, and multilevel logistic regression was performed to find determinants of undertreatment. We found that statin treatment was initiated in 10.2% of patients (50.0% female, median age 59 years) during one year of follow up. Treatment decisions were classified as guideline-concordant in 63.0%, as undertreatment in 35.8% and as overtreatment in 1.2%. Among determinants of undertreatment were small deviation from LDL-C treatment thresholds (odds ratio per decrease by 1 mmol/L: 2.09 [95% confidence interval 1.87-2.35]), high compared with very high cardiovascular risk (1.64 [1.30-2.05]), female sex (1.31 [1.05-1.64]), and being treated by older general practitioners (per 10 year decrease: 0.74 [0.61-0.90]). In conclusion, undertreatment of patients at high or very high cardiovascular risk was common, but general practitioners considered cardiovascular risk and LDL-C in their treatment decisions.

The Impact of the 2019 European Guideline for Cardiovascular Risk Management: A Cross-Sectional Study in General Practice.

The aim of this study was to assess the impact of the 2019 published European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guideline on cardiovascular (CV) risk management compared with its predecessor from 2016 in a cohort in general practice. We performed a cross-sectional retrospective study with data from electronic medical records. The study cohort included 103,351 patients with known CV risk. We assessed changes in CV risk classification and low-density lipoprotein cholesterol (LDL-C) target values, the impact on LDL-C achievement rates, and the current lipid-lowering treatments. Under the 2019 ESC guideline, CV risk categories changed in 27.5% of patients, LDL-C target levels decreased in 71.4% of patients, and LDL-C target achievement rate dropped from 31.1% to 16.5%. Among non-achievers according to the 2019 guideline, 52.2% lacked lipid-lowering drugs entirely, and 41.5% had conventional drugs at a submaximal intensity. Of patients in the high-risk and very high-risk categories, at least 5% failed to achieve the LDL-C target level despite treatment at maximal intensity with conventional lipid-lowering drugs, making them eligible for PCSK-9 inhibitors. In conclusion, the 2019 ESC/EAS guideline lowered LDL-C target values for the majority of patients in general practice and halved LDL-C target achievement rates. There is still a large undeveloped potential to lower CV risk by introducing conventional lipid-lowering drugs, particularly in patients at high or very high CV risk. A substantial proportion of the patients can only achieve their LDL-C targets using PCSK-9 inhibitors, which would currently require an at least 10-fold increase in prescribing of these drugs.

Trends and Between-Physician Variation in Laboratory Testing: A Retrospective Longitudinal Study in General Practice.

Laboratory tests are frequently ordered by general practitioners (GPs), but little is known about time trends and between-GP variation of their use. In this retrospective longitudinal study, we analyzed over six million consultations by Swiss GPs during the decade 2009-2018. For 15 commonly used test types, we defined specific laboratory testing rates (sLTR) as the percentage of consultations involving corresponding laboratory testing requests. Patient age- and sex-adjusted time trends of sLTR were modeled with mixed-effect logistic regression accounting for clustering of patients within GPs. We quantified between-GP variation by means of intraclass correlation coefficients (ICC). Nine out of the 15 laboratory test types considered showed significant temporal increases, most eminently vitamin D (ten-year odds ratio (OR) 1.88, 95% confidence interval (CI) 1.71-2.06) and glycated hemoglobin (ten-year OR 1.87, 95% CI 1.82-1.92). Test types both subject to substantial increase and high between-GP variation of sLTR were vitamin D (ICC 0.075), glycated hemoglobin (ICC 0.101), C-reactive protein (ICC 0.202), and vitamin B12 (ICC 0.166). Increasing testing frequencies and large between-GP variation of specific test type use pointed at inconsistencies of medical practice and potential overuse.