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ABSTRACTObjective:Many studies have shown differences between statins based on surrogate endpoints, but few have studied differences in reaching clinical endpoints.This study compares the risk of cardiovascular and cerebrovascular events between atorvastatin users and other statin users in daily general practice.Research design and methods:A cohort study was performed in the Integrated Primary Care Information project database, a longitudinal general practice research database with electronic patient records of more than 500 000 individuals in the Netherlands. All new statin users in the period 1st September 1999 to 31st December 2002 were included. Multivariate Cox-regression analysis was used to compare the occurrence of the primary endpoint between atorvastatin users and other statin users.Main outcome measures:The primary endpoint was the composite outcome of fatal or non-fatal myocardial infarction, admission for unstable angina pectoris, fatal or non-fatal cerebrovascular accidents, or transient ischaemic events.Results:3499 new statin users were identified, including 797 patients with a history of cardiovascular disease. 1341 persons started with simvastatin (38.3%), 1154 with atorvastatin (33.0%), 811 with pravastatin (23.2%) and 193 with other statins (5.5%). The median follow-up was 1.9 years. Two hundred and thirty three patients (6.7%) experienced a primary endpoint. Atorvastatin users had a significantly lower risk of cardiovascular and cerebrovascular events than users of other statins (relative risk [RR]: 0.70, 95% confidence interval [CI]: 0.55–0.96). The relative risks of atorvastatin users compared to simvastatin and pravastatin users individually were 0.70 (95% CI: 0.48–1.02) and 0.78 (95% CI: 0.52–1.16), respectively. The protective effect of atorvastatin was more pronounced in persons without a history of cardiovascular or cerebrovascular events.Conclusion:Atorvastatin showed a more favourable effect on fatal and non-fatal cardiovascular and cerebrovascular events in the general population than other statins.

ABSTRACTObjective:Screening, treatment and monitoring guidelines for hypertension and hypercholesterolaemia have been developed to assist physicians in providing evidence-based health care. We conducted a retrospective study to assess the management of patients with these single or combined conditions.Research design and methods: This was a retrospective cohort study conducted using data from the Integrated Primary Care Information (IPCI) project based in the Netherlands. Management of hypertension and hypercholesterolaemia was assessed from 2000–2003 by measuring the numbers of patients screened for these conditions, treated pharmacologically and monitored for treatment success.Results:Approximately 11%, 3% and 10% of participants were eligible for screening for hypertension alone, hypercholesterolaemia alone and both conditions, respectively. Blood pressure screening was high in patients eligible for both blood pressure and cholesterol screening (> 86%), whereas cholesterol screening was low (< 56%). Among patients newly identified with hypertension or hypercholesterolaemia who were eligible for pharmacotherapy, 29% and 43% respectively were not treated within one year of diagnosis. Undertreatment was significantly lower in patients with both conditions (24% and 37% for antihypertensive and lipid-lowering treatment, respectively and 28% were not treated for both). Among newly treated patients, in the first year of treatment there was no record of a blood pressure or cholesterol assessment, for 35% and 72%, respectively.Conclusion:Management was sub-optimal in patients with hypertension or hypercholesterolaemia as well as in those with both of these conditions. The results of this study are likely to be widely applicable, particularly to other European and industrialised countries that have similar free-access health care systems to the Netherlands.

Introducing decision-support systems as a tool to stimulate the dissemination of clinical guidelines in daily practice has been disappointing. Researchers have argued that integration of such systems with clinical practice is a prerequisite for acceptance. The big question concerns the feasibility of a true integration--if only routinely recorded data are used for such a system, can patient-specific feedback be produced?

Objective: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. Methods: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. Results: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. Conclusion: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.