Primary prevention of cardiovascular diseases by lipid-lowering treatment in German general practice: results from GPs ignoring guidelines and risk calculators.

OBJECTIVE: Guidelines/risk calculators for the primary prevention of cardiovascular disease have been developed, which could make decisions for or against therapy easier. However, it has been shown for different countries that there is still quite a discrepancy between what is done and what should be done according to guidelines/risk calculators. Usually, in Germany, neither guidelines nor risk calculators are used. On what basis, then, and with what result do German general practitioners decide for or against a treatment?

METHODS: 26 GPs agreed to participate in the study. From their surgeries, data from a random sample of 401 patients diagnosed with hyperlipidaemia were taken, of which 290 were eligible for the study on primary prevention. Patient risk factors were taken from their files to analyse their need for treatment using risk calculators for ERCP III (US guideline) and the European guideline. These results were compared with the treatment they received from their GPs. In semi-structured interviews, GPs were asked about their decision-making process (in four randomly chosen patients from each surgery) concerning the chosen treatment. Additionally, GPs were asked about their attitude towards guidelines/risk calculators.

RESULTS: 89% of the patients who received treatment would also have received it according to ERCP III. According to European guidelines, only 38% of those receiving treatment need it. Concerning those not receiving treatment, 54% would not receive it according to NCEP III and 89% would not according to the European guideline. In interviews, around 75% of doctors demonstrated that they follow a multifactorial approach and a high-risk strategy. However, about 50% and 70% explicitly stated not using guidelines or risk calculators, respectively, and even among those stating that they used them, the majority were unaware of names/sources. Patient values or wishes as well as the healthcare system influenced their decisions.

CONCLUSION: German GPs seem to follow quite effectively a high-risk strategy in primary prevention, usually using a multifactorial approach, even without using risk calculators/guidelines. This kind of personalized care is also reflected in the considered importance of patient wishes and values. It is difficult to judge GPs concerning their quality of care having as a "gold standard" different risk calculators/guidelines that define whether such different populations receive treatment or not.