Gaps and opportunities in the practice of medicine: the need for improved systems of care

The medical profession is increasingly confronted with the disconcerting fact that despite the impressive scientific advances in clinical knowledge and improved outcomes that have been achieved, substantial opportunities for improvement remain. For example, a growing body of evidence points to the need for new approaches to ensure that each patient is treated according to the best scientific knowledge that is available in order to optimize outcomes. In this issue, Hengstenberg and colleagues, using data from the Ausberg cohort of the World Health Organization’s MONICA myocardial infarction registry, add to the literature revealing gaps in the performance of health care delivery. These investigators evaluated cardiovascular risk factors in siblings of patients who had had a myocardial infarction before 60 years of age. These patients are of particular interest because they presumably have a high risk of cardiovascular disease and thus much to gain from risk factor modification. Subjects in the study were examined for the primary preventive care they received in order to assess its consistency with practice objectives defined by guidelines written by combined task forces of the European Society of Cardiology, European Atherosclerosis Society, and the European Society of Hypertension (ESC/EAS/ESH). The investigators found a high prevalence of cardiovascular risk factors in the siblings. Among those with hypertension, most were receiving antihypertensive medication, but relatively few attained recommended blood pressure target levels. Less than half of the siblings with indications for lipid-lowering therapy were treated, and target cholesterol levels established by the guidelines were reached by less than 10% of treated patients. In addition, patients’ likelihood of achieving target levels for blood pressure and cholesterol were not related to their underlying risk of cardiovascular disease. Thus, siblings with the most to gain from risk reduction were no more likely to be treated in accordance